99%. BBS clear/diminished in bases.\\n\\nNeuro: Pt speaks portugese only; difficulty comprehending english. When asked if in pain will nod head appropriately per family. Also, per family patient was oriented to self/place but occasionally experienced mild confusion. Pt c/o pain right arm...right arm puffy and red, so PIV removed and replaced on left arm. Pt moans and yells out with turning and positioning, otherwise sleeps and appears to be resting comfortably. Medicated with 1mg IV morphine with good effect.\\n\\nGI/GU: Abdomen softly distended, BS present. Foley cath draining adequate UO; amber with sediment. Fecal bag replaced d/t leaking...pt continues to have liquid green stool. Pt on clear liquid diet, but having difficulty taking thin liquids. Last evening was only able to swallow pills with jello. K this am 2.9 and PO repletion attempted, however patient will just hold pills and jello on right side of mouth and not attempt to swallow. 40meq IV KCL ordered as well.\\n\\nID: WBC 48.3, low-grade temp 100. Cipro switched to Levofloxacin IV. Pt continues on PO flagyl.\\n\\nPlan: Pt was c/o floor yesterday, but then spiked temp and tachycardic. Status stable through night, c/o floor today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2116-07-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558344,\n \"text\": \"Nursing Admission Note 1530-1900\\nPt brought to ER by family for persistent diarrhea and dehydration. One episode of \\\"hypotension\\\"- SBP of 89 in ED. Given 1 Liter NS w/ resolution of s/s. Transfered to MICU 6 for monitoring at MD request. Pt arrives in NAD, normotensive.\\n\\nROS/PE:\\n\\nCV: NSR, HR 70-80's. rare PVC. NIBP 100-120's systolic. extremities W&D, neg edema.\\n\\nRESP: LS CTA, poor inspiratory effort, decreased at bases. no cough or SOB. Spo2 >95% on RA.\\n\\nNEURO: speaks portugese. Per daughter, pain free. Alert and O x2-3. MAE on the bed, no focal defecits. Low level of functioning- WC and bed bound. very deconditioned.\\n\\nGI/GU: abd a bit distended, tympanic. no stool out since arrival. reportedly 2 small loose stools in ED. NPO at this time. IVF- NS at 100cc/hr. Foley w/ adeq U/O.\\n\\nSKIN: Grossly intact. dry.\\n\\nACCESS: Piv x2, intact.\\n\\nSOCIAL: Daughter here. Wife is reportedly not in good health, but family does not think that they can make DNR decisions, therefore full code at this time. Lives at home w/ family to take care of him.\\n\\nPLAN: likely c/o either later tonoc or tomorrow. monitor for s/s of hypotension, may need more fluid. stool clx x2 needed. f/u on culture data. FULL CODE.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2116-07-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558350,\n \"text\": \"7am to 4:30 pm:\\n\\nNeuro)\\nPt is awake and alert, but does not follow any commands. Pt was oriented to person this am per interpreter. Pt is portugese speaking only. Pt has very limited ROM to all ext's ? pain with any movent of ext's ? AR.\\n\\nCV)\\nPt remains in NSR with rare PVC's with HR 80-90's. BP stable at 120-130's. Pt cont to have low grade temps Tmax 100.1 (A) at this shift. Pt has edema to lower legs.\\n\\nID)\\nWBC's remains elevated. Pt is on Levaquin as noted. All cx's remains pending.\\n\\nRESP)\\nLS CTA wit decreased bases. No SOB/DOE. Pt needs to be inc to DB&C W/A. 02sat 98-100% on RA.\\n\\nGI)\\nAbd sl distended and soft to touch (non-tender) with + hypoactive BS. TF at goal at 40 cc/hr with max 5 cc of residuals. NGT in place and placement + via ascultation. Pt cont to have liq dark green stool. Sample sent off this pm (#2). Stool Guiac neg. IVF as noted.\\n\\nGU)\\nU/o as noted. U/o with color and with sediment.\\n\\nSKIN)\\nskin intact as noted. Pt has yellow-green colored drainage from bil eyes. Pt to be started on med's for this.\\n\\nPLAN:\\n Transfer to floor with bed avalible.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2116-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 60023,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Congestive heart failure.\\nHeight: (in) 68\\nWeight (lb): 140\\nBSA (m2): 1.76 m2\\nBP (mm Hg): 140/70\\nHR (bpm): 111\\nStatus: Inpatient\\nDate/Time: at 14:55\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild-moderate\\nregional LV systolic dysfunction. No resting LVOT gradient.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\\nhypo;\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Moderately dilated aortic root.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\\nannular calcification. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\\nsystolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\\nSuboptimal image quality as the patient was difficult to position.\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thicknesses and\\ncavity size are normal. There is mild to moderate regional left ventricular\\nsystolic dysfunction with hypokinesis of the anterior wall and septum. Right\\nventricular chamber size and free wall motion are normal. The aortic root is\\nmoderately dilated. The aortic valve leaflets (3) are mildly thickened but\\naortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The\\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\\nMild (1+) mitral regurgitation is seen. The estimated pulmonary artery\\nsystolic pressure is normal. There is no pericardial effusion.\\n\\nIMPRESSION: Mild-to-moderate regional left ventricular systolic dysfunction.\\nMild mitral regurgitation. Mild aortic regurgitation.\\n\\nCompared with the prior study (images reviewed) of , left ventricular\\nsystolic function appears similar. Severity of mitral regurgitation may be\\nslightly less. Aortic root dimensions are slightly larger. The other findings\\nappear similar.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2116-07-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 108963,\n \"text\": \"Sinus tachycardia. Ventricular premature beats. Otherwise, probably normal\\ntracing. Since the previous tracing of sinus tachycardia is present.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2116-07-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 108964,\n \"text\": \"Sinus rhythm with PVCs\\nNo change from previous\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-07-10 00:00:00.000\",\n \"description\": \"PICC W/O PORT\",\n \"row_id\": 922781,\n \"text\": \" 10:09 AM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: Please place PICC for access.\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ********************************* CPT Codes ********************************\\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with CAD, admitted with diarrhea, anemia, thrombocytopenia;\\n lost IV access overnight.\\n REASON FOR THIS EXAMINATION:\\n Please place PICC for access.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION FOR EXAM: 86-year-old man with coronary artery disease admitted\\n with thrombocytopenia and has a history of allergy to heparin induced\\n thrombocytopenia.\\n\\n RADIOLOGISTS: The procedure was performed by Drs and , the\\n attending radiologist, who was present and supervising throughout.\\n\\n PROCEDURE AND FINDINGS: The patient's right arm was prepped and draped in\\n standard sterile fashion. As no suitable superficial veins were visible,\\n ultrasound was used for the evaluation of the right upper extremity veins. The\\n right basilic vein was found to be patent and compressible. Local anesthesia\\n was achieved with subcutaneous injection of 3 cc of 1% lidocaine. Under\\n realtime ultrasound guidance, the vein was accessed using a 21 gauge\\n micropuncture needle. Hard copies images of the pre- and post puncture were\\n obtained. A 0.018 guidewire was then advanced through the needle using\\n fluoroscopic guidance. The needle was then exchanged for the micropuncture\\n sheath contained in the catheter kit. line was then\\n advanced into the sheath through the superior vena cava. The wire contained\\n in the catheter was then removed as well as the peel-away sheath\\n The catheter was cut to a length of 40 cm with 34 cm of length,\\n corresponding to the distance between the skin puncture and the distal part of\\n the SVC. The line was then secured with a StatLock device and a sterile\\n transparent dressing. A final limited chest radiography confirmed placement\\n of the tip of the catheter to be in the lower SVC. The patient\\n tolerated the procedure well with no immediate complications.\\n\\n IMPRESSION: Successful placement of a single lumen line with 34 cm\\n lenght intra-vascular, via the right basilic vein with the tip terminating in\\n the lower SVC. The line is ready for use.\\n\\n\\n\\n (Over)\\n\\n 10:09 AM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: Please place PICC for access.\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-07-08 00:00:00.000\",\n \"description\": \"R WRIST(3 + VIEWS) RIGHT\",\n \"row_id\": 922472,\n \"text\": \" 11:18 AM\\n WRIST(3 + VIEWS) RIGHT; ELBOW (AP, LAT & OBLIQUE) RIGHT Clip # \\n SHOULDER VIEWS NON TRAUMA RIGHT\\n Reason: Evaluate for degenerative changes, trauma.\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man admitted with colitis, history of right arm pain with\\n increasing pain.\\n REASON FOR THIS EXAMINATION:\\n Evaluate for degenerative changes, trauma.\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Right wrist, three views; right elbow, three views; right shoulder,\\n three views; .\\n\\n HISTORY: Patient with increasing shoulder, elbow, and wrist pain. Evaluate\\n for degenerative changes.\\n\\n FINDINGS:\\n\\n RIGHT WRIST: No acute fractures or dislocations are identified. There are\\n degenerative changes seen of the first MCP joint with osteophyte seen at the\\n metacarpal head. There is preservation of the radiocarpal joint space. There\\n is normal osseous mineralization.\\n\\n RIGHT ELBOW: There is no joint effusion. No acute fractures or dislocations\\n are seen. There are no soft tissue calcifications.\\n\\n RIGHT SHOULDER:\\n\\n There are some degenerative changes seen in the acromioclavicular joint.\\n Glenohumeral joint is preserved. However, the humeral head is slightly high\\n riding. There is normal mineralization. No abnormal soft tissue\\n calcifications are identified.\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-07-08 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 922547,\n \"text\": \" 10:03 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: Asses pancreatic abscess, phlegmon, subphrenic process\\n Admitting Diagnosis: ABDOMINAL PAIN\\n Field of view: 36 Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with pancreatis and continued fevers, please assess for\\n pancreatic abscess, phlegmon, subphrenic process.\\n REASON FOR THIS EXAMINATION:\\n Asses pancreatic abscess, phlegmon, subphrenic process\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 86-year-old man with pancreatitis and continued fevers. Evaluate\\n for pancreatic abscess or phlegmon.\\n\\n COMPARISON: Study from .\\n\\n TECHNIQUE: MDCT acquired contiguous axial images were obtained from the lung\\n bases to the pubic symphysis. Multiplanar reconstructions were performed.\\n\\n CONTRAST: Oral contrast and 100 cc of IV Optiray contrast administered due to\\n the rapid rate of bolus injection required for this study.\\n\\n CT OF THE ABDOMEN WITH IV CONTRAST: There are bilateral simple-appearing\\n pleural effusions with associated atelectasis, which appear to have increased\\n slightly in comparison to the prior study. The heart and pericardium are\\n normal in appearance.\\n\\n An NG tube is positioned within the stomach. The spleen, kidneys, adrenal\\n glands, and liver are stable in appearance.\\n\\n Again seen is stranding around the head of the pancreas, and fullness of the\\n pancreas, consistent with the known history of pancreatitis. There is\\n extension of the stranding into the mesentery of the small bowel, and there is\\n soft tissue stranding and fluid extending along Gerota's fascia into the\\n pericolic gutters. The amount of fluid in the pericolic gutters and in the\\n pelvis appears to have increased slightly in comparison to the prior study.\\n There has been interval decrease in the degree of colonic wall thickening,\\n though there is residual mild soft tissue stranding around the cecum and the\\n appendix. The aorta demonstrates normal caliber and contour, without any\\n filling defects. Extensive calcification is seen along the aorta throughout\\n its course. No free intraperitoneal air is seen. No definite focal abscesses\\n or fluid collections are identified. There is a small amount of fluid around\\n the gallbladder, which is not distended, and there is no evidence of intra- or\\n extra-hepatic biliary ductal dilatation. Again seen is a right lumbar hernia.\\n\\n CT OF THE PELVIS WITH IV CONTRAST: There is a small amount of fluid within\\n the pelvis, which is increased slightly in comparison to prior study. A Foley\\n catheter is seen within the bladder. The sigmoid colon is decompressed. There\\n is a fat-containing inguinal hernia, which contains a small amount of fluid on\\n the right. No pelvic lymphadenopathy is seen.\\n (Over)\\n\\n 10:03 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: Asses pancreatic abscess, phlegmon, subphrenic process\\n Admitting Diagnosis: ABDOMINAL PAIN\\n Field of view: 36 Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n BONE WINDOWS: The osseous structures are stable in appearance.\\n\\n CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating\\n the anatomy and pathology.\\n\\n IMPRESSION:\\n 1. Again seen is stranding around the pancreas, consistent with pancreatitis.\\n There appears to be some interval increase in the degree of stranding within\\n the small bowel mesentery, and along the pericolic gutters. There is a small\\n amount of fluid along the pericolic gutters and within the pelvis, which is\\n slightly increased from the prior study. No focal abscesses are identified.\\n 2. There are bilateral pleural effusions which also have increased slightly\\n in comparison to the prior study. The remainder of the exam is unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-07-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 922265,\n \"text\": \" 7:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Assess for PNA.\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 y/o M adm w/pancreatitis, now febrile and tachypneic.\\n\\n REASON FOR THIS EXAMINATION:\\n Assess for PNA.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST\\n\\n INDICATION: Pancreatitis. Now febrile and tachypneic. Evaluate for\\n pneumonia.\\n\\n FINDINGS: Compared with , there is now mild prominence of the\\n pulmonary vascularity probably due at least in part to the elevated\\n hemidiaphragms. Mild CHF cannot be excluded. No obvious pulmonary\\n infiltrates.\\n\\n Tip of the NG tube remains projected over the right upper quadrant, probably\\n at or near the pylorus.\\n\\n IMPRESSION: No pneumonia identified.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-07-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 923036,\n \"text\": \" 11:10 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please assess for cardiopulmonary process\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 y/o M adm w/pancreatitis, now tachycardic and tachypneic. Increasing\\n oxygen requirement.\\n REASON FOR THIS EXAMINATION:\\n please assess for cardiopulmonary process\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: Single AP portable view of the chest.\\n\\n REASON FOR EXAM: Assess for changes, patient with increasing oxygen\\n requirement, h/o pancreatitis.\\n\\n COMPARISON: Comparison is made with prior study dated .\\n\\n FINDINGS: New left pleural effusion with increase in left lower lobe\\n atelectasis. Stable mild right lower lobe atelectasis. Mild pulmonary edema.\\n The size of the heart is normal. The NG tube with tip in the Treitz\\n ligament\\n\\n IMPRESSION:\\n\\n Mild pulmonary edema. New left pleural effusion. Increase left lower\\n atelectasis and stable right lower lobe atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-07-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 921835,\n \"text\": \" 11:06 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for pna\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with n/v, diarrhea, leukocytosis\\n REASON FOR THIS EXAMINATION:\\n assess for pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: AP chest, 11:22 a.m. .\\n\\n HISTORY: Diarrhea and leukocytosis.\\n\\n IMPRESSION: AP chest compared to :\\n\\n Lungs are clear. Heart size normal. No pleural abnormality or evidence of\\n central adenopathy. Right hemidiaphragm is persistently elevated given part\\n to interposition of the hepatic flexure of the colon between diaphragm and\\n liver.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-07-03 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 921871,\n \"text\": \" 2:44 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: assess for pancreatitis (d/ techologist; pt is\\n Admitting Diagnosis: ABDOMINAL PAIN\\n Field of view: 36 Contrast: OPTIRAY Amt:\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with elevated lipase and abd pain, + u/a\\n REASON FOR THIS EXAMINATION:\\n assess for pancreatitis (d/ techologist; pt is not willing to take\\n po contrast; will try w/ IV contrast only)\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT OF THE ABDOMEN WITH AND WITHOUT CONTRAST. CT OF THE PELVIS WITH AND\\n WITHOUT CONTRAST. CORONAL AND SAGITTAL RECONSTRUCTIONS WERE OBTAINED.\\n\\n INDICATION: 86-year-old male with elevated lipase and abdominal pains, assess\\n for pancreatitis.\\n\\n COMPARISON: Comparison is made with CT abdomen and pelvis, .\\n\\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\\n lung bases to the pubic symphysis with and without IV and oral contrast.\\n Coronal and sagittal reconstructions were obtained.\\n\\n CONTRAST: Oral contrast and IV non-ionic contrast were administered with IV\\n 100 cc Optiray 350.\\n\\n CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: The heart appears normal\\n without pericardial effusion. The right lung demonstrates a mild effusion\\n posteriorly with associated passive atelectasis. The liver, gallbladder, and\\n spleen are visualized and are unremarkable. The pancreas is swollen without\\n peripancreatic fluid collection noted. The abdominal aorta demonstrates mural\\n thrombus with calcification throughout. Extensive calcification of the renal\\n artery ostia bilaterally. The kidneys are mildly atrophic bilaterally. _____\\n retroperitoneal lymphadenopathy is noted and unchanged from previous study of\\n undetermined significance. There is mild increase in stranding in the\\n perirenal spaces when compared to previous exam. There is no free fluid or\\n free air within the abdomen.\\n\\n CT OF THE PELVIS WITH AND WITHOUT IV AND ORAL CONTRAST: The bladder\\n demonstrates wall thickening, unchanged from previous exam, and a Foley is\\n seen within the bladder lumen. There is diffuse thickening of the rectum,\\n sigmoid colon, and descending colon likely representing colitis. There is\\n mild enlargement of the prostate.\\n\\n OSSEOUS STRUCTURES: There is diffuse DJD of the lumbar spine. There are no\\n fractures, dislocations, or lesions identified within the bones.\\n\\n IMPRESSION:\\n 1. Diffusely swollen pancreas consistent with mild pancreatitis without\\n peripancreatic fluid collections noted.\\n (Over)\\n\\n 2:44 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: assess for pancreatitis (d/ techologist; pt is\\n Admitting Diagnosis: ABDOMINAL PAIN\\n Field of view: 36 Contrast: OPTIRAY Amt:\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 2. Mildly atrophic kidneys with diffuse calcification of the renal artery\\n ostia are noted. MRA of the renal artery is recommended bilaterally if\\n clinical suspicious for stenosis.\\n 3. Diffuse rectal, sigmoid, and descending colon wall thickening suggestive\\n of colitis.\\n 4. Enlarged paraaortic lymph nodes noted on previous exam, unchanged and of\\n unknown significance.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-07-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 922003,\n \"text\": \" 6:11 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? pulm edema ? infiltrate\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 y/o M adm w/pancreatitis, now febrile and tachypneic\\n REASON FOR THIS EXAMINATION:\\n ? pulm edema ? infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, SINGLE VIEW, ON \\n\\n HISTORY: Pancreatitis, febrile, and tachypneic.\\n\\n REFERENCE EXAM: .\\n\\n FINDINGS: This is a slightly rotated film. The left heart border is ill\\n defined, and it is unclear if this is due to motion or small area of volume\\n loss or lingular infiltrate. Otherwise, the lungs are clear without focal\\n infiltrate. A lateral film would be helpful to further assess the lingula.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-07-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 922085,\n \"text\": \" 3:49 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: NG tube placement\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 y/o M adm w/pancreatitis, now febrile and tachypneic\\n\\n REASON FOR THIS EXAMINATION:\\n NG tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST SINGLE VIEW ON \\n\\n HISTORY: NG tube placement.\\n\\n FINDINGS: There is an NG tube with tip crossing the midline, in the proximal\\n portion of the duodenum. Right hemidiaphragm is mildly elevated, as seen\\n previously. There is no infiltrate or effusion. The previous ill-defined\\n area in the lingula is better visualized today and appears clear.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-07-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 922565,\n \"text\": \" 1:51 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Etiology for respiratory distress.\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 y/o M adm w/pancreatitis, now tachycardic and tachypneic.\\n\\n REASON FOR THIS EXAMINATION:\\n Etiology for respiratory distress.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Tachypnea and tachycardia.\\n\\n Portable AP chest radiograph compared to .\\n\\n The NG tube tip terminates in the stomach. The heart size is normal. The\\n mediastinum position, contour and width are unremarkable. The lungs are clear\\n except for bibasilar atelectasis. There is no sizeable pleural effusion or\\n pneumothorax.\\n\\n Small bibasilar atelectasis. No evidence of acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-07-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 923319,\n \"text\": \" 9:53 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evaluate if NJ tube post-pyloric.\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 y/o M adm w/presumptive c. diff/chemical pancreatitis. NJ tube placed, was\\n pulled out approximately 2 inches and replaced. Please evaluate if\\n post-pyloric.\\n REASON FOR THIS EXAMINATION:\\n Evaluate if NJ tube post-pyloric.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: Single AP portable view of the chest.\\n\\n REASON FOR EXAM: Check placement of NG tube. Patient with pancreatitis.\\n\\n COMPARISON: Comparison is made with prior study dated .\\n\\n FINDINGS: NG tube tip is located in the third to fourth portion of the\\n duodenum. There is no pneumothorax. Improvement in the right lower lobe\\n atelectasis. Stable small left pleural effusion and left lower lobe\\n retrocardiac atelectasis. Improved mild pulmonary edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-07-06 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 922254,\n \"text\": \" 11:02 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Increased ICP, hemorrhage.\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man admitted with diarrhea, increased wbc count now with change in\\n mental status.\\n REASON FOR THIS EXAMINATION:\\n Increased ICP, hemorrhage.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: _____, increased white blood cell count. Evaluate for\\n hemorrhage.\\n\\n TECHNIQUE: Non-contrast axial head CT.\\n\\n FINDINGS: There is no evidence for intracranial hemorrhage. There is no mass\\n effect, shift of normally midline structures. The ventricles, cisterns, and\\n sulci are prominent secondary to marked involutional change. An area of a\\n more focal encephalomalacia in the left frontoparietal lobe may be secondary\\n to previous infarction. The osseous structures are unremarkable. There is\\n atherosclerotic calcification of the cavernous carotids. The paranasal\\n sinuses are clear except for mild mucosal thickening of the right ethmoid air\\n cells. The mastoid air cells are clear.\\n\\n IMPRESSION: Brain atrophy, but no evidence for intracranial hemorrhage.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-07-07 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 922285,\n \"text\": \" 8:56 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \\n Reason: Rule out gallbladder disease.\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with f/c/n/v. Please rule out gallbladder disease.\\n REASON FOR THIS EXAMINATION:\\n Rule out gallbladder disease.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Fever, chills, nausea, and vomiting. Evaluate for gallbladder\\n disease.\\n\\n COMPARISON: CT of the abdomen and pelvis of .\\n\\n ABDOMEN ULTRASOUND: The liver echotexture is normal. There is no focal liver\\n lesion or intrahepatic biliary ductal dilation. The main portal vein is\\n patent with the appropriate direction of flow. The gallbladder is contracted,\\n without stones. The common duct measures 5 mm. The right kidney measures 9.7\\n cm. The left kidney measures 11.9 cm. No hydronephrosis. The spleen is\\n normal. The pancreas is not well visualized due to overlying bowel gas. There\\n are small bilateral pleural effusions.\\n\\n IMPRESSION:\\n 1. Contracted gallbladder, without apparent abnormalities.\\n 2. No intra- or extra-hepatic biliary ductal dilation.\\n 3. Small bilateral pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-07-09 00:00:00.000\",\n \"description\": \"NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)\",\n \"row_id\": 922651,\n \"text\": \" 1:11 PM\\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \\n Reason: Please place -intestinal tube for feeding\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with pancreatitis; please place -intestinal tube for\\n feeding.\\n REASON FOR THIS EXAMINATION:\\n Please place -intestinal tube for feeding\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 86-year-old gentleman with history of pancreatitis referred for\\n placement of postpyloric feeding tube.\\n\\n PROCEDURE AND FINDINGS: The patient was placed in supine position on the\\n fluoroscopy table. Topical anesthetic placed into the right naris of patient.\\n An 8-French - feeding tube guided with fluoroscopy through\\n right naris into the stomach and advanced, with the tip terminating at the\\n ligament of Treitz. Five mL of Conray administered through the -\\n feeding tube with opacification of the distal duodenum at the ligament\\n of Treitz.\\n\\n COMPLICATIONS: None.\\n\\n\"\n }\n]"}}},{"rowIdx":78,"cells":{"subject_id":{"kind":"number","value":59702,"string":"59,702"},"hadm_id":{"kind":"number","value":154545,"string":"154,545"},"target_text":{"kind":"string","value":"The patient was brought to the operating room on where the patient underwent CABG x 4 (LIMA-LAD, RSVG-OM1, RSVG-OM2, RSVG-Diag). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD#4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in stable condition on POD#4."},"extractive_notes_summ":{"kind":"string","value":"Normal ascending aortadiameter. Normal descending aorta diameter. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. FINDINGS: There is minimal bulb thickening and extension into the internal carotid arteries bilaterally. Cardiomediastinal contours are unchanged with mild cardiomegaly. Good (>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness. The left ventricular cavity sizeis normal. Right bundle-branch block.Non-specific ST-T wave abnormalities. Bilateral pleural effusions are small, probably unchanged allowing the difference in positioning of the patient. Mild (1+) mitral regurgitation is seen.Dr. IMPRESSION: No acute cardiopulmonary abnormality. However, the peak systolic velocities bilaterally are normal as are the ICA/CCA ratios. The cardiac silhouette is top normal. No overt pulmonary edema is seen. Overall left ventricular systolic function is normal (LVEF>55%).Right ventricular chamber size and free wall motion are normal.There are simple atheroma in the descending thoracic aorta.There are three aortic valve leaflets. Normal sinus rhythm. There is some consolidation/volume loss in the retrocardiac region, otherwise the lungs are clear. was notified in person of the results.Post CPB:The patient is being atrial paced.There is trace MR.The biventricular systolic function is preserved.The visible contours of the thoracic aorta are intact. Left lower lobe retrocardiac opacity consistent with atelectasis has minimally improved. Non-specific ST-T waveabnormalities. Trace AR.MITRAL VALVE: No MVP. Intraoperative TEE for CABG.Height: (in) 71Weight (lb): 213BSA (m2): 2.17 m2Status: InpatientDate/Time: at 10:16Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the LAA. Normal LV cavity size. FINDINGS: The endotracheal tube has been removed. Otherwise, no diagnostic change.TRACING #2 There is no aortic valve stenosis.Trace aortic regurgitation is seen.There is no mitral valve prolapse. Left-sided chest tube has been removed. Right lower lobe and right perihilar opacities have minimally worsened consistent with increasing atelectasis. IMPRESSION: Minimal bilateral plaque, however, no appreciable ICA stenosis bilaterally (graded as less than 40% bilaterally). Overallnormal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Results were personally reviewed with the MD caring for thepatient.Conclusions:Pre CPB:No spontaneous echo contrast or thrombus is seen in the body of the leftatrium or left atrial appendage.No atrial septal defect is seen by 2D or color Doppler.Left ventricular wall thicknesses are normal. There is a left-sided chest tube and mediastinal drains in place. Pulmonic valve not well seen.GENERAL COMMENTS: A TEE was performed in the location listed above. Simple atheroma in descendingaorta.AORTIC VALVE: Three aortic valve leaflets. No TEE relatedcomplications. Compared to tracing #1 suggestion of left atrial enlargement isless prominent. The aorta is slightly tortuous. There are low lung volumes. No focal consolidation, pleural effusion, or pneumothorax is seen. There is no pneumothorax. There is no pneumothorax. No PS.Physiologic PR. The patient was undergeneral anesthesia throughout the procedure. There is right IJ line with tip in the SVC. Possible left atrial enlargement. Right IJ line tip is in the right atrium. No previous tracing available forcomparison.TRACING #1 Right bundle-branch block. Sinus rhythm. COMPARISON: None. No AS. No MS. There is volume loss in the left lower lung. There is also normal antegrade flow involving both vertebral arteries. FINDINGS: Frontal and lateral views of the chest are obtained. Mitral valve disease. The sternal wires are aligned. REFERENCE EXAM: ET tube tip is 3.4 cm above the carina. I certifyI was present in compliance with HCFA regulations. The TEE probe was passed withassistance from the anesthesioology staff using a laryngoscope. 3:09 PM CHEST PORT. PATIENT/TEST INFORMATION:Indication: Coronary artery disease. NG tube tip is in the stomach. 1:52 PM CHEST (PA & LAT) Clip # Reason: r/o inf, eff Admitting Diagnosis: DYSPNEA ON EXERTION\\RIGHT AND LEFT HEART CATH MEDICAL CONDITION: 62 year old man with s/p CABG REASON FOR THIS EXAMINATION: r/o inf, eff FINAL REPORT PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: Status post CABG, asses pleural effusion. CLINICAL INFORMATION: 62-year-old male with history of coronary artery disease, pre-op chest radiograph. 4:01 PM CAROTID SERIES COMPLETE Clip # Reason: LM DISEASE, R/O CAS MEDICAL CONDITION: 62 year old man with LM disease REASON FOR THIS EXAMINATION: r/o carotid stenosis FINAL REPORT CAROTID STUDY HISTORY: \"LM\" disease, which is presumed to represent left main coronary disease, though not formally stated. LINE PLACEMENT Clip # Reason: *CARDIAC SURGERY FAST TRACK EXTUBATION PROTOCOL* evaluate li Admitting Diagnosis: DYSPNEA ON EXERTION\\RIGHT AND LEFT HEART CATH MEDICAL CONDITION: 62 year old man with s/p CABG REASON FOR THIS EXAMINATION: *CARDIAC SURGERY FAST TRACK EXTUBATION PROTOCOL* evaluate lines, and for hemo/ptx FINAL REPORT CHEST ON HISTORY: Status post CABG."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2185-09-09 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":1157330,"text":" 6:49 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: DYSPNEA ON EXERTION\\RIGHT AND LEFT HEART CATH\n Admitting Diagnosis: DYSPNEA ON EXERTION\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with cad\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest frontal and lateral views.\n\n CLINICAL INFORMATION: 62-year-old male with history of coronary artery\n disease, pre-op chest radiograph.\n\n COMPARISON: None.\n\n FINDINGS: Frontal and lateral views of the chest are obtained. No focal\n consolidation, pleural effusion, or pneumothorax is seen. The aorta is\n slightly tortuous. The cardiac silhouette is top normal. No overt pulmonary\n edema is seen.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n\n"},{"category":"Radiology","chartdate":"2185-09-14 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1157924,"text":" 1:52 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o inf, eff\n Admitting Diagnosis: DYSPNEA ON EXERTION\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Status post CABG, asses pleural effusion.\n\n Comparison is made with prior study .\n\n Bilateral pleural effusions are small, probably unchanged allowing the\n difference in positioning of the patient. Left lower lobe retrocardiac\n opacity consistent with atelectasis has minimally improved. Right lower lobe\n and right perihilar opacities have minimally worsened consistent with\n increasing atelectasis. There is no pneumothorax. Cardiomediastinal contours\n are unchanged with mild cardiomegaly. There are low lung volumes. The\n sternal wires are aligned.\n\n\n"},{"category":"Radiology","chartdate":"2185-09-10 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1157407,"text":" 3:09 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: *CARDIAC SURGERY FAST TRACK EXTUBATION PROTOCOL* evaluate li\n Admitting Diagnosis: DYSPNEA ON EXERTION\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n *CARDIAC SURGERY FAST TRACK EXTUBATION PROTOCOL* evaluate lines, and for\n hemo/ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Status post CABG.\n\n REFERENCE EXAM: \n\n ET tube tip is 3.4 cm above the carina. Right IJ line tip is in the right\n atrium. There is some consolidation/volume loss in the retrocardiac region,\n otherwise the lungs are clear. NG tube tip is in the stomach. There is a\n left-sided chest tube and mediastinal drains in place.\n\n\n"},{"category":"Radiology","chartdate":"2185-09-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1157495,"text":" 11:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx\n Admitting Diagnosis: DYSPNEA ON EXERTION\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p ct pull\n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Question pneumothorax.\n\n FINDINGS: The endotracheal tube has been removed. There is right IJ line\n with tip in the SVC. There is volume loss in the left lower lung. Left-sided\n chest tube has been removed. There is no pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2185-09-09 00:00:00.000","description":"CAROTID SERIES COMPLETE","row_id":1157303,"text":" 4:01 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: LM DISEASE, R/O CAS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with LM disease\n REASON FOR THIS EXAMINATION:\n r/o carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID STUDY\n\n HISTORY: \"LM\" disease, which is presumed to represent left main coronary\n disease, though not formally stated.\n\n FINDINGS: There is minimal bulb thickening and extension into the internal\n carotid arteries bilaterally. However, the peak systolic velocities\n bilaterally are normal as are the ICA/CCA ratios. There is also normal\n antegrade flow involving both vertebral arteries.\n\n IMPRESSION: Minimal bilateral plaque, however, no appreciable ICA stenosis\n bilaterally (graded as less than 40% bilaterally).\n\n"},{"category":"Echo","chartdate":"2185-09-10 00:00:00.000","description":"Report","row_id":90170,"text":"PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Mitral valve disease. Intraoperative TEE for CABG.\nHeight: (in) 71\nWeight (lb): 213\nBSA (m2): 2.17 m2\nStatus: Inpatient\nDate/Time: at 10:16\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the \nLAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal descending aorta diameter. Simple atheroma in descending\naorta.\n\nAORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR.\n\nMITRAL VALVE: No MVP. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Pulmonic valve not well seen.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications. Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nPre CPB:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium or left atrial appendage.\nNo atrial septal defect is seen by 2D or color Doppler.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. Overall left ventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal.\nThere are simple atheroma in the descending thoracic aorta.\nThere are three aortic valve leaflets. There is no aortic valve stenosis.\nTrace aortic regurgitation is seen.\nThere is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen.\nDr. was notified in person of the results.\n\nPost CPB:\nThe patient is being atrial paced.\nThere is trace MR.\nThe biventricular systolic function is preserved.\nThe visible contours of the thoracic aorta are intact.\n\n\n"},{"category":"ECG","chartdate":"2185-09-10 00:00:00.000","description":"Report","row_id":239243,"text":"Normal sinus rhythm. Right bundle-branch block. Non-specific ST-T wave\nabnormalities. Compared to tracing #1 suggestion of left atrial enlargement is\nless prominent. Otherwise, no diagnostic change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2185-09-09 00:00:00.000","description":"Report","row_id":239244,"text":"Sinus rhythm. Possible left atrial enlargement. Right bundle-branch block.\nNon-specific ST-T wave abnormalities. No previous tracing available for\ncomparison.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2185-09-09 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 1157330,\n \"text\": \" 6:49 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: DYSPNEA ON EXERTION\\\\RIGHT AND LEFT HEART CATH\\n Admitting Diagnosis: DYSPNEA ON EXERTION\\\\RIGHT AND LEFT HEART CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man with cad\\n REASON FOR THIS EXAMINATION:\\n r/o inf, eff\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: Chest frontal and lateral views.\\n\\n CLINICAL INFORMATION: 62-year-old male with history of coronary artery\\n disease, pre-op chest radiograph.\\n\\n COMPARISON: None.\\n\\n FINDINGS: Frontal and lateral views of the chest are obtained. No focal\\n consolidation, pleural effusion, or pneumothorax is seen. The aorta is\\n slightly tortuous. The cardiac silhouette is top normal. No overt pulmonary\\n edema is seen.\\n\\n IMPRESSION: No acute cardiopulmonary abnormality.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2185-09-14 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1157924,\n \"text\": \" 1:52 PM\\n CHEST (PA & LAT) Clip # \\n Reason: r/o inf, eff\\n Admitting Diagnosis: DYSPNEA ON EXERTION\\\\RIGHT AND LEFT HEART CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man with s/p CABG\\n REASON FOR THIS EXAMINATION:\\n r/o inf, eff\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA AND LATERAL VIEWS OF THE CHEST\\n\\n REASON FOR EXAM: Status post CABG, asses pleural effusion.\\n\\n Comparison is made with prior study .\\n\\n Bilateral pleural effusions are small, probably unchanged allowing the\\n difference in positioning of the patient. Left lower lobe retrocardiac\\n opacity consistent with atelectasis has minimally improved. Right lower lobe\\n and right perihilar opacities have minimally worsened consistent with\\n increasing atelectasis. There is no pneumothorax. Cardiomediastinal contours\\n are unchanged with mild cardiomegaly. There are low lung volumes. The\\n sternal wires are aligned.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2185-09-10 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1157407,\n \"text\": \" 3:09 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: *CARDIAC SURGERY FAST TRACK EXTUBATION PROTOCOL* evaluate li\\n Admitting Diagnosis: DYSPNEA ON EXERTION\\\\RIGHT AND LEFT HEART CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man with s/p CABG\\n REASON FOR THIS EXAMINATION:\\n *CARDIAC SURGERY FAST TRACK EXTUBATION PROTOCOL* evaluate lines, and for\\n hemo/ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST ON \\n\\n HISTORY: Status post CABG.\\n\\n REFERENCE EXAM: \\n\\n ET tube tip is 3.4 cm above the carina. Right IJ line tip is in the right\\n atrium. There is some consolidation/volume loss in the retrocardiac region,\\n otherwise the lungs are clear. NG tube tip is in the stomach. There is a\\n left-sided chest tube and mediastinal drains in place.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2185-09-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1157495,\n \"text\": \" 11:25 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for ptx\\n Admitting Diagnosis: DYSPNEA ON EXERTION\\\\RIGHT AND LEFT HEART CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man s/p ct pull\\n REASON FOR THIS EXAMINATION:\\n eval for ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST ON \\n\\n HISTORY: Question pneumothorax.\\n\\n FINDINGS: The endotracheal tube has been removed. There is right IJ line\\n with tip in the SVC. There is volume loss in the left lower lung. Left-sided\\n chest tube has been removed. There is no pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2185-09-09 00:00:00.000\",\n \"description\": \"CAROTID SERIES COMPLETE\",\n \"row_id\": 1157303,\n \"text\": \" 4:01 PM\\n CAROTID SERIES COMPLETE Clip # \\n Reason: LM DISEASE, R/O CAS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man with LM disease\\n REASON FOR THIS EXAMINATION:\\n r/o carotid stenosis\\n ______________________________________________________________________________\\n FINAL REPORT\\n CAROTID STUDY\\n\\n HISTORY: \\\"LM\\\" disease, which is presumed to represent left main coronary\\n disease, though not formally stated.\\n\\n FINDINGS: There is minimal bulb thickening and extension into the internal\\n carotid arteries bilaterally. However, the peak systolic velocities\\n bilaterally are normal as are the ICA/CCA ratios. There is also normal\\n antegrade flow involving both vertebral arteries.\\n\\n IMPRESSION: Minimal bilateral plaque, however, no appreciable ICA stenosis\\n bilaterally (graded as less than 40% bilaterally).\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2185-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 90170,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Coronary artery disease. Mitral valve disease. Intraoperative TEE for CABG.\\nHeight: (in) 71\\nWeight (lb): 213\\nBSA (m2): 2.17 m2\\nStatus: Inpatient\\nDate/Time: at 10:16\\nTest: TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the \\nLAA. Good (>20 cm/s) LAA ejection velocity.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\\nnormal LVEF (>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter. Normal descending aorta diameter. Simple atheroma in descending\\naorta.\\n\\nAORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR.\\n\\nMITRAL VALVE: No MVP. No MS. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR. Pulmonic valve not well seen.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was under\\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\\ncomplications. Results were personally reviewed with the MD caring for the\\npatient.\\n\\nConclusions:\\nPre CPB:\\nNo spontaneous echo contrast or thrombus is seen in the body of the left\\natrium or left atrial appendage.\\nNo atrial septal defect is seen by 2D or color Doppler.\\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\\nis normal. Overall left ventricular systolic function is normal (LVEF>55%).\\nRight ventricular chamber size and free wall motion are normal.\\nThere are simple atheroma in the descending thoracic aorta.\\nThere are three aortic valve leaflets. There is no aortic valve stenosis.\\nTrace aortic regurgitation is seen.\\nThere is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen.\\nDr. was notified in person of the results.\\n\\nPost CPB:\\nThe patient is being atrial paced.\\nThere is trace MR.\\nThe biventricular systolic function is preserved.\\nThe visible contours of the thoracic aorta are intact.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2185-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 239243,\n \"text\": \"Normal sinus rhythm. Right bundle-branch block. Non-specific ST-T wave\\nabnormalities. Compared to tracing #1 suggestion of left atrial enlargement is\\nless prominent. Otherwise, no diagnostic change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2185-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 239244,\n \"text\": \"Sinus rhythm. Possible left atrial enlargement. Right bundle-branch block.\\nNon-specific ST-T wave abnormalities. No previous tracing available for\\ncomparison.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":79,"cells":{"subject_id":{"kind":"number","value":11474,"string":"11,474"},"hadm_id":{"kind":"number","value":156704,"string":"156,704"},"target_text":{"kind":"string","value":"# UGIB: pt is 52 F h/o hepC cirrhosis who underwent 9.8L paracentesis on without receiving albumin, then presented to OSH with LH/dizzy, fatigue. At OSH, pt developed hemetemesis x 1, for which he was transfered to OSH ICU, received 3U PRBC, and underwent EGD which showed oozing at GE junction (erosion vs. variceal bleed), for which he was started on an octreotide gtt and protonix. EGD was repeated on and showed esophageal varices without active bleed. . Pt was transferred to MICU on for TIPS evaluation (he is s/p banding of known esophageal varices). In MICU, patient remained hemodynamically stable and did not experience further episodes of bleeding. He was transfused 1 unit of platelets. Diagnostic tap was performed for ascites, which was negative for SBP. He was transferred to the floor awaiting TIPs. Pt underwent uneventful TIPs on , with confirmation of TIPs patency of . He was discharged home for routine f/u with his hepatologist. An appointment was made for him with Dr. , with whom he would like to transfer his care. . . # FEVER/HYPOTENSION: Upon transfer to the floor, was found to be hypotensive, and febrile 100.7, with drop in SBP to 70s/50s. He was given ~750cc IVF with improvement in SBP to 90s. He was asymptomatic throughout, mentating well, with good urine output. . hypotension concerning for sepsis vs variceal bleeding, though HCT remained stable, and pt responding to small IVF bolus. repeat SBP ~2hr later was 115/80, and pt not tachycardic. black stools presents, however pt s/p recent UGIB. pt was febrile, though no obvious source currently, so he was empirically started on a 7d course of zosyn. no culture data was found, and pt completed his course of zosyn without further event. . . # CIRRHOSIS: pt with cirrhosis c/b recurrent ascites, s/p recent UGIB at OSH. His HCT was stable after transfusion of 3U PRBCs. Repeat EGD was without active bleeding. he was treated with TIPs as above for variceal bleeding. His diuretics were held hyponatremia, which was treated with 1L fluid restriction, and improving upon discharge. he was continued on lactulose. . diagnostic paracentesis in MICU on presentation was negative for SBP. pt underwent 1.5L therapeutic paracentesis at time of TIPs. nadolol was held initially given concern for hypotension in setting of bleeding, then restarted upon discharge. pt will f/u with Dr. as below for transplant evaluation. . . # THROMBOCYTOPENIA: pt presented with platlets of 34, felt to chronic liver disease. he was given 1U platelets in MICU, and his platlets were stable 47-50 throughout his hospitalization. . . # SCHIZOPHRENIA: pt was continued on home regimen of risperdal. . . # TOOTHACHE: pt has poor dentition, with bottom R molar that is causing him significant pain. he was treated with oxycodone for pain, and provided with information on dentists he could contact as an outpatient for extraction. . . # CONTACTS: . is OSH gastroenterologost . PCP . . . # DISPO: pt was discharged home on , after TIPs evaluation by RUQ USN. he will f/u with his current hepatologist regarding restarting diuretic therapy. he will also f/u with Dr. regarding transplanation, as he would like to have his care transferred to . Medications on Admission: MEDICATIONS AT HOME: 1. Nadolol 20 mg QD 2. Lactulose 15 ccs 2-3 times per day 3. Risperdone 1 mg q.h.s. 4. Ciprofloxacin 250 mg q.d. 5. Spironolactone 200 mg 6. Lasix 160 mg 7. Protonix 40 mg QD 8. Calcitriol 0.25 mg QDay 9. Calcium Carbonate 1500 mg QDay . MEDICATIONS ON TRANSFER 1. Pantoprazole 40 mg IV Q12H 2. Octreotide Acetate 50 mcg/hr IV DRIP INFUSION 3. Lactulose 30 ml PO TID 4. Ciprofloxacin HCl 250 mg PO Q24H 5. Risperidone 1 mg PO HS Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 7. Calcium Carbonate 500 mg Tablet Sig: Three (3) Tablet PO once a day. 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for 1 weeks. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Medical Resources Home Health Corp Discharge Diagnosis: primary diagnoses: Hepatitis C cirrhosis upper GI bleed . Secondary diagnoses: Schizophrenia Discharge Condition: stable Discharge Instructions: You were admitted to the hospital because of bleeding from your GI tract. A TIPS (transhepatic intrahepatic porto-systemic shunt placement shunt) was placed; this should help to relieve the pressure that builds up in your abdomen. Hopefully, your ascites will improve. Your lasix and spirinolactone were held because of the bleeding and your low sodium. They were not restarted prior to your discharge. Given your TIPS you may not need as a high a dose of Lasix or spironolactone. Please ask your hepatologist Dr. if you should restart your lasix/spirinolactone when you see her in weeks. if you develop recurrence of your vomitting of blood, abdominal pain, or other worrisome symptoms, you should contact your primary care physician, hepatologist, or the emergency department. Followup Instructions: You have a follow appointment with Dr. on at 10:20AM. (. You should plan to follow up with your local hepatologist Dr. (413)- 5652-4456 within 1-2 weeks. We contact her office and they are aware you are being discharged. They were unable to confirm an appointment time on your day of discharge but they will contact you at home. Please be sure to call them if you don't hear from them in the next 1-2 days."},"extractive_notes_summ":{"kind":"string","value":"HE WAS TREATED WITH IV PROTONIX, REGALN AND OCTREOTIDE. A 0.035 glidewire was then advanced through the - set and steered into the main portal vein and finally advanced into the inferior mesenteric vein. am hct 30.9.. repeat pending.. am NA 120.. repeat 124.. 1 L fluid restriction. A 0.035 wire was advanced through the micropuncture sheath up to the levelof the IVC under fluoroscopic guidance. (Over) 2:45 PM LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOPP ABD/PEL Reason: please evaluate for patency of tips. 2:45 PM LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOPP ABD/PEL Reason: please evaluate for patency of tips. Test injection was performed with contrast documenting satisfactory position in the right portal vein. Subsequently, a 0.035 Amplatz guidewire was delivered through the catheter and left in situ as the (Over) 7:53 AM TIPS Clip # Reason: TIPS Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED Contrast: OPTIRAY Amt: 95 FINAL REPORT (Cont) catheter was withdrawn and employed for determination of the transhepatic tract length. The anterior right portal vein demonstrates bidirectional flow, with the main direction being hepatofugal, towards the TIPS shunt. NURSING ADMISSION NOTE -0700(Continued)NK YOU! POSSIBLE EGD TODAY, PT HAS BEEN NPO SINCE MN EXCEPT FOR MEDS. TRANSFERRED TO FOR POSSIBLE TIPS PROCEDURE.ALLERGIES: HALDOL, DOXYCYCLINECODE STATUS: FULL CODEACCESS: #18 PIV IN L HAND, #20 PIV RAC, #20 PIV R HANDNEURO: PT IS ALERT AND ORIENTED X3, CALM AND COOPERATIVE WITH CARE. FLUID RESTRICT ONCE ABLE TO TAKE PO'S HYPONATREMIA. COVERED WITH ALLEVYN DSG. Using the micropuncture system access was gained into the right internal jugular vein under ultrasonographic guidance. The CO2 hepatic venogram demonstrates left hepatic vein, the right and left portal veins, and the main portal vein to be widely patent. A straight multi- side-hole catheter was then delivered over the guidewire position into the main portal vein. MONITOR FOR S/S OF ENCEPHALOPATHY. Direct portal venography was then performed which detected right and left portal veins, main portal vein and mesenteric vein to be widely patent. The micropuncture sheath was exchanged for a 10 French vascular sheath which was connected to a continuous sidearm flush. PER NOTES, THE PT UNDERWENT PARACENTESIS LAST ON AND SUBSEQUENTLY DEVELOPED HYPOTENSION ASSOCIATED WITH WORSENING HYPONATREMIA. Pressure measurements were obtained after the stent deployment in the main portal vein and the hepatic vein and the gradient pressure was recorded as 7 mmHg. NURSING ADMISSION NOTE -0700REPORT RECEIVED, PT ARRIVED TO AT APPROX . There is surrounding ascites and a right lower lobe pleural effusion. Paracenteses of 1500 cc of ascites using ultrasonographic guidance. Using standard sterile technique, the right neck and right abdomen were prepped and draped. BOWEL SOUNDS PRESENT X4, PASSING FLATUS. A TIPS shunt has been placed in the interim between and today's exam. General anesthesia was administered throughout the procedure. Using a C2 Cobra catheter and a 0.035 wire, access was gained into the left hepatic vein and the sheath was advanced with tip within the hepatic vein. Patent high flow velocity TIPS by Doppler analysis. After four passes, the - needle was advanced to the right portal vein. LARGE UMBILICAL HERNIA NOTED. The wire was removed and the patient was transferred to the PACU in good condition. Nursing 7a-7P: please see transfer note for details of admit and latest assessment.. pt tx with 1 bag plts today for plt count 38k.. repeat 50k. Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED FINAL REPORT (Cont) HE WAS TRANSFERRED TO ICU FOR FURTHER EVAL, AND HE UNDERWENT AN UPPER ENDOSCOPY WHICH REVEALED NO ACTIVE SOURCE OF BLEEDING EXCEPT OOZING AT THE GE JUNCTION. PALPABLE RADIAL/DP PULSES BILATERALLY. The C2 catheter was removed and exchanged for a balloon occlusion catheter which was used to perform a CO2 hepatic venogram. The flow in the left portal vein is concerning for possible gradual occlusion, and short term interval follow-up as clinically indicated is recommended. 7:53 AM TIPS Clip # Reason: TIPS Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED Contrast: OPTIRAY Amt: 95 ********************************* CPT Codes ******************************** * INSERT HEPATIC HUNT TIPS PARACENTESIS INITAL PROC * * -51 MULTI-PROCEDURE SAME DAY UD GUID FOR NEEDLE PLACMENT * * -59 DISTINCT PROCEDURAL SERVICE * **************************************************************************** MEDICAL CONDITION: 57 year old man with hep c cirrhosis for TIPS REASON FOR THIS EXAMINATION: TIPS FINAL REPORT INDICATION FOR EXAM: This is a 57-year-old man with hep C cirrhosis with refractory ascites."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2118-05-04 00:00:00.000","description":"DUPLEX DOPP ABD/PEL","row_id":961373,"text":" 2:45 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: please evaluate for patency of tips.\n Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hepC cirhosis, now s/p TIPS.\n REASON FOR THIS EXAMINATION:\n please evaluate for patency of tips.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old man with hep C cirrhosis, now status post TIPS,\n evaluate.\n\n TECHNIQUE: Dedicated son imaging of the patient's TIPS was performed.\n Findings are compared with patient's prior examination dated , prior to\n TIPS placement.\n\n FINDINGS: The liver demonstrates increased echogenicity, with a small nodular\n and shrunken morphology. There is surrounding ascites and a right lower lobe\n pleural effusion. No focal hepatic masses are appreciated on this limited\n son evaluation of the liver parenchyma.\n\n A TIPS shunt has been placed in the interim between and today's exam.\n There is patent wall- to- wall flow within the TIPS, which is slightly limited\n in evaluation due to artifact within the TIPS wall. Doppler of the liver\n demonstrates flow in the hepatic veins, main portal vein, and inferior vena\n cava. The main portal vein demonstrates a velocity of 78.3 cm per second in\n its proximal aspect. Angle-corrected velocity in the proximal TIPS is 136 cm\n per second in the proximal tips. In the mid TIPS it is 201.5 cm second, and\n in the distal TIPS it is 167 cm per second.\n\n The anterior right portal vein demonstrates bidirectional flow, with the main\n direction being hepatofugal, towards the TIPS shunt. The left portal vein\n similarly demonstrates bidirectional flow, without dominant direction. The\n flow in the left portal vein is concerning for possible gradual occlusion, and\n short term interval follow-up as clinically indicated is recommended. The\n spleen measures 16.1 cm in size. No varices are seen.\n\n IMPRESSION:\n 1. Patent high flow velocity TIPS by Doppler analysis.\n 2. Bidirectional low flow within the left portal vein is concerning for\n possible eventual thrombosis, and short term interval follow up in 3 months as\n clinically indicated is recommended to reasssess.\n\n\n\n\n\n\n\n (Over)\n\n 2:45 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: please evaluate for patency of tips.\n Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2118-05-02 00:00:00.000","description":"MULTI-PROCEDURE SAME DAY","row_id":960957,"text":" 7:53 AM\n TIPS Clip # \n Reason: TIPS\n Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 95\n ********************************* CPT Codes ********************************\n * INSERT HEPATIC HUNT TIPS PARACENTESIS INITAL PROC *\n * -51 MULTI-PROCEDURE SAME DAY UD GUID FOR NEEDLE PLACMENT *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hep c cirrhosis for TIPS\n REASON FOR THIS EXAMINATION:\n TIPS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: This is a 57-year-old man with hep C cirrhosis with\n refractory ascites.\n\n RADIOLOGISTS: The procedure was performed by Drs. and , the\n attending radiologist who was present and supervising throughout the\n procedure.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the risks and benefits of the procedure, the patient was placed\n supine on angiography table. General anesthesia was administered throughout\n the procedure. Using standard sterile technique, the right neck and right\n abdomen were prepped and draped. Paracentesis was performed with drainage of\n 1500 cc of ascites before the procedure was initiated. Using the\n micropuncture system access was gained into the right internal jugular vein\n under ultrasonographic guidance. A 0.035 wire was advanced through the\n micropuncture sheath up to the levelof the IVC under fluoroscopic guidance.\n The micropuncture sheath was exchanged for a 10 French vascular sheath which\n was connected to a continuous sidearm flush. Using a C2 Cobra catheter and a\n 0.035 wire, access was gained into the left hepatic vein and the sheath\n was advanced with tip within the hepatic vein. The C2 catheter was removed\n and exchanged for a balloon occlusion catheter which was used to perform a CO2\n hepatic venogram. The CO2 hepatic venogram demonstrates left hepatic vein,\n the right and left portal veins, and the main portal vein to be widely patent.\n The CO2 venogram was also performed on the lateral projection and was employed\n to plan the trajectory of the - access set employed. After four\n passes, the - needle was advanced to the right portal vein. Test\n injection was performed with contrast documenting satisfactory position in the\n right portal vein. A 0.035 glidewire was then advanced through the -\n set and steered into the main portal vein and finally advanced into the\n inferior mesenteric vein. A straight multi- side-hole catheter was then\n delivered over the guidewire position into the main portal vein. Direct\n pressure measurements were obtained at the main portal vein and at the hepatic\n vein levels and the gradient was recorded as 15 mmHg. Direct portal\n venography was then performed which detected right and left portal veins, main\n portal vein and mesenteric vein to be widely patent. Subsequently, a 0.035\n Amplatz guidewire was delivered through the catheter and left in situ as the\n (Over)\n\n 7:53 AM\n TIPS Clip # \n Reason: TIPS\n Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 95\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n catheter was withdrawn and employed for determination of the transhepatic\n tract length. Then, a 10 mm Wallstent was advanced over the wire up to the\n level of the intraparenchymal tract and was deployed followed by post-dilation\n with a 10-mm balloon. Pressure measurements were obtained after the stent\n deployment in the main portal vein and the hepatic vein and the gradient\n pressure was recorded as 7 mmHg. The wire was removed and the patient was\n transferred to the PACU in good condition. The vascular sheath was removed\n and manual compression was held for 10 minutes until hemostasis was achieved\n in the neck.\n\n IMPRESSION:\n 1. Successful TIPS placement.\n 2. Initial gradient pressure of 15 mmHg and final gradient pressure of 7\n mmHg.\n 3. Paracenteses of 1500 cc of ascites using ultrasonographic guidance.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2118-04-29 00:00:00.000","description":"Report","row_id":1412975,"text":"NURSING ADMISSION NOTE -0700\nREPORT RECEIVED, PT ARRIVED TO AT APPROX . TRANSFERRED FROM STRETCHER TO BED WITHOUT INCIDENT. PT IS A 57 Y.O MALE WITH A PMH SIGNIFICANT FOR CIRRHOSIS AND ESOPHAGEAL VARICIES CHRONIC VIRAL HEPATITIS C - HAS REFRACTORY ASCITES, GI BLEED, CRI AND SCHIZOPHRENIA. APPARENTLY, THE PT UNDERGOES LARGE VOLUME ABDOMINAL PARACENTESIS ON A FREQUENT BASIS WITH REMOVAL OF UP TO 9L OF FLUID. PER NOTES, THE PT UNDERWENT PARACENTESIS LAST ON AND SUBSEQUENTLY DEVELOPED HYPOTENSION ASSOCIATED WITH WORSENING HYPONATREMIA. HE WAS ADMITTED TO . WHILE ON THE MEDICAL FLOOR AT OSH, THE PT A LARGE AMOUNT OF BLOOD X1. HE WAS TRANSFERRED TO ICU FOR FURTHER EVAL, AND HE UNDERWENT AN UPPER ENDOSCOPY WHICH REVEALED NO ACTIVE SOURCE OF BLEEDING EXCEPT OOZING AT THE GE JUNCTION. HE WAS TREATED WITH IV PROTONIX, REGALN AND OCTREOTIDE. HE ALSO RECEIVED SUPPORTIVE TREATMENT WITH PRBC'S AND FFP PRODUCTS. TRANSFERRED TO FOR POSSIBLE TIPS PROCEDURE.\n\nALLERGIES: HALDOL, DOXYCYCLINE\n\nCODE STATUS: FULL CODE\n\nACCESS: #18 PIV IN L HAND, #20 PIV RAC, #20 PIV R HAND\n\nNEURO: PT IS ALERT AND ORIENTED X3, CALM AND COOPERATIVE WITH CARE. PERRL 2MM/BRISK BILATERALLY. MAEX4 WITH FULL STRENGTH AND FOLLOWS COMMANDS CONSISTENTLY. DENIES ANY DISCOMFORT. AFEBRILE. NO SEIZURE ACTIVITY NOTED.\n\nCV: S1 S2 AS PER AUSCULTATION, HR 70'S-80'S NSR WITHOUT ECTOPY NOTED. SBP 90'S-140'S. PT WAS NOTED TO HAVE BRIEF DROP IN SBP TO 88 AT APPROX 0445 WHILE SLEEPING, HOWEVER QUICKLY INCREASED TO >90 WITHOUT INTERVENTION. DENIES CP. PALPABLE RADIAL/DP PULSES BILATERALLY. NO SIGNS OF ACTIVE BLEEDING, HCT STABLE AT 30.9.\n\nRESP: LUNGS ESSENTIALLY CLEAR THROUGHOUT ALL FIELDS, SPO2 > OR = 95% ON ROOM AIR. DENIES DIFFICULTY BREATHING OR SOB. NO INCREASED WOB NOTED. RR 20'S WITH REGULAR PATTERN.\n\nGI/GU: ABDOMEN FIRM, DISTENDED AND NONTENDER - DENIES DISCOMFORT. LARGE UMBILICAL HERNIA NOTED. BOWEL SOUNDS PRESENT X4, PASSING FLATUS. PT HAS BEEN NPO SINCE MIDNIGHT EXCEPT FOR MEDS FOR POSSIBLE EGD . NO STOOL THIS SHIFT. INDWELLING FOLEY CATHETER SECURE AND PATENT WITH APPROX 40-150ML/HOUR CLEAR AMBER URINE.\n\nINTEG: SKIN WARM AND DRY, COLOR NORMAL FOR RACE. NO SIGNS OF BREAKDOWN TO BACK. PT IS NOTED TO HAVE A PINK AREA ON INNER LEFT BUTTOCK WHICH APPEARS TO BE A BOIL OR CALLOUS THAT HAS POPPED. PINK AREA IS APPROX THE SIZE OF A NICKEL WITH SMALL AMT OF SANGUINOUS DRAINAGE FROM AN OPENING IN THE CENTER THAT IS ABOUT HALF THE SIZE OF AN ERASER HEAD. COVERED WITH ALLEVYN DSG. THE PT STATES HE DEVELOPED THIS FROM SITTING WHILE AT HOME.\n\nSOCIAL: PT LIVES ALONE. HE STATES THAT HE HAS 2 SISTERS, ONE OF WHICH IS ACTIVE IN HIS MEDICAL CARE. NO CONTACT FROM FAMILY THIS SHIFT.\n\nPLAN: CONTINUE ICU SUPPORTIVE CARE. MONITOR HCT EVERY 6 HOURS, NEXT DUE AT 1000. MONITOR FOR S/S OF ENCEPHALOPATHY. POSSIBLE EGD TODAY, PT HAS BEEN NPO SINCE MN EXCEPT FOR MEDS. FLUID RESTRICT ONCE ABLE TO TAKE PO'S HYPONATREMIA. ? TIPS PROCEDURE. PLEASE SEE CAREVUE FOR OBJECTIVE DATA, THA\n"},{"category":"Nursing/other","chartdate":"2118-04-29 00:00:00.000","description":"Report","row_id":1412976,"text":"NURSING ADMISSION NOTE -0700\n(Continued)\nNK YOU!\n\n\n\n"},{"category":"Nursing/other","chartdate":"2118-04-29 00:00:00.000","description":"Report","row_id":1412977,"text":"Nursing 7a-7P:\n please see transfer note for details of admit and latest assessment.. pt tx with 1 bag plts today for plt count 38k.. repeat 50k. am hct 30.9.. repeat pending.. am NA 120.. repeat 124.. 1 L fluid restriction. per IV team ok for pt have 20g iv's for access.. team aware. no further orders at this time.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2118-05-04 00:00:00.000\",\n \"description\": \"DUPLEX DOPP ABD/PEL\",\n \"row_id\": 961373,\n \"text\": \" 2:45 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOPP ABD/PEL\\n Reason: please evaluate for patency of tips.\\n Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with hepC cirhosis, now s/p TIPS.\\n REASON FOR THIS EXAMINATION:\\n please evaluate for patency of tips.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 57-year-old man with hep C cirrhosis, now status post TIPS,\\n evaluate.\\n\\n TECHNIQUE: Dedicated son imaging of the patient's TIPS was performed.\\n Findings are compared with patient's prior examination dated , prior to\\n TIPS placement.\\n\\n FINDINGS: The liver demonstrates increased echogenicity, with a small nodular\\n and shrunken morphology. There is surrounding ascites and a right lower lobe\\n pleural effusion. No focal hepatic masses are appreciated on this limited\\n son evaluation of the liver parenchyma.\\n\\n A TIPS shunt has been placed in the interim between and today's exam.\\n There is patent wall- to- wall flow within the TIPS, which is slightly limited\\n in evaluation due to artifact within the TIPS wall. Doppler of the liver\\n demonstrates flow in the hepatic veins, main portal vein, and inferior vena\\n cava. The main portal vein demonstrates a velocity of 78.3 cm per second in\\n its proximal aspect. Angle-corrected velocity in the proximal TIPS is 136 cm\\n per second in the proximal tips. In the mid TIPS it is 201.5 cm second, and\\n in the distal TIPS it is 167 cm per second.\\n\\n The anterior right portal vein demonstrates bidirectional flow, with the main\\n direction being hepatofugal, towards the TIPS shunt. The left portal vein\\n similarly demonstrates bidirectional flow, without dominant direction. The\\n flow in the left portal vein is concerning for possible gradual occlusion, and\\n short term interval follow-up as clinically indicated is recommended. The\\n spleen measures 16.1 cm in size. No varices are seen.\\n\\n IMPRESSION:\\n 1. Patent high flow velocity TIPS by Doppler analysis.\\n 2. Bidirectional low flow within the left portal vein is concerning for\\n possible eventual thrombosis, and short term interval follow up in 3 months as\\n clinically indicated is recommended to reasssess.\\n\\n\\n\\n\\n\\n\\n\\n (Over)\\n\\n 2:45 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOPP ABD/PEL\\n Reason: please evaluate for patency of tips.\\n Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2118-05-02 00:00:00.000\",\n \"description\": \"MULTI-PROCEDURE SAME DAY\",\n \"row_id\": 960957,\n \"text\": \" 7:53 AM\\n TIPS Clip # \\n Reason: TIPS\\n Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED\\n Contrast: OPTIRAY Amt: 95\\n ********************************* CPT Codes ********************************\\n * INSERT HEPATIC HUNT TIPS PARACENTESIS INITAL PROC *\\n * -51 MULTI-PROCEDURE SAME DAY UD GUID FOR NEEDLE PLACMENT *\\n * -59 DISTINCT PROCEDURAL SERVICE *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with hep c cirrhosis for TIPS\\n REASON FOR THIS EXAMINATION:\\n TIPS\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION FOR EXAM: This is a 57-year-old man with hep C cirrhosis with\\n refractory ascites.\\n\\n RADIOLOGISTS: The procedure was performed by Drs. and , the\\n attending radiologist who was present and supervising throughout the\\n procedure.\\n\\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\\n explaining the risks and benefits of the procedure, the patient was placed\\n supine on angiography table. General anesthesia was administered throughout\\n the procedure. Using standard sterile technique, the right neck and right\\n abdomen were prepped and draped. Paracentesis was performed with drainage of\\n 1500 cc of ascites before the procedure was initiated. Using the\\n micropuncture system access was gained into the right internal jugular vein\\n under ultrasonographic guidance. A 0.035 wire was advanced through the\\n micropuncture sheath up to the levelof the IVC under fluoroscopic guidance.\\n The micropuncture sheath was exchanged for a 10 French vascular sheath which\\n was connected to a continuous sidearm flush. Using a C2 Cobra catheter and a\\n 0.035 wire, access was gained into the left hepatic vein and the sheath\\n was advanced with tip within the hepatic vein. The C2 catheter was removed\\n and exchanged for a balloon occlusion catheter which was used to perform a CO2\\n hepatic venogram. The CO2 hepatic venogram demonstrates left hepatic vein,\\n the right and left portal veins, and the main portal vein to be widely patent.\\n The CO2 venogram was also performed on the lateral projection and was employed\\n to plan the trajectory of the - access set employed. After four\\n passes, the - needle was advanced to the right portal vein. Test\\n injection was performed with contrast documenting satisfactory position in the\\n right portal vein. A 0.035 glidewire was then advanced through the -\\n set and steered into the main portal vein and finally advanced into the\\n inferior mesenteric vein. A straight multi- side-hole catheter was then\\n delivered over the guidewire position into the main portal vein. Direct\\n pressure measurements were obtained at the main portal vein and at the hepatic\\n vein levels and the gradient was recorded as 15 mmHg. Direct portal\\n venography was then performed which detected right and left portal veins, main\\n portal vein and mesenteric vein to be widely patent. Subsequently, a 0.035\\n Amplatz guidewire was delivered through the catheter and left in situ as the\\n (Over)\\n\\n 7:53 AM\\n TIPS Clip # \\n Reason: TIPS\\n Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED\\n Contrast: OPTIRAY Amt: 95\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n catheter was withdrawn and employed for determination of the transhepatic\\n tract length. Then, a 10 mm Wallstent was advanced over the wire up to the\\n level of the intraparenchymal tract and was deployed followed by post-dilation\\n with a 10-mm balloon. Pressure measurements were obtained after the stent\\n deployment in the main portal vein and the hepatic vein and the gradient\\n pressure was recorded as 7 mmHg. The wire was removed and the patient was\\n transferred to the PACU in good condition. The vascular sheath was removed\\n and manual compression was held for 10 minutes until hemostasis was achieved\\n in the neck.\\n\\n IMPRESSION:\\n 1. Successful TIPS placement.\\n 2. Initial gradient pressure of 15 mmHg and final gradient pressure of 7\\n mmHg.\\n 3. Paracenteses of 1500 cc of ascites using ultrasonographic guidance.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-04-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1412975,\n \"text\": \"NURSING ADMISSION NOTE -0700\\nREPORT RECEIVED, PT ARRIVED TO AT APPROX . TRANSFERRED FROM STRETCHER TO BED WITHOUT INCIDENT. PT IS A 57 Y.O MALE WITH A PMH SIGNIFICANT FOR CIRRHOSIS AND ESOPHAGEAL VARICIES CHRONIC VIRAL HEPATITIS C - HAS REFRACTORY ASCITES, GI BLEED, CRI AND SCHIZOPHRENIA. APPARENTLY, THE PT UNDERGOES LARGE VOLUME ABDOMINAL PARACENTESIS ON A FREQUENT BASIS WITH REMOVAL OF UP TO 9L OF FLUID. PER NOTES, THE PT UNDERWENT PARACENTESIS LAST ON AND SUBSEQUENTLY DEVELOPED HYPOTENSION ASSOCIATED WITH WORSENING HYPONATREMIA. HE WAS ADMITTED TO . WHILE ON THE MEDICAL FLOOR AT OSH, THE PT A LARGE AMOUNT OF BLOOD X1. HE WAS TRANSFERRED TO ICU FOR FURTHER EVAL, AND HE UNDERWENT AN UPPER ENDOSCOPY WHICH REVEALED NO ACTIVE SOURCE OF BLEEDING EXCEPT OOZING AT THE GE JUNCTION. HE WAS TREATED WITH IV PROTONIX, REGALN AND OCTREOTIDE. HE ALSO RECEIVED SUPPORTIVE TREATMENT WITH PRBC'S AND FFP PRODUCTS. TRANSFERRED TO FOR POSSIBLE TIPS PROCEDURE.\\n\\nALLERGIES: HALDOL, DOXYCYCLINE\\n\\nCODE STATUS: FULL CODE\\n\\nACCESS: #18 PIV IN L HAND, #20 PIV RAC, #20 PIV R HAND\\n\\nNEURO: PT IS ALERT AND ORIENTED X3, CALM AND COOPERATIVE WITH CARE. PERRL 2MM/BRISK BILATERALLY. MAEX4 WITH FULL STRENGTH AND FOLLOWS COMMANDS CONSISTENTLY. DENIES ANY DISCOMFORT. AFEBRILE. NO SEIZURE ACTIVITY NOTED.\\n\\nCV: S1 S2 AS PER AUSCULTATION, HR 70'S-80'S NSR WITHOUT ECTOPY NOTED. SBP 90'S-140'S. PT WAS NOTED TO HAVE BRIEF DROP IN SBP TO 88 AT APPROX 0445 WHILE SLEEPING, HOWEVER QUICKLY INCREASED TO >90 WITHOUT INTERVENTION. DENIES CP. PALPABLE RADIAL/DP PULSES BILATERALLY. NO SIGNS OF ACTIVE BLEEDING, HCT STABLE AT 30.9.\\n\\nRESP: LUNGS ESSENTIALLY CLEAR THROUGHOUT ALL FIELDS, SPO2 > OR = 95% ON ROOM AIR. DENIES DIFFICULTY BREATHING OR SOB. NO INCREASED WOB NOTED. RR 20'S WITH REGULAR PATTERN.\\n\\nGI/GU: ABDOMEN FIRM, DISTENDED AND NONTENDER - DENIES DISCOMFORT. LARGE UMBILICAL HERNIA NOTED. BOWEL SOUNDS PRESENT X4, PASSING FLATUS. PT HAS BEEN NPO SINCE MIDNIGHT EXCEPT FOR MEDS FOR POSSIBLE EGD . NO STOOL THIS SHIFT. INDWELLING FOLEY CATHETER SECURE AND PATENT WITH APPROX 40-150ML/HOUR CLEAR AMBER URINE.\\n\\nINTEG: SKIN WARM AND DRY, COLOR NORMAL FOR RACE. NO SIGNS OF BREAKDOWN TO BACK. PT IS NOTED TO HAVE A PINK AREA ON INNER LEFT BUTTOCK WHICH APPEARS TO BE A BOIL OR CALLOUS THAT HAS POPPED. PINK AREA IS APPROX THE SIZE OF A NICKEL WITH SMALL AMT OF SANGUINOUS DRAINAGE FROM AN OPENING IN THE CENTER THAT IS ABOUT HALF THE SIZE OF AN ERASER HEAD. COVERED WITH ALLEVYN DSG. THE PT STATES HE DEVELOPED THIS FROM SITTING WHILE AT HOME.\\n\\nSOCIAL: PT LIVES ALONE. HE STATES THAT HE HAS 2 SISTERS, ONE OF WHICH IS ACTIVE IN HIS MEDICAL CARE. NO CONTACT FROM FAMILY THIS SHIFT.\\n\\nPLAN: CONTINUE ICU SUPPORTIVE CARE. MONITOR HCT EVERY 6 HOURS, NEXT DUE AT 1000. MONITOR FOR S/S OF ENCEPHALOPATHY. POSSIBLE EGD TODAY, PT HAS BEEN NPO SINCE MN EXCEPT FOR MEDS. FLUID RESTRICT ONCE ABLE TO TAKE PO'S HYPONATREMIA. ? TIPS PROCEDURE. PLEASE SEE CAREVUE FOR OBJECTIVE DATA, THA\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-04-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1412976,\n \"text\": \"NURSING ADMISSION NOTE -0700\\n(Continued)\\nNK YOU!\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-04-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1412977,\n \"text\": \"Nursing 7a-7P:\\n please see transfer note for details of admit and latest assessment.. pt tx with 1 bag plts today for plt count 38k.. repeat 50k. am hct 30.9.. repeat pending.. am NA 120.. repeat 124.. 1 L fluid restriction. per IV team ok for pt have 20g iv's for access.. team aware. no further orders at this time.\\n\"\n }\n]"}}},{"rowIdx":80,"cells":{"subject_id":{"kind":"number","value":53804,"string":"53,804"},"hadm_id":{"kind":"number","value":168109,"string":"168,109"},"target_text":{"kind":"string","value":"He was admitted to the Acute Care Surgery team with a right temporal lobe intraparenchymal hemorrhage, left distal clavicle fracture, left rib fractures , moderate left pneumothorax and spinous process fractures T3,4. he was transferred to the Trauma ICU for close monitoring and hourly neuro checks. Orthopedic and Neurosurgery were consulted and non-operative managements were recommended. He was placed in a sling for the clavicle fracture and is non weight bearing but may actively and passively have range of motion exercises. He was started on Keppra for seizure prophylaxis for a total of 7 days and will follow up in 1 month in clinic for repeat head CT. He is neurologically intact- awake, alert and oriented x3 without any observed or reported seizure activity. He was doing well on hospital day #2 and transferred to regular floor. Once transferred out of the ICU he progressed slowly primarily limited by pain and deconditioned status from being in the ICU. His pain medications were adjusted and an adequate oral pain regimen was eventually in place. He was also treated for a urinary tract infection with Cipro for 5 day course. Sensitivites were pending at time of discharge. Will plan to contact rehab facility once this data is available in the event that therapy needs to be changed. He was evaluated by Physical and Occupational therapy and is being recommended for discharge to rehab after his acute hospital stay."},"extractive_notes_summ":{"kind":"string","value":"Moderate left parietal subgaleal hematoma. Moderate left parietal subgaleal hematoma. Moderate left parietal and occipital subgaleal hematoma. Moderate left parietal and occipital subgaleal hematoma. Moderate left pneumothorax. IMPRESSION: Non-displaced left clavicle fracture, probably with some comminution. Left distal clavicle fracture, only slightly displaced. Moderate interval decrease in the left parieto-occipital subgaleal hematoma with surgical staples in place. There is a moderate left parietal (series 2, image 54)and occipital subgaleal hematoma (series 2, image 14). 2.Progression of mild pleural effusion. Progression of bilateral mild pleural effusion. There is moderate left parieto-occipital subgaleal hematoma with surgical staples in place. Left anterior fascicular block.Non-specific lateral ST-T wave abnormalities. The glenohumeral and acromioclavicular joints appear preserved. FINDINGS: The cardiac, mediastinal and hilar contours appear unchanged. There is mild atherosclerotic calcification of the aortic arch. FINDINGS: The previously described right temporal hemorrhagic contusion, appears slightly smaller in the current examination, also there has been interval decrease in the pattern of vasogenic edema in this region. FINDINGS: CT OF THE HEAD: There is acute right temporal lobe intraparenchymal hemorrhage (series 2, image 22) without significant mass effect or midline shift. Grossly unchanged fracture throughout the squamous portion of the left temporal bone, the possible small subdural hematoma in this region is not clearly identified. There is a fracture through the squamous portion of the left temporal bone with a possible tiny subdural hematoma (se 3, img 72). Fracture through the squamous portion of the left temporal bone with a possible tiny subdural hematoma (se 3, img 72). Slight lucency in the left costophrenic angle may reflect a pneumothorax. Fracture of the left distal clavicle 2. Acute right temporal lobe intraparenchymal hemorrhage. Acute right temporal lobe intraparenchymal hemorrhage. Acute right temporal lobe intraparenchymal hemorrhage. COMPARISON: Chest radiograph dated . Left subcutaneous air. Fracture through the squamous portion of the left temporal bone with a possible tiny subdural hematoma. TECHNIQUE: PA and lateral chest radiographs. The right temporal lobe intraparenchymal hemorrhage has been decreased in size, with mild decrease in the pattern of vasogenic edema. Nondisplaced spinous process fractures at T3 and T4. There is an old sternal fracture. Left ribs fractures. Subcutaneous air is noted along the left lateral chest wall. Old sternal fracture. FINDINGS: Heart appears mildly enlarged. Traumatic findings in the chest better delineated on CT. 2. There is no pericardial and only small bilateral pleural effusions are demonstrated. COMPARISON: Prior head CT dated and prior head CT dated , . The fracture of the squamous portion of the left temporal bone remains unchanged, and the possible small subdural hematoma in the region is not visible on the current examination. Non-displaced fractures of the left anterolateral #3 through 8 ribs. Axial, coronal, and sagittal reformats were acquired. Lingular lung contusions. FINDINGS: As depicted on a CT from the same day, there is a left-sided pneumothorax with subcutaneous emphysema. TECHNIQUE: Chest, AP portable supine, and pelvis AP view. Left axis deviation. Sinus rhythm. (Over) 3:58 PM CT CHEST W/CONTRAST Clip # Reason: trauma Contrast: OMNIPAQUE Amt: 75 FINAL REPORT (Cont) BONES: Left comminuted distal clavicle fracture. COMPARISON: Chest radiograph . Coronal and sagittal reformats were acquired. The airways are patent to the subsegmental level. CLINICAL INDICATION: Status post trauma, history of right temporal lobe intraparenchymal hemorrhage and small left subdural hematoma, evaluate for interval change. There are opacities in the lingula, representing contusions. Secretions are seen in the proximal right main stem bronchus (series 2, image 22). Displaced fractures of the left third through eighth ribs with moderate chest wall emphysema and a small-to-moderate pneumothorax. FINDINGS: CT OF THE CHEST: There is a small 11 x 12 mm right lower pole thyroid nodule. Spinous process fracture of #3 and 4. Cardiomediastinal contours are unremarkable. The fracture extends in the greater of the left sphenoid bone with hemorrhage in the sphenoid sinus. The fracture extends in the greater of the left sphenoid bone with hemorrhage in the sphenoid sinus. Several left-sided rib fractures are better delineated on dedicated CT of the same day. There is also subcutaneous emphysema and a non-displaced fracture involving the left mid clavicular shaft. FINDINGS: Amelioration of the bibasal opacities with residual plate-like atelectasis. There are displaced rib fractures of the left third through eighth ribs with moderate soft tissue emphysema at the left chest wall and a small-to-moderate left pneumothorax. There are bibasilar opacities, mainly within the costophrenic angles, most likely representing atelectasis. COMPARISON: Exam compared to a chest CT of . Left-sided pneumothorax with subcutaneous emphysema, associated with left-sided rib fractures, better described on earlier CT of the same day. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. There are spinous process fracture of T3 and T4. No major change from theprevious tracing. Bibasilar opacities likely representing atelectasis. The partially visualized upper abdomen demonstrates gallstones, but no evidence of acute cholecystitis. Bibasilar opacities likely represent sequela of atelectasis. No pneumothorax is appreciated. There is also patchy opacification in the right lung which may be associated with a contusion or atelectasis or both. Borderline widening at the pubic symphysis, of uncertain significance, particularly noting no evidence for fracture or sacroiliac widening. There is a slightly prominent widening at the pubic symphysis, at the upper limits of normal range, but borderline, up to 9 mm. OPINION: 1.Improvement of the bibasal opacities with residual plate-like atelectasis."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2125-08-05 00:00:00.000","description":"CT CHEST W/CONTRAST","row_id":1246421,"text":" 3:58 PM\n CT CHEST W/CONTRAST Clip # \n Reason: trauma\n Contrast: OMNIPAQUE Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man trauma pt\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SUN 4:24 PM\n 1. Fracture of the left distal clavicle\n 2. Non-displaced fractures of the left anterolateral #3 through 8 ribs.\n 3. Moderate left pneumothorax.\n 4. Spinous process fracture of #3 and 4.\n 5. Old sternal fracture.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with status post trauma.\n\n TECHNIQUE: Contiguous MDCT images through the chest were obtained after\n administration of intravenous contrast. Axial, coronal, and sagittal\n reformats were acquired.\n\n COMPARISON: Chest radiograph .\n\n FINDINGS:\n\n CT OF THE CHEST: There is a small 11 x 12 mm right lower pole thyroid nodule.\n There is no axillary, hilar, or mediastinal lymphadenopathy. There is no\n pneumomediastinum, no acute aortic syndrome including no aortic dissection, or\n aortic aneurysm. There is mild atherosclerotic calcification of the aortic\n arch. A stent is seen in the LAD.\n\n There is no pericardial and only small bilateral pleural effusions are\n demonstrated.\n\n There are displaced rib fractures of the left third through eighth ribs with\n moderate soft tissue emphysema at the left chest wall and a small-to-moderate\n left pneumothorax. No mediastinal shift. There are opacities in the lingula,\n representing contusions. Bibasilar opacities likely represent sequela of\n atelectasis.\n\n The airways are patent to the subsegmental level. Secretions are seen in the\n proximal right main stem bronchus (series 2, image 22).\n\n The partially visualized upper abdomen demonstrates gallstones, but no\n evidence of acute cholecystitis. The partially visualized liver, spleen,\n pancreas, adrenal glands, and kidneys are normal.\n\n (Over)\n\n 3:58 PM\n CT CHEST W/CONTRAST Clip # \n Reason: trauma\n Contrast: OMNIPAQUE Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONES: Left comminuted distal clavicle fracture. There are spinous process\n fracture of T3 and T4. There is an old sternal fracture. No evidence of\n thoracic vertebral body fractures.\n\n IMPRESSION:\n 1. Displaced fractures of the left third through eighth ribs with moderate\n chest wall emphysema and a small-to-moderate pneumothorax.\n 2. Lingular lung contusions.\n 3. Nondisplaced spinous process fractures at T3 and T4.\n 4. Left distal clavicle fracture, only slightly displaced.\n\n\n"},{"category":"Radiology","chartdate":"2125-08-07 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1246626,"text":" 10:33 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change in subdural hematoma and right temp\n Admitting Diagnosis: RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p trauma with h/o right temporal lobe intraparenchymal\n hemorrhage and small left subdural hematoma\n REASON FOR THIS EXAMINATION:\n eval for interval change in subdural hematoma and right temporal lobe IPH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Head CT without contrast.\n\n CLINICAL INDICATION: Status post trauma, history of right temporal lobe\n intraparenchymal hemorrhage and small left subdural hematoma, evaluate for\n interval change.\n\n COMPARISON: Prior head CT dated and prior head CT dated , .\n\n TECHNIQUE: Axial MDCT images were obtained through the head, no contrast was\n administered, the images were reviewed using soft tissue and bone window\n algorithms.\n\n FINDINGS: The previously described right temporal hemorrhagic contusion,\n appears slightly smaller in the current examination, also there has been\n interval decrease in the pattern of vasogenic edema in this region. There is\n no evidence of shifting of the normally midline structures or new areas with\n hemorrhage. Grossly unchanged fracture throughout the squamous portion of the\n left temporal bone, the possible small subdural hematoma in this region is not\n clearly identified. There is moderate left parieto-occipital subgaleal\n hematoma with surgical staples in place. The ventricles are normal in size\n and configuration for the patient's age with new areas of hemorrhage.\n Persistent mucosal thickening identified at the sphenoid sinus.\n\n IMPRESSION:\n 1. The right temporal lobe intraparenchymal hemorrhage has been decreased in\n size, with mild decrease in the pattern of vasogenic edema. There is no\n evidence of shifting of the normally midline structures.\n 2. No new areas of intracranial hemorrhage are identified. The fracture of\n the squamous portion of the left temporal bone remains unchanged, and the\n possible small subdural hematoma in the region is not visible on the current\n examination.\n 3. Moderate interval decrease in the left parieto-occipital subgaleal\n hematoma with surgical staples in place.\n\n"},{"category":"Radiology","chartdate":"2125-08-05 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1246417,"text":" 3:45 PM\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: please reread head CT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man trauma pt\n REASON FOR THIS EXAMINATION:\n please reread head CT\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SUN 6:05 PM\n 1. Acute right temporal lobe intraparenchymal hemorrhage.\n 2. Fracture through the squamous portion of the left temporal bone with a\n possible tiny subdural hematoma (se 3, img 72). The fracture extends in the\n greater of the left sphenoid bone with hemorrhage in the sphenoid sinus.\n 3. Moderate left parietal and occipital subgaleal hematoma.\n WET READ VERSION #1\n WET READ VERSION #2 JBRe SUN 4:30 PM\n 1. No acute intracranial process.\n 2. Moderate left parietal subgaleal hematoma.\n WET READ VERSION #3 JBRe SUN 5:10 PM\n 1. Acute right temporal lobe intraparenchymal hemorrhage.\n 2. Moderate left parietal subgaleal hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old with trauma.\n\n TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal\n reformats were acquired. The study was performed at an outside hospital. The\n emergency room staff requested a official second read by radiology.\n\n COMPARISON: There are no prior studies for comparison available.\n\n FINDINGS:\n\n CT OF THE HEAD: There is acute right temporal lobe intraparenchymal hemorrhage\n (series 2, image 22) without significant mass effect or midline shift.\n\n There is a fracture through the squamous portion of the left temporal bone\n with a possible tiny subdural hematoma (se 3, img 72). The fracture extends in\n the greater of the left sphenoid bone with hemorrhage in the sphenoid\n sinus. There is a moderate left parietal (series 2, image 54)and occipital\n subgaleal hematoma (series 2, image 14).\n\n The ventricles and sulci are normal in size and configuration. There is no\n hydrocephalus. The basal cisterns are patent.\n\n The maxillary sinuses, frontal sinuses, and mastoid air cells are clear.\n\n IMPRESSION:\n 1. Acute right temporal lobe intraparenchymal hemorrhage.\n 2. Fracture through the squamous portion of the left temporal bone with a\n possible tiny subdural hematoma. The fracture extends in the greater of\n (Over)\n\n 3:45 PM\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: please reread head CT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the left sphenoid bone with hemorrhage in the sphenoid sinus.\n 3. Moderate left parietal and occipital subgaleal hematoma.\n\n"},{"category":"Radiology","chartdate":"2125-08-07 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1246609,"text":" 8:51 AM\n CHEST (PA & LAT) Clip # \n Reason: L PTX\n Admitting Diagnosis: RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p bicycle accident\n REASON FOR THIS EXAMINATION:\n L PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old gentleman status post bicycle accident and left\n pneumothorax.\n\n COMPARISON: Chest radiograph dated .\n\n TECHNIQUE: PA and lateral chest radiographs.\n\n FINDINGS: Heart appears mildly enlarged. Cardiomediastinal contours are\n unremarkable. There are bibasilar opacities, mainly within the costophrenic\n angles, most likely representing atelectasis. No pneumothorax is appreciated.\n Subcutaneous air is noted along the left lateral chest wall. There are also\n multiple rib fractures on the left as previously seen.\n\n IMPRESSION:\n 1. Left-sided rib fractures with no radiographic evidence of pneumothorax.\n 2. Bibasilar opacities likely representing atelectasis.\n\n"},{"category":"Radiology","chartdate":"2125-08-05 00:00:00.000","description":"TRAUMA #2 (AP CXR & PELVIS PORT)","row_id":1246409,"text":" 3:25 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n RADIOGRAPHS OF THE CHEST AND PELVIS\n\n HISTORY: Trauma.\n\n COMPARISONS: The chest can be compared to .\n\n TECHNIQUE: Chest, AP portable supine, and pelvis AP view.\n\n FINDINGS: The cardiac, mediastinal and hilar contours appear unchanged.\n Several left-sided rib fractures are better delineated on dedicated CT of the\n same day. There is also subcutaneous emphysema and a non-displaced fracture\n involving the left mid clavicular shaft. Slight lucency in the left\n costophrenic angle may reflect a pneumothorax. There is no shift of\n mediastinal structures.\n\n Regarding the pelvis, there is no evidence for fracture, dislocation or bone\n destruction. There is a slightly prominent widening at the pubic symphysis,\n at the upper limits of normal range, but borderline, up to 9 mm.\n\n IMPRESSION:\n\n 1. Traumatic findings in the chest better delineated on CT.\n\n 2. Borderline widening at the pubic symphysis, of uncertain significance,\n particularly noting no evidence for fracture or sacroiliac widening. However,\n correlation with clinical presentation and physical findings along the pelvis\n are recommended. Finding discussed with Dr. by telephone at 11:50\n pm by telephone.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2125-08-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1246451,"text":" 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval chqange\n Admitting Diagnosis: RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with polytrauma, TBI, ptx\n REASON FOR THIS EXAMINATION:\n interval chqange\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST X-RAY\n\n INDICATION: Polytrauma, traumatic brain injury.\n\n COMPARISON: Exam compared to a chest CT of .\n\n FINDINGS: Amelioration of the bibasal opacities with residual plate-like\n atelectasis. Progression of bilateral mild pleural effusion. No\n pneumothorax. Left subcutaneous air. Left ribs fractures. The heart contour\n seems a slightly enlarged since yesterday, probably secondary to the\n technique. Mediastinal contour is normal.\n\n OPINION:\n\n 1.Improvement of the bibasal opacities with residual plate-like atelectasis.\n 2.Progression of mild pleural effusion. No pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2125-08-05 00:00:00.000","description":"L SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT","row_id":1246415,"text":" 4:36 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p trauma\n REASON FOR THIS EXAMINATION:\n trauma\n ______________________________________________________________________________\n FINAL REPORT\n RADIOGRAPHS OF THE LEFT SHOULDER\n\n HISTORY: Trauma.\n\n COMPARISONS: None.\n\n TECHNIQUE: Left shoulder, four views.\n\n FINDINGS: As depicted on a CT from the same day, there is a left-sided\n pneumothorax with subcutaneous emphysema. There is also patchy opacification\n in the right lung which may be associated with a contusion or atelectasis or\n both. Left-sided rib fractures are also better depicted on the CT. Starting\n the left shoulder, there is a fracture of the distal clavicle, but there is no\n evidence for fracture or dislocation involving the scapula or humerus. The\n glenohumeral and acromioclavicular joints appear preserved.\n\n IMPRESSION: Non-displaced left clavicle fracture, probably with some\n comminution. Left-sided pneumothorax with subcutaneous emphysema, associated\n with left-sided rib fractures, better described on earlier CT of the same day.\n\n"},{"category":"ECG","chartdate":"2125-08-05 00:00:00.000","description":"Report","row_id":228947,"text":"Sinus rhythm. Left axis deviation. Left anterior fascicular block.\nNon-specific lateral ST-T wave abnormalities. No major change from the\nprevious tracing.\n\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-08-05 00:00:00.000\",\n \"description\": \"CT CHEST W/CONTRAST\",\n \"row_id\": 1246421,\n \"text\": \" 3:58 PM\\n CT CHEST W/CONTRAST Clip # \\n Reason: trauma\\n Contrast: OMNIPAQUE Amt: 75\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man trauma pt\\n REASON FOR THIS EXAMINATION:\\n trauma\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JBRe SUN 4:24 PM\\n 1. Fracture of the left distal clavicle\\n 2. Non-displaced fractures of the left anterolateral #3 through 8 ribs.\\n 3. Moderate left pneumothorax.\\n 4. Spinous process fracture of #3 and 4.\\n 5. Old sternal fracture.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 53-year-old man with status post trauma.\\n\\n TECHNIQUE: Contiguous MDCT images through the chest were obtained after\\n administration of intravenous contrast. Axial, coronal, and sagittal\\n reformats were acquired.\\n\\n COMPARISON: Chest radiograph .\\n\\n FINDINGS:\\n\\n CT OF THE CHEST: There is a small 11 x 12 mm right lower pole thyroid nodule.\\n There is no axillary, hilar, or mediastinal lymphadenopathy. There is no\\n pneumomediastinum, no acute aortic syndrome including no aortic dissection, or\\n aortic aneurysm. There is mild atherosclerotic calcification of the aortic\\n arch. A stent is seen in the LAD.\\n\\n There is no pericardial and only small bilateral pleural effusions are\\n demonstrated.\\n\\n There are displaced rib fractures of the left third through eighth ribs with\\n moderate soft tissue emphysema at the left chest wall and a small-to-moderate\\n left pneumothorax. No mediastinal shift. There are opacities in the lingula,\\n representing contusions. Bibasilar opacities likely represent sequela of\\n atelectasis.\\n\\n The airways are patent to the subsegmental level. Secretions are seen in the\\n proximal right main stem bronchus (series 2, image 22).\\n\\n The partially visualized upper abdomen demonstrates gallstones, but no\\n evidence of acute cholecystitis. The partially visualized liver, spleen,\\n pancreas, adrenal glands, and kidneys are normal.\\n\\n (Over)\\n\\n 3:58 PM\\n CT CHEST W/CONTRAST Clip # \\n Reason: trauma\\n Contrast: OMNIPAQUE Amt: 75\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n BONES: Left comminuted distal clavicle fracture. There are spinous process\\n fracture of T3 and T4. There is an old sternal fracture. No evidence of\\n thoracic vertebral body fractures.\\n\\n IMPRESSION:\\n 1. Displaced fractures of the left third through eighth ribs with moderate\\n chest wall emphysema and a small-to-moderate pneumothorax.\\n 2. Lingular lung contusions.\\n 3. Nondisplaced spinous process fractures at T3 and T4.\\n 4. Left distal clavicle fracture, only slightly displaced.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-08-07 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1246626,\n \"text\": \" 10:33 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for interval change in subdural hematoma and right temp\\n Admitting Diagnosis: RIB FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man s/p trauma with h/o right temporal lobe intraparenchymal\\n hemorrhage and small left subdural hematoma\\n REASON FOR THIS EXAMINATION:\\n eval for interval change in subdural hematoma and right temporal lobe IPH\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Head CT without contrast.\\n\\n CLINICAL INDICATION: Status post trauma, history of right temporal lobe\\n intraparenchymal hemorrhage and small left subdural hematoma, evaluate for\\n interval change.\\n\\n COMPARISON: Prior head CT dated and prior head CT dated , .\\n\\n TECHNIQUE: Axial MDCT images were obtained through the head, no contrast was\\n administered, the images were reviewed using soft tissue and bone window\\n algorithms.\\n\\n FINDINGS: The previously described right temporal hemorrhagic contusion,\\n appears slightly smaller in the current examination, also there has been\\n interval decrease in the pattern of vasogenic edema in this region. There is\\n no evidence of shifting of the normally midline structures or new areas with\\n hemorrhage. Grossly unchanged fracture throughout the squamous portion of the\\n left temporal bone, the possible small subdural hematoma in this region is not\\n clearly identified. There is moderate left parieto-occipital subgaleal\\n hematoma with surgical staples in place. The ventricles are normal in size\\n and configuration for the patient's age with new areas of hemorrhage.\\n Persistent mucosal thickening identified at the sphenoid sinus.\\n\\n IMPRESSION:\\n 1. The right temporal lobe intraparenchymal hemorrhage has been decreased in\\n size, with mild decrease in the pattern of vasogenic edema. There is no\\n evidence of shifting of the normally midline structures.\\n 2. No new areas of intracranial hemorrhage are identified. The fracture of\\n the squamous portion of the left temporal bone remains unchanged, and the\\n possible small subdural hematoma in the region is not visible on the current\\n examination.\\n 3. Moderate interval decrease in the left parieto-occipital subgaleal\\n hematoma with surgical staples in place.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-08-05 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1246417,\n \"text\": \" 3:45 PM\\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \\n Reason: please reread head CT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man trauma pt\\n REASON FOR THIS EXAMINATION:\\n please reread head CT\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JBRe SUN 6:05 PM\\n 1. Acute right temporal lobe intraparenchymal hemorrhage.\\n 2. Fracture through the squamous portion of the left temporal bone with a\\n possible tiny subdural hematoma (se 3, img 72). The fracture extends in the\\n greater of the left sphenoid bone with hemorrhage in the sphenoid sinus.\\n 3. Moderate left parietal and occipital subgaleal hematoma.\\n WET READ VERSION #1\\n WET READ VERSION #2 JBRe SUN 4:30 PM\\n 1. No acute intracranial process.\\n 2. Moderate left parietal subgaleal hematoma.\\n WET READ VERSION #3 JBRe SUN 5:10 PM\\n 1. Acute right temporal lobe intraparenchymal hemorrhage.\\n 2. Moderate left parietal subgaleal hematoma.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 53-year-old with trauma.\\n\\n TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal\\n reformats were acquired. The study was performed at an outside hospital. The\\n emergency room staff requested a official second read by radiology.\\n\\n COMPARISON: There are no prior studies for comparison available.\\n\\n FINDINGS:\\n\\n CT OF THE HEAD: There is acute right temporal lobe intraparenchymal hemorrhage\\n (series 2, image 22) without significant mass effect or midline shift.\\n\\n There is a fracture through the squamous portion of the left temporal bone\\n with a possible tiny subdural hematoma (se 3, img 72). The fracture extends in\\n the greater of the left sphenoid bone with hemorrhage in the sphenoid\\n sinus. There is a moderate left parietal (series 2, image 54)and occipital\\n subgaleal hematoma (series 2, image 14).\\n\\n The ventricles and sulci are normal in size and configuration. There is no\\n hydrocephalus. The basal cisterns are patent.\\n\\n The maxillary sinuses, frontal sinuses, and mastoid air cells are clear.\\n\\n IMPRESSION:\\n 1. Acute right temporal lobe intraparenchymal hemorrhage.\\n 2. Fracture through the squamous portion of the left temporal bone with a\\n possible tiny subdural hematoma. The fracture extends in the greater of\\n (Over)\\n\\n 3:45 PM\\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \\n Reason: please reread head CT\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n the left sphenoid bone with hemorrhage in the sphenoid sinus.\\n 3. Moderate left parietal and occipital subgaleal hematoma.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-08-07 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1246609,\n \"text\": \" 8:51 AM\\n CHEST (PA & LAT) Clip # \\n Reason: L PTX\\n Admitting Diagnosis: RIB FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man s/p bicycle accident\\n REASON FOR THIS EXAMINATION:\\n L PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 53-year-old gentleman status post bicycle accident and left\\n pneumothorax.\\n\\n COMPARISON: Chest radiograph dated .\\n\\n TECHNIQUE: PA and lateral chest radiographs.\\n\\n FINDINGS: Heart appears mildly enlarged. Cardiomediastinal contours are\\n unremarkable. There are bibasilar opacities, mainly within the costophrenic\\n angles, most likely representing atelectasis. No pneumothorax is appreciated.\\n Subcutaneous air is noted along the left lateral chest wall. There are also\\n multiple rib fractures on the left as previously seen.\\n\\n IMPRESSION:\\n 1. Left-sided rib fractures with no radiographic evidence of pneumothorax.\\n 2. Bibasilar opacities likely representing atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-08-05 00:00:00.000\",\n \"description\": \"TRAUMA #2 (AP CXR & PELVIS PORT)\",\n \"row_id\": 1246409,\n \"text\": \" 3:25 PM\\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \\n Reason: TRAUMA\\n ______________________________________________________________________________\\n FINAL REPORT\\n RADIOGRAPHS OF THE CHEST AND PELVIS\\n\\n HISTORY: Trauma.\\n\\n COMPARISONS: The chest can be compared to .\\n\\n TECHNIQUE: Chest, AP portable supine, and pelvis AP view.\\n\\n FINDINGS: The cardiac, mediastinal and hilar contours appear unchanged.\\n Several left-sided rib fractures are better delineated on dedicated CT of the\\n same day. There is also subcutaneous emphysema and a non-displaced fracture\\n involving the left mid clavicular shaft. Slight lucency in the left\\n costophrenic angle may reflect a pneumothorax. There is no shift of\\n mediastinal structures.\\n\\n Regarding the pelvis, there is no evidence for fracture, dislocation or bone\\n destruction. There is a slightly prominent widening at the pubic symphysis,\\n at the upper limits of normal range, but borderline, up to 9 mm.\\n\\n IMPRESSION:\\n\\n 1. Traumatic findings in the chest better delineated on CT.\\n\\n 2. Borderline widening at the pubic symphysis, of uncertain significance,\\n particularly noting no evidence for fracture or sacroiliac widening. However,\\n correlation with clinical presentation and physical findings along the pelvis\\n are recommended. Finding discussed with Dr. by telephone at 11:50\\n pm by telephone.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-08-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1246451,\n \"text\": \" 5:03 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval chqange\\n Admitting Diagnosis: RIB FRACTURES\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man with polytrauma, TBI, ptx\\n REASON FOR THIS EXAMINATION:\\n interval chqange\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST X-RAY\\n\\n INDICATION: Polytrauma, traumatic brain injury.\\n\\n COMPARISON: Exam compared to a chest CT of .\\n\\n FINDINGS: Amelioration of the bibasal opacities with residual plate-like\\n atelectasis. Progression of bilateral mild pleural effusion. No\\n pneumothorax. Left subcutaneous air. Left ribs fractures. The heart contour\\n seems a slightly enlarged since yesterday, probably secondary to the\\n technique. Mediastinal contour is normal.\\n\\n OPINION:\\n\\n 1.Improvement of the bibasal opacities with residual plate-like atelectasis.\\n 2.Progression of mild pleural effusion. No pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2125-08-05 00:00:00.000\",\n \"description\": \"L SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT\",\n \"row_id\": 1246415,\n \"text\": \" 4:36 PM\\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT Clip # \\n Reason: trauma\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man s/p trauma\\n REASON FOR THIS EXAMINATION:\\n trauma\\n ______________________________________________________________________________\\n FINAL REPORT\\n RADIOGRAPHS OF THE LEFT SHOULDER\\n\\n HISTORY: Trauma.\\n\\n COMPARISONS: None.\\n\\n TECHNIQUE: Left shoulder, four views.\\n\\n FINDINGS: As depicted on a CT from the same day, there is a left-sided\\n pneumothorax with subcutaneous emphysema. There is also patchy opacification\\n in the right lung which may be associated with a contusion or atelectasis or\\n both. Left-sided rib fractures are also better depicted on the CT. Starting\\n the left shoulder, there is a fracture of the distal clavicle, but there is no\\n evidence for fracture or dislocation involving the scapula or humerus. The\\n glenohumeral and acromioclavicular joints appear preserved.\\n\\n IMPRESSION: Non-displaced left clavicle fracture, probably with some\\n comminution. Left-sided pneumothorax with subcutaneous emphysema, associated\\n with left-sided rib fractures, better described on earlier CT of the same day.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2125-08-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 228947,\n \"text\": \"Sinus rhythm. Left axis deviation. Left anterior fascicular block.\\nNon-specific lateral ST-T wave abnormalities. No major change from the\\nprevious tracing.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":81,"cells":{"subject_id":{"kind":"number","value":52978,"string":"52,978"},"hadm_id":{"kind":"number","value":129936,"string":"129,936"},"target_text":{"kind":"string","value":"63M with systolic and diastolic CHF with dilated CMP and recent RHC consistent with cardiogenic shock who presents from home for inotrope initiation and diuresis. # Acute on chronic systolic and diastolic CHF with dilated CMP (EF <20%)/PUMP: No clear precipitant for his worsening heart failure, he did not report symptoms of ischemia, infection and denies dietary indiscretion or medication non-compliance. Appeared volume overloaded on exam with crackles and ascites. CI was 1.3 on recent RHC with mean PCWP of 25. The patient was started on a lasix drip and milrinone infusion for inotropic support. Pt's BP tolerated milrinone well with SBPs in 90s-100s. On , pt underwent right heart catheterization with PA cath placement which showed initial numbers: CI 2.92, demonstarting improved hemodynamics on milrinone. The patient spiked a temp to 101 on and therefore the PA catheter was pulled and cultures sent (see below). On lasix gtt was stopped and patient transitioned to PO torsemide. Initially given 60mg torsemide. Patient weaned from milrinone on and isordil and hydralazine were started for afterload reduction. Torsemide increased to 80 mg on . Once patient appeared euvolemic torsemide was decreased to daily and dose titrated to maintain euvolemia. On metoprolol was restarted. Physical therapy evaluated patient and determined ok to return home with walker. He was discharged with a dry weight of 161.5 lbs and on the following diuretic regimen: torsemide 60 mg daily."},"extractive_notes_summ":{"kind":"string","value":"Atrial tachycardia and biventricular pacing, similar to that recordedon , without diagnostic interim change.TRACING #2 Atrial tachycardia and biventricular pacing similar to that recordedon .TRACING #1 Compared to the previous tracingof pseudofusion beats are not seen on the current tracing. Unchanged evidence of mild pulmonary edema. Unchanged size of the cardiac silhouette. Cardiomegaly is severe, unchanged. Left pectoral pacemaker, no pleural effusions. There is unchanged appearance of the pacemaker leads. There is interval development of interstitial pulmonary edema. FINDINGS: As compared to the previous radiograph, the patient has received a new Swan-Ganz catheter via a right internal jugular vein approach. Portable AP radiograph of the chest was reviewed in comparison to . Sinus rhythm with biventricular pacing. Atrialtachycardia is not clearly seen on the current tracing, although there is somebaseline artifact which makes interpretation difficult. No pneumothorax. There is improved ventilation of the lung parenchyma in both the retrocardiac lung areas and the right lung bases. More pronounced bibasal opacities might be concerning for interval development of infectious process. 10:56 AM CHEST (PORTABLE AP) Clip # Reason: PTX, new consolidation, edema Admitting Diagnosis: HEART FAILURE MEDICAL CONDITION: 63 year old man with CHF, swan, increasing catheter REASON FOR THIS EXAMINATION: PTX, new consolidation, edema FINAL REPORT CHEST RADIOGRAPH INDICATION: Chronic heart failure, Swan-Ganz catheter, evaluation. 10:02 PM CHEST (PORTABLE AP) Clip # Reason: Evaluate for edema or effusions Admitting Diagnosis: HEART FAILURE MEDICAL CONDITION: 63 year old man with systolic and diastolic heart failure, presenting with fatigue and lethargy REASON FOR THIS EXAMINATION: Evaluate for edema or effusions FINAL REPORT REASON FOR EXAMINATION: Systolic and diastolic heart failure presenting with fatigue and lethargy."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2196-09-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1256240,"text":" 10:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for edema or effusions\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with systolic and diastolic heart failure, presenting with\n fatigue and lethargy\n REASON FOR THIS EXAMINATION:\n Evaluate for edema or effusions\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Systolic and diastolic heart failure presenting with\n fatigue and lethargy.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n Cardiomegaly is severe, unchanged. There is unchanged appearance of the\n pacemaker leads. There is interval development of interstitial pulmonary\n edema. More pronounced bibasal opacities might be concerning for interval\n development of infectious process.\n\n\n"},{"category":"Radiology","chartdate":"2196-09-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1256390,"text":" 10:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX, new consolidation, edema\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with CHF, swan, increasing catheter\n REASON FOR THIS EXAMINATION:\n PTX, new consolidation, edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Chronic heart failure, Swan-Ganz catheter, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n new Swan-Ganz catheter via a right internal jugular vein approach. There is\n improved ventilation of the lung parenchyma in both the retrocardiac lung\n areas and the right lung bases. Unchanged size of the cardiac silhouette.\n Unchanged evidence of mild pulmonary edema. Left pectoral pacemaker, no\n pleural effusions. No pneumothorax.\n\n\n"},{"category":"ECG","chartdate":"2196-09-25 00:00:00.000","description":"Report","row_id":297220,"text":"Atrial tachycardia and biventricular pacing, similar to that recorded\non , without diagnostic interim change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2196-09-24 00:00:00.000","description":"Report","row_id":297221,"text":"Atrial tachycardia and biventricular pacing similar to that recorded\non .\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2196-09-21 00:00:00.000","description":"Report","row_id":297222,"text":"Sinus rhythm with biventricular pacing. Compared to the previous tracing\nof pseudofusion beats are not seen on the current tracing. Atrial\ntachycardia is not clearly seen on the current tracing, although there is some\nbaseline artifact which makes interpretation difficult.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-09-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1256240,\n \"text\": \" 10:02 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evaluate for edema or effusions\\n Admitting Diagnosis: HEART FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with systolic and diastolic heart failure, presenting with\\n fatigue and lethargy\\n REASON FOR THIS EXAMINATION:\\n Evaluate for edema or effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Systolic and diastolic heart failure presenting with\\n fatigue and lethargy.\\n\\n Portable AP radiograph of the chest was reviewed in comparison to .\\n\\n Cardiomegaly is severe, unchanged. There is unchanged appearance of the\\n pacemaker leads. There is interval development of interstitial pulmonary\\n edema. More pronounced bibasal opacities might be concerning for interval\\n development of infectious process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-09-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1256390,\n \"text\": \" 10:56 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: PTX, new consolidation, edema\\n Admitting Diagnosis: HEART FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with CHF, swan, increasing catheter\\n REASON FOR THIS EXAMINATION:\\n PTX, new consolidation, edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Chronic heart failure, Swan-Ganz catheter, evaluation.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, the patient has received a\\n new Swan-Ganz catheter via a right internal jugular vein approach. There is\\n improved ventilation of the lung parenchyma in both the retrocardiac lung\\n areas and the right lung bases. Unchanged size of the cardiac silhouette.\\n Unchanged evidence of mild pulmonary edema. Left pectoral pacemaker, no\\n pleural effusions. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2196-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 297220,\n \"text\": \"Atrial tachycardia and biventricular pacing, similar to that recorded\\non , without diagnostic interim change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2196-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 297221,\n \"text\": \"Atrial tachycardia and biventricular pacing similar to that recorded\\non .\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2196-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 297222,\n \"text\": \"Sinus rhythm with biventricular pacing. Compared to the previous tracing\\nof pseudofusion beats are not seen on the current tracing. Atrial\\ntachycardia is not clearly seen on the current tracing, although there is some\\nbaseline artifact which makes interpretation difficult.\\n\\n\"\n }\n]"}}},{"rowIdx":82,"cells":{"subject_id":{"kind":"number","value":97181,"string":"97,181"},"hadm_id":{"kind":"number","value":147084,"string":"147,084"},"target_text":{"kind":"string","value":"72 yo female with a PMH significant for ESRD on HD, CAD, CHF with EF 20%, and DM type II admitted with fever, MS change, hypoxia, and AVF failure. . 1) Fever: Had temperature upon arrival to , which resolved within 24 hours. Placed on vancomycin, zosyn for coverage for hospital acquired PNA and left basilar opacity was seen on CXR, althought it was unclear if this was truly a new opacity vs. secondary to pulmonary edema. Bld cxs with no growth. Initial urine cx with 1000 GPC but then subsequent urine cx no growth. Urinary legionella antigen negative. Unable to obtain sputum cultures. There was also initial concern for meningitis; however, the family declined a LP and the pt's mental status did improve off of meningtic doses of abxs. She was then transferred to the medical floor where she remained afebrile. . 2) AMS: MS change improved within 24 hrs of admission and AAO X 2 upon transfer to floor. Initial w/u with NCHCT negative, less likely meningitis/encephalitis given MS improvement on non-meningtis abx coverage as above. However, within 2 hrs of initial medical floor evaluation, pt became obtunded to sternal rub. FS 180s, EKG without ischemic changes, attempted ABG X 3 without success in L wrist. VSS, AF throughout. Stat NCHCT without acute change. Did notice new neck stiffness on exam, and t here was a question of encephalitis/meningitis but it was felt to be unusual to develop meningitis in hospital. Pt's MS eventually improved within 4 hours. Neurology was consulted for question of non-convulsive status epilepticus and EEG obtained that showed no epileptiform waveforms but did reveal diffuse slowing suggestive of encephalopathy from metabolic causes. Another LP was offered to the family, who again declined. Pt was started on ceftriaxone and acylovir in addition to pre-existing vancomycin for meningitic/HSV encephalitis coverage. A MRI head revealed irregularity of the MCA branch vessels that can be suggestive of small vessel disease, meningitis, or vasculitis. The pt's mental status continued to remain poor, and after d/w the pt's PCP, confirmed that pt has had prior dx of Alzheimer's, and the family, it was decided to make the pt comfort measures. Abxs were discontinued, procedures should be avoided with the exception of hemodialysis. . 3) ESRD/clotted AVF: Underwent placement of R temporary femoral HD line for HD access in setting of clotted R AVF upon admission. The patient underwent AVF thrombectomy by transplant surgery on ; however, revision failed and the pt required placement of a tunneled L IJ HD catheter by IR on . The family is in agreement to continue HD for now in spite of being comfort measures; however, did agree to not place any further lines for HD access should her LIJ tunneled catheter fail. The family was made aware of the risks of infection with a tunneled catheter. . 4) CAD: Continued digoxin, ASA, plavix. . 5) Systolic CHF: Chronic. Does have pulm edema on CXR, likely underduiresis as pt unable to be dialyzed upon presentation. O2 sats now improved after HD. Pt was restarted on beta-blocker and ACEI upon transfer out of the ICU. . 6) DM type II: Continued ISS, FS qid. . 7) Transaminitis: Patient with elevated AST of unknown etiology. Appears as if patient has had elevated transaminases since 3/. Possibly med effect (i.e statin) but degree of transaminitis not high enough to hold statin in pt with known DM II and CAD. . 8) Gout: Continued allopurinol. . 9) Psych: Continued wellbutrin and prozac. . 10) FEN: Underwent S&S eval who cleared pt for ground solids, nectar thickened liquids with 1:1 supervision with meals. Pt has poor po intake, will need to encourage po intake. Given comfort measures, would be ok to offer pt thin liquids and solid foods. . 11) Code: DNR/DNI, comfort measures. The patient was at hemodialysis on the final hospital day prior to going back to NH with hospice care when she was noted to be hypotensive in the 80-90s after have 2.5 L UF taken off. Given 1 L IVF bolus which then was followed by report of respiratory distress from HD unit. Report of pt then becoming increasing obtunded, and then expired. Family and PCP notified, family declined autopsy."},"extractive_notes_summ":{"kind":"string","value":"# PPx: Heparin sq, famotidine . # PPx: Heparin sq, famotidine . # PPx: Heparin sq, famotidine . # PPx: Heparin sq, famotidine . # PPx: Heparin sq, famotidine . Temporary R femoral HD line placed. # Psych: Continue wellbutrin and prozac. # Psych: Continue wellbutrin and prozac. # Psych: Continue wellbutrin and prozac. # Dispo: ICU level of care for now. # Dispo: ICU level of care for now. # Dispo: ICU level of care for now. # Dispo: ICU level of care for now. # CAD: Continue digoxin, ASA, plavix. # CAD: Continue digoxin, ASA, plavix. # CAD: Continue digoxin, ASA, plavix. # CAD: Continue digoxin, ASA, plavix. # CAD: Continue digoxin, ASA, plavix. # Code: DNR/DNI (confirmed with f . Pt continues on vanc per HD protocol and has been started on zosyn. Pt continues on vanc per HD protocol and has been started on zosyn. Pt continues on vanc per HD protocol and has been started on zosyn. Pt continues on vanc per HD protocol and has been started on zosyn. # Gout: Continue allopurinol . # Gout: Continue allopurinol . # Gout: Continue allopurinol . # Gout: Continue allopurinol . # Gout: Continue allopurinol . Plan to unclot fistula and HD today. Plan: Plan HD once fistula unclotted or adequate access obtained. Plan: Plan HD once fistula unclotted or adequate access obtained. Episode of emesis at HD, ?aspiration. Femoral line inserted for HD. Response: Renal c/s and intervention pnd. # Transaminitis: Patient with elevated AST of unknown etiology. # Transaminitis: Patient with elevated AST of unknown etiology. # Transaminitis: Patient with elevated AST of unknown etiology. # Transaminitis: Patient with elevated AST of unknown etiology. # ESRD: Patient on MWF HD. # ESRD: Patient on MWF HD. # ESRD: Patient on MWF HD. # ESRD: Patient on MWF HD. # ESRD: Patient on MWF HD. Plan: Sputum cx to be sent (imduced), F/U on cx results, de clot the fistula in Rt upper extremity and ? Action: temp and hemodynamic status. Action: temp and hemodynamic status. Action: temp and hemodynamic status. Action: temp and hemodynamic status. Depression: Continue prozac/welbutrin. # Code: DNR/DNI (confirmed with family including HCP) . # Code: DNR/DNI (confirmed with family including HCP) . # Code: DNR/DNI (confirmed with family including HCP) . # Code: DNR/DNI (confirmed with family including HCP) . She was treated with vancomycin Zosyn, received 1L IVF, and was transferred to the for further management. She was treated with vancomycin Zosyn, received 1L IVF, and was transferred to the for further management. Unchanged marked enlargement of the ventricles since , out of proportion to the enlargement of the sulci, which may be related to central atrophy or normal-pressure hydrocephalus. REASON FOR THIS EXAMINATION: r/o encephalitis, ischemia No contraindications for IV contrast PFI REPORT Irregularity of left greater than right MCA branch vessels. # Dispo: ICU level of care for now. Rule out encephalitis or ischemia. Slight interval decrease in possible exophytic right-sided fibroid. # Transaminitis: Patient with elevated AST of unknown etiology. Increased interstitial markings are demonstrated bilaterally, compatible with minimal interstitial edema. REASON FOR THIS EXAMINATION: r/o encephalitis, ischemia No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl MON 3:14 PM Irregularity of left greater than right MCA branch vessels. Restart in AM if hemodynamically stable. The wire was subsequently exchanged for a 0.035 wire, the tip of which was positioned in the inferior vena cava under fluoroscopic guidance. Attenuation of the lenses bilaterally is consistent with prior cataract surgery. # PPx: Heparin sq, famotidine . COMPARISON: Head CTs, , and . Sinus rhythmLeft axis deviationLeft bundle branch blockTall T waves - consider acute ischemia or hyperkalemiaSince previous tracing of , ST-T wave abnormalities more marked # Psych: Continue wellbutrin and prozac. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST ONLY: Limited evaluation of lung bases displays scattered regions of ground-glass opacity noted within the right middle lobe and lower lobes bilaterally as well as more streaky linear opacities at the left base and a small simple right pleural effusion with adjacent compression atelectasis. Marked enlargement of the ventricles, out of proportion to the enlargement of the sulci, is unchanged since . Incidentally noted is a fat- containing right inguinal hernia. Intraventricular conduction delay of left bundle-branch blocktype. Right basal ganglia calcifications again noted. New left basilar opacity concerning for pneumonia or aspiration. A new left basilar opacity is present, which could represent aspiration or infection. There is calcification of the aortic knob. Please place tunneled hemodialysis catheter. Ultrasound images before and after venopuncture were obtained. REASON FOR THIS EXAMINATION: needs HD tunneled catheter. Extensive periventricular white matter hypoattenuating changes, most marked within the right centrum semiovale is stable as is central atrophy. Sterile dressing was applied. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST ONLY: Air is noted within a Foley- containing urinary bladder. mild free fluid in pelvis, stable to slight decrease in size to presumed fibroid. If any, bilateral small pleural effusions are unchanged, greater on the left side. There are changes consistent with mild small vessel occlusive disease. # CAD: Continue digoxin, ASA, plavix. # ESRD: Patient on MWF HD. Diffuse periventricular white matter hypodensities are consistent with a small vessel disease, unchanged."},"n_notes":{"kind":"number","value":30,"string":"30"},"notes":{"kind":"list like","value":[{"category":"Physician ","chartdate":"2171-09-28 00:00:00.000","description":"Physician Attending Admission Note - MICU","row_id":538177,"text":"Chief Complaint: hypoxia, fever\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 72 y.o. nursing home resident seen in dialysis today, noted to had\n altered mental status, temp taken and reportedly was 105, noted to have\n saturation 84%. Episode of emesis at HD, ?aspiration. Called EMTs and\n brought to ED. Noted to be tachypneic at 42, NRB-100% sat. CXR c/w\n LLL pneumonia. Daughters had reported that she often coughs when being\n fed/eating. Vanco/pip/tazo in ED.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: nonverbal at baseline\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n senekot\n compazine\n digoxin\n lisinopril\n welbutrin\n prozac\n ativan prior to dialysis\n simvastatin\n nephrocaps\n allopurinol\n plavix\n humara\n metoprolol\n zantac\n Past medical history:\n Family history:\n Social History:\n CAD\n CHF, EF = 20%, TR/MR\n CRF on hemodialysis\n UTIs\n Gout\n Depression\n Anemia\n Hyperlipidemia\n noncontributory\n Occupation:\n Drugs: none\n Tobacco: quit in ; pack years\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Nutritional Support: NPO\n Gastrointestinal: Emesis\n Heme / Lymph: Anemia\n Neurologic: nonverbal\n Pain: No pain / appears comfortable\n Flowsheet Data as of 01:26 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (104.3\n Tcurrent: 37\nC (98.6\n HR: 74 (74 - 74) bpm\n BP: 156/46(71) {156/46(71) - 156/46(71)} mmHg\n RR: 42 (24 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 10 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -10 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), S3\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n left base, Diminished: )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 241\n 38.9\n 186\n 4.2\n 36\n 31\n 90\n 4.2\n 136\n 10.6\n [image002.jpg]\n Other labs: ALT / AST:/46, Alk Phos / T Bili:/0.9,\n Differential-Neuts:87.4, Lymph:8, Mono:3.2, Eos:1, Albumin:3.6,\n Ca++:10.5, Mg++:3.1, PO4:2.5\n Imaging: CXR: enlarged cardiac silohuette, retrocardiac density, some\n silohuetting of left hemidiphragm. No CHF\n ECG: SR @89, LBBB\n Assessment and Plan\n 1. Hypoxia, fever and question of witnessed aspiration. be\n chronically aspirating as fever this high unlikely due to a chemical\n pneumonitis. Likely superimposed infection, nosocomial organisms given\n resident of nursing home. Reasonable to continue current abx.\n Oxygenating fine on 4L NC in MICU.\n 2. CAD/CHF: No evident CHF/edema. Check cardiac enzymes albeit\n suspicion for ischemic event is low.\n 3. CRF: No evidence of volume overload, electrolytes fine. Dose\n medications accordingly.\n 4. Depression: Continue prozac/welbutrin. Follow clinically.\n 5. NPO. Needs speech and swallow evaluation given aspiration risk.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 12:09 AM\n 20 Gauge - 12:10 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n Total time spent: 50 minutes\n"},{"category":"Physician ","chartdate":"2171-09-28 00:00:00.000","description":"Physician Resident Admission Note","row_id":538178,"text":"Chief Complaint: Mental status change, fever, and hypoxia\n HPI:\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\n to have a LLL infiltrate concerning for left basilar pneumonia versus\n aspiration. She was treated with vancomycin and pip/tazo, received 1L\n IVF, and was transferred to the .\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -CAD, s/p \"silent MI\" per patient\n -CHF, systolic dysfunction with EF 20%\n -3+ mitral regurgitation, 3+ TR\n -DM, type 2\n -ESRD on HD\n -Gout\n -Depression\n -GERD\n -Rheumatoid arthritis\n -Anemia\n -Hypercholesterolemia\n Multiple family members with DM II, otherwise non-contributory.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives at nursing home. Has 6 children that live locally. Quit\n smoking in the ; previously smoked approx 5cigs/day x30\n years. Rare EtOH.\n Review of systems:\n Flowsheet Data as of 01:39 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 74 (74 - 74) bpm\n BP: 156/46(71) {156/46(71) - 156/46(71)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 100%\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 10 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -10 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n Gen: Opens eyes to stimuli, unable to follow commands\n HEENT: Perrl, MM dry, neck supple\n Pulm: Bibasilar rales\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\n Abd: S/NT/ND, +bs\n Ext: 2+ dp b/l, trace edema. Right AVF without signs of erythema\n Neuro: Patient non-verbal\n Labs / Radiology\n 241\n 12.2\n 186\n 4.2\n 36\n 31\n 90\n 4.2\n 136\n 38.9\n 10.6\n [image002.jpg]\n Imaging: CXR: 1. Cardiomegaly with mild pulmonary edema.\n 2. New left basilar opacity concerning for pneumonia or aspiration.\n .\n CTH: No acute intracranial pathology. MRI more sensitive for ischemia.\n .\n CTAP: 1. Slightly limited examination due to patient positioning and\n lack of oral contrast. No intra-abdominal source for infection\n identified.\n 2. Patchy right middle and lower lobe opacities, some which are clearly\n compression atelectasis and others of which are suspicious for regions\n of pneumonia or aspiration. Small right effusion.\n 3. Extensive calcified atherosclerotic vascular disease.\n 4. Slight interval decrease in possible exophytic right-sided fibroid.\n Please note it is atypical for the fibroid to not have involuted more\n in a patient of this age. If alteration in care will occur, can\n consider further evaluation with a dedicated pelvic ultrasound and/or\n MRI as no dedicated pelvic imaging of this lesion is noted at .\n Microbiology: Blood cultures - pending\n Urine cultures - pending\n ECG: NSR, old LBBB,interventricular conduction delay\n Assessment and Plan\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\n hypoxia.\n .\n # Fever, mental status change: Patient with acute mental status change\n and fever. Patient was reported to have been hypoxic at outpatient HD\n with vomiting, and has history per family of coughing while eating.\n Given degree of fever, this is unlikely to be a chemical pneumonitis\n and more likely to represent a HA-pneumonia. She also has a urinalysis\n with significant pyuria although with 3-5 epi, with recent admission\n for UTI (urine cultures negative).\n - Continue vanco and pip/tazo for HA-pneumonia and UTI\n - Follow urine and blood cultures\n - Sputum cultures\n - Legionella urinary antigen\n - Wean supplemental O2\n .\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\n secondary to fever, mental status change, and clotted AVF. Discussed\n with renal fellow, and plan to dialysize tomorrow.\n - Renally dose all meds\n .\n # CAD: Continue digoxin, ASA, plavix.\n .\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\n .\n # DM type II: RISS\n .\n # Gout: Continue allopurinol\n .\n # Psych: Continue\n .\n # FEN: NPO, speech and swallow consult. Replete as necessary.\n .\n # PPx: Heparin sq, famotidine\n .\n # Code: DNR/DNI (confirmed with f\n .\n # Lines: PIV, FC\n .\n # Dispo: ICU level of care for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:09 AM\n 20 Gauge - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Nursing","chartdate":"2171-09-28 00:00:00.000","description":"Nursing Progress Note","row_id":538179,"text":"Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\n to have a LLL infiltrate concerning for left basilar pneumonia versus\n aspiration. She was treated with vancomycin Zosyn, received 1L IVF,\n and was transferred to the for further management.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2171-09-28 00:00:00.000","description":"Nursing Progress Note","row_id":538249,"text":"Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\n was found to have a LLL infiltrate concerning for left basilar\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\n received 1L IVF, and was transferred to the for further\n management.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt was febrile in ED, thought to be having PNA or UTI, in ICU afebrile.\n Action:\n 2 sets of bld cx sent in ED. In ICU Given Zosyn one dose and started on\n Zosyn and vancomycin. Breathing regularly on Oe NC 5 LPM (NRB D/Ced\n upon arrival to ICU).\n Response:\n Afebrile, alert, opened eyes first to stimuli then spontaneously, not\n follow commands.\n Plan:\n Sputum cx to be sent (imduced), F/U on cx results, de clot the fistula\n in Rt upper extremity and ? HD today, consult renal fellow, contact\n family (daughters) prior to HD initiation, wean O2 as tolerated..\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt in ESRD on HD MWF, anuric.\n Action:\n Failed to be dialyzed yesterday due to clotting of Fistula.\n Response:\n BUN/Cr 40/4.2, U/O 25 cc/shift.\n Plan:\n For HD today after consulting renal fellow to declot fistula, monitor\n lytes and seria cardiac enzymes.l Monitor FS and insulin per sliding\n scale.\n"},{"category":"Nursing","chartdate":"2171-09-28 00:00:00.000","description":"Nursing Progress Note","row_id":538220,"text":"Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\n to have a LLL infiltrate concerning for left basilar pneumonia versus\n aspiration. She was treated with vancomycin Zosyn, received 1L IVF,\n and was transferred to the for further management.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt was febrile in ED, thought to be having PNA or UTI, in ICU afebrile.\n Action:\n 2 sets of bld cx sent in ED. In ICU Given Zosyn one dose and started on\n Zosyn and vancomycin. Breathing regularly on Oe NC 5 LPM (NRB D/Ced\n upon arrival to ICU).\n Response:\n Afebrile, alert, opened eyes first to stimuli then spontaneously, not\n following commands.\n Plan:\n sputum cx and urine cx to be sent, F/U on cx results, de clot the\n fistula in Rt upper extremity and ? HD today, consult renal fellow,\n contact family (daughters) prior to HD initiation, wean O2 as\n tolerated..\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt in ESRD on HD MWF, anuric.\n Action:\n Failed to be dialyzed yesterday due to clotting of Fistula.\n Response:\n U/O 10-15 cc/shift.\n Plan:\n For HD today after consulting renal fellow to declot fistula, monitor\n lytes and seria cardiac enzymes.l\n"},{"category":"Nursing","chartdate":"2171-09-28 00:00:00.000","description":"Nursing Progress Note","row_id":538342,"text":"Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\n was found to have a LLL infiltrate concerning for left basilar\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\n received 1L IVF, and was transferred to the for further\n management.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T-max 105 at HD, 104.8 in EW. Pt w/ recent UTI as above. Pt afebrile\n over noc s/p abx and Tylenol as above. Pt aphasic, though alert and\n follows simple commands at baseline; although pt unresponsive on\n arrival to EW. Pt w/ frequent coughing during meals at NH per report as\n above. Pt also hypoxic w/ SpO2 84% on RA requiring NRB in EW.\n Action:\n temp and hemodynamic status. MS. \n as ordered. Pt continues on vanc per HD protocol and has been started\n on zosyn. Blood and urine cx pnd (U/A + for UTI). Pt NPO w/\n speech/swallow eval pnd. FiO2 weaned to NC on arrival to .\n respiratory status.\n Response:\n Pt remains afebrile. BP remains stable\n see flowsheet. Pt now\n arousable to voice/stimuli, MS improving t/o shift. Pt now following\n commands, mouthing words and occasionally speaking. Pt\ns daughters have\n been in to visit. Pt requesting to eat, team in to discuss w/ pt and\n family, including high risk for aspiration; however pt wishes to be\n able to eat prior to speech/swallow eval., and daughters agree. Pt\n ordered for ground solids, nectar thick liquids. WBC 9.6 down from 10.6\n on admit. SpO2 remains >95% on O2 5L via NC. BBS CTA.\n Plan:\n Continue to monitor temp, hemodynamic status and resp. status. Follow\n . Continue abx as ordered. F/U on culture data. Increase PO intake\n as tolerated. Maintain aspiration precautions. Wean FiO2 as tolerated.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt on HD M/W/F. Fistula clotted as above. Pt unable to undergo HD .\n BUN 40, Creat 4.2.\n Action:\n Renal to see pt. Temporary R femoral HD line placed. Pt underwent HD w/\n 3.5L off.\n Response:\n Pt tolerated HD well.\n Plan:\n Pt to resume M/W/F HD schedule. Pt C/O to w/ plan for\n possible repair of fistula on Monday.\n"},{"category":"Nursing","chartdate":"2171-09-29 00:00:00.000","description":"Nursing Transfer Note","row_id":538391,"text":"Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\n was found to have a LLL infiltrate concerning for left basilar\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\n received 1L IVF, and was transferred to the for further\n management.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T-max 105 at HD, 104.8 in EW. Pt w/ recent UTI as above. Pt afebrile\n over noc s/p abx and Tylenol as above. Pt aphasic, though alert and\n follows simple commands at baseline; although pt unresponsive on\n arrival to EW. Pt w/ frequent coughing during meals at NH per report as\n above. Pt also hypoxic w/ SpO2 84% on RA requiring NRB in EW.\n Presently, pt is alert, oriented to name and place, though aphacic but\n mouthing words.\n Action:\n temp and hemodynamic status. MS. \n as ordered. Pt continues on vanc per HD protocol and has been started\n on zosyn. Blood and urine cx pnd (U/A + for UTI). Pt NPO w/\n speech/swallow eval pnd. FiO2 weaned to NC on arrival to .\n respiratory status.\n Response:\n Pt remains afebrile. BP remains stable\n see flowsheet. Pt now\n arousable to voice/stimuli; however, does not follow commands. SpO2\n remains >95% on O2 5L via NC. BBS CTA.\n Plan:\n Continue to monitor temp, hemodynamic status and resp. status. Follow\n . Continue abx as ordered. F/U on culture data. Continue NPO pnd\n speech/swallow eval. Wean FiO2 as tolerated.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt on HD M/W/F. Fistula clotted as above. Pt unable to undergo HD .\n BUN 40, Creat 4.2.\n Action:\n Renal to see pt. Plan to unclot fistula and HD on Monday\n Response:\n Renal c/s and intervention pnd. Femoral line inserted for HD.\n Plan:\n Plan HD once fistula unclotted or adequate access obtained.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PNEUMONIA\n Code status:\n DNR / DNI\n Height:\n 60 Inch\n Admission weight:\n 65 kg\n Daily weight:\n Allergies/Reactions:\n Morphine\n Nausea/Vomiting\n Precautions: Contact\n PMH: Anemia, Diabetes - Insulin, HEMO or PD, Renal Failure\n CV-PMH: CAD, CHF\n Additional history: 3+ mitral regurg, goutm depression, GERD,\n rheumatoid arthritis, hypercholesterolemia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:134\n D:65\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 65 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 24h total out:\n 40 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:36 AM\n Potassium:\n 4.6 mEq/L\n 04:36 AM\n Chloride:\n 100 mEq/L\n 04:36 AM\n CO2:\n 27 mEq/L\n 04:36 AM\n BUN:\n 27 mg/dL\n 04:36 AM\n Creatinine:\n 3.7 mg/dL\n 04:36 AM\n Glucose:\n 114 mg/dL\n 04:36 AM\n Hematocrit:\n 35.7 %\n 04:36 AM\n Finger Stick Glucose:\n 120\n 06:00 AM\n Valuables / Signature\n Patient valuables: none\n Other valuables: none\n Clothes: Sent home with:\n Wallet / Money: npne\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: 412\n Transferred to: 921\n Date & time of Transfer: 10/5/08/ 0700\n"},{"category":"Physician ","chartdate":"2171-09-29 00:00:00.000","description":"Physician Attending Progress Note","row_id":538442,"text":"Chief Complaint: Obtundation\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n DIALYSIS CATHETER - START 01:00 PM\n CALLED OUT\n History obtained from Medical records\n Patient unable to provide history: Confused\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Metoprolol - 10:25 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Neurologic: hemiparesis\n Signs or concerns for abuse : No\n Flowsheet Data as of 12:05 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 76 (59 - 76) bpm\n BP: 142/72(87) {112/39(57) - 142/72(87)} mmHg\n RR: 23 (18 - 25) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 200 mL\n 460 mL\n PO:\n 360 mL\n TF:\n IVF:\n 200 mL\n 100 mL\n Blood products:\n Total out:\n 3,525 mL\n 40 mL\n Urine:\n 25 mL\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,325 mL\n 420 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Crackles : scattered)\n Abdominal: No(t) Bowel sounds present, Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed, hemi paresis\n Labs / Radiology\n 11.3 g/dL\n 191 K/uL\n 114 mg/dL\n 3.7 mg/dL\n 27 mEq/L\n 4.6 mEq/L\n 27 mg/dL\n 100 mEq/L\n 139 mEq/L\n 35.7 %\n 7.0 K/uL\n [image002.jpg]\n 02:01 AM\n 11:08 AM\n 04:36 AM\n WBC\n 9.6\n 7.0\n Hct\n 34.0\n 35.7\n Plt\n 174\n 191\n Cr\n 4.2\n 3.7\n TropT\n 0.17\n 0.19\n Glucose\n 209\n 114\n Other labs: PT / PTT / INR:16.2/29.1/1.4, CK / CKMB /\n Troponin-T:22/3/0.19, Differential-Neuts:78.9 %, Lymph:13.0 %, Mono:5.1\n %, Eos:2.7 %, Albumin:3.2 g/dL, Ca++:9.7 mg/dL, Mg++:2.0 mg/dL, PO4:4.5\n mg/dL\n Assessment and Plan\n Obtundation\n UTI\n ESRD\n HD\n Vascular Access\n Much improved. More alert. Seems to be her ususal response to\n infection. Vascular will try to salvage Fistula. Daughters suggest in\n future comfort is their primary priority.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition :\n Total time spent: 35 minutes\n"},{"category":"Nursing","chartdate":"2171-09-29 00:00:00.000","description":"Nursing Transfer Note","row_id":538411,"text":"Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\n was found to have a LLL infiltrate concerning for left basilar\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\n received 1L IVF, and was transferred to the for further\n management.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T-max 105 at HD, 104.8 in EW. Pt w/ recent UTI as above. Pt afebrile\n over noc s/p abx and Tylenol as above. Pt aphasic, though alert and\n follows simple commands at baseline; although pt unresponsive on\n arrival to EW. Pt w/ frequent coughing during meals at NH per report as\n above. Pt also hypoxic w/ SpO2 84% on RA requiring NRB in EW.\n Presently, pt is alert, oriented to name and place, aphasic per\n baseline but mouthing words and occasionally speaking a few words.\n Action:\n temp and hemodynamic status. MS. \n as ordered. Pt continues on vanc per HD protocol and has been started\n on zosyn. Blood and urine cx pnd (U/A + for UTI). Pt has been NPO w/\n speech/swallow eval pnd; however, pt and family wish for pt to be able\n to take PO intake despite high risk for aspiration. Risks discussed w/\n pt and family by team yesterday and ground solids w/ nectar thick diet\n was ordered. FiO2 weaned to NC on arrival to . \n respiratory status.\n Response:\n Pt remains afebrile. BP remains stable\n see flowsheet. Pt now\n arousable to voice/stimuli; however, does not follow commands. SpO2\n remains >95% on O2 5L via NC. BBS CTA. Pt lethargic and unable to take\n PO intake after HD last noc.\n Plan:\n Continue to monitor temp, hemodynamic status and resp. status. Follow\n . Continue abx as ordered. F/U on culture data. Increase PO intake\n as able. Wean FiO2 as tolerated.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt on HD M/W/F. Fistula clotted as above. Pt unable to undergo HD .\n BUN 40, Creat 4.2.\n Action:\n Pt seen by renal yesterday. R femoral temporary HD line placed and pt\n received HD yesterday.\n Response:\n Pt tolerated HD line insertion and HD well yesterday.\n Plan:\n Plan for possible repair of AV fistula on Monday. Anticipate pt to\n resume M/W/F HD schedule. Increase activity as tolerated.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PNEUMONIA\n Code status:\n DNR / DNI\n Height:\n 60 Inch\n Admission weight:\n 65 kg\n Daily weight:\n Allergies/Reactions:\n Morphine\n Nausea/Vomiting\n Precautions: Contact\n PMH: Anemia, Diabetes - Insulin, HEMO or PD, Renal Failure\n CV-PMH: CAD, CHF\n Additional history: 3+ mitral regurg, goutm depression, GERD,\n rheumatoid arthritis, hypercholesterolemia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:134\n D:65\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 65 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 100 mL\n 24h total out:\n 40 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:36 AM\n Potassium:\n 4.6 mEq/L\n 04:36 AM\n Chloride:\n 100 mEq/L\n 04:36 AM\n CO2:\n 27 mEq/L\n 04:36 AM\n BUN:\n 27 mg/dL\n 04:36 AM\n Creatinine:\n 3.7 mg/dL\n 04:36 AM\n Glucose:\n 114 mg/dL\n 04:36 AM\n Hematocrit:\n 35.7 %\n 04:36 AM\n Finger Stick Glucose:\n 120\n 06:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 412\n Transferred to: 9\n Date & time of Transfer: \n"},{"category":"Physician ","chartdate":"2171-09-28 00:00:00.000","description":"Physician Resident Admission Note","row_id":538186,"text":"Chief Complaint: Mental status change, fever, and hypoxia\n HPI:\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\n to have a LLL infiltrate concerning for left basilar pneumonia versus\n aspiration. She was treated with vancomycin and pip/tazo, received 1L\n IVF, and was transferred to the .\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -CAD, s/p \"silent MI\" per patient\n -CHF, systolic dysfunction with EF 20%\n -3+ mitral regurgitation, 3+ TR\n -DM, type 2\n -ESRD on HD\n -Gout\n -Depression\n -GERD\n -Rheumatoid arthritis\n -Anemia\n -Hypercholesterolemia\n Multiple family members with DM II, otherwise non-contributory.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives at nursing home. Has 6 children that live locally. Quit\n smoking in the ; previously smoked approx 5cigs/day x30\n years. Rare EtOH.\n Review of systems:\n Flowsheet Data as of 01:39 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 74 (74 - 74) bpm\n BP: 156/46(71) {156/46(71) - 156/46(71)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 100%\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 10 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -10 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n Gen: Opens eyes to stimuli, unable to follow commands\n HEENT: Perrl, MM dry, neck supple\n Pulm: Bibasilar rales\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\n Abd: S/NT/ND, +bs\n Ext: 2+ dp b/l, trace edema. Right AVF without signs of erythema\n Neuro: Patient non-verbal\n Labs / Radiology\n 241\n 12.2\n 186\n 4.2\n 36\n 31\n 90\n 4.2\n 136\n 38.9\n 10.6\n [image002.jpg]\n Imaging: CXR: 1. Cardiomegaly with mild pulmonary edema.\n 2. New left basilar opacity concerning for pneumonia or aspiration.\n .\n CTH: No acute intracranial pathology. MRI more sensitive for ischemia.\n .\n CTAP: 1. Slightly limited examination due to patient positioning and\n lack of oral contrast. No intra-abdominal source for infection\n identified.\n 2. Patchy right middle and lower lobe opacities, some which are clearly\n compression atelectasis and others of which are suspicious for regions\n of pneumonia or aspiration. Small right effusion.\n 3. Extensive calcified atherosclerotic vascular disease.\n 4. Slight interval decrease in possible exophytic right-sided fibroid.\n Please note it is atypical for the fibroid to not have involuted more\n in a patient of this age. If alteration in care will occur, can\n consider further evaluation with a dedicated pelvic ultrasound and/or\n MRI as no dedicated pelvic imaging of this lesion is noted at .\n Microbiology: Blood cultures - pending\n Urine cultures - pending\n ECG: NSR, old LBBB,interventricular conduction delay\n Assessment and Plan\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\n hypoxia.\n .\n # Fever, mental status change: Patient with acute mental status change\n and fever. Patient was reported to have been hypoxic at outpatient HD\n with vomiting, and has history per family of coughing while eating.\n Given degree of fever, this is unlikely to be a chemical pneumonitis\n and more likely to represent a HA-pneumonia. She also has a urinalysis\n with significant pyuria although with 3-5 epi, with recent admission\n for UTI (urine cultures negative).\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\n - Follow urine and blood cultures, repeat UA and culture\n - Sputum cultures\n - Check Legionella urinary antigen\n - Wean supplemental O2\n .\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\n secondary to fever, mental status change, and clotted AVF. Discussed\n with renal fellow, and plan for dialysis tomorrow.\n - Renally dose all meds\n .\n # CAD: Continue digoxin, ASA, plavix.\n .\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\n .\n # DM type II: RISS\n .\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\n as if patient has had elevated transaminase since 3/.\n - Trend LFTs\n .\n # Gout: Continue allopurinol\n .\n # Psych: Continue\n .\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\n .\n # PPx: Heparin sq, famotidine\n .\n # Code: DNR/DNI (confirmed with family including HCP)\n .\n # Lines: PIV, FC\n .\n # Dispo: ICU level of care for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:09 AM\n 20 Gauge - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Physician ","chartdate":"2171-09-28 00:00:00.000","description":"Physician Resident Admission Note","row_id":538188,"text":"Chief Complaint: Mental status change, fever, and hypoxia\n HPI:\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\n to have a LLL infiltrate concerning for left basilar pneumonia versus\n aspiration. She was treated with vancomycin and pip/tazo, received 1L\n IVF, and was transferred to the .\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -CAD, s/p \"silent MI\" per patient\n -CHF, systolic dysfunction with EF 20%\n -3+ mitral regurgitation, 3+ TR\n -DM, type 2\n -ESRD on HD\n -Gout\n -Depression\n -GERD\n -Rheumatoid arthritis\n -Anemia\n -Hypercholesterolemia\n Multiple family members with DM II, otherwise non-contributory.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives at nursing home. Has 6 children that live locally. Quit\n smoking in the ; previously smoked approx 5cigs/day x30\n years. Rare EtOH.\n Review of systems:\n Flowsheet Data as of 01:39 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 74 (74 - 74) bpm\n BP: 156/46(71) {156/46(71) - 156/46(71)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 100%\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 10 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -10 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n Gen: Opens eyes to stimuli, unable to follow commands\n HEENT: Perrl, MM dry, neck supple\n Pulm: Bibasilar rales\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\n Abd: S/NT/ND, +bs\n Ext: 2+ dp b/l, trace edema. Right AVF without signs of erythema\n Neuro: Patient non-verbal\n Labs / Radiology\n 241\n 12.2\n 186\n 4.2\n 36\n 31\n 90\n 4.2\n 136\n 38.9\n 10.6\n [image002.jpg]\n Imaging: CXR: 1. Cardiomegaly with mild pulmonary edema.\n 2. New left basilar opacity concerning for pneumonia or aspiration.\n .\n CTH: No acute intracranial pathology. MRI more sensitive for ischemia.\n .\n CTAP: 1. Slightly limited examination due to patient positioning and\n lack of oral contrast. No intra-abdominal source for infection\n identified.\n 2. Patchy right middle and lower lobe opacities, some which are clearly\n compression atelectasis and others of which are suspicious for regions\n of pneumonia or aspiration. Small right effusion.\n 3. Extensive calcified atherosclerotic vascular disease.\n 4. Slight interval decrease in possible exophytic right-sided fibroid.\n Please note it is atypical for the fibroid to not have involuted more\n in a patient of this age. If alteration in care will occur, can\n consider further evaluation with a dedicated pelvic ultrasound and/or\n MRI as no dedicated pelvic imaging of this lesion is noted at .\n Microbiology: Blood cultures - pending\n Urine cultures - pending\n ECG: NSR, old LBBB,interventricular conduction delay\n Assessment and Plan\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\n hypoxia.\n .\n # Fever, mental status change: Patient with acute mental status change\n and fever. Patient was reported to have been hypoxic at outpatient HD\n with vomiting, and has history per family of coughing while eating.\n Given degree of fever, this is unlikely to be a chemical pneumonitis\n and more likely to represent a HA-pneumonia. She also has a urinalysis\n with significant pyuria although with 3-5 epi, with recent admission\n for UTI (urine cultures negative).\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\n - Follow urine and blood cultures, repeat UA and culture\n - Sputum cultures\n - Check Legionella urinary antigen\n - Wean supplemental O2\n .\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\n secondary to fever, mental status change, and clotted AVF. Discussed\n with renal fellow, and plan for dialysis tomorrow.\n - Renally dose all meds\n .\n # CAD: Continue digoxin, ASA, plavix.\n .\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\n .\n # DM type II: RISS\n .\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\n as if patient has had elevated transaminase since 3/.\n - Trend LFTs\n .\n # Gout: Continue allopurinol\n .\n # Psych: Continue wellbutrin and prozac.\n .\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\n .\n # PPx: Heparin sq, famotidine\n .\n # Code: DNR/DNI (confirmed with family including HCP)\n .\n # Lines: PIV, FC\n .\n # Dispo: ICU level of care for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:09 AM\n 20 Gauge - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Nursing","chartdate":"2171-09-28 00:00:00.000","description":"Nursing Transfer Note","row_id":538257,"text":"Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\n was found to have a LLL infiltrate concerning for left basilar\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\n received 1L IVF, and was transferred to the for further\n management.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T-max 105 at HD, 104.8 in EW. Pt w/ recent UTI as above. Pt afebrile\n over noc s/p abx and Tylenol as above. Pt aphasic, though alert and\n follows simple commands at baseline; although pt unresponsive on\n arrival to EW. Pt w/ frequent coughing during meals at NH per report as\n above. Pt also hypoxic w/ SpO2 84% on RA requiring NRB in EW.\n Action:\n temp and hemodynamic status. MS. \n as ordered. Pt continues on vanc per HD protocol and has been started\n on zosyn. Blood and urine cx pnd (U/A + for UTI). Pt NPO w/\n speech/swallow eval pnd. FiO2 weaned to NC on arrival to .\n respiratory status.\n Response:\n Pt remains afebrile. BP remains stable\n see flowsheet. Pt now\n arousable to voice/stimuli; however, does not follow commands. WBC 9.6\n down from 10.6 on admit. SpO2 remains >95% on O2 5L via NC. BBS CTA.\n Plan:\n Continue to monitor temp, hemodynamic status and resp. status. Follow\n . Continue abx as ordered. F/U on culture data. Continue NPO pnd\n speech/swallow eval. Wean FiO2 as tolerated.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt on HD M/W/F. Fistula clotted as above. Pt unable to undergo HD .\n BUN 40, Creat 4.2.\n Action:\n Renal to see pt. Plan to unclot fistula and HD today.\n Response:\n Renal c/s and intervention pnd.\n Plan:\n Plan HD once fistula unclotted or adequate access obtained.\n"},{"category":"General","chartdate":"2171-09-28 00:00:00.000","description":"ICU Event Note","row_id":538280,"text":"Clinician: Attending\n Critical Care\n Remains profoundly obtunded which occurs each time she develops an\n infection. I think likelihood of meningitis is low so will continue to\n cover broadly but not for CNS infection. CXR is difficult to read but I\n am not convinced she has pneumonia. CHF is currently in good control.\n Total time spent: 35 minutes\n Patient is critically ill.\n"},{"category":"Physician ","chartdate":"2171-09-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":538288,"text":"Chief Complaint: Fever, hypoxia, mental status change\n 24 Hour Events:\n - No acute events overnight.\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.2\n HR: 69 (65 - 74) bpm\n BP: 114/60(73) {84/44(58) - 156/71(76)} mmHg\n RR: 22 (21 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 100 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 0 mL\n 25 mL\n Urine:\n 25 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 75 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Gen: Opens eyes to stimuli, unable to follow commands\n HEENT: Perrl, MM dry, neck supple\n Pulm: Bibasilar rales\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\n Abd: S/NT/ND, +bs\n Ext: 2+ dp b/l, trace edema. Right AVG without signs of erythema\n Neuro: Patient non-verbal\n Labs / Radiology\n 174 K/uL\n 11.0 g/dL\n 209 mg/dL\n 4.2 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 90 mEq/L\n 135 mEq/L\n 34.0 %\n 9.6 K/uL\n [image002.jpg]\n 02:01 AM\n WBC\n 9.6\n Hct\n 34.0\n Plt\n 174\n Cr\n 4.2\n TropT\n 0.17\n Glucose\n 209\n Other labs: PT / PTT / INR:16.2/29.1/1.4, CK / CKMB /\n Troponin-T:21/3/0.17, Albumin:3.2 g/dL, Ca++:9.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.5 mg/dL\n Assessment and Plan\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\n hypoxia.\n .\n # Fever, mental status change: Patient with acute mental status change\n and fever. Patient was reported to have been hypoxic at outpatient HD\n with vomiting, and has history per family of coughing while eating.\n Given degree of fever, this is unlikely to be a chemical pneumonitis\n and more likely to represent a HA-pneumonia, although her CXR is\n underwhelming for a significant consolidation. She also has a\n urinalysis with significant pyuria although with 3-5 epi, with recent\n admission for UTI (urine cultures negative). Low suspicion at this\n time for meningitis, and patient\ns HCP has repeatedly refused LP on\n past admissions for similar presentation, but will check with family\n regarding LP. Will hold off on empiric treatment of meningitis for\n now.\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\n - Follow urine and blood cultures, repeat UA and culture\n - Sputum cultures\n - Check Legionella urinary antigen\n - Wean supplemental O2\n .\n # ESRD: Patient on MWF HD. Did not receive outpatient HD yesterday\n secondary to fever, mental status change, and clotted AVF. Discussed\n with renal fellow, and plan for dialysis today.\n - Renally dose all meds\n - f/u with renal transplant regarding AVG\n .\n # CAD: Continue digoxin, ASA, plavix. Initial set of cardiac enzymes\n with troponin slightly elevated but a recent baseline with flat CK.\n - CCE\n .\n # CHF: BB and ACE-I held on admission. Patient hemodynamically stable\n overnight, will restart today.\n .\n # DM type II: RISS\n .\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\n as if patient has had elevated transaminase since 3/.\n - Trend LFTs\n .\n # Gout: Continue allopurinol\n .\n # Psych: Continue wellbutrin and prozac.\n .\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\n .\n # PPx: Heparin sq, famotidine\n .\n # Code: DNR/DNI (confirmed with family including HCP)\n .\n # Lines: PIV, FC\n .\n # Dispo: Call out today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:09 AM\n 20 Gauge - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Physician ","chartdate":"2171-09-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":538266,"text":"Chief Complaint: Fever, hypoxia, mental status change\n 24 Hour Events:\n - No acute events overnight.\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.2\n HR: 69 (65 - 74) bpm\n BP: 114/60(73) {84/44(58) - 156/71(76)} mmHg\n RR: 22 (21 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 100 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 0 mL\n 25 mL\n Urine:\n 25 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 75 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 174 K/uL\n 11.0 g/dL\n 209 mg/dL\n 4.2 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 90 mEq/L\n 135 mEq/L\n 34.0 %\n 9.6 K/uL\n [image002.jpg]\n 02:01 AM\n WBC\n 9.6\n Hct\n 34.0\n Plt\n 174\n Cr\n 4.2\n TropT\n 0.17\n Glucose\n 209\n Other labs: PT / PTT / INR:16.2/29.1/1.4, CK / CKMB /\n Troponin-T:21/3/0.17, Albumin:3.2 g/dL, Ca++:9.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.5 mg/dL\n Assessment and Plan\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\n hypoxia.\n .\n # Fever, mental status change: Patient with acute mental status change\n and fever. Patient was reported to have been hypoxic at outpatient HD\n with vomiting, and has history per family of coughing while eating.\n Given degree of fever, this is unlikely to be a chemical pneumonitis\n and more likely to represent a HA-pneumonia. She also has a urinalysis\n with significant pyuria although with 3-5 epi, with recent admission\n for UTI (urine cultures negative).\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\n - Follow urine and blood cultures, repeat UA and culture\n - Sputum cultures\n - Check Legionella urinary antigen\n - Wean supplemental O2\n .\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\n secondary to fever, mental status change, and clotted AVF. Discussed\n with renal fellow, and plan for dialysis tomorrow.\n - Renally dose all meds\n .\n # CAD: Continue digoxin, ASA, plavix. Initial set of cardiac enzymes\n with troponin slightly elevated but a recent baseline with flat CK.\n - CCE\n .\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\n .\n # DM type II: RISS\n .\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\n as if patient has had elevated transaminase since 3/.\n - Trend LFTs\n .\n # Gout: Continue allopurinol\n .\n # Psych: Continue wellbutrin and prozac.\n .\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\n .\n # PPx: Heparin sq, famotidine\n .\n # Code: DNR/DNI (confirmed with family including HCP)\n .\n # Lines: PIV, FC\n .\n # Dispo: ICU level of care for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:09 AM\n 20 Gauge - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Physician ","chartdate":"2171-09-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":538267,"text":"Chief Complaint: Fever, hypoxia, mental status change\n 24 Hour Events:\n - No acute events overnight.\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.2\n HR: 69 (65 - 74) bpm\n BP: 114/60(73) {84/44(58) - 156/71(76)} mmHg\n RR: 22 (21 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 100 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 0 mL\n 25 mL\n Urine:\n 25 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 75 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Gen: Opens eyes to stimuli, unable to follow commands\n HEENT: Perrl, MM dry, neck supple\n Pulm: Bibasilar rales\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\n Abd: S/NT/ND, +bs\n Ext: 2+ dp b/l, trace edema. Right AVF without signs of erythema\n Neuro: Patient non-verbal\n Labs / Radiology\n 174 K/uL\n 11.0 g/dL\n 209 mg/dL\n 4.2 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 90 mEq/L\n 135 mEq/L\n 34.0 %\n 9.6 K/uL\n [image002.jpg]\n 02:01 AM\n WBC\n 9.6\n Hct\n 34.0\n Plt\n 174\n Cr\n 4.2\n TropT\n 0.17\n Glucose\n 209\n Other labs: PT / PTT / INR:16.2/29.1/1.4, CK / CKMB /\n Troponin-T:21/3/0.17, Albumin:3.2 g/dL, Ca++:9.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.5 mg/dL\n Assessment and Plan\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\n hypoxia.\n .\n # Fever, mental status change: Patient with acute mental status change\n and fever. Patient was reported to have been hypoxic at outpatient HD\n with vomiting, and has history per family of coughing while eating.\n Given degree of fever, this is unlikely to be a chemical pneumonitis\n and more likely to represent a HA-pneumonia. She also has a urinalysis\n with significant pyuria although with 3-5 epi, with recent admission\n for UTI (urine cultures negative).\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\n - Follow urine and blood cultures, repeat UA and culture\n - Sputum cultures\n - Check Legionella urinary antigen\n - Wean supplemental O2\n .\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\n secondary to fever, mental status change, and clotted AVF. Discussed\n with renal fellow, and plan for dialysis tomorrow.\n - Renally dose all meds\n .\n # CAD: Continue digoxin, ASA, plavix. Initial set of cardiac enzymes\n with troponin slightly elevated but a recent baseline with flat CK.\n - CCE\n .\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\n .\n # DM type II: RISS\n .\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\n as if patient has had elevated transaminase since 3/.\n - Trend LFTs\n .\n # Gout: Continue allopurinol\n .\n # Psych: Continue wellbutrin and prozac.\n .\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\n .\n # PPx: Heparin sq, famotidine\n .\n # Code: DNR/DNI (confirmed with family including HCP)\n .\n # Lines: PIV, FC\n .\n # Dispo: ICU level of care for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:09 AM\n 20 Gauge - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Radiology","chartdate":"2171-09-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037944,"text":" 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ?LLB pneumonia\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 2:50 PM\n Unchanged left lower lobe consolidation. Band-like atelectasis in the right\n base is new.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Followup left lower lobe pneumonia.\n\n Left lower lobe consolidation is persistent and unchanged. Band-like\n atelectasis in the right base is new. There is no pneumothorax. If any,\n bilateral small pleural effusions are unchanged, greater on the left side.\n Cardiomegaly is stable.\n\n\n DR. \n"},{"category":"Radiology","chartdate":"2171-09-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037945,"text":", MED 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ?LLB pneumonia\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n PFI REPORT\n Unchanged left lower lobe consolidation. Band-like atelectasis in the right\n base is new.\n\n\n"},{"category":"Radiology","chartdate":"2171-09-29 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1038047,"text":", A. MED FA9A 2:21 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o SAH, SDH, hemorrhage, ischemia\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ESRD on HD, DM II p/w fever, AMS, was resolving but now\n obtunded.\n REASON FOR THIS EXAMINATION:\n r/o SAH, SDH, hemorrhage, ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No acute intracranial pathology.\n DFDkq\n\n"},{"category":"Radiology","chartdate":"2171-09-29 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1038046,"text":" 2:21 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o SAH, SDH, hemorrhage, ischemia\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ESRD on HD, DM II p/w fever, AMS, was resolving but now\n obtunded.\n REASON FOR THIS EXAMINATION:\n r/o SAH, SDH, hemorrhage, ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr SUN 4:25 PM\n No acute intracranial pathology.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman with acute mental status change and fever.\n\n Comparison is made to , and .\n\n NONCONTRAST HEAD CT: No edema, mass effect, acute hemorrhage, or evidence of\n a major vascular territorial infarction. Marked enlargement of the\n ventricles, out of proportion to the enlargement of the sulci, is unchanged\n since . Diffuse periventricular white matter hypodensities are\n consistent with a small vessel disease, unchanged. The visualized part of the\n paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n 1. No evidence of acute intracranial abnormalities.\n\n 2. Unchanged marked enlargement of the ventricles since , out of\n proportion to the enlargement of the sulci, which may be related to central\n atrophy or normal-pressure hydrocephalus. Clinical correlation is advised.\n DFDkq\n\n"},{"category":"Radiology","chartdate":"2171-10-03 00:00:00.000","description":"TUNNELED W/O PORT","row_id":1038997,"text":" 1:55 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: needs HD tunneled catheter.\n Admitting Diagnosis: PNEUMONIA\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ESRD on HD a/w AMS, thrombosed RUE AVF s/p failed\n revision by transplant surgery yesterday.\n REASON FOR THIS EXAMINATION:\n needs HD tunneled catheter.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female with end-stage renal disease on hemodialysis,\n status post failed revision of right upper extremity AV fistula. Please place\n tunneled hemodialysis catheter.\n\n RADIOLOGISTS: Dr. and attending radiologist, Dr. , who was\n present and supervised the entire procedure.\n\n FINDINGS AND PROCEDURE: The risks and benefits of the procedure were\n explained to the patient and informed consent was obtained. The patient was\n placed supine on the angiographic table and the left neck and chest were\n prepped and draped in standard sterile fashion. A preprocedure timeout was\n performed to identify the patient by name, medical record number, date of\n birth and the nature of the procedure to be performed.\n\n Using ultrasound guidance, the left internal jugular vein was accessed with a\n 21-gauge needle. Ultrasound images before and after venopuncture were\n obtained. A 0.018 wire was then placed through the needle into the SVC under\n fluoroscopic guidance. The needle was exchanged for a 4.5 French\n micropuncture sheath. The wire was subsequently exchanged for a 0.035 \n wire, the tip of which was positioned in the inferior vena cava under\n fluoroscopic guidance. Following this, attention was directed to the\n construction of the tunnel, which was performed using blunt dissection and\n administration of 10 cc of 1% lidocaine with epinephrine. Once the catheter\n was tunneled, a 15.5 French peel-away sheath was then placed over the wire.\n The wire and inner dilator were removed. The catheter was advanced through\n the peel-away sheath and sheath removed.\n\n The neck incision was closed with a 4-0 Vicryl suture. Lumens of the catheter\n were flushed and heplocked, and the line was secured to the skin with two silk\n sutures. Sterile dressing was applied. Final fluoroscopic image of the chest\n demonstrates the tip of the catheter to be located in the right atrium. There\n were no immediate complications.\n\n Moderate sedation was provided by administering divided doses of fentanyl (25\n mcg) throughout the total intra-service time of 55 minutes, during which the\n patient's hemodynamic parameters were continuously monitored.\n\n (Over)\n\n 1:55 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: needs HD tunneled catheter.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Successful placement of a left internal jugular 23 cm tip-to-cuff\n dual-lumen angiodynamics hemodialysis catheter with the tip located in the\n right atrium. The line is ready to use.\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2171-09-29 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":1038067,"text":" 6:05 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: r/o encephalitis, ischemia\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ESRD on HD, DM II a/w MS change and fevers. Now with\n obtundation.\n REASON FOR THIS EXAMINATION:\n r/o encephalitis, ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl MON 3:14 PM\n Irregularity of left greater than right MCA branch vessels. Differential\n diagnoses include vasculitis, meningitis, or atheromatous change. Cerebral\n atrophy, with ventricular enlargement. There is no obstruction, although\n communicating hydrocephalus cannot be excluded.\n ______________________________________________________________________________\n FINAL REPORT\n MRI AND MRA OF THE BRAIN.\n\n HISTORY: 72-year-old woman with end-stage renal disease on hemodialysis,\n diabetes type 2, with mental status change and fevers. Now with obtundation.\n Rule out encephalitis or ischemia.\n\n COMPARISON: Head CTs, , and .\n\n TECHNIQUE: Multiplanar brain MR was obtained without the administration of\n intravenous gadolinium. Three-dimensional time-of-flight MR arteriography was\n performed.\n\n FINDINGS:\n MRI OF THE BRAIN:\n There is no evidence of hemorrhage, edema, masses, mass effect or infarction.\n No diffusion abnormalities are detected. The ventricles are enlarged,\n somewhat out of proportion to the degree of atrophy, but unchanged in\n comparison to , and without evidence of obstruction. There are\n changes consistent with mild small vessel occlusive disease.\n\n MRA OF THE BRAIN: There is irregularity of branches of the middle cerebral\n arteries, right greater than left. However, there is no evidence of\n occlusion. The intracranial vertebral internal carotid arteries and vertebral\n arteries and their branches are normal, without evidence of stenosis,\n occlusion, or aneurysm.\n\n IMPRESSION:\n 1. Irregularity of MCA branch vessels, right greater than left. The\n differential diagnosis includes vasculitis and meningitis. Considerations\n also include atheromatous change, although the location and appearance is\n atypical for atheromatous change.\n 2. Ventricular enlargement, without evidence of obstruction. However,\n communicating hydrocephalus cannot be excluded.\n\n (Over)\n\n 6:05 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: r/o encephalitis, ischemia\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Findings were discussed with Dr. on at 11:00 a.m.\n\n"},{"category":"Radiology","chartdate":"2171-09-29 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":1038068,"text":", A. MED FA9A 6:05 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: r/o encephalitis, ischemia\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ESRD on HD, DM II a/w MS change and fevers. Now with\n obtundation.\n REASON FOR THIS EXAMINATION:\n r/o encephalitis, ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Irregularity of left greater than right MCA branch vessels. Differential\n diagnoses include vasculitis, meningitis, or atheromatous change. Cerebral\n atrophy, with ventricular enlargement. There is no obstruction, although\n communicating hydrocephalus cannot be excluded.\n\n"},{"category":"Radiology","chartdate":"2171-09-27 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":1037721,"text":" 7:13 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for intraabdominal process as source of fever/N/V\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ESRD on HD p/w N/V too altered for abd exam to be\n significant\n REASON FOR THIS EXAMINATION:\n eval for intraabdominal process as source of fever/N/V\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKPe FRI 9:10 PM\n no abdominal source for fever. mild free fluid in pelvis, stable to slight\n decrease in size to presumed fibroid. patchy lower lobe opacities may\n represent pna/pneumonitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever of 105, worsening mental status. Patient with end-stage renal\n disease on hemodialysis:\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis with IV contrast only. Oral contrast was not administered due to\n inability to tolerate p.o. and timid airway preventing OGT.\n\n Comparison is made to CT examination and CT\n examination.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST ONLY: Limited evaluation of lung\n bases displays scattered regions of ground-glass opacity noted within the\n right middle lobe and lower lobes bilaterally as well as more streaky linear\n opacities at the left base and a small simple right pleural effusion with\n adjacent compression atelectasis. Heart size is enlarged. No pericardial\n effusion is identified. The liver, spleen with small calcified granulomas,\n stomach, small bowel, atrophic-appearing pancreas, atrophic-appearing kidneys,\n and adrenal glands appear unremarkable. There is extensive vascular\n calcification noted within the aorta and all branch vessels. No free air,\n free fluid or pathologically enlarged lymph nodes are identified within the\n abdominal cavity.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST ONLY: Air is noted within a Foley-\n containing urinary bladder. The uterus is again noted to be enlarged with an\n exophytic low attenuation heterogeneous mass again noted to extend off the\n right fundal region measuring approximately 4.8 x 5.5 cm, slightly decreased\n in size from where it measured 5.6 x 6.9 cm but stable from . A\n mild- to- moderate amount of simple free fluid is noted within the pelvic\n cavity. Intrapelvic bowel and Foley-containing urinary bladder appear normal.\n Incidentally noted is a fat- containing right inguinal hernia.\n\n BONE WINDOWS: No malignant-appearing osseous lesions are identified. Mild\n degenerative disc disease noted at L5-S1 and multiple left-sided rib fractures\n are unchanged.\n\n (Over)\n\n 7:13 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for intraabdominal process as source of fever/N/V\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1. Slightly limited examination due to patient positioning and lack of oral\n contrast. No intra-abdominal source for infection identified.\n\n 2. Patchy right middle and lower lobe opacities, some which are clearly\n compression atelectasis and others of which are suspicious for regions of\n pneumonia or aspiration. Small right effusion.\n\n 3. Extensive calcified atherosclerotic vascular disease.\n\n 4. Slight interval decrease in possible exophytic right-sided fibroid. Please\n note it is atypical for the fibroid to not have involuted more in a patient of\n this age. If alteration in care will occur, can consider further evaluation\n with a dedicated pelvic ultrasound and/or MRI as no dedicated pelvic imaging\n of this lesion is noted at .\n\n"},{"category":"Radiology","chartdate":"2171-09-27 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1037722,"text":" 7:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with acute change in MS w/ N/V and febrile no visible signs\n of head trauma\n REASON FOR THIS EXAMINATION:\n eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKPe FRI 8:54 PM\n no acute pathology, stable\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever up to 105 with decline in mental status.\n\n Comparison is made to , examination.\n\n NON-CONTRAST HEAD CT\n\n FINDINGS: There is no evidence of intracranial hemorrhage, mass effect, shift\n of midline structures, hydrocephalus, or acute major vascular territorial\n infarct. -white matter differentiation appears well preserved. Extensive\n periventricular white matter hypoattenuating changes, most marked within the\n right centrum semiovale is stable as is central atrophy. Right\n basal ganglia calcifications again noted. Attenuation of the lenses\n bilaterally is consistent with prior cataract surgery. No other soft tissue\n abnormalities are identified. Bony structures are unremarkable, and the\n mastoid air cells and paranasal sinuses are well aerated. Atherosclerotic\n calcifications are noted within the carotid siphons bilaterally.\n\n IMPRESSION:\n\n No acute intracranial pathology. MRI more sensitive for ischemia.\n\n"},{"category":"Radiology","chartdate":"2171-09-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037715,"text":" 6:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ESRD on HD p/w N/V and hypoxia likely aspiration\n REASON FOR THIS EXAMINATION:\n eval for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage renal disease on hemodialysis with nausea, vomiting,\n and hypoxia. Possibly aspiration.\n\n COMPARISON: Chest radiographs of .\n\n UPRIGHT AP VIEW OF THE CHEST: Cardiomegaly is unchanged from the previous\n exam. There is calcification of the aortic knob. Increased interstitial\n markings are demonstrated bilaterally, compatible with minimal interstitial\n edema. A new left basilar opacity is present, which could represent\n aspiration or infection. Small left pleural effusion may be present. The\n right lung otherwise is grossly clear without focal consolidation or pleural\n effusion. No pneumothorax. Known left-sided healed rib fractures are not as\n well seen on the current examination.\n\n IMPRESSION:\n\n 1. Cardiomegaly with mild pulmonary edema.\n\n 2. New left basilar opacity concerning for pneumonia or aspiration.\n\n\n DFDdp\n\n"},{"category":"ECG","chartdate":"2171-09-30 00:00:00.000","description":"Report","row_id":134606,"text":"Sinus rhythm\nLeft axis deviation\nLeft bundle branch block\nTall T waves - consider acute ischemia or hyperkalemia\nSince previous tracing of , ST-T wave abnormalities more marked\n\n"},{"category":"ECG","chartdate":"2171-09-29 00:00:00.000","description":"Report","row_id":134607,"text":"Sinus rhythm. The P-R interval is prolonged. Left axis deviation.\nLeft bundle-branch block. Compared to the previous tracing the axis has\nshifted.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2171-09-28 00:00:00.000","description":"Report","row_id":134608,"text":"Artifact is present. Sinus rhythm. Indeterminate axis. Left bundle-branch\nblock. Compared to the previous tracing there is no significant change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2171-09-27 00:00:00.000","description":"Report","row_id":134609,"text":"Sinus rhythm. Intraventricular conduction delay of left bundle-branch block\ntype. Compared to the previous tracing of there is no significant\ndiagnostic change.\n\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2171-09-28 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 538177,\n \"text\": \"Chief Complaint: hypoxia, fever\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 72 y.o. nursing home resident seen in dialysis today, noted to had\\n altered mental status, temp taken and reportedly was 105, noted to have\\n saturation 84%. Episode of emesis at HD, ?aspiration. Called EMTs and\\n brought to ED. Noted to be tachypneic at 42, NRB-100% sat. CXR c/w\\n LLL pneumonia. Daughters had reported that she often coughs when being\\n fed/eating. Vanco/pip/tazo in ED.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Patient unable to provide history: nonverbal at baseline\\n Allergies:\\n Morphine\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n senekot\\n compazine\\n digoxin\\n lisinopril\\n welbutrin\\n prozac\\n ativan prior to dialysis\\n simvastatin\\n nephrocaps\\n allopurinol\\n plavix\\n humara\\n metoprolol\\n zantac\\n Past medical history:\\n Family history:\\n Social History:\\n CAD\\n CHF, EF = 20%, TR/MR\\n CRF on hemodialysis\\n UTIs\\n Gout\\n Depression\\n Anemia\\n Hyperlipidemia\\n noncontributory\\n Occupation:\\n Drugs: none\\n Tobacco: quit in ; pack years\\n Alcohol: none\\n Other:\\n Review of systems:\\n Constitutional: Fatigue\\n Ear, Nose, Throat: Dry mouth\\n Nutritional Support: NPO\\n Gastrointestinal: Emesis\\n Heme / Lymph: Anemia\\n Neurologic: nonverbal\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 01:26 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (104.3\\n Tcurrent: 37\\nC (98.6\\n HR: 74 (74 - 74) bpm\\n BP: 156/46(71) {156/46(71) - 156/46(71)} mmHg\\n RR: 42 (24 - 24) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 60 Inch\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 10 mL\\n Urine:\\n 10 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -10 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 100%\\n ABG: ////\\n Physical Examination\\n General Appearance: Anxious\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Lymphatic: Cervical WNL\\n Cardiovascular: (S1: Normal), (S2: Normal), S3\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n left base, Diminished: )\\n Abdominal: Soft, Bowel sounds present\\n Extremities: Right: Absent\\n Skin: Not assessed\\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\\n assessed, Tone: Not assessed\\n Labs / Radiology\\n 241\\n 38.9\\n 186\\n 4.2\\n 36\\n 31\\n 90\\n 4.2\\n 136\\n 10.6\\n [image002.jpg]\\n Other labs: ALT / AST:/46, Alk Phos / T Bili:/0.9,\\n Differential-Neuts:87.4, Lymph:8, Mono:3.2, Eos:1, Albumin:3.6,\\n Ca++:10.5, Mg++:3.1, PO4:2.5\\n Imaging: CXR: enlarged cardiac silohuette, retrocardiac density, some\\n silohuetting of left hemidiphragm. No CHF\\n ECG: SR @89, LBBB\\n Assessment and Plan\\n 1. Hypoxia, fever and question of witnessed aspiration. be\\n chronically aspirating as fever this high unlikely due to a chemical\\n pneumonitis. Likely superimposed infection, nosocomial organisms given\\n resident of nursing home. Reasonable to continue current abx.\\n Oxygenating fine on 4L NC in MICU.\\n 2. CAD/CHF: No evident CHF/edema. Check cardiac enzymes albeit\\n suspicion for ischemic event is low.\\n 3. CRF: No evidence of volume overload, electrolytes fine. Dose\\n medications accordingly.\\n 4. Depression: Continue prozac/welbutrin. Follow clinically.\\n 5. NPO. Needs speech and swallow evaluation given aspiration risk.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines / Intubation:\\n 18 Gauge - 12:09 AM\\n 20 Gauge - 12:10 AM\\n Comments:\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP: HOB elevation\\n Need for restraints reviewed\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n Total time spent: 50 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2171-09-28 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 538178,\n \"text\": \"Chief Complaint: Mental status change, fever, and hypoxia\\n HPI:\\n Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\\n was found to have a clotted right AVF, MS change, oral temp of 105, and\\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\\n well. Of note, the patient was admitted to from for\\n altered mental status and hypoglycemia secondary to UTI treated with\\n ciprofloxacin. Discussing with patient's daughters, she has been\\n coughing frequently with meals at her nursing home, and has baseline\\n aphasia but is able to follow simple commands.\\n .\\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\\n to have a LLL infiltrate concerning for left basilar pneumonia versus\\n aspiration. She was treated with vancomycin and pip/tazo, received 1L\\n IVF, and was transferred to the .\\n Patient admitted from: ER\\n History obtained from Family / Medical records\\n Patient unable to provide history: Unresponsive\\n Allergies:\\n Morphine\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n -CAD, s/p \\\"silent MI\\\" per patient\\n -CHF, systolic dysfunction with EF 20%\\n -3+ mitral regurgitation, 3+ TR\\n -DM, type 2\\n -ESRD on HD\\n -Gout\\n -Depression\\n -GERD\\n -Rheumatoid arthritis\\n -Anemia\\n -Hypercholesterolemia\\n Multiple family members with DM II, otherwise non-contributory.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: Lives at nursing home. Has 6 children that live locally. Quit\\n smoking in the ; previously smoked approx 5cigs/day x30\\n years. Rare EtOH.\\n Review of systems:\\n Flowsheet Data as of 01:39 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 37\\nC (98.6\\n HR: 74 (74 - 74) bpm\\n BP: 156/46(71) {156/46(71) - 156/46(71)} mmHg\\n RR: 24 (24 - 24) insp/min\\n SpO2: 100%\\n Height: 60 Inch\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 10 mL\\n Urine:\\n 10 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -10 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 100%\\n Physical Examination\\n Gen: Opens eyes to stimuli, unable to follow commands\\n HEENT: Perrl, MM dry, neck supple\\n Pulm: Bibasilar rales\\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\\n Abd: S/NT/ND, +bs\\n Ext: 2+ dp b/l, trace edema. Right AVF without signs of erythema\\n Neuro: Patient non-verbal\\n Labs / Radiology\\n 241\\n 12.2\\n 186\\n 4.2\\n 36\\n 31\\n 90\\n 4.2\\n 136\\n 38.9\\n 10.6\\n [image002.jpg]\\n Imaging: CXR: 1. Cardiomegaly with mild pulmonary edema.\\n 2. New left basilar opacity concerning for pneumonia or aspiration.\\n .\\n CTH: No acute intracranial pathology. MRI more sensitive for ischemia.\\n .\\n CTAP: 1. Slightly limited examination due to patient positioning and\\n lack of oral contrast. No intra-abdominal source for infection\\n identified.\\n 2. Patchy right middle and lower lobe opacities, some which are clearly\\n compression atelectasis and others of which are suspicious for regions\\n of pneumonia or aspiration. Small right effusion.\\n 3. Extensive calcified atherosclerotic vascular disease.\\n 4. Slight interval decrease in possible exophytic right-sided fibroid.\\n Please note it is atypical for the fibroid to not have involuted more\\n in a patient of this age. If alteration in care will occur, can\\n consider further evaluation with a dedicated pelvic ultrasound and/or\\n MRI as no dedicated pelvic imaging of this lesion is noted at .\\n Microbiology: Blood cultures - pending\\n Urine cultures - pending\\n ECG: NSR, old LBBB,interventricular conduction delay\\n Assessment and Plan\\n Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\\n hypoxia.\\n .\\n # Fever, mental status change: Patient with acute mental status change\\n and fever. Patient was reported to have been hypoxic at outpatient HD\\n with vomiting, and has history per family of coughing while eating.\\n Given degree of fever, this is unlikely to be a chemical pneumonitis\\n and more likely to represent a HA-pneumonia. She also has a urinalysis\\n with significant pyuria although with 3-5 epi, with recent admission\\n for UTI (urine cultures negative).\\n - Continue vanco and pip/tazo for HA-pneumonia and UTI\\n - Follow urine and blood cultures\\n - Sputum cultures\\n - Legionella urinary antigen\\n - Wean supplemental O2\\n .\\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\\n secondary to fever, mental status change, and clotted AVF. Discussed\\n with renal fellow, and plan to dialysize tomorrow.\\n - Renally dose all meds\\n .\\n # CAD: Continue digoxin, ASA, plavix.\\n .\\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\\n .\\n # DM type II: RISS\\n .\\n # Gout: Continue allopurinol\\n .\\n # Psych: Continue\\n .\\n # FEN: NPO, speech and swallow consult. Replete as necessary.\\n .\\n # PPx: Heparin sq, famotidine\\n .\\n # Code: DNR/DNI (confirmed with f\\n .\\n # Lines: PIV, FC\\n .\\n # Dispo: ICU level of care for now.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 12:09 AM\\n 20 Gauge - 12:10 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2171-09-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 538179,\n \"text\": \"Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\\n was found to have a clotted right AVF, MS change, oral temp of 105, and\\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\\n well. Of note, the patient was admitted to from for\\n altered mental status and hypoglycemia secondary to UTI treated with\\n ciprofloxacin. Discussing with patient's daughters, she has been\\n coughing frequently with meals at her nursing home, and has baseline\\n aphasia but is able to follow simple commands.\\n .\\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\\n to have a LLL infiltrate concerning for left basilar pneumonia versus\\n aspiration. She was treated with vancomycin Zosyn, received 1L IVF,\\n and was transferred to the for further management.\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2171-09-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 538249,\n \"text\": \"Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\\n was found to have a clotted right AVF, MS change, oral temp of 105, and\\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\\n well. Of note, the patient was admitted to from for\\n altered mental status and hypoglycemia secondary to UTI treated with\\n ciprofloxacin. Discussing with patient's daughters, she has been\\n coughing frequently with meals at her nursing home, and has baseline\\n aphasia but is able to follow simple commands.\\n .\\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\\n was found to have a LLL infiltrate concerning for left basilar\\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\\n received 1L IVF, and was transferred to the for further\\n management.\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n Pt was febrile in ED, thought to be having PNA or UTI, in ICU afebrile.\\n Action:\\n 2 sets of bld cx sent in ED. In ICU Given Zosyn one dose and started on\\n Zosyn and vancomycin. Breathing regularly on Oe NC 5 LPM (NRB D/Ced\\n upon arrival to ICU).\\n Response:\\n Afebrile, alert, opened eyes first to stimuli then spontaneously, not\\n follow commands.\\n Plan:\\n Sputum cx to be sent (imduced), F/U on cx results, de clot the fistula\\n in Rt upper extremity and ? HD today, consult renal fellow, contact\\n family (daughters) prior to HD initiation, wean O2 as tolerated..\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt in ESRD on HD MWF, anuric.\\n Action:\\n Failed to be dialyzed yesterday due to clotting of Fistula.\\n Response:\\n BUN/Cr 40/4.2, U/O 25 cc/shift.\\n Plan:\\n For HD today after consulting renal fellow to declot fistula, monitor\\n lytes and seria cardiac enzymes.l Monitor FS and insulin per sliding\\n scale.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2171-09-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 538220,\n \"text\": \"Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\\n was found to have a clotted right AVF, MS change, oral temp of 105, and\\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\\n well. Of note, the patient was admitted to from for\\n altered mental status and hypoglycemia secondary to UTI treated with\\n ciprofloxacin. Discussing with patient's daughters, she has been\\n coughing frequently with meals at her nursing home, and has baseline\\n aphasia but is able to follow simple commands.\\n .\\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\\n to have a LLL infiltrate concerning for left basilar pneumonia versus\\n aspiration. She was treated with vancomycin Zosyn, received 1L IVF,\\n and was transferred to the for further management.\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n Pt was febrile in ED, thought to be having PNA or UTI, in ICU afebrile.\\n Action:\\n 2 sets of bld cx sent in ED. In ICU Given Zosyn one dose and started on\\n Zosyn and vancomycin. Breathing regularly on Oe NC 5 LPM (NRB D/Ced\\n upon arrival to ICU).\\n Response:\\n Afebrile, alert, opened eyes first to stimuli then spontaneously, not\\n following commands.\\n Plan:\\n sputum cx and urine cx to be sent, F/U on cx results, de clot the\\n fistula in Rt upper extremity and ? HD today, consult renal fellow,\\n contact family (daughters) prior to HD initiation, wean O2 as\\n tolerated..\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt in ESRD on HD MWF, anuric.\\n Action:\\n Failed to be dialyzed yesterday due to clotting of Fistula.\\n Response:\\n U/O 10-15 cc/shift.\\n Plan:\\n For HD today after consulting renal fellow to declot fistula, monitor\\n lytes and seria cardiac enzymes.l\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2171-09-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 538342,\n \"text\": \"Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\\n was found to have a clotted right AVF, MS change, oral temp of 105, and\\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\\n well. Of note, the patient was admitted to from for\\n altered mental status and hypoglycemia secondary to UTI treated with\\n ciprofloxacin. Discussing with patient's daughters, she has been\\n coughing frequently with meals at her nursing home, and has baseline\\n aphasia but is able to follow simple commands.\\n .\\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\\n was found to have a LLL infiltrate concerning for left basilar\\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\\n received 1L IVF, and was transferred to the for further\\n management.\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n T-max 105 at HD, 104.8 in EW. Pt w/ recent UTI as above. Pt afebrile\\n over noc s/p abx and Tylenol as above. Pt aphasic, though alert and\\n follows simple commands at baseline; although pt unresponsive on\\n arrival to EW. Pt w/ frequent coughing during meals at NH per report as\\n above. Pt also hypoxic w/ SpO2 84% on RA requiring NRB in EW.\\n Action:\\n temp and hemodynamic status. MS. \\n as ordered. Pt continues on vanc per HD protocol and has been started\\n on zosyn. Blood and urine cx pnd (U/A + for UTI). Pt NPO w/\\n speech/swallow eval pnd. FiO2 weaned to NC on arrival to .\\n respiratory status.\\n Response:\\n Pt remains afebrile. BP remains stable\\n see flowsheet. Pt now\\n arousable to voice/stimuli, MS improving t/o shift. Pt now following\\n commands, mouthing words and occasionally speaking. Pt\\ns daughters have\\n been in to visit. Pt requesting to eat, team in to discuss w/ pt and\\n family, including high risk for aspiration; however pt wishes to be\\n able to eat prior to speech/swallow eval., and daughters agree. Pt\\n ordered for ground solids, nectar thick liquids. WBC 9.6 down from 10.6\\n on admit. SpO2 remains >95% on O2 5L via NC. BBS CTA.\\n Plan:\\n Continue to monitor temp, hemodynamic status and resp. status. Follow\\n . Continue abx as ordered. F/U on culture data. Increase PO intake\\n as tolerated. Maintain aspiration precautions. Wean FiO2 as tolerated.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt on HD M/W/F. Fistula clotted as above. Pt unable to undergo HD .\\n BUN 40, Creat 4.2.\\n Action:\\n Renal to see pt. Temporary R femoral HD line placed. Pt underwent HD w/\\n 3.5L off.\\n Response:\\n Pt tolerated HD well.\\n Plan:\\n Pt to resume M/W/F HD schedule. Pt C/O to w/ plan for\\n possible repair of fistula on Monday.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2171-09-29 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 538391,\n \"text\": \"Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\\n was found to have a clotted right AVF, MS change, oral temp of 105, and\\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\\n well. Of note, the patient was admitted to from for\\n altered mental status and hypoglycemia secondary to UTI treated with\\n ciprofloxacin. Discussing with patient's daughters, she has been\\n coughing frequently with meals at her nursing home, and has baseline\\n aphasia but is able to follow simple commands.\\n .\\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\\n was found to have a LLL infiltrate concerning for left basilar\\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\\n received 1L IVF, and was transferred to the for further\\n management.\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n T-max 105 at HD, 104.8 in EW. Pt w/ recent UTI as above. Pt afebrile\\n over noc s/p abx and Tylenol as above. Pt aphasic, though alert and\\n follows simple commands at baseline; although pt unresponsive on\\n arrival to EW. Pt w/ frequent coughing during meals at NH per report as\\n above. Pt also hypoxic w/ SpO2 84% on RA requiring NRB in EW.\\n Presently, pt is alert, oriented to name and place, though aphacic but\\n mouthing words.\\n Action:\\n temp and hemodynamic status. MS. \\n as ordered. Pt continues on vanc per HD protocol and has been started\\n on zosyn. Blood and urine cx pnd (U/A + for UTI). Pt NPO w/\\n speech/swallow eval pnd. FiO2 weaned to NC on arrival to .\\n respiratory status.\\n Response:\\n Pt remains afebrile. BP remains stable\\n see flowsheet. Pt now\\n arousable to voice/stimuli; however, does not follow commands. SpO2\\n remains >95% on O2 5L via NC. BBS CTA.\\n Plan:\\n Continue to monitor temp, hemodynamic status and resp. status. Follow\\n . Continue abx as ordered. F/U on culture data. Continue NPO pnd\\n speech/swallow eval. Wean FiO2 as tolerated.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt on HD M/W/F. Fistula clotted as above. Pt unable to undergo HD .\\n BUN 40, Creat 4.2.\\n Action:\\n Renal to see pt. Plan to unclot fistula and HD on Monday\\n Response:\\n Renal c/s and intervention pnd. Femoral line inserted for HD.\\n Plan:\\n Plan HD once fistula unclotted or adequate access obtained.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n PNEUMONIA\\n Code status:\\n DNR / DNI\\n Height:\\n 60 Inch\\n Admission weight:\\n 65 kg\\n Daily weight:\\n Allergies/Reactions:\\n Morphine\\n Nausea/Vomiting\\n Precautions: Contact\\n PMH: Anemia, Diabetes - Insulin, HEMO or PD, Renal Failure\\n CV-PMH: CAD, CHF\\n Additional history: 3+ mitral regurg, goutm depression, GERD,\\n rheumatoid arthritis, hypercholesterolemia\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:134\\n D:65\\n Temperature:\\n 98.2\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 22 insp/min\\n Heart Rate:\\n 65 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 98% %\\n O2 flow:\\n 4 L/min\\n FiO2 set:\\n 24h total in:\\n 24h total out:\\n 40 mL\\n Pertinent Lab Results:\\n Sodium:\\n 139 mEq/L\\n 04:36 AM\\n Potassium:\\n 4.6 mEq/L\\n 04:36 AM\\n Chloride:\\n 100 mEq/L\\n 04:36 AM\\n CO2:\\n 27 mEq/L\\n 04:36 AM\\n BUN:\\n 27 mg/dL\\n 04:36 AM\\n Creatinine:\\n 3.7 mg/dL\\n 04:36 AM\\n Glucose:\\n 114 mg/dL\\n 04:36 AM\\n Hematocrit:\\n 35.7 %\\n 04:36 AM\\n Finger Stick Glucose:\\n 120\\n 06:00 AM\\n Valuables / Signature\\n Patient valuables: none\\n Other valuables: none\\n Clothes: Sent home with:\\n Wallet / Money: npne\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry: none\\n Transferred from: 412\\n Transferred to: 921\\n Date & time of Transfer: 10/5/08/ 0700\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2171-09-29 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 538442,\n \"text\": \"Chief Complaint: Obtundation\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n DIALYSIS CATHETER - START 01:00 PM\\n CALLED OUT\\n History obtained from Medical records\\n Patient unable to provide history: Confused\\n Allergies:\\n Morphine\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Metoprolol - 10:25 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Neurologic: hemiparesis\\n Signs or concerns for abuse : No\\n Flowsheet Data as of 12:05 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.2\\nC (99\\n Tcurrent: 37.2\\nC (99\\n HR: 76 (59 - 76) bpm\\n BP: 142/72(87) {112/39(57) - 142/72(87)} mmHg\\n RR: 23 (18 - 25) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 60 Inch\\n Total In:\\n 200 mL\\n 460 mL\\n PO:\\n 360 mL\\n TF:\\n IVF:\\n 200 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 3,525 mL\\n 40 mL\\n Urine:\\n 25 mL\\n 40 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,325 mL\\n 420 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///27/\\n Physical Examination\\n General Appearance: Well nourished\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : , Crackles : scattered)\\n Abdominal: No(t) Bowel sounds present, Distended\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\\n Clubbing\\n Musculoskeletal: Muscle wasting, Unable to stand\\n Skin: Warm\\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\\n Movement: Not assessed, Tone: Not assessed, hemi paresis\\n Labs / Radiology\\n 11.3 g/dL\\n 191 K/uL\\n 114 mg/dL\\n 3.7 mg/dL\\n 27 mEq/L\\n 4.6 mEq/L\\n 27 mg/dL\\n 100 mEq/L\\n 139 mEq/L\\n 35.7 %\\n 7.0 K/uL\\n [image002.jpg]\\n 02:01 AM\\n 11:08 AM\\n 04:36 AM\\n WBC\\n 9.6\\n 7.0\\n Hct\\n 34.0\\n 35.7\\n Plt\\n 174\\n 191\\n Cr\\n 4.2\\n 3.7\\n TropT\\n 0.17\\n 0.19\\n Glucose\\n 209\\n 114\\n Other labs: PT / PTT / INR:16.2/29.1/1.4, CK / CKMB /\\n Troponin-T:22/3/0.19, Differential-Neuts:78.9 %, Lymph:13.0 %, Mono:5.1\\n %, Eos:2.7 %, Albumin:3.2 g/dL, Ca++:9.7 mg/dL, Mg++:2.0 mg/dL, PO4:4.5\\n mg/dL\\n Assessment and Plan\\n Obtundation\\n UTI\\n ESRD\\n HD\\n Vascular Access\\n Much improved. More alert. Seems to be her ususal response to\\n infection. Vascular will try to salvage Fistula. Daughters suggest in\\n future comfort is their primary priority.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: DNR / DNI\\n Disposition :\\n Total time spent: 35 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2171-09-29 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 538411,\n \"text\": \"Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\\n was found to have a clotted right AVF, MS change, oral temp of 105, and\\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\\n well. Of note, the patient was admitted to from for\\n altered mental status and hypoglycemia secondary to UTI treated with\\n ciprofloxacin. Discussing with patient's daughters, she has been\\n coughing frequently with meals at her nursing home, and has baseline\\n aphasia but is able to follow simple commands.\\n .\\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\\n was found to have a LLL infiltrate concerning for left basilar\\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\\n received 1L IVF, and was transferred to the for further\\n management.\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n T-max 105 at HD, 104.8 in EW. Pt w/ recent UTI as above. Pt afebrile\\n over noc s/p abx and Tylenol as above. Pt aphasic, though alert and\\n follows simple commands at baseline; although pt unresponsive on\\n arrival to EW. Pt w/ frequent coughing during meals at NH per report as\\n above. Pt also hypoxic w/ SpO2 84% on RA requiring NRB in EW.\\n Presently, pt is alert, oriented to name and place, aphasic per\\n baseline but mouthing words and occasionally speaking a few words.\\n Action:\\n temp and hemodynamic status. MS. \\n as ordered. Pt continues on vanc per HD protocol and has been started\\n on zosyn. Blood and urine cx pnd (U/A + for UTI). Pt has been NPO w/\\n speech/swallow eval pnd; however, pt and family wish for pt to be able\\n to take PO intake despite high risk for aspiration. Risks discussed w/\\n pt and family by team yesterday and ground solids w/ nectar thick diet\\n was ordered. FiO2 weaned to NC on arrival to . \\n respiratory status.\\n Response:\\n Pt remains afebrile. BP remains stable\\n see flowsheet. Pt now\\n arousable to voice/stimuli; however, does not follow commands. SpO2\\n remains >95% on O2 5L via NC. BBS CTA. Pt lethargic and unable to take\\n PO intake after HD last noc.\\n Plan:\\n Continue to monitor temp, hemodynamic status and resp. status. Follow\\n . Continue abx as ordered. F/U on culture data. Increase PO intake\\n as able. Wean FiO2 as tolerated.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt on HD M/W/F. Fistula clotted as above. Pt unable to undergo HD .\\n BUN 40, Creat 4.2.\\n Action:\\n Pt seen by renal yesterday. R femoral temporary HD line placed and pt\\n received HD yesterday.\\n Response:\\n Pt tolerated HD line insertion and HD well yesterday.\\n Plan:\\n Plan for possible repair of AV fistula on Monday. Anticipate pt to\\n resume M/W/F HD schedule. Increase activity as tolerated.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n PNEUMONIA\\n Code status:\\n DNR / DNI\\n Height:\\n 60 Inch\\n Admission weight:\\n 65 kg\\n Daily weight:\\n Allergies/Reactions:\\n Morphine\\n Nausea/Vomiting\\n Precautions: Contact\\n PMH: Anemia, Diabetes - Insulin, HEMO or PD, Renal Failure\\n CV-PMH: CAD, CHF\\n Additional history: 3+ mitral regurg, goutm depression, GERD,\\n rheumatoid arthritis, hypercholesterolemia\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:134\\n D:65\\n Temperature:\\n 98.2\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 22 insp/min\\n Heart Rate:\\n 65 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 98% %\\n O2 flow:\\n 4 L/min\\n FiO2 set:\\n 24h total in:\\n 100 mL\\n 24h total out:\\n 40 mL\\n Pertinent Lab Results:\\n Sodium:\\n 139 mEq/L\\n 04:36 AM\\n Potassium:\\n 4.6 mEq/L\\n 04:36 AM\\n Chloride:\\n 100 mEq/L\\n 04:36 AM\\n CO2:\\n 27 mEq/L\\n 04:36 AM\\n BUN:\\n 27 mg/dL\\n 04:36 AM\\n Creatinine:\\n 3.7 mg/dL\\n 04:36 AM\\n Glucose:\\n 114 mg/dL\\n 04:36 AM\\n Hematocrit:\\n 35.7 %\\n 04:36 AM\\n Finger Stick Glucose:\\n 120\\n 06:00 AM\\n Valuables / Signature\\n Patient valuables: None\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: 412\\n Transferred to: 9\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2171-09-28 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 538186,\n \"text\": \"Chief Complaint: Mental status change, fever, and hypoxia\\n HPI:\\n Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\\n was found to have a clotted right AVF, MS change, oral temp of 105, and\\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\\n well. Of note, the patient was admitted to from for\\n altered mental status and hypoglycemia secondary to UTI treated with\\n ciprofloxacin. Discussing with patient's daughters, she has been\\n coughing frequently with meals at her nursing home, and has baseline\\n aphasia but is able to follow simple commands.\\n .\\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\\n to have a LLL infiltrate concerning for left basilar pneumonia versus\\n aspiration. She was treated with vancomycin and pip/tazo, received 1L\\n IVF, and was transferred to the .\\n Patient admitted from: ER\\n History obtained from Family / Medical records\\n Patient unable to provide history: Unresponsive\\n Allergies:\\n Morphine\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n -CAD, s/p \\\"silent MI\\\" per patient\\n -CHF, systolic dysfunction with EF 20%\\n -3+ mitral regurgitation, 3+ TR\\n -DM, type 2\\n -ESRD on HD\\n -Gout\\n -Depression\\n -GERD\\n -Rheumatoid arthritis\\n -Anemia\\n -Hypercholesterolemia\\n Multiple family members with DM II, otherwise non-contributory.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: Lives at nursing home. Has 6 children that live locally. Quit\\n smoking in the ; previously smoked approx 5cigs/day x30\\n years. Rare EtOH.\\n Review of systems:\\n Flowsheet Data as of 01:39 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 37\\nC (98.6\\n HR: 74 (74 - 74) bpm\\n BP: 156/46(71) {156/46(71) - 156/46(71)} mmHg\\n RR: 24 (24 - 24) insp/min\\n SpO2: 100%\\n Height: 60 Inch\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 10 mL\\n Urine:\\n 10 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -10 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 100%\\n Physical Examination\\n Gen: Opens eyes to stimuli, unable to follow commands\\n HEENT: Perrl, MM dry, neck supple\\n Pulm: Bibasilar rales\\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\\n Abd: S/NT/ND, +bs\\n Ext: 2+ dp b/l, trace edema. Right AVF without signs of erythema\\n Neuro: Patient non-verbal\\n Labs / Radiology\\n 241\\n 12.2\\n 186\\n 4.2\\n 36\\n 31\\n 90\\n 4.2\\n 136\\n 38.9\\n 10.6\\n [image002.jpg]\\n Imaging: CXR: 1. Cardiomegaly with mild pulmonary edema.\\n 2. New left basilar opacity concerning for pneumonia or aspiration.\\n .\\n CTH: No acute intracranial pathology. MRI more sensitive for ischemia.\\n .\\n CTAP: 1. Slightly limited examination due to patient positioning and\\n lack of oral contrast. No intra-abdominal source for infection\\n identified.\\n 2. Patchy right middle and lower lobe opacities, some which are clearly\\n compression atelectasis and others of which are suspicious for regions\\n of pneumonia or aspiration. Small right effusion.\\n 3. Extensive calcified atherosclerotic vascular disease.\\n 4. Slight interval decrease in possible exophytic right-sided fibroid.\\n Please note it is atypical for the fibroid to not have involuted more\\n in a patient of this age. If alteration in care will occur, can\\n consider further evaluation with a dedicated pelvic ultrasound and/or\\n MRI as no dedicated pelvic imaging of this lesion is noted at .\\n Microbiology: Blood cultures - pending\\n Urine cultures - pending\\n ECG: NSR, old LBBB,interventricular conduction delay\\n Assessment and Plan\\n Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\\n hypoxia.\\n .\\n # Fever, mental status change: Patient with acute mental status change\\n and fever. Patient was reported to have been hypoxic at outpatient HD\\n with vomiting, and has history per family of coughing while eating.\\n Given degree of fever, this is unlikely to be a chemical pneumonitis\\n and more likely to represent a HA-pneumonia. She also has a urinalysis\\n with significant pyuria although with 3-5 epi, with recent admission\\n for UTI (urine cultures negative).\\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\\n - Follow urine and blood cultures, repeat UA and culture\\n - Sputum cultures\\n - Check Legionella urinary antigen\\n - Wean supplemental O2\\n .\\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\\n secondary to fever, mental status change, and clotted AVF. Discussed\\n with renal fellow, and plan for dialysis tomorrow.\\n - Renally dose all meds\\n .\\n # CAD: Continue digoxin, ASA, plavix.\\n .\\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\\n .\\n # DM type II: RISS\\n .\\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\\n as if patient has had elevated transaminase since 3/.\\n - Trend LFTs\\n .\\n # Gout: Continue allopurinol\\n .\\n # Psych: Continue\\n .\\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\\n .\\n # PPx: Heparin sq, famotidine\\n .\\n # Code: DNR/DNI (confirmed with family including HCP)\\n .\\n # Lines: PIV, FC\\n .\\n # Dispo: ICU level of care for now.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 12:09 AM\\n 20 Gauge - 12:10 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2171-09-28 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 538188,\n \"text\": \"Chief Complaint: Mental status change, fever, and hypoxia\\n HPI:\\n Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\\n was found to have a clotted right AVF, MS change, oral temp of 105, and\\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\\n well. Of note, the patient was admitted to from for\\n altered mental status and hypoglycemia secondary to UTI treated with\\n ciprofloxacin. Discussing with patient's daughters, she has been\\n coughing frequently with meals at her nursing home, and has baseline\\n aphasia but is able to follow simple commands.\\n .\\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\\n to have a LLL infiltrate concerning for left basilar pneumonia versus\\n aspiration. She was treated with vancomycin and pip/tazo, received 1L\\n IVF, and was transferred to the .\\n Patient admitted from: ER\\n History obtained from Family / Medical records\\n Patient unable to provide history: Unresponsive\\n Allergies:\\n Morphine\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n -CAD, s/p \\\"silent MI\\\" per patient\\n -CHF, systolic dysfunction with EF 20%\\n -3+ mitral regurgitation, 3+ TR\\n -DM, type 2\\n -ESRD on HD\\n -Gout\\n -Depression\\n -GERD\\n -Rheumatoid arthritis\\n -Anemia\\n -Hypercholesterolemia\\n Multiple family members with DM II, otherwise non-contributory.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: Lives at nursing home. Has 6 children that live locally. Quit\\n smoking in the ; previously smoked approx 5cigs/day x30\\n years. Rare EtOH.\\n Review of systems:\\n Flowsheet Data as of 01:39 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 37\\nC (98.6\\n HR: 74 (74 - 74) bpm\\n BP: 156/46(71) {156/46(71) - 156/46(71)} mmHg\\n RR: 24 (24 - 24) insp/min\\n SpO2: 100%\\n Height: 60 Inch\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 10 mL\\n Urine:\\n 10 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -10 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 100%\\n Physical Examination\\n Gen: Opens eyes to stimuli, unable to follow commands\\n HEENT: Perrl, MM dry, neck supple\\n Pulm: Bibasilar rales\\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\\n Abd: S/NT/ND, +bs\\n Ext: 2+ dp b/l, trace edema. Right AVF without signs of erythema\\n Neuro: Patient non-verbal\\n Labs / Radiology\\n 241\\n 12.2\\n 186\\n 4.2\\n 36\\n 31\\n 90\\n 4.2\\n 136\\n 38.9\\n 10.6\\n [image002.jpg]\\n Imaging: CXR: 1. Cardiomegaly with mild pulmonary edema.\\n 2. New left basilar opacity concerning for pneumonia or aspiration.\\n .\\n CTH: No acute intracranial pathology. MRI more sensitive for ischemia.\\n .\\n CTAP: 1. Slightly limited examination due to patient positioning and\\n lack of oral contrast. No intra-abdominal source for infection\\n identified.\\n 2. Patchy right middle and lower lobe opacities, some which are clearly\\n compression atelectasis and others of which are suspicious for regions\\n of pneumonia or aspiration. Small right effusion.\\n 3. Extensive calcified atherosclerotic vascular disease.\\n 4. Slight interval decrease in possible exophytic right-sided fibroid.\\n Please note it is atypical for the fibroid to not have involuted more\\n in a patient of this age. If alteration in care will occur, can\\n consider further evaluation with a dedicated pelvic ultrasound and/or\\n MRI as no dedicated pelvic imaging of this lesion is noted at .\\n Microbiology: Blood cultures - pending\\n Urine cultures - pending\\n ECG: NSR, old LBBB,interventricular conduction delay\\n Assessment and Plan\\n Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\\n hypoxia.\\n .\\n # Fever, mental status change: Patient with acute mental status change\\n and fever. Patient was reported to have been hypoxic at outpatient HD\\n with vomiting, and has history per family of coughing while eating.\\n Given degree of fever, this is unlikely to be a chemical pneumonitis\\n and more likely to represent a HA-pneumonia. She also has a urinalysis\\n with significant pyuria although with 3-5 epi, with recent admission\\n for UTI (urine cultures negative).\\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\\n - Follow urine and blood cultures, repeat UA and culture\\n - Sputum cultures\\n - Check Legionella urinary antigen\\n - Wean supplemental O2\\n .\\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\\n secondary to fever, mental status change, and clotted AVF. Discussed\\n with renal fellow, and plan for dialysis tomorrow.\\n - Renally dose all meds\\n .\\n # CAD: Continue digoxin, ASA, plavix.\\n .\\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\\n .\\n # DM type II: RISS\\n .\\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\\n as if patient has had elevated transaminase since 3/.\\n - Trend LFTs\\n .\\n # Gout: Continue allopurinol\\n .\\n # Psych: Continue wellbutrin and prozac.\\n .\\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\\n .\\n # PPx: Heparin sq, famotidine\\n .\\n # Code: DNR/DNI (confirmed with family including HCP)\\n .\\n # Lines: PIV, FC\\n .\\n # Dispo: ICU level of care for now.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 12:09 AM\\n 20 Gauge - 12:10 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2171-09-28 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 538257,\n \"text\": \"Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\\n was found to have a clotted right AVF, MS change, oral temp of 105, and\\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\\n well. Of note, the patient was admitted to from for\\n altered mental status and hypoglycemia secondary to UTI treated with\\n ciprofloxacin. Discussing with patient's daughters, she has been\\n coughing frequently with meals at her nursing home, and has baseline\\n aphasia but is able to follow simple commands.\\n .\\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\\n was found to have a LLL infiltrate concerning for left basilar\\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\\n received 1L IVF, and was transferred to the for further\\n management.\\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\\n Assessment:\\n T-max 105 at HD, 104.8 in EW. Pt w/ recent UTI as above. Pt afebrile\\n over noc s/p abx and Tylenol as above. Pt aphasic, though alert and\\n follows simple commands at baseline; although pt unresponsive on\\n arrival to EW. Pt w/ frequent coughing during meals at NH per report as\\n above. Pt also hypoxic w/ SpO2 84% on RA requiring NRB in EW.\\n Action:\\n temp and hemodynamic status. MS. \\n as ordered. Pt continues on vanc per HD protocol and has been started\\n on zosyn. Blood and urine cx pnd (U/A + for UTI). Pt NPO w/\\n speech/swallow eval pnd. FiO2 weaned to NC on arrival to .\\n respiratory status.\\n Response:\\n Pt remains afebrile. BP remains stable\\n see flowsheet. Pt now\\n arousable to voice/stimuli; however, does not follow commands. WBC 9.6\\n down from 10.6 on admit. SpO2 remains >95% on O2 5L via NC. BBS CTA.\\n Plan:\\n Continue to monitor temp, hemodynamic status and resp. status. Follow\\n . Continue abx as ordered. F/U on culture data. Continue NPO pnd\\n speech/swallow eval. Wean FiO2 as tolerated.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt on HD M/W/F. Fistula clotted as above. Pt unable to undergo HD .\\n BUN 40, Creat 4.2.\\n Action:\\n Renal to see pt. Plan to unclot fistula and HD today.\\n Response:\\n Renal c/s and intervention pnd.\\n Plan:\\n Plan HD once fistula unclotted or adequate access obtained.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2171-09-28 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 538280,\n \"text\": \"Clinician: Attending\\n Critical Care\\n Remains profoundly obtunded which occurs each time she develops an\\n infection. I think likelihood of meningitis is low so will continue to\\n cover broadly but not for CNS infection. CXR is difficult to read but I\\n am not convinced she has pneumonia. CHF is currently in good control.\\n Total time spent: 35 minutes\\n Patient is critically ill.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2171-09-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 538288,\n \"text\": \"Chief Complaint: Fever, hypoxia, mental status change\\n 24 Hour Events:\\n - No acute events overnight.\\n Allergies:\\n Morphine\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 01:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:33 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.8\\nC (98.2\\n HR: 69 (65 - 74) bpm\\n BP: 114/60(73) {84/44(58) - 156/71(76)} mmHg\\n RR: 22 (21 - 24) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 60 Inch\\n Total In:\\n 100 mL\\n PO:\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 25 mL\\n Urine:\\n 25 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 75 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///30/\\n Physical Examination\\n Gen: Opens eyes to stimuli, unable to follow commands\\n HEENT: Perrl, MM dry, neck supple\\n Pulm: Bibasilar rales\\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\\n Abd: S/NT/ND, +bs\\n Ext: 2+ dp b/l, trace edema. Right AVG without signs of erythema\\n Neuro: Patient non-verbal\\n Labs / Radiology\\n 174 K/uL\\n 11.0 g/dL\\n 209 mg/dL\\n 4.2 mg/dL\\n 30 mEq/L\\n 4.2 mEq/L\\n 40 mg/dL\\n 90 mEq/L\\n 135 mEq/L\\n 34.0 %\\n 9.6 K/uL\\n [image002.jpg]\\n 02:01 AM\\n WBC\\n 9.6\\n Hct\\n 34.0\\n Plt\\n 174\\n Cr\\n 4.2\\n TropT\\n 0.17\\n Glucose\\n 209\\n Other labs: PT / PTT / INR:16.2/29.1/1.4, CK / CKMB /\\n Troponin-T:21/3/0.17, Albumin:3.2 g/dL, Ca++:9.8 mg/dL, Mg++:2.0 mg/dL,\\n PO4:4.5 mg/dL\\n Assessment and Plan\\n Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\\n hypoxia.\\n .\\n # Fever, mental status change: Patient with acute mental status change\\n and fever. Patient was reported to have been hypoxic at outpatient HD\\n with vomiting, and has history per family of coughing while eating.\\n Given degree of fever, this is unlikely to be a chemical pneumonitis\\n and more likely to represent a HA-pneumonia, although her CXR is\\n underwhelming for a significant consolidation. She also has a\\n urinalysis with significant pyuria although with 3-5 epi, with recent\\n admission for UTI (urine cultures negative). Low suspicion at this\\n time for meningitis, and patient\\ns HCP has repeatedly refused LP on\\n past admissions for similar presentation, but will check with family\\n regarding LP. Will hold off on empiric treatment of meningitis for\\n now.\\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\\n - Follow urine and blood cultures, repeat UA and culture\\n - Sputum cultures\\n - Check Legionella urinary antigen\\n - Wean supplemental O2\\n .\\n # ESRD: Patient on MWF HD. Did not receive outpatient HD yesterday\\n secondary to fever, mental status change, and clotted AVF. Discussed\\n with renal fellow, and plan for dialysis today.\\n - Renally dose all meds\\n - f/u with renal transplant regarding AVG\\n .\\n # CAD: Continue digoxin, ASA, plavix. Initial set of cardiac enzymes\\n with troponin slightly elevated but a recent baseline with flat CK.\\n - CCE\\n .\\n # CHF: BB and ACE-I held on admission. Patient hemodynamically stable\\n overnight, will restart today.\\n .\\n # DM type II: RISS\\n .\\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\\n as if patient has had elevated transaminase since 3/.\\n - Trend LFTs\\n .\\n # Gout: Continue allopurinol\\n .\\n # Psych: Continue wellbutrin and prozac.\\n .\\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\\n .\\n # PPx: Heparin sq, famotidine\\n .\\n # Code: DNR/DNI (confirmed with family including HCP)\\n .\\n # Lines: PIV, FC\\n .\\n # Dispo: Call out today.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 12:09 AM\\n 20 Gauge - 12:10 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2171-09-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 538266,\n \"text\": \"Chief Complaint: Fever, hypoxia, mental status change\\n 24 Hour Events:\\n - No acute events overnight.\\n Allergies:\\n Morphine\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 01:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:33 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.8\\nC (98.2\\n HR: 69 (65 - 74) bpm\\n BP: 114/60(73) {84/44(58) - 156/71(76)} mmHg\\n RR: 22 (21 - 24) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 60 Inch\\n Total In:\\n 100 mL\\n PO:\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 25 mL\\n Urine:\\n 25 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 75 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///30/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 174 K/uL\\n 11.0 g/dL\\n 209 mg/dL\\n 4.2 mg/dL\\n 30 mEq/L\\n 4.2 mEq/L\\n 40 mg/dL\\n 90 mEq/L\\n 135 mEq/L\\n 34.0 %\\n 9.6 K/uL\\n [image002.jpg]\\n 02:01 AM\\n WBC\\n 9.6\\n Hct\\n 34.0\\n Plt\\n 174\\n Cr\\n 4.2\\n TropT\\n 0.17\\n Glucose\\n 209\\n Other labs: PT / PTT / INR:16.2/29.1/1.4, CK / CKMB /\\n Troponin-T:21/3/0.17, Albumin:3.2 g/dL, Ca++:9.8 mg/dL, Mg++:2.0 mg/dL,\\n PO4:4.5 mg/dL\\n Assessment and Plan\\n Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\\n hypoxia.\\n .\\n # Fever, mental status change: Patient with acute mental status change\\n and fever. Patient was reported to have been hypoxic at outpatient HD\\n with vomiting, and has history per family of coughing while eating.\\n Given degree of fever, this is unlikely to be a chemical pneumonitis\\n and more likely to represent a HA-pneumonia. She also has a urinalysis\\n with significant pyuria although with 3-5 epi, with recent admission\\n for UTI (urine cultures negative).\\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\\n - Follow urine and blood cultures, repeat UA and culture\\n - Sputum cultures\\n - Check Legionella urinary antigen\\n - Wean supplemental O2\\n .\\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\\n secondary to fever, mental status change, and clotted AVF. Discussed\\n with renal fellow, and plan for dialysis tomorrow.\\n - Renally dose all meds\\n .\\n # CAD: Continue digoxin, ASA, plavix. Initial set of cardiac enzymes\\n with troponin slightly elevated but a recent baseline with flat CK.\\n - CCE\\n .\\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\\n .\\n # DM type II: RISS\\n .\\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\\n as if patient has had elevated transaminase since 3/.\\n - Trend LFTs\\n .\\n # Gout: Continue allopurinol\\n .\\n # Psych: Continue wellbutrin and prozac.\\n .\\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\\n .\\n # PPx: Heparin sq, famotidine\\n .\\n # Code: DNR/DNI (confirmed with family including HCP)\\n .\\n # Lines: PIV, FC\\n .\\n # Dispo: ICU level of care for now.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 12:09 AM\\n 20 Gauge - 12:10 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2171-09-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 538267,\n \"text\": \"Chief Complaint: Fever, hypoxia, mental status change\\n 24 Hour Events:\\n - No acute events overnight.\\n Allergies:\\n Morphine\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 01:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:33 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 36.8\\nC (98.2\\n HR: 69 (65 - 74) bpm\\n BP: 114/60(73) {84/44(58) - 156/71(76)} mmHg\\n RR: 22 (21 - 24) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 60 Inch\\n Total In:\\n 100 mL\\n PO:\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 25 mL\\n Urine:\\n 25 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 75 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///30/\\n Physical Examination\\n Gen: Opens eyes to stimuli, unable to follow commands\\n HEENT: Perrl, MM dry, neck supple\\n Pulm: Bibasilar rales\\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\\n Abd: S/NT/ND, +bs\\n Ext: 2+ dp b/l, trace edema. Right AVF without signs of erythema\\n Neuro: Patient non-verbal\\n Labs / Radiology\\n 174 K/uL\\n 11.0 g/dL\\n 209 mg/dL\\n 4.2 mg/dL\\n 30 mEq/L\\n 4.2 mEq/L\\n 40 mg/dL\\n 90 mEq/L\\n 135 mEq/L\\n 34.0 %\\n 9.6 K/uL\\n [image002.jpg]\\n 02:01 AM\\n WBC\\n 9.6\\n Hct\\n 34.0\\n Plt\\n 174\\n Cr\\n 4.2\\n TropT\\n 0.17\\n Glucose\\n 209\\n Other labs: PT / PTT / INR:16.2/29.1/1.4, CK / CKMB /\\n Troponin-T:21/3/0.17, Albumin:3.2 g/dL, Ca++:9.8 mg/dL, Mg++:2.0 mg/dL,\\n PO4:4.5 mg/dL\\n Assessment and Plan\\n Mrs. is a 72 year old female with a PMH significant for ESRD on\\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\\n hypoxia.\\n .\\n # Fever, mental status change: Patient with acute mental status change\\n and fever. Patient was reported to have been hypoxic at outpatient HD\\n with vomiting, and has history per family of coughing while eating.\\n Given degree of fever, this is unlikely to be a chemical pneumonitis\\n and more likely to represent a HA-pneumonia. She also has a urinalysis\\n with significant pyuria although with 3-5 epi, with recent admission\\n for UTI (urine cultures negative).\\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\\n - Follow urine and blood cultures, repeat UA and culture\\n - Sputum cultures\\n - Check Legionella urinary antigen\\n - Wean supplemental O2\\n .\\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\\n secondary to fever, mental status change, and clotted AVF. Discussed\\n with renal fellow, and plan for dialysis tomorrow.\\n - Renally dose all meds\\n .\\n # CAD: Continue digoxin, ASA, plavix. Initial set of cardiac enzymes\\n with troponin slightly elevated but a recent baseline with flat CK.\\n - CCE\\n .\\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\\n .\\n # DM type II: RISS\\n .\\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\\n as if patient has had elevated transaminase since 3/.\\n - Trend LFTs\\n .\\n # Gout: Continue allopurinol\\n .\\n # Psych: Continue wellbutrin and prozac.\\n .\\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\\n .\\n # PPx: Heparin sq, famotidine\\n .\\n # Code: DNR/DNI (confirmed with family including HCP)\\n .\\n # Lines: PIV, FC\\n .\\n # Dispo: ICU level of care for now.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 12:09 AM\\n 20 Gauge - 12:10 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-09-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037944,\n \"text\": \" 4:33 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please evaluate for interval change\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with ?LLB pneumonia\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 2:50 PM\\n Unchanged left lower lobe consolidation. Band-like atelectasis in the right\\n base is new.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Followup left lower lobe pneumonia.\\n\\n Left lower lobe consolidation is persistent and unchanged. Band-like\\n atelectasis in the right base is new. There is no pneumothorax. If any,\\n bilateral small pleural effusions are unchanged, greater on the left side.\\n Cardiomegaly is stable.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-09-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037945,\n \"text\": \", MED 4:33 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please evaluate for interval change\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with ?LLB pneumonia\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n Unchanged left lower lobe consolidation. Band-like atelectasis in the right\\n base is new.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-09-29 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1038047,\n \"text\": \", A. MED FA9A 2:21 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o SAH, SDH, hemorrhage, ischemia\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with ESRD on HD, DM II p/w fever, AMS, was resolving but now\\n obtunded.\\n REASON FOR THIS EXAMINATION:\\n r/o SAH, SDH, hemorrhage, ischemia\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n No acute intracranial pathology.\\n DFDkq\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-09-29 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1038046,\n \"text\": \" 2:21 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o SAH, SDH, hemorrhage, ischemia\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with ESRD on HD, DM II p/w fever, AMS, was resolving but now\\n obtunded.\\n REASON FOR THIS EXAMINATION:\\n r/o SAH, SDH, hemorrhage, ischemia\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr SUN 4:25 PM\\n No acute intracranial pathology.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72-year-old woman with acute mental status change and fever.\\n\\n Comparison is made to , and .\\n\\n NONCONTRAST HEAD CT: No edema, mass effect, acute hemorrhage, or evidence of\\n a major vascular territorial infarction. Marked enlargement of the\\n ventricles, out of proportion to the enlargement of the sulci, is unchanged\\n since . Diffuse periventricular white matter hypodensities are\\n consistent with a small vessel disease, unchanged. The visualized part of the\\n paranasal sinuses and mastoid air cells are clear.\\n\\n IMPRESSION:\\n 1. No evidence of acute intracranial abnormalities.\\n\\n 2. Unchanged marked enlargement of the ventricles since , out of\\n proportion to the enlargement of the sulci, which may be related to central\\n atrophy or normal-pressure hydrocephalus. Clinical correlation is advised.\\n DFDkq\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-03 00:00:00.000\",\n \"description\": \"TUNNELED W/O PORT\",\n \"row_id\": 1038997,\n \"text\": \" 1:55 PM\\n TUNNELLED CATH PLACE SCH Clip # \\n Reason: needs HD tunneled catheter.\\n Admitting Diagnosis: PNEUMONIA\\n ********************************* CPT Codes ********************************\\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\\n * US GUID FOR VAS. ACCESS *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with ESRD on HD a/w AMS, thrombosed RUE AVF s/p failed\\n revision by transplant surgery yesterday.\\n REASON FOR THIS EXAMINATION:\\n needs HD tunneled catheter.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72-year-old female with end-stage renal disease on hemodialysis,\\n status post failed revision of right upper extremity AV fistula. Please place\\n tunneled hemodialysis catheter.\\n\\n RADIOLOGISTS: Dr. and attending radiologist, Dr. , who was\\n present and supervised the entire procedure.\\n\\n FINDINGS AND PROCEDURE: The risks and benefits of the procedure were\\n explained to the patient and informed consent was obtained. The patient was\\n placed supine on the angiographic table and the left neck and chest were\\n prepped and draped in standard sterile fashion. A preprocedure timeout was\\n performed to identify the patient by name, medical record number, date of\\n birth and the nature of the procedure to be performed.\\n\\n Using ultrasound guidance, the left internal jugular vein was accessed with a\\n 21-gauge needle. Ultrasound images before and after venopuncture were\\n obtained. A 0.018 wire was then placed through the needle into the SVC under\\n fluoroscopic guidance. The needle was exchanged for a 4.5 French\\n micropuncture sheath. The wire was subsequently exchanged for a 0.035 \\n wire, the tip of which was positioned in the inferior vena cava under\\n fluoroscopic guidance. Following this, attention was directed to the\\n construction of the tunnel, which was performed using blunt dissection and\\n administration of 10 cc of 1% lidocaine with epinephrine. Once the catheter\\n was tunneled, a 15.5 French peel-away sheath was then placed over the wire.\\n The wire and inner dilator were removed. The catheter was advanced through\\n the peel-away sheath and sheath removed.\\n\\n The neck incision was closed with a 4-0 Vicryl suture. Lumens of the catheter\\n were flushed and heplocked, and the line was secured to the skin with two silk\\n sutures. Sterile dressing was applied. Final fluoroscopic image of the chest\\n demonstrates the tip of the catheter to be located in the right atrium. There\\n were no immediate complications.\\n\\n Moderate sedation was provided by administering divided doses of fentanyl (25\\n mcg) throughout the total intra-service time of 55 minutes, during which the\\n patient's hemodynamic parameters were continuously monitored.\\n\\n (Over)\\n\\n 1:55 PM\\n TUNNELLED CATH PLACE SCH Clip # \\n Reason: needs HD tunneled catheter.\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n IMPRESSION: Successful placement of a left internal jugular 23 cm tip-to-cuff\\n dual-lumen angiodynamics hemodialysis catheter with the tip located in the\\n right atrium. The line is ready to use.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-09-29 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 1038067,\n \"text\": \" 6:05 PM\\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \\n Reason: r/o encephalitis, ischemia\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with ESRD on HD, DM II a/w MS change and fevers. Now with\\n obtundation.\\n REASON FOR THIS EXAMINATION:\\n r/o encephalitis, ischemia\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl MON 3:14 PM\\n Irregularity of left greater than right MCA branch vessels. Differential\\n diagnoses include vasculitis, meningitis, or atheromatous change. Cerebral\\n atrophy, with ventricular enlargement. There is no obstruction, although\\n communicating hydrocephalus cannot be excluded.\\n ______________________________________________________________________________\\n FINAL REPORT\\n MRI AND MRA OF THE BRAIN.\\n\\n HISTORY: 72-year-old woman with end-stage renal disease on hemodialysis,\\n diabetes type 2, with mental status change and fevers. Now with obtundation.\\n Rule out encephalitis or ischemia.\\n\\n COMPARISON: Head CTs, , and .\\n\\n TECHNIQUE: Multiplanar brain MR was obtained without the administration of\\n intravenous gadolinium. Three-dimensional time-of-flight MR arteriography was\\n performed.\\n\\n FINDINGS:\\n MRI OF THE BRAIN:\\n There is no evidence of hemorrhage, edema, masses, mass effect or infarction.\\n No diffusion abnormalities are detected. The ventricles are enlarged,\\n somewhat out of proportion to the degree of atrophy, but unchanged in\\n comparison to , and without evidence of obstruction. There are\\n changes consistent with mild small vessel occlusive disease.\\n\\n MRA OF THE BRAIN: There is irregularity of branches of the middle cerebral\\n arteries, right greater than left. However, there is no evidence of\\n occlusion. The intracranial vertebral internal carotid arteries and vertebral\\n arteries and their branches are normal, without evidence of stenosis,\\n occlusion, or aneurysm.\\n\\n IMPRESSION:\\n 1. Irregularity of MCA branch vessels, right greater than left. The\\n differential diagnosis includes vasculitis and meningitis. Considerations\\n also include atheromatous change, although the location and appearance is\\n atypical for atheromatous change.\\n 2. Ventricular enlargement, without evidence of obstruction. However,\\n communicating hydrocephalus cannot be excluded.\\n\\n (Over)\\n\\n 6:05 PM\\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \\n Reason: r/o encephalitis, ischemia\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n Findings were discussed with Dr. on at 11:00 a.m.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-09-29 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 1038068,\n \"text\": \", A. MED FA9A 6:05 PM\\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \\n Reason: r/o encephalitis, ischemia\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with ESRD on HD, DM II a/w MS change and fevers. Now with\\n obtundation.\\n REASON FOR THIS EXAMINATION:\\n r/o encephalitis, ischemia\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n Irregularity of left greater than right MCA branch vessels. Differential\\n diagnoses include vasculitis, meningitis, or atheromatous change. Cerebral\\n atrophy, with ventricular enlargement. There is no obstruction, although\\n communicating hydrocephalus cannot be excluded.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-09-27 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 1037721,\n \"text\": \" 7:13 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: eval for intraabdominal process as source of fever/N/V\\n Field of view: 40 Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with ESRD on HD p/w N/V too altered for abd exam to be\\n significant\\n REASON FOR THIS EXAMINATION:\\n eval for intraabdominal process as source of fever/N/V\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JKPe FRI 9:10 PM\\n no abdominal source for fever. mild free fluid in pelvis, stable to slight\\n decrease in size to presumed fibroid. patchy lower lobe opacities may\\n represent pna/pneumonitis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Fever of 105, worsening mental status. Patient with end-stage renal\\n disease on hemodialysis:\\n\\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\\n pelvis with IV contrast only. Oral contrast was not administered due to\\n inability to tolerate p.o. and timid airway preventing OGT.\\n\\n Comparison is made to CT examination and CT\\n examination.\\n\\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST ONLY: Limited evaluation of lung\\n bases displays scattered regions of ground-glass opacity noted within the\\n right middle lobe and lower lobes bilaterally as well as more streaky linear\\n opacities at the left base and a small simple right pleural effusion with\\n adjacent compression atelectasis. Heart size is enlarged. No pericardial\\n effusion is identified. The liver, spleen with small calcified granulomas,\\n stomach, small bowel, atrophic-appearing pancreas, atrophic-appearing kidneys,\\n and adrenal glands appear unremarkable. There is extensive vascular\\n calcification noted within the aorta and all branch vessels. No free air,\\n free fluid or pathologically enlarged lymph nodes are identified within the\\n abdominal cavity.\\n\\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST ONLY: Air is noted within a Foley-\\n containing urinary bladder. The uterus is again noted to be enlarged with an\\n exophytic low attenuation heterogeneous mass again noted to extend off the\\n right fundal region measuring approximately 4.8 x 5.5 cm, slightly decreased\\n in size from where it measured 5.6 x 6.9 cm but stable from . A\\n mild- to- moderate amount of simple free fluid is noted within the pelvic\\n cavity. Intrapelvic bowel and Foley-containing urinary bladder appear normal.\\n Incidentally noted is a fat- containing right inguinal hernia.\\n\\n BONE WINDOWS: No malignant-appearing osseous lesions are identified. Mild\\n degenerative disc disease noted at L5-S1 and multiple left-sided rib fractures\\n are unchanged.\\n\\n (Over)\\n\\n 7:13 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: eval for intraabdominal process as source of fever/N/V\\n Field of view: 40 Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n IMPRESSION:\\n\\n 1. Slightly limited examination due to patient positioning and lack of oral\\n contrast. No intra-abdominal source for infection identified.\\n\\n 2. Patchy right middle and lower lobe opacities, some which are clearly\\n compression atelectasis and others of which are suspicious for regions of\\n pneumonia or aspiration. Small right effusion.\\n\\n 3. Extensive calcified atherosclerotic vascular disease.\\n\\n 4. Slight interval decrease in possible exophytic right-sided fibroid. Please\\n note it is atypical for the fibroid to not have involuted more in a patient of\\n this age. If alteration in care will occur, can consider further evaluation\\n with a dedicated pelvic ultrasound and/or MRI as no dedicated pelvic imaging\\n of this lesion is noted at .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-09-27 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1037722,\n \"text\": \" 7:13 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for ICH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with acute change in MS w/ N/V and febrile no visible signs\\n of head trauma\\n REASON FOR THIS EXAMINATION:\\n eval for ICH\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JKPe FRI 8:54 PM\\n no acute pathology, stable\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Fever up to 105 with decline in mental status.\\n\\n Comparison is made to , examination.\\n\\n NON-CONTRAST HEAD CT\\n\\n FINDINGS: There is no evidence of intracranial hemorrhage, mass effect, shift\\n of midline structures, hydrocephalus, or acute major vascular territorial\\n infarct. -white matter differentiation appears well preserved. Extensive\\n periventricular white matter hypoattenuating changes, most marked within the\\n right centrum semiovale is stable as is central atrophy. Right\\n basal ganglia calcifications again noted. Attenuation of the lenses\\n bilaterally is consistent with prior cataract surgery. No other soft tissue\\n abnormalities are identified. Bony structures are unremarkable, and the\\n mastoid air cells and paranasal sinuses are well aerated. Atherosclerotic\\n calcifications are noted within the carotid siphons bilaterally.\\n\\n IMPRESSION:\\n\\n No acute intracranial pathology. MRI more sensitive for ischemia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-09-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037715,\n \"text\": \" 6:53 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for cardiopulm process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with ESRD on HD p/w N/V and hypoxia likely aspiration\\n REASON FOR THIS EXAMINATION:\\n eval for cardiopulm process\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: End-stage renal disease on hemodialysis with nausea, vomiting,\\n and hypoxia. Possibly aspiration.\\n\\n COMPARISON: Chest radiographs of .\\n\\n UPRIGHT AP VIEW OF THE CHEST: Cardiomegaly is unchanged from the previous\\n exam. There is calcification of the aortic knob. Increased interstitial\\n markings are demonstrated bilaterally, compatible with minimal interstitial\\n edema. A new left basilar opacity is present, which could represent\\n aspiration or infection. Small left pleural effusion may be present. The\\n right lung otherwise is grossly clear without focal consolidation or pleural\\n effusion. No pneumothorax. Known left-sided healed rib fractures are not as\\n well seen on the current examination.\\n\\n IMPRESSION:\\n\\n 1. Cardiomegaly with mild pulmonary edema.\\n\\n 2. New left basilar opacity concerning for pneumonia or aspiration.\\n\\n\\n DFDdp\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-09-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 134606,\n \"text\": \"Sinus rhythm\\nLeft axis deviation\\nLeft bundle branch block\\nTall T waves - consider acute ischemia or hyperkalemia\\nSince previous tracing of , ST-T wave abnormalities more marked\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-09-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 134607,\n \"text\": \"Sinus rhythm. The P-R interval is prolonged. Left axis deviation.\\nLeft bundle-branch block. Compared to the previous tracing the axis has\\nshifted.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 134608,\n \"text\": \"Artifact is present. Sinus rhythm. Indeterminate axis. Left bundle-branch\\nblock. Compared to the previous tracing there is no significant change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 134609,\n \"text\": \"Sinus rhythm. Intraventricular conduction delay of left bundle-branch block\\ntype. Compared to the previous tracing of there is no significant\\ndiagnostic change.\\n\\n\"\n }\n]"}}},{"rowIdx":83,"cells":{"subject_id":{"kind":"number","value":23317,"string":"23,317"},"hadm_id":{"kind":"number","value":143562,"string":"143,562"},"target_text":{"kind":"string","value":"54 yo M w/ETOH cirrhosis, portal vein thrombus, DM, ARF p/w ascites, hepatic encephalopathy and w/u for liver transplant . # CIRRHOSIS: Patient's cirrhosis most likely secondary to alcohol and patient was admitted with multiple complications. Ultrasound at OSH demonstrated possible portal vein thrombosis, although this finding was not present on 1st doppler study at . Patient underwent therapeutic paracentesis many times during this admission. He was always negative for SBP. He was continued on cipro for SBP prophylaxis. Pt's initial U/S was unremarkable for portal vein thrombus, subsequent Abd U/S with doppler as well as CT and MRI, notable for Portal vein thrombus. Anticoagulation was contraindicated given his thrombocytopenia, pt also developed some oozing around temporary central lines. His clot then extended into SVC and was no longer a candidate for transplant surgery. Further transplant work up stopped and pt was made DNR/DNI given no further options for treatment. . # RENAL FAILURE: Patient was admitted with oliguric renal failure. Patient's renal function decreased rapidly during this episode of hepatic decompensation, suggesting hepatorenal syndrome although likely compounded by intravascular depletion and increased intra-abdominal pressure. Patient was started on octreotide, midodrine, and albumin at the OSH. Patient's SBP dropped during HD from base line BP of 90's to low 80's. He was then transferred to the ICU for CVVH. He tolerated several sessions of HD. Plan for continued HD as outpatient as pt would like to continue HD. Plan was to provide HD as outpatient close to home. The patient was admitted to the MICU for ongoing CVVHD given his pressures were prohibitive for traditional HD. The patient was maintained on midodrine and octreotide for possible hepatorenal syndrome and was additionally treated with IV albumin, which was discontinued on . Midodrine was increased to 12.5mg . The patient's pressures tolerated CVVHD well and his creatinine decreased from 5.9 to 2.5. He has required dialysis, though, since being transferred from the MICU to the floor, and his renal function has not improved. Unfortunately, given his coagulopathy, he has had issues with bleeding from the dialysis catheter site following dialysis. He did not bleed following his last course of hemodialysis and was deemed safe to go home. . # COAGULOPATHY: Pt developed some oozing around line sites. Labs showed picture consistent with DIC but this could also be from underlying liver disease. He received FFP/Cryo before procedures. He recieved several units of PRBC for low HCT but remained stable. Had some bleeding from tunneled line. Was given conjugated estrogen and Vitamin K x 3 doses. . # HEPATIC ENCEPHALOPATHY: During this admission, patient had waxing and mental status, suggesting likely hepatic encephalopathy. Patient's mental status much improved with lactulose therapy. The patient was maintained on lactulose for encephalopathy. He was noted to have some fluctuation in mental status but was generally appropriate and oriented. . # LIVER MASS: Patient also noted to have hepatic mass on abdominal ultrasound, suggestive for possible HCC although AFP only 2.9. Unclear etiology of mass."},"extractive_notes_summ":{"kind":"string","value":"+ palp peripheral pulses.GI - Abd + ascites. NURSING NOTE 0700HRS-1600HRSEVENTS..B/P STABLE AWAIT HD.....IF TOLLERATES ? + contact precautions for c-dif - completed course of flagyl.Endo - RISSAccess - RIJ TLC by MD. run pt slightly neg as BP tolerates given lg + TFB . + contact precautions Vanco dosed by level for staph UTI. SO FAR THIS SHIFT PT IS ANURIC. Sarna lotion to pruritic back.A+P - Continue - replete lytes as indicated. Abd/pelvic CT performed to R/o SMV clot - results pend. Pt completed K phos infusion. Carafate and PPI for varices.F/E - CVVHD initiated with fluid removal rate goal 0. Post transfusion hct 26.1. Remain hyponatremic with Na 132 - on 1000cc fluid restriction. Pt remains hyponatremic, Na 126 - on 1000ml fluid restriction. mae x4 w/equal strength.gi-> abd w/+bs and significant ascites. restarted.Neuro - Pt oriented x 3, fatigued appearing. Vanco level pend this am. Transfuse hct < 25.ID - Afeb, normothermic. 7p to 7a Micu Progress NoteOverview of Events - pt went for abd/pelvic CT - results pend. Vanco level pend. GI/GU: Abdomen ascitic with +bs. staph uti being empirically covered with vanco. REPLETE LYTES PRN. Phos 2.8 Ca and K drips infusing on sliding scale per protocol ( most recent K 4.3 and ionized Ca 1.15). Pt stable during HD. + dry cough.C-V - HR 66-80 NSR. ?another attempt at hd soon since he has been hemodynamically stable.id-> afebrile w/a normal wbc. HR slightly elevated to 105 ST during HD and lowest BP was 80/44.Neuro - Alert and oriented x 3. Transfuse hct< 25.GI - + Ascites. 24hr fluid balance MN->1700 + 1300ml, LOS balance + 4liters.Access: New HD and PICC lines with small amt blood @ sites. Infusion of K-Phos interrupted when pt off floor, now cont to infuse. Anemia rx with epogen 3 x/wk. Epogen given 3 x/wk. K 3.9 Ionized ca 1.20. Still hyponatremic with Na of 129 - on 1000cc fluid restriction. BUN 18 Cr 2.0. + contact precautions - hx c-dif. PT consult ordered as pt's overall strength has deconditioned. SURGICEL AND SURGIFOAM USED. Cipro dose tomm. HD lines heparinized. FS QID ON S/S COVERAGE 118-194. Alternating replacement solution b/w NaCl and prismasate. Hct down 24 (26.2)...transfuse for Hct <21. Abd CT showed atelectasis of RLL. OCTREOTIDE SQ AND MIDODRINE PO CONTINUES. GI/GU: Abdomen ascitic with + bs. Phos 2.4 - Per renal, sucralfate should be dcd. OINTMENT APPLIED BY NRSG. Normalregional LV systolic function. CONTINUE ICU SUPPROTIVE CARE. Pt remains on strict I/O (1000cc fluid restriction);hyponatremic. Cont to receive Lactulose RTC, no BM this shift.GU: Filter of CVVHD clotted @ 1130 and dialysis was subsequently D/C'd. need to adjust SSC.ID: Afebrile. BUN/Cr improving - down to 29/2.5 respectively. Lactulose for encephelopathy prophylaxis.Resp - LS clear. NBP 85-114/40-50.GI - Abd + ascites. restarting HD. Portal thrombus.Height: (in) 66Weight (lb): 200BSA (m2): 2.00 m2BP (mm Hg): 102/60HR (bpm): 64Status: InpatientDate/Time: at 16:17Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement. Endo: Fs 122/135/156. Normal ascending aorta diameter. Receiving lactulose; no BM this shift.ID: low grade temp 99.5. DRSG AND AT THIS TIME. Pt voiding small amts.Review of systems:Neuro: Pt dozing intermit, otherwise AAO X 3. Encourage po intake with fluid restiction. System clotted x 1. Trivial MR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality.Conclusions:Suboptimal study.1. Ascites. Lt sc dialysis line site wnl. Hydrocortisone rectal cream to be ordered by MD.F/E - TFB + 1150ccs ( pt not dialzyed). IR to be consulted re Dialysis line. CVVHD restarted @ 1745, with alternating replacement solutions of NA and Prismasate per order.ID: Afebrile. HEPARIN GIVEN IN HD PORTS ON , CITRATE GIVEN IN HD PORTS INSTEAD TODAY. NBP= 92-108/43-58. NBP=90-110/37-52. Lung snds clear throughout.CV: HR 67-82SR without VEA. KCL and CaGluconate replacement according to sliding scale. BC pnd. ALL RESOLVED AFTER HD COMPLETED. Catheter heparinized. Plan: Start hd tomm. Coagulopathy; FFP/cryo if evidence of bleeding.Resp: RR 10-17; sats >94% RA. Right internal jugular central venous catheter tip terminates in the distal SVC. CONCLUSION: Thrombosis of intrahepatic portal vein. A delayed portal venous phase as well as coronal and sagittal reformatted images were obtained. Ascites marked for paracentesis at right lower quadrant. A mark was made over the right lower quadrant for paracentesis. INDICATION: Cirrhosis, ascites, portal vein thrombosis. Please mark spot for paracentesis. FINAL REPORT HISTORY: Cirrhosis, ascites, status post paracentesis today. Left-sided vascular catheter has been inserted with its tip overlying the expected location of the SVC. A small chronic nonocclusive thrombus within the infrarenal IVC is similar to MR . Portal vein thrombosis extends 1-cm into the superior mesenteric vein and 1.5-cm into the splenic vein. The thrombus extends 1-cm into the SMV and 1.5-cm into the splenic vein. COMPARISON: AP upright portable chest x-ray dated . FINDINGS: Right internal jugular vein with tip in the inferior third of the SVC. CT OF THE PELVIS WITH IV CONTRAST: Ascites tracks into the pelvis. Airways are patent to the subsegmental bronchi bilaterally. CLINICAL INDICATION: Durable hemodialysis access requirement. Splenomegaly with splenic and esophageal varices and ascites indicate portal hypertension. PA AND LATERAL CHEST X-RAY: A right internal jugular central venous catheter terminates in unchanged position in the distal SVC. 4) Cirrhosis with portal hypertension. Small mediastinal venous collaterals feed into a distended azygos vein. A 0.035 wire was advanced into the IVC under flouroscopic guidance. Status post successful placement of tunneled hemodialysis catheter in exchange for a previous positioned left internal jugular post-temporary hemodialysis catheter. Subsequently, a 1.5 mm J, 0.035- inch wire was advanced through the catheter and steered using fluoroscopic visualization to the inferior vena cava. TECHNIQUE: MDCT acquired contiguous axial images from the thoracic inlet to the upper abdomen were obtained without intravenous contrast. Small bilateral pleural effusions, right greater than left, are associated with dependent parenchymal opacities, likely atelectasis. TECHNIQUE: Non-contrast head CT."},"n_notes":{"kind":"number","value":46,"string":"46"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2150-07-20 00:00:00.000","description":"Report","row_id":1566950,"text":"NURSING NOTE 0700HRS-1600HRS\n\n\n\nEVENTS..B/P STABLE AWAIT HD.....IF TOLLERATES ? CALL OUT TO FLOOR...\n\n\nNEURO..A/O X3, OOB TO CHAIR WITH X1 NURSE..C/O LOWER BACK PAIN RELIEVED WITH PO ANALAGESIA...\n\n\nRESP..ROOM AIR SATS !@98%..CLERA UPPER DIMINSHED LOWER...\n\n\nCVS...GOOD B/P, CONTINUES ON MIDIRINE, 100-110 SYSTOLIC..WAIT TO OBSERVE ON HD...HR STABLE 65-70BPM...\nAFEBRILE, ALTHOUGH DID HAVE TEMP AT 100.1 LAST PM SO IF TEMP GOES UP AGAIN FOR B/ CULTS..VANC LAST PM WAS LAST DOSE...\nB/S COVERED WITH S/S..\nHCT @ 23.6 THIS AM , DOWN FROM YESTERDAY, FOR RE-CHECK THIS PM...PLTS REMAINS LOW @ 128, IS 1.5FLUID RESTRICTION\n\n\nGI.. LARGE DISTENDED/ASCITES ..LAST TAP ..B/S PRESENT/GAS..TAJKEN SAMLL AMOUNT OF FOOD, NO BOWEL MOTION SO FAR TODAY..CONTINES ON LACTULOSE..\nLIVER TEAM FOLLOWING..CT LAST FRIDAY SHOWED LARGE AMOUNT OF OLD CLOT IN PORTAL VEIN/MESENTERIC ARTERY...MEETING TOMORROW TO DISCUSS LIKELIHOOD OF GOING AHEAD WITH SURGERY GIVEN THIS INFORMATIONAS MAKES TRANSPLANT TECHNIQUELY VERY DIFFICULT\n\n\nGU...FINISHED YESTERDAY @ 1300HRS...AM LABS SATBLE, AWAIT HD BOOKED FOR 1700HRS...NO URINE OUTPUT,NA, FLUID RESTRICTION AS ABOVE...\n\n\nSKIN..ABRASION ON SACRUM, CREAM AAPPLIED..RELECTANT TO TURN ON SIDE..\n\n\nLINES..PICC/DIALYSIS \n\n\nSOCIAL..BROTHER TO VISIT PM..MEETING TOMORROW RE FINAL DECISION OF LIVER/KIDNEY TRANSPLANT...\n\n\n\nPLAN...TO ATTEMPT HD/OBSERVE B/P..TRANSFER WRITTEN IN PREP FOR C/O\n"},{"category":"Nursing/other","chartdate":"2150-07-20 00:00:00.000","description":"Report","row_id":1566951,"text":"ADDENDUM..HCT STABLE, BUT PATIENT STOOLED THIS PM AND STREAKY BLOOD EVIDENT IN STOL..TEAM AWARE..CONTINUE AT PRESEENT AS HCT STABLE AND VITALS STABLE, REPEAT HCT @ 2200HRS\n"},{"category":"Nursing/other","chartdate":"2150-07-21 00:00:00.000","description":"Report","row_id":1566952,"text":"7p to 7a Micu Progress Note\n\nOverview of Events - Pt underwent HD last eve. 02 sat dropped to 84% during procedure. 02 5 L NC applied temporarily with sats increasing to low 90's. HR slightly elevated to 105 ST during HD and lowest BP was 80/44.\n\nNeuro - Alert and oriented x 3. OOB to chair with minimal assist x 1. Lactulose for encephelopathy. Medicated with 5 mg oxycodone for back pain x 1 with good effect.\n\nResp - LS clear, diminished at bases. RR 11-19. Sats > 95% except for above mentioned incident during HD. Expectorating sm amts clear sputum with flecks of blood.\n\nC-V HR 60-110 ST. NBP 80-120/40-50. HR increased with HD and with exertion.\n\nF/E - HD administered over ~ 2 1/2 hrs. 500ccs fluid removed. BUN 24 CR 3.3. K 3.6. Pt remains hyponatremic at 127 despite 1000cc fluid restriction. Voided 30ccs amber colored urine. TFB + ~400ccs .\n\nGI - Abd + ascites +BS. Tolerating renal diet without n/v. Passed mod amt loose green stool on commode. Minute amt of BRB noted on tissue after pt defecated.\n\nHeme/Access- Hct stable throughout the night at 23.6. Transfuse hct < 21. Epogen given 3 x/wk. Pt bleeding from Dial LSC after instillation of heparin by dialysis R.N. Also bleeding from former skin tear site on RUE. Tegaderm dssg reapplied to RUE. Surgicel and DSD to LSC site and former line site above LSC with decrease in bleeding noted. INR 2.3\n\nID - Afeb. WBC 8.5. + contact precautions Vanco dosed by level for staph UTI. Cipro given for hx SBP.\n\nSocial - Brother visited with pt last eve.\n\nA+P - Continue to monitor for bleeding - follow hcts, INR. Pt stable during HD. ? call-out to floor today. Nsg transfer note updated. Surgery to make decision re ? liver transplant today.\n"},{"category":"Nursing/other","chartdate":"2150-07-20 00:00:00.000","description":"Report","row_id":1566949,"text":"npn 7p-7a\n\n the pt remained off of crrt overnoc with the plan to attempt hd again later today. sbp remain stable ~90-100.\n\nreview of systems\n\nrespiratory-> lung sounds diminished bibasilarly. pt is maintaining sats >93% on room air. he denies c/o sob.\n\ncardiac-> hemodynamically stable. hr 60-70's, sr w/no noted ectopy. sbp @baseline ~90-100.\n\nneuro-> a&o x3. able to participate in care. oob to chair x several hours last noc, but he required a 2 person assist back to bed. mae x4 w/equal strength.\n\ngi-> abd w/+bs and significant ascites. denies c/o n/v. no bm overnoc.\nneeds encouragement to take in more than po fluids. pt is aware that he is on a 1500cc free water fluid restriction.\n\ngu-> no void overnoc. anticipate attempt at hemodialysis again sometime later today.\n\nid-> tmax 100.1 orally earlier in the shift with no actual fever spike. received vancomycin x1 ~2100.\n\nendocrine-> received regular insulin coverage per sliding scale parameters.\n\naccess- right arm dl picc line and a left sc dialysis catheter are both patent and intact. peripheral iv was d/c'd this morning.\n\ndispo-> ?transfer back to floor if pt tolerates hemodialysis.\n\nsocial-> pt's brother was in visiting last evening. plan for family meeting on tues w/the transplant team re: final decision re: possible liver/kidney transplant.\n"},{"category":"Nursing/other","chartdate":"2150-07-12 00:00:00.000","description":"Report","row_id":1566933,"text":"7p to 7a Micu Progress Note\n\nNeuro - Pt remains alert and oriented x 3. MAE. Assists with self care. Jaundiced and fatigued appearing. c/o chronic back pain - . Medicated with 5 mg oxycodone x 2 with good results.\n\nResp - LS clear with few crackles. RR 10-16. 02 sat > 96% RA.\n\nC-V - HR 55 SB - 65 SR, no ectopy. NBP 86-100/40's. + Palp peripheral pulses. Hct stable at 26.8. No epistaxis or bleeding from lines noted. Transfuse hct< 25.\n\nGI - + Ascites. Pt not passing stool despite 3 doses of lactulose. + flatus. Tolerating renal diet although appetite is poor.\n\nF/E - Continues on CVVHD, with even fluid goal. System has clotted once and warning has appeared that system is clotting again as of this writing. TFB + 24ccs. Presently +16. No spontaneous voiding of urine. AM lytes pend but BUN/Cr improving to 53/3.2 with eve labs. Still hyponatremic with Na of 129 - on 1000cc fluid restriction. Ca and K infusing via sliding scale per CRRT protocol.\n\nID - Afeb. WBC 3.2. Lactic acid 2.6. + contact precautions.\n\nSocial - Brother and family members visited pm.\n\nA+P - Hemodynamically stable on CVVHD. Electrolye repletion as needed. ? nutrition consult to improve po intake.\n"},{"category":"Nursing/other","chartdate":"2150-07-12 00:00:00.000","description":"Report","row_id":1566934,"text":"Micu Nursing Progress Note\nEvents: remains on CRRT, filter seems to be clotting ~12h.\n\nNeuro: Pt is awake, alert, pleasant and cooperative. Moving around in bed without difficulty. C/O back pain 1400 and was medicated with oxycodone 5mg given with good relief.\n\nCardiac: B/P 90-104/50's, HR 68-72, SR. K+ 4.3 at 10am and 3.9 at1700, potassium replacement gtt maintained at 20ml/hr, Ca+ 1.14 at 10a and calcium gtt increased to 30ml/hr then decreased to 25 at 1700 for Ca+ 1.25.\n\nResp: breath sounds clear, room air O2 sats 99-100%. RR 10-14.\n\nGI: taking renal diet well with good appetite. Pt taking lactulose tid as ordered. He had a mod amount of soft golden stool X1. Abd- distended with ascities (+) BS.\n\nEndo: BS slightly higher today with 12n 248, covered with 4u regular insulin and 1800 BS 174 covered with 2u insulin.\n\nGU: Pt voided ~300cc amber colored urine, specimen sent for U/A and C&S. CRRT continues, filter started to develope clots arounf 1300 and clotted off at 1700. Flow rate increased to 100 mg at 12n due to increasely positive. FLow rate decreased when access pressure alarming continueously, return and access lines also reversed to help stop the alarm. However due to decreased flow rates pt is currently 380cc positive.\n\nID: remains afebrile, not on any antibotics.\n\nSocial: no contact with pt's family today.\n\nPlan: continue CRRT, attempt to keep pt even. Lab review due at 2200.\n"},{"category":"Nursing/other","chartdate":"2150-07-18 00:00:00.000","description":"Report","row_id":1566945,"text":"7p to 7a Micu Progress Note\n\nNeuro - Pt remains oriented x 3. Lethargic and fatigued at times - easily arousable. MAE. Medicated wtih 5 mg oxycodone x 1 for back pain. Sleeping intermittently throughout the night.\n\nResp - LS clear. RR 10-16. 02 sat > 97%. + dry cough.\n\nC-V - HR 66-80 NSR. NBP 110-126/54-61. + palp peripheral pulses.\n\nGI - Abd + ascites. +BS. Pt s/p paracentesis on previous shift. Ate a couple of bites of a tuna after. c/o intermittent abd discomfort assoc with nausea and vomiting x 2. Pt vomiting bilious material with undigested food. MD notified. Abd soft on exam. Hct sent, which was stable at 28.6 KUB taken. Medicated with dolasteron mesylate iv x 2 and one dose of maalox po with fair results. Pt reports feeling better after vomiting and after moving his bowels. Passed a lg amt loose brown guiac neg stool on the bedpan.\n\nF/E - TFB neg ~5000 cc on . Continues on with goal fluid removal rate of neg 30ccs/hr. Presently neg 191. LOS + 345. Access and return lines remain reversed when prisma reaccessed due to fluctuating access pressures. Filter pressures elevated throughout the night to 150-176, despite changing system x 1. Ca and K infusing via sliding scale per protocol. BUN 18 Cr 2.0. Remain hyponatremic with Na 132 - on 1000cc fluid restriction. Pt voided 50ccs clear amber urine with urinal.\n\nHeme - Hct stable at 27.2 this am. s/p transfusion 2 units prbcs on eves. Anemia rx with epogen 3 x/wk. INR 1.8\n\nID - Afeb. WBC 3.6. + contact precautions. Vanco level pend. ? staph uti being empirically covered with vanco. Cipro 1x/wk for hx SBP.\n\nSkin - Barrier cream applied to reddened rectal area. Sarna lotion to pruritic back.\n\nA+P - Continue - replete lytes as indicated. ? gastroenteritis s/p eating tuna - continue to assess abd pain, ? abd CT should pain worsen.\n"},{"category":"Nursing/other","chartdate":"2150-07-11 00:00:00.000","description":"Report","row_id":1566931,"text":"7p to 7a Micu Progress Note\n\nNeuro - Pt alert and oriented x 3. MAE. Up to commode with minimal assist. Lactulose for encephelopathy prophylaxis. Denies any pain.\n\nResp - LS clear. RR 12-20. 02 sat > 96 on RA.\n\nC-V- HR 60's NSR, no ectopy noted. NBP 86-96/40's. Baseline SBP 90's per pt. No edema.\n\nGI - Abd + ascites. Tolerating renal diet without difficulty but po intake poor. Passed sm amt loose brown stool on commode. Carafate and PPI for varices.\n\nF/E - CVVHD initiated with fluid removal rate goal 0. Ca and K drips infusing per sliding scale protocol. K 3.9 Ionized ca 1.20. BUN and Cr slighlty improved - 88/5.3 respectively. Pt remains hyponatremic, Na 126 - on 1000ml fluid restriction. Pt oliguric but but voided 50ccs clear yellow urine with urinal.\n\nHeme - Pt s/p transfusion 2 units FFP and cryoprecipitate on previous shift. INR 2.1, previously 2.7. Hct 25.3. Transfuse hct < 25.\n\nID - Afeb, normothermic. WBC 3.0. + contact precautions for c-dif - completed course of flagyl.\n\nEndo - RISS\n\nAccess - RIJ TLC by MD. sent for cult. Pt has access port on LSC Quinton catheter. One peripheral #20 angio iv inserted into R forearm. Quinton site bleeding mod amt at onset of shift. Surgicel and new DSD applied with resolution of bleeding.\n\nSocial - Brother, who is HCP, visited with pt last eve.\n\nA+P - Pt tolerating CVVHD with marginal BP. Monitor for bleeding, FFP prior to invasive procedures. ? transfusion PRBCS if hct continues to decline. Na and fluid restriction for hyponatremia. Lyte repletion per sl scale.\n"},{"category":"Nursing/other","chartdate":"2150-07-11 00:00:00.000","description":"Report","row_id":1566932,"text":"MICU 6 NSG 7A-7PM\nRESP--PT CONTS ON RA LUNGS STA WITH SOME INTERMITTENT RIGHT BASE CRACKLES. DENIES SOB OR RESP DISTRESS.\n\nCV--REMAINS IN SB 50-60'S, NO ECTOPY NOTED. BP 80'S-100/. TOL CRRT SO FAR THIS SHIFT. NO PERIPHERAL EDEMA NOTED. INTERMITTENTLY MILD EPISTAXIS NOTED. NO FURTHER BLEED ING FROM RIGHT NECK AT SITE OF PREVIOUS TLCL. HD LINE SITE ALSO WITHOUT BLEEDING. CLOT SENT FOR BLOOD BANK WITH REPEAT HCT THIS AFTERNOON.\n\nGI--TOL RENAL DIET WELL. LACTULOSE X1 DOSE WITH NO BM SO FAR THIS SHIFT, PT PASSING FLATUS. ABD REMAINS DISTENDED DUE TO ASCITIES.\n\nRENAL--PT WILL NEED UA NEXT TIME HE VOIDS. SO FAR THIS SHIFT PT IS ANURIC. CONTS ON CVVHDF, FLUID GOAL IS TO RUN PT EVEN, SO FAR TOL WELL. CONTS ON IV KCL AND CALCIUM INFUSIONS, TITRATED PER SS. CRRT SYSTEM CLOTTED X1 AND RESTARTED THIS SHIFT.\n\nNEURO--PT A&OX3. MAE WELL, AND REPSOITIONS SELF IN BED. PNEUMO BOOTS APPLIED FOPR DVT PREVENTION.\n\nSOCIAL--NO CONTACT WITH FAMILY SO FAR THIS SHIFT.\n\nPLAN--F/U HCT TRANSFUSE FOR HCT <25\n--CONTS CRRT WITH FLUID GOAL NET EVEN\n"},{"category":"Nursing/other","chartdate":"2150-07-18 00:00:00.000","description":"Report","row_id":1566946,"text":"MICU NURSING PROGRESS NOTE. 0700-1900\n PLEASE SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Continues on cvvhdf, filter changed this pm. Medicated for nausea x 1. Emesis x 2. No c/o discomfort, reports feeling slightly better this pm.\n\n Neuro: Alert and oriented x 3. Is able to make needs known verbally in soft clear voice in full sentences. Intermittent napping throughout shift, easily arouses to verbal stimulus. Able to move all extrem. freely. Follows commands. Temperature max. 98.0 No c/o discomfort this shift.\n\n Respiratory: Lung sounds are clear throughout. RR 12-20 and non labored. O2 saturation on ra 97-100%. Cxr reportdly showed rll opacity.\n\n CV: Sinus rhythm with no ecopy noted, rate 60's to 70's. Nbp low 100's to 110's systolic. Rt ac picc line patent, site wnl. Lt sc hd line site wnl, remains patent with access reversed. Hct stable this pm at 26.6.\n\n GI/GU: Abdomen ascitic with +bs. Continues nausea although reporting feels better this pm, s/p 12.5mg anzemet i.v. Several episodes of green bilious emesis this am. Reports he is passing gas, no bm this shift. Continues on lactulose. No urine this shift.\n\n Cvvhdf: Continues on crrt, pfr at 90, goal is negative 30 per hr. Filter changed this pm at 1500 hrs with access and return lines reversed. Renal wants crrt to continue thru weekend despite pt being hemodynamically stable and a questionable transplant candidate r/t his large clot in his portal vein.\n\n Social: No social contacts this shift, has received calls in room.\n\n Integ: Skin remains grossly intact, sarna lotion applied to back.\n\n F/e/n: Pneumo boots. Renal diet.\n\n Plan: Continue on crrt. Monitor electorlytes per protocol, next set due at 2200, and adjust potassium, calcium drips accordingly. Medicate for nausea.\n"},{"category":"Nursing/other","chartdate":"2150-07-19 00:00:00.000","description":"Report","row_id":1566947,"text":"pmicu npn 7p-7a\n\n crrt clotted off again earlier this morning and was restarted w/o incident ~0230. he has met his fluid removal goal and is actually tfb negative for his los after having a large, liquid stool.\n\nreview of systems\n\nrespiratory-> lung sounds are course w/sats >97% on room air. pt denies c/o sob.\n\ncardiac-> sbp ranging 100-120's. hr 60-70's, sr w/no noted ectopy. pt is receiving continuous potassium and calcium repletion per ccrt sliding scales.\n\nneuro-> pt is alert and cooperative although he requires motivation to be repositioned. he is able to mae x4, ue >le's. c/o lower back pain and medicated w/oxycodeine x1 w/good effect.\n\ngi-> abd w/significant ascites despite recent paracentesis. he denies any n/v overnoc but refuses to eat. he did drink several cups of water and gingerale. he had 500cc of liquid stool x1.\n\ngu-> crrt continues to clot off at least 2-3x/24hrs. he was restarted again this morning. pt's inr is marginally elevated, ?need to start systemtic heparin. as noted above, he is tolerating a goal fluid loss of 30cc/hr and is currently tfb negative for his los. ?another attempt at hd soon since he has been hemodynamically stable.\n\nid-> afebrile w/a normal wbc. awaiting level before redosing w/vanco today.\n\naccess-> right arm dl picc line and a left sc tunneled dialysis catheter are both patent and intact.\n\nsocial-> no contact w/family overnoc. family meeting planned on tuesday w/liver team to discuss possibily of transplantation.\n\n\n"},{"category":"Nursing/other","chartdate":"2150-07-10 00:00:00.000","description":"Report","row_id":1566930,"text":"Nursing Progress Note.\n\nBriefly, this is a pleasant 51 yr old male transferred to MICU 6 West from 10 for the initiation of CVVHDF. Pt initially admitted on c confusion which responded well to PO Lactulose therapy. PMH includes; cirrhosis, portal vein thrombosis, varices, DM II, SBP, ETOH, cigs and now ARF. Pt had been doing well on 10 (ambulating, self ADL's, fair PO intake) but unfortunately unable to tol regular HD on floor c SBP dropping to low 80's (from a baseline SBP values in the 90's). Pt therefore transferred to MICU WEST 6 for initiation of CVVHDF. NKDA. The pt is a Full Code. Contact precautions in place.\n\nMS: AAO times three currently, follows commands, pleasant/cooperative and appropriate. Poor short term memory noted. Pt reports intermittent R eye pain, intermittent dental and belly pain. Pt currently denies pain, team to assess eye shortly. Pt reports poor PO intake and recent weight loss of 40 lbs in past year. Pt given call light c instruction.\n\nCV: Hemodynamically stable and afebrile. NSR c no ectopy. Pt c an INR value this AM of 2.9 c some minor bleeding around two central lines (RIJ TLC & LSC Quinton), pt received two units of FFP on floor f/b one unit Cryoprecipitate -- HO to d/c RIJ TLC shortly (placed @ an outside facility and deemed unessential @ this time). Nursing staff to place PIV shortly and LSC Quinton cath has a side port for central access needs.\n\nRESP: RA c nl sats, RR and resp effort @ rest in bed.\n\nGI: Pt reports poor PO appetite, will encourage PO supplements and cont to encourage good PO intake.\n\nGU: Oliguric per report from 10.\n\nDERM: Pt is jaundiced.\n\nSOC: Brother now visiting @ BS.\n\nOTHER: Please see CareVue for additional pt care data/comments.\n"},{"category":"Nursing/other","chartdate":"2150-07-15 00:00:00.000","description":"Report","row_id":1566940,"text":"Micu Nursing Progress Notes\nEvents: CRRT continued, filter clotted at 12n and changed.\n\nGU: CRRT continued with fluid volume goal continues to be even. Problems with the access pressure continue contributing to the clotting difficulty. Pt will be NPO after MN for a tunnel catheter to be placed tomorrow. He continues to be acidotic so the replacement and dialysate were changed to compensate. Also the blood flow rate was increased to 150 (per Renal fellow Dr. ) to help with the clotting issue.\nPt voided 250cc dark amber urine.\nK+ at 12n 3.8 so gtt increased to 30ml/hr, at 1700 K+ 4.1 so Kcl gtt decreased to 20ml/hr, ionized Ca at 12n was 1.14 so calcium ftt increased to 30mg/hr, but at 1700 ionized Ca was 1.21 so rate decreased to 25ml/hr.\n\nCardiac: B/P 92-101/40's, HR 62-74.\n\nResp: remains on room air with RR 12-18, O2 sats 99-100. Breath sounds clear.\n\nGI: Appetite remains good. Pt receiving lactulose tid. He was transfered to the bedside commode when he had a moderate amount of golden soft stool. Abd remains distended with asities. (+) bowel sounds.\n\nEndo: Blood sugar 150 at 12n and 189 at 1800-received 2u regular insulin.\n\nNeuro: He remains alert and oriented, able to transfer to the bedside commode with minimal assistance.\n\nID: Pt received a one time dose of vanco at 12n for a low vanco level. He remains afebrile with temps 97.0-98.0.\n\nSocial: there is to be a family meeting tomorrow at 1500 with the liver team, transplant, renal and the Micu team to determine if pt will receive enough support if he receives a liver transplant. He will remain on CRRT.\n\nPlan: fluid balance goal is even, NPO after MN for tunnel catheter tomorrow, family meeting tomorrow.\n"},{"category":"Nursing/other","chartdate":"2150-07-16 00:00:00.000","description":"Report","row_id":1566941,"text":"NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVRIONMENT SECURED FOR SAFETY.\n\nTHIS IS A VERY PLEASANT 51 Y/O MALE PT TRANSFERRED TO THE MICU FROM 10 FOR INITIATION OF . PT INITIALLY ADMITTED ON FOR CONFUSION WHICH RESPONDED WELL TO PO LACTULOSE THERAPY. PMH SIGNIFICANT FOR CIRRHOSIS, PORTAL VEIN THROMBOSIS, VARICES, DMII, SBP, ETOH AND ARF. PT HAD BEEN DOING WELL ON 10 (AMBULATING, SELF ADL'S) BUT UNABLE TO TOLERATE HD. S/P ESOPHAGEAL VARICIES BANDING ON - ALSO FOUND TO HAVE NEW LIVER MASS.\n\nNEURO: ALERT AND ORIENTED X 3. SPEECH IS CLEAR, ABLE TO VERBALIZE NEEDS WITHOUT DIFFICULTY. SELF SUFFICIENT IN ADL'S FOR THE MOST PART. AFEBRILE. PERRLA, 3/BRISK. MAE X 4 WITHOUT DIFFICULTY. STEADY GAIT. NO SEIZURE ACTIVITY NOTED.\n\nRR: ROOM AIR. RR 15-20. BBS= ESSENTIALLY CTA X ALL LUNG FIELDS. STRONG COUGH EFFORT- NON-PRODUCTIVE. BILATERAL CHEST EXPANSION NOTED. DENIES ANY SOB OR DIFFICULTY BREATHING. SP02 > OR = TO 95%.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, HR 60-70'S WITH NO SIGNS OF ECTOPY NOTED. SBP > OR = TO 90 WITH NO HYPER OR HYPOTENSIVE EPISODES NOTED. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. PT NOTED TO HAVE CRIT OF 22- DR/ MADE AWARE. DENIES ANY CHEST PAIN. ALSO NOTED TO HAVE INR OF 2.0.\n\nGI: ABD IS LARGE WITH ASCITES. PT ABLE TO TOLERATE PO'S WITH NO C/O N,V,D. PT HAS BEEN NPO SINCE MIDNIGHT FOR IMPENDING PROCEDURE TODAY. PT HAS BEEN ABLE TO USE THE BEDSIDE COMMODE FAIRLY INDEPENDTLY. I MEDIUM SIZED GOLDEN, SOFT STOOL NOTED. PASSING FLATUS.\n\nGU: PT VOIDS IN URINAL- ALTHOUGH HAS BEEN ANURIC THIS SHIFT. ONGOING AT BEDSIDE. GOAL IS TO RUN PT EVEN. FILTER HAS BEEN CHANGED TOTAL OF 3 TIMES. PLAN IS FOR PT TO HAVE HD TUNNEL CATHETER REPLCMT DONE TODAY. OF NOTE, ALTERNATING NORMAL SALINE AND REPLACEMENT FLUIDS.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS. PT HAS SOME SKIN TEARS TO BILATERAL UPPER EXTREMITIES.\n\nLYTES: PT CURRENTLY ON K AND ION CA GTT. PT TO RECEIVE TOTAL OF 4GMS OF MAG AND 15MMOL OF K-PHOS BASED ON 0400 LABS.\n\nSOCIAL: NO CONTACT FROM FAMILY THIS SHIFT.\n\nPLAN: LABS AT 1000 AND 1600. WILL NEED TO CONSIDER PRBC AND FFP TX FOR DECREASED CRIT AND INCREASED INR. REPLETE LYTES PRN. PT TO HAVE HD TUNNEL CATHETER INSERTION TODAY. CONTINUE AS PT WILL EVENTUAL PLAN TO SWITCH TO HD. FAMILY MEETING TO DISCUSS POSSIBILITY OF LIVER TX. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n"},{"category":"Nursing/other","chartdate":"2150-07-16 00:00:00.000","description":"Report","row_id":1566942,"text":"Nursing Progress note 0700-1900\nEvents: off @ 1115 for pt transport to IR for double lumen PICC and tunneled HD lines. Procedure tolerated well. On return to unit, family mtg with liver transplant team/MICU team took place. Pt then prepped for abd CT to check for ?SMV clot, as part of liver transplant check list. Pt also to have PFT's and stress test done before liver transplant team meets next Tuesday.\n\nReview of Systems:\n\nNeuro: Pt generally AAO X 3, cooperative, turning self STS in bed. He C/O back pain @ 1200 and rec'd Oxycodone 5mg X 1 with good results. Pt also rec'd small amts Fentanyl and Versed (0.5mg) in IR for procedure. He remains lethargic, but easily woken and appropriate.\n\nResp: O2 sat 99-100% on RA with RR 11-15 and regular. Lung snds clear throughout. Occas clears throat, but not expectorating sputum.\n\nCV: HR 63-77SR without VEA. BP 101/51-109/48. Infusion of K-Phos interrupted when pt off floor, now cont to infuse. Pt rec'd 1 bag platelets and 1 u FFP before going to IR, and 1 u FFP in IR. Post-procedure labs pndg, with K+ 4.2 and ionized Ca 1.08.\n\nGI: Pt remains NPO except for Baricat solution and ice chips. Abd with ascites, appears larger. Paracentesis planned, ? tomorrow. Bowel snds present and pt passing flatus, no stool.\n\nGU: stopped @ 1115 per above. 24hr fluid balance MN->1700 + 1300ml, LOS balance + 4liters.\n\nAccess: New HD and PICC lines with small amt blood @ sites. Periph IV inserted in L arm for contrast dye for Abd CT scan.\n\nSocial: Family mtg per above. See liver team social worker's note. Nurse re-stated to pt importance of compliance, as his roommate again brought in gum/candy that was not sugarfree.\n\nPlan: Abd CT tonight, PFT's and stress test in next few days if pt candidate for liver transplant. Cont to impress on pt and family necessity of complying with orders in order to qualify for liver transplant(ie. follow /renal diet, fluid restriction, etc.). Re-start this PM after abd CT scan.\n"},{"category":"Nursing/other","chartdate":"2150-07-17 00:00:00.000","description":"Report","row_id":1566943,"text":"7p to 7a Micu Progress Note\n\nOverview of Events - pt went for abd/pelvic CT - results pend. restarted.\n\nNeuro - Pt oriented x 3, fatigued appearing. Slept most of the night. MAE. Medicated with 5 mg oxycodone x 1 for back pain () with good effect.\n\nResp - LS clear. RR 11-16. 02 sat > 96% RA.\n\nC-V - HR 60-80 NSR, no ectopy noted. NBP 100-110/50's.\n\nGI - Pt given barocat as prep for abd ct. c/o nausea and abd discomfort after ingesting 800ccs of barocat. Medicated with 12.5 mg dolasetron mesylate iv with good results. Abd/pelvic CT performed to R/o SMV clot - results pend. Abd + ascites. + BS. ? paracentesis to be performed today. Passing flatus, no stool.\n\nF/E - restarted ~2300 last eve. Goal even fluid balance. Pt + ~ 2750ccs ( barocat and blood products). Presently running - 13. Access and return lines reversed as access pressure extremely neg. Bld flow rate increased to 80 as filter and effluent pressures began to rise. Bld clots present in filter - anticipate system will need to be changed shortly despite infusion taking place via new tunnel dialysis catheter. Pt completed K phos infusion. Phos 2.8 Ca and K drips infusing on sliding scale per protocol ( most recent K 4.3 and ionized Ca 1.15). BUN 20 Creat 2.2. Pt on 1000cc fluid restriciton. Na decreasing to 132.\n\nHeme - Pt transfused 2 units PRBCS without incident for hct 19.5. Post transfusion hct 26.1. INR 1.7\n\nID - Afeb. WBC 3.8. Pt given one dose of vanco for staph UTI. Vanco level pend this am. Also being rx with cipro once a week for hx of SBP. Remains on contact precautions.\n\nSkin - Minor skin tears and ecchymotic areas to upper exts.\n\nEndo - RISS.\n\nAccess - Minor bleeding from HD LSC insertion site. PIC dssg D+I - line draws and flushes easily. #20 LLA peripheral iv patent.\n\nSocial - No contacts overnight.\n\nA+P - Continue - ? use of citrate as pt continues to clot off filters freq ( no heparin given hx of coagulopathy). ? run pt slightly neg as BP tolerates given lg + TFB . Plan is to proceed with w/u for liver transplant - PFTs and stress test today.\n"},{"category":"Nursing/other","chartdate":"2150-07-17 00:00:00.000","description":"Report","row_id":1566944,"text":"Nursing Progress note 0700-1900\nEvents: Pre liver transplant tests (PFT's and stress test) cancelled as abd CT revealed portal vein thrombus extends to SMV, making surgery very difficult. Final decision re transplant to be made Tuesday by committee. restarted @ 1230 with pressures high but machine running smoothly @ this time. Paracentesis done, taking off 5 liters fluid.\n\nReview of Systems:\n\nNeuro: Pt remains AAO X 3, occas dozing but woken easily. Rec'd Oxycodone 5mg X 1 for C/O back pain with good relief. When transferring bed to chair pt C/O bilat leg pain (length of legs) and required assist of 1. Tolerating alternating pressure sleeves well on legs.\n\nResp: O2 sat 97-100% on RA with RR 10-14 and regular. Lung snds clear throughout. Abd CT showed atelectasis of RLL. Non-productive cough.\n\nCV: HR 64-83SR without VEA. BP 108/68-118/61. Pt rec'ing Calcium Gluconate and KCL per sliding scale.\n\nGI: Pt with poor appetite which he attributes to increased ascites. Occas belching and flatus, no BM. Multivites changed to nephrocaps.\n\nGU: Pt voided 340ml amber/clear urine X 1. restarted @ 1230, with goal -30ml/hr. Filter pressure remains elevated after red/blue lines switched, but machine running well/continuously @ this time. Site of tunneled HD line C&D.\n\nAccess: Red port of PICC with heparin infused, blue port flushed with NS and good blood return.\n\nSocial: Liver team informed pt and his brother and proxy, , re low chance of transplant D/T clot.\n\nPlan: Cont . Await transplant committee decision on Tuesday.\n"},{"category":"Nursing/other","chartdate":"2150-07-14 00:00:00.000","description":"Report","row_id":1566937,"text":"Shift Note 1900-0700\nCV: HR 70's, NSR with no ectopy. NIBP 90/40-60's. Pt was running on CVVH until yesterday afternoon when d/c. Hct down 24 (26.2)...transfuse for Hct <21. Coagulopathy; FFP/cryo if evidence of bleeding.\n\nResp: RR 10-17; sats >94% RA. BBS CTA.\n\nNeuro: A/Ox3. Pt c/o aching in back, relieved by repositioning until around 0500 when he awoke and having pain in back. Given prn oxycodone 5mg and currently asleep.\n\nGI/GU: Ascites. BS present. Tolerating renal diet; pt continually requesting PO fluids. Pt remains on strict I/O (1000cc fluid restriction);hyponatremic. Voided urinal for 50cc dark yellow/amber urine. Receiving lactulose; no BM this shift.\n\nID: low grade temp 99.5. BC sent with am labs. Contact precautions.\n\nPlan: ? need for dialysis; possible c/o to floor when okay with renal.\n\nSocial: brother to visit; copy of HCP in chart.\n"},{"category":"Nursing/other","chartdate":"2150-07-14 00:00:00.000","description":"Report","row_id":1566938,"text":"Nursing Progress note 0700-1900\nEvents: Restarted on CVVHD @ 1745 in prep for liver transplant.\n\nReview of systems:\n\nNeuro: Pt remains AAO X 3, dozing less freq today. Did not require any pain med for back this shift. Moves self in bed, and amb to commode without assist.\n\nResp: O2 sat 99-100% on RA with RR 9-14 and regular. Lung snds clear throughout.\n\nCV: HR 64-76SR without VEA. BP 84/40-103/48. Hct stable @ 26.\n\nGI: Appetite cont good. Fluid restriction increased to 1200ml/day. Pt with loose brown stool X 2, lactulose and reglan held.\n\nGU: Pt voided 50ml amber urine X 1. CVVHD restarted @ 1745, with alternating replacement solutions of NA and Prismasate per order.\n\nID: Afebrile. Rec'd Vanco X 1.\n\nPlan: Cont CVVHD to stabilize pt for liver transplant.\n"},{"category":"Nursing/other","chartdate":"2150-07-15 00:00:00.000","description":"Report","row_id":1566939,"text":"Shift Note 1900-0700\nPt 54 y/o M with ETOH cirrhosis, liver failure, renal failure on CVVH; placed on liver transplant.\n\nCV: HR 60-70's, NSR with no ectopy. NIBP 90's/40(baseline hypotension). Hct 25.5; Plt 53.\n\nAccess: PIV x1 20g right posterior forearm; flushes well\nLSC dialysis with med port.\n\nResp: RR 12-15; sats >98% on RA. BBS CTA. Pt with strong congested cough.\n\nNeuro: Pt receiving lactulose TID; hepatic enceph. improved. A/O x3; pleasant and cooperative with care. c/o aching and pain in back and medicated last at 0200 with prn 5mg oxycodone with some relief. Back pain improves with frequent repositioning.\n\nGI/GU: Ascites, abdomen distended. No UO/BM this shift. BS hyperactive. Pt on renal diet; tolerating well. 1000cc fluid restriction.\n\nCVVH: Pt started on CVVH around 1800 yesterday. Filter clotted around 0100, requiring new set. Blood flow increased from 80 to 100. Goal to run patient even. Alternating replacement solution b/w NaCl and prismasate. Na 128. Following VBG's 7.34/42/30/21 last evening and 7.28/42/30/21 this am. KCL and CaGluconate replacement according to sliding scale. Continue to monitor lytes and VBG Q6hrs.\n\nSkin: Intact; skin cool/dry...jaundiced.\n\nEndo: SSC; BS elevated, monitor closely. need to adjust SSC.\n\nID: Afebrile. BC pnd. Additional set of peripheral BC sent this am with labs. Urine cx from with staph, ?UTI.\n\nSocial: brother to visit last evening.\n"},{"category":"Nursing/other","chartdate":"2150-07-21 00:00:00.000","description":"Report","row_id":1566953,"text":"0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET AND TRANSFER NOTE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT ALERT AND ORIENTED X3. PLEASANT AND COOPERATIVE W/ CARE. FOLLOWS COMMANDS, MAE, PERLA. PT DENIES PAIN. OOB TO CHAIR W/ ASSIST X1 FOR MOST OF SHIFT. NSR @ 69-79, NO ECTOPY NOTED. NBP= 92-108/43-58. AM HCT= 23.6, MICU TEAM ORDERED HCT CHECKS DAILY W/ PARAMETERS TO TRANSFUSE IF BELOW 21. AFEBRILE. AM WBC= 8.5. CIPRO PO 1X/WEEK AND NO IV VANCO ORDERED THIS SHIFT. CONTACT PRECAUTIONS CONTINUE FOR STAPH UTI. LEFT DUAL LUMEN PICC INTACT. RIGHT SUBCLAV DIALYSIS INTACT, DRSG X2 THIS SHIFT R/T BLEEDING AT SITE. SURGICEL AND SURGIFOAM USED. AM INR=2.3. LS= CLEAR/DIM. 02 SAT 93-100%. RR=. PT TOLERATING RENAL DIET. PRESENT BS. LACTULOSE CONTINUES TID FOR ENCEPHALOPATHY. OCTREOTIDE SQ AND MIDODRINE PO CONTINUES. POSITIVE ASCITES. NO VOID THIS SHIFT. LAST DIAYLSIS TREATMENT COMPLETED LAST HS AT APPROX 2300, NEXT DUE WED . FS QID ON S/S COVERAGE 118-194. LIVER AND RENAL TEAM MET TODAY TO DISCUSS PLAN OF CARE AND POSSIBILITY OF LIVER TRANSPLANT. SURGICAL TEAM UNABLE TO ATTEND MEETING, DECISION WILL BE MADE TOMORROW REGARDING LIVER TRANSPLANT. PT MADE AWARE, EMOTIONAL SUPPORT PROVIDED R/T PT LOOKING FORWARD TO FINDING OUT SOME NEWS TODAY. PT SPOKE W/ BROTHER AND REPORTS FEELING BETTER. PT CALLED OUT TO FLOOR. PT STABLE, READY TO TRANSFER TO FLOOR WHEN PRIVATE BED AVAILABLE ON 10.\n"},{"category":"Nursing/other","chartdate":"2150-07-22 00:00:00.000","description":"Report","row_id":1566954,"text":"7p to 7a Micu Progress Note\n\nOverview of events - pt stable overnight but continued to ooze lg amt BRB from Dial LSC line. Surgicel, gelfoam and elastoplast pressure dssg applied without resolution. FFP to be given and IR consulted re: line.\n\nNeuro - Pt alert and oriented x 3. OOB to chair. Minimal assist with transfers. PT consult ordered as pt's overall strength has deconditioned. Pt declined any pain med for chronic back pain.\n\nResp - LS clear, diminished at bases. RR 11-16. 02 sat > 97% on RA.\n\nC-V - HR 70-80 NSR, no ectopy. NBP 85-114/40-50.\n\nGI - Abd + ascites. Tolerating renal diet without n/v, although intake poor. Nutrition has been consulted. Rx with lactulose tid for encephelopathy. Passed mod amt loose golden guiac + stool on bedpan. c/o pain from hemorrhoids. Hydrocortisone rectal cream to be ordered by MD.\n\nF/E - TFB + 1150ccs ( pt not dialzyed). To have HD today. BUN and Cr rising to 30/4.2 respectively. Phos 2.4 - Per renal, sucralfate should be dcd. Na 126 - remains on 1000cc fluid restriction. Pt voided 25ccs amber colored urine with urinal.\n\nHeme/Access - INR 2.0 at onset of shift. Rx with 5 mg vit K sc. As per above pt continued to bleed lg amt of blood from Dial LSC line despite surgicel, gelfoam and elastoplast pressure dssg. Hct 24.5 last eve, dropping to 22.2 this am. PT 19.5 PTT 57.4. INR 1.9. To be transfused one unit frozen plasma. IR to be consulted re Dialysis line. ? purse string sutures to be applied. Telfa pad applied to RUE skin tear which has also been bleeding.\n\nID - Afeb. WBC 4.5. + contact precautions. Vanco dosed per level for staph uti, no vanco administered. ? vanco to be dcd per transplant team recommendations.\n\nSocial - Brother and numerous family members visited with pt last eve. Liver and surgical service to meet with pt and brother at 3pm today.\n\nA+P - FFP to be administered. ? purse string sutures need to be utilized to prevent further bleeding from dialysis line. Pt to receive HD today. Pt called out - stable to go to floor once bleeding from RSC dialysis line is resolved.\n\n\n"},{"category":"Nursing/other","chartdate":"2150-07-22 00:00:00.000","description":"Report","row_id":1566955,"text":"0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET AND TRANSFER NOTE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT CALLED OUT TO FLOOR, AWAIT AVAILABLE BED AND LEFT SUBCLAV BLEEDING TO RESOLVE. PT ALERT AND ORIENTED X3. PLEASANT AND COOPERATIVE W/ CARE. PT FOLLOWS COMMANDS, MAE, PERLA. PT DENIES PAIN AT THIS TIME. OOB TO CHAIR X 1 ASSIST. WHILE IN BED EARLIER IN SHIFT, PT C/O BACK PAIN AND MEDICATED W/ OXYCODONE 5MG PO X2 DOSES W/ GOOD EFFECTS. SB TO NSR 62-90. AFEBRILE. NBP=89-110/37-56. PT C/O SLIGHT PALPITATION DURING HEMODIALYSIS TODAY, HR UP TO 104 AND SBP DOWN TO 89. 02 SAT DROPPED TO 85%. 5L N/C AND FACE TENT APPLIED R/T PT ASLEEP AND MOUTH BREATHING. ALL RESOLVED AFTER HD COMPLETED. LS= CLEAR/DIM. RR=. 02 SAT 92-100% ON RA. PT TOLERATING RENAL DIET. PRESENT BS. POSITIVE ASCITES. LACTULOSE CONTINUES TID FOR ENCEPHALOPATHY. PT VOIDS , NONE THIS SHIFT. HEMODIALYSIS DONE FOR APPROX 1 HR TODAY, NO VOLUME REMOVED. LEFT SUBCLAV DIALYSIS LINE INTACT, BLEEDING FROM SITE CONTINUES SINCE LAST HD TREATMENT ON MON PM. HEPARIN GIVEN IN HD PORTS ON , CITRATE GIVEN IN HD PORTS INSTEAD TODAY. AM INR=1.9. AM HCT=22.2. PT RECEIVED K X2 DOSES YESTERDAY. 2 UNITS OF FFP TODAY. DDAVP THIS SHIFT AND MULTIPLE DRSG / SURGICEL AND SURGIFOAM TO AID CLOTTING. IR CONSULTED AND ASSESSED HD LINE FOR POSSIBLE PURSE STRING SUTURE. PLEASE SEE PROGRESS NOTES FOR RECOMM, NO SUTURE PLACED AT THIS TIME. MICU TEAM AWARE SITE STILL BLEEDING AND PM HCT DOWN TO 20.9 AND PM INR 1.7. AMINOCAPROIC ACID OR AMICAR RINSE ORDERED TO BE APPLIED DIRECTLY TO SITE. LIVER AND SURGICAL TEAM MADE FINAL DECISION THIS SHIFT. LIVER ATTENDING DR MET W/ PT AND BROTHER TO INFORM THEM THAT PT IS NO LONGER LIVER CANDIDATE. EMOTIONAL SUPPORT PROVIDED. PT HAS DECIDED AT THIS TIME THAT HE WOULD LIKE TO STOP DIALYSIS AND RETURN HOME. MICU TEAM AWARE AND WILL NEED TO GET PALLIATIVE CARE INVOLVED TOMORROW. PT CALLED BACK IN AND WILL STAY IN MICU TONIGHT DUE TO DROPPING HCT, DOWN 6 PTS SINCE . MICU TEAM ORDER UNITS OF PRBC FOR TONIGHT IF PT AGREES. FS QID ON S/S COVERAGE. FULL CODE. PT AND BROTHER UPDATING REST OF FAMILY R/T FINDINGS.\n\nPLAN- ASSESS DIALYSIS SITE FOR BLEEDING, ADMIN PRBC AND MONITOR HCT AS ORDERED. PROVIDE EMOTIONAL SUPPORT AND FOLLOW UP W/ PALLIATIVE CARE IN AM. SOCIAL WORK CONSULT AS NEEDED. POSSIBLE REMOVAL OF DIALYSIS LINE IN IR TOMORROW IF PT REQUESTS. CONTINUE ICU SUPPORTIVE CARE.\n"},{"category":"Nursing/other","chartdate":"2150-07-23 00:00:00.000","description":"Report","row_id":1566956,"text":"MICU Nursing Note 1900-0700\nEvents: Left SC Dialysis catheter continues to ooze during night with HCT down to 20.9. Transfused with 1 unit Cryoprecipitate, 1 unit FFP, and 1 unit pRBC's overnight with am labs to be sent.\n\nNeuro: A+OX3, pleasant and cooperative, verbalizing about plan to go home over next few days, Moves all extremities and follows all commands, OOB to chair until MN and rested in naps overnight. Denies lightheadedness or dizziness.\n\nCardiac: HR= 60-80's SR with no ectopy noted, BP= 95-110/50's, Right PICC site C/D/I with no oozing and ports patent, Left SC Dialysis catheter continued to ooze blood throughout evening---MICU team and Attending assessed pt, HCT down to 20.9, asymptomatic for blood loss, Thrombin dressing placed over site at MN with no further bleeding noted---dressing remains D/I, Transfused with 1 unit cryoprecipitate, 1 unit FFP, and 1 unit pRBC's---without evidence of reaction noted.\n\nResp: Lungs clear upper lobes and rales at bilat. bases, denies SOB, RR= with Sats= 97-99 on RA.\n\nGI: Abd with large amt. ascites, tolerating renal diet, taking sips during night, no N/V, no BM, + bowel sounds all quads.\n\nGU: no void\n\nSkin: no acute change noted.\n\nEndo: fingerstick 199 at MN---treated with 2 units SC insulin and am fingerstick 135.\n\nSocial: pt on phone with family members most of evening. No contact from family members or friends with nursing staff, MICU resident addressed code status with pt during evening and pt remains full code until he can discuss it further with his brother and have more time to think about his options. Stating that he would like to go home to as soon as possible.\n\nPlan: Monitor blood levels and transfuse if needed, Monitor Dialysis site for further bleeding and change dressing prn, ? of HD in future, Begin discharge plan to , If bleeding subsides transfer pt out to medical floor for further management, Support pt and family prn.\n"},{"category":"Nursing/other","chartdate":"2150-07-23 00:00:00.000","description":"Report","row_id":1566957,"text":"0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET AND TRANSFER NOTE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT ALERT AND ORIENTED X3. PLEASANT AND COOPERATIVE W/ CARE. PT FOLLOWS COMMANDS, MAE, PERLA. PT DENIES PAIN AT THIS TIME, OOB TO CHAIR X 1 ASSIST. WHILE IN BED, C/O BACK PAIN AND MEDICATED W/ OXYCODONE 5MG PO X 2 DOSES PRN W/ GOOD EFFECTS. SB TO NSR @ 56-95. AFEBRILE. NBP=90-110/37-52. LS= CLEAR/DIM. 02 SAT 95-100% ON RA. PT DENIES SOB. NO INCREASED WOB NOTED. PT RECEIVED CRYO, 1U PRBC, AND 3U FFP OVER PAST 24HRS FOR BLEEDING DIALYSIS LINE. HCT DROPPED TO 20.9 FROM 22.2, FOR A TOTAL 6 PT HCT DROP FROM 26.2 ON . TOPICAL THROMBIN APPLIED LAST HS W/ GOOD EFFECTS, NO BLEEDING FOR APPROX 12HRS. PT RECEIVED HEMODIALYSIS TODAY FOR 3 HRS, NO FLUID REMOVED. 02 SAT DROP TO 87%, SBP TO 89, AND HR TO 100. 02 N/C 5L AND FACE TENT APPLIED, 02 SAT UP TO 93-94%. PT TOLERATED WELL, OVERALL ASYMPTOMATIC. BLEEDING FROM DIALYSIS LINE AFTER HD COMPLETE. TOPICAL THROMBIN APPLIED AGAIN W/ GOOD EFFECTS. DRSG AND AT THIS TIME. AM HCT=22.2 AND AM INR=1.6. WILL CONTINUE TO MONITOR DIALYSIS SITE. ABD MORE DISTENDED TODAY, INCREASING ASCITES. MICU TEAM PLANS TO DO PARACENTESIS BEFORE D/C HOME, PT AWARE AND AGREES. PRESENT BS. LOOSE BROWN STOOL W/ BRB DUE TO HEMORRHOIDS. RECTAL EXAM DONE BY LIVER/GI FELLOW TO CONFIRM BRB MOST LIKELY DUE TO HEMORRHOIDS. OINTMENT APPLIED BY NRSG. LACTULOSE CONTINUES TID FOR ENCEPHALOPATHY. PT VOIDS , APPROX 30CC DARK AMBER THIS SHIFT. PALPABLE PEDAL PULSES. FS QID ON S/S COVERAGE. FULL CODE. PT'S FAMILY VISITED AND UPDATED ON CONDITION. EMOTIONAL SUPPORT PROVIDED. MICU AND RENAL SOCIAL WORKER AS WELL AS CASE MANAGEMENT INVOLVED R/T END OF LIFE CARE.\n\n TRANSFER TO 10 WHEN BED AVAILABLE. PT REQUESTS TO BE D/C'D HOME W/ SERVICES ON FRIDAY. PLAN FOR DIALYSIS 3X/WEEK AT FACILITY IN . PROVIDE SUPPORT AND TEACHING R/T CHOICES INVOLVED IN END OF LIFE CARE. CODE STATUS TO BE RE-ADDRESSED BY MICU TEAM. POSSIBLE PARACENTESIS TONIGHT VS TOMORROW. CONTINUE ICU SUPPROTIVE CARE.\n"},{"category":"Nursing/other","chartdate":"2150-07-13 00:00:00.000","description":"Report","row_id":1566935,"text":"7p to 7a Micu Progress Note\n\nNeuro - Pt remains alert and oriented x 3. MAE. Medicated with 5mg oxycodone x 2 for back pain with good effect. Lactulose for encephelopathy prophylaxis.\n\nResp - LS clear. + dry cough. RR 10-18. 02 sat > 96%.\n\nC-V - HR 66-80 NSR. NBP 90-110/40's. Hct stable at 26.2. INR increased to 2.7.\n\nGI - Abd + ascites. Tolerating renal diet. No n/v or abd pain. Passed lg amt loose brown stool on bedpan with minute amt of blood - pt reports bleeding from internal hemorrhoids in the past.\n\nF/E - Remains on CVVHD with even fluid rate goal. TFB + 41ccs . Currently + 18. System clotted x 1. Access and Return lines reversed due to high access pressures. Ca and K drips infusing via sliding scale per CCRT protocol. BUN/Cr improving - down to 29/2.5 respectively. Pt with persistant hyponatremia, Na dropping to 129 despite 1000cc fluid restriction. Phos 1.7 - ? replacement. Pt voided 125ccs amber colored urine in urinal.\n\nID - Afeb. WBC 3.9. + contact precautions - hx c-dif. ? VRE in urine - results pend.\n\nSocial - No visitors. Pt spoke with brother on phone.\n\nA+P - BP remains stable during CVVHD. BUN/CR improving. ? pt can return to HD soon.\n\n\n"},{"category":"Nursing/other","chartdate":"2150-07-13 00:00:00.000","description":"Report","row_id":1566936,"text":"Nursing Progress note 0700-1900\nEvents: CVVHD D/C'd @ 1200. Pt voiding small amts.\n\nReview of systems:\n\nNeuro: Pt dozing intermit, otherwise AAO X 3. Pleasant, follows comands consistantly. Occas slurring of words. Requested pain med for back X 1, rec'd Oxycodone with good relief. Sucking almost continuously on lozanges or chew gum (smoker).\n\nResp: O2 sat 97-99% on RA with RR 8-14 and regular. Lung snds clear throughout.\n\nCV: HR 67-82SR without VEA. BP generally 86/39-103/57, with rare dips in SBP to high 70's. K+ and ionized Ca WNL @ 1100. Phos-lo D/C'd(phos 1.7) and pt started on epogen.\n\nGI: Pt with good appetite, tolerating renal/ diet well. Cont to receive Lactulose RTC, no BM this shift.\n\nGU: Filter of CVVHD clotted @ 1130 and dialysis was subsequently D/C'd. HD lines heparinized. Pt voided 75ml of amber urine with sed in am which was sent for U/A. 24hr fluid balance MN->1700 +555ml, with LOS balance +941ml. Pt cont to push limits of 1000ml/day fluid restriction.\n\nID: T max 99.0po@ 1600. Pt to receive Cipro Q week.\n\nPlan: Straight if pt without void this pm. Cont to monitor blood levels for ? restarting HD. Cont to enforce fluid restriction. Awaiting proxy papers from brother, .\n"},{"category":"Nursing/other","chartdate":"2150-07-19 00:00:00.000","description":"Report","row_id":1566948,"text":"MICU NURSING PROGRESS NOTE. 0700-1900\n PLEASE SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Crrt machine failed this pm, placed on hold by team. Minimal medication changes. Denies any nausea this shift but still only taking po liquids.\n\n Neuro: Alert and oriented x 3. Speach is clear and is able to make needs known verbally. Mae. Following commands. Denies discomfort as of this time. Temperature max. 97.5 oral.\n\n Resp: Lung sounds are clear throughout, diminished in rt base. RR 12-22 and non labored. O2 saturation 95-100% ra.\n\n CV: Sinus rhythm with no ectopy noted, rate 60-100's. Nbp 90's to 110's systolic. Picc line rt ac patent, site wnl. Lt sc dialysis line site wnl.\n\n GI/GU: Abdomen ascitic with + bs. Taking liquid po's. No bm this shift. No urine this shift.\n\n Social: No social contacts this shift.\n\n Crrt: Cvvhdf machine failed, failure code 0080. Team aware, crrt on hold as of this time. Catheter heparinized.\n\n Endo: Fs 122/135/156. This pm fs covered with 2 units regular insulin.\n\n ID: Awaiting ID approval for vancomycin dose.\n\n Plan: Start hd tomm. Monitor electrolytes and repleat as required. Medicate for discomfort. Encourage po intake with fluid restiction. Cipro dose tomm.\n\n\n"},{"category":"Echo","chartdate":"2150-07-08 00:00:00.000","description":"Report","row_id":82658,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. /Pre liver transplant. Portal thrombus.\nHeight: (in) 66\nWeight (lb): 200\nBSA (m2): 2.00 m2\nBP (mm Hg): 102/60\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 16:17\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality.\n\nConclusions:\nSuboptimal study.\n\n1. The left atrium is mildly dilated. The left atrium is elongated.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. The LV is not well seen but limited views demonstrate normal\nregional left ventricular wall motion.. Overall left ventricular systolic\nfunction appears normal (LVEF>55%).\n3. Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation\n5.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen.\n6.There is no pericardial effusion.\n\n\n"},{"category":"Radiology","chartdate":"2150-07-08 00:00:00.000","description":"RENAL U.S.","row_id":923388,"text":" 12:48 PM\n RENAL U.S. Clip # \n Reason: please eval for hydronephrosis\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis, renal failure worsening after Foley removal\n\n REASON FOR THIS EXAMINATION:\n please eval for hydronephrosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Worsening renal failure, cirrhosis.\n\n RENAL ULTRASOUND: The right kidney measures 10.3 cm, and the left kidney\n measures 10.8 cm. There is limited evaluation of the lower pole of the right\n kidney. There are no renal masses, stones, or hydronephrosis. The echogenicity\n of the kidneys is normal. Ascites is noted in the right upper and lower\n quadrants. The bladder is partially collapsed.\n There is a small nodular liver consistent with known cirrhosis.\n\n IMPRESSION: No hydronephrosis. Ascites.\n\n"},{"category":"Radiology","chartdate":"2150-06-29 00:00:00.000","description":"MRI ABDOMEN W/O & W/CONTRAST","row_id":922238,"text":" 6:44 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \n MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\n Reason: please evaluate mass\n Admitting Diagnosis: CIRRHOSIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis and new finding of liver mass\n REASON FOR THIS EXAMINATION:\n please evaluate mass\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: MRI of the abdomen with and without contrast \n\n COMPARISON: Abdominal ultrasound, .\n\n TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 Tesla\n magnet including dynamic 3d imaging obtained prior to, during, and after the\n uneventful intravenous administration of 0.1 millimole per kilogram of\n gadolinium-DTPA.\n Multiplanar reformats were essential in providing multiple perspectives for\n the dynamic series.\n\n There is a small right pleural effusion and right lower lobe atelectasis.\n There is a region of susceptibility artifact on the in-and-out-of-phase images\n within the right lower lobe which may represent artifact from a granuloma.\n Diffuse ascites is demonstrated within the abdomen. The liver contour is\n nodular, the liver is shrunken consistent with cirrhosis. There is\n splenomegaly and multiple portosplenic collaterals including paraesophageal\n varices and spontaneous splenorenal shunt, consistent with portal\n hypertension. Increased T1 signal is demonstrated within the portal vein on\n the in-and-out-of-phase images with lack of enhancement on post-contrast\n images suspicious for portal venous thrombosis. The liver lesion in question\n on the ultrasound is seen within segment VIII and measures 1.8 cm and\n demonstrates no evidence of early arterial enhancement, but does demonstrate\n delayed enhancement, which may represent a pseudocapsule. There is an 8 mm\n nodular focus of enhancement at the periphery of this lesion which is bright\n on the in-phase image and drops out on the out-of-phase image consistent with\n microscopic fat within the nodule. Although this is an atypical appearing\n nodule, an early hepatocellular carcinoma cannot be excluded. No other\n intrahepatic lesions are demonstrated. The pancreas, adrenal glands, and\n kidneys are unremarkable. Small periportal lymph nodes are demonstrated, the\n largest measuring 8 mm in short axis diameter.\n\n IMPRESSION:\n\n 1. Cirrhosis and evidence of portal hypertension given portosystemic\n collaterals, splenomegaly, and large volume ascites.\n\n 2. 1.7 cm lesion within segment VIII with unusual enhancement\n characteristics; however, which does contain an 8 mm peripheral nodule which\n contains some microscopic fat, early hepatocellular carcinoma cannot be\n (Over)\n\n 6:44 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \n MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\n Reason: please evaluate mass\n Admitting Diagnosis: CIRRHOSIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n excluded. A hemangioma would be much less likely.\n\n 3. No portal venous enhancement on the post-contrast images, these findings\n are suspicious for portal vein thrombosis.\n\n These findings were discussed with Dr. on .\n\n"},{"category":"Radiology","chartdate":"2150-07-16 00:00:00.000","description":"PICC W/O PORT","row_id":924370,"text":" 12:42 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC. Failed attempt on floor\n Admitting Diagnosis: CIRRHOSIS\n ********************************* CPT Codes ********************************\n * PICC W/O PORT -59 DISTINCT PROCEDURAL SERVICE *\n * FLUOR GUID PLCT/REPLCT/REMOVE -59 DISTINCT PROCEDURAL SERVICE *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with ETOH cirrhosis, Hepatorenal syndrome, currently on CVVH as\n a bridge to transplant. Needs PICC access\n REASON FOR THIS EXAMINATION:\n Please place PICC. Failed attempt on floor\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT-SIDED 5 FRENCH DUAL LUMEN PICC LINE PLACEMENT VIA RIGHT BASILIC VEIN\n APPROACH; ULTRASOUND-GUIDED VENIPUNCTURE\n\n RADIOLOGISTS: and . Dr. , the Attending Radiologist,\n was present throughout the entire procedure.\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, and appropriate\n requisition. Once the above were verified, the patient was positioned in\n supine fashion with the right arm abducted and externally rotated. The right\n arm was then prepped and draped from the axilla to the antecubital fossa. A\n tourniquet was applied to the upper arm. Ultrasound was employed to visualize\n the right basilic vein which was noted to be widely patent and compressible.\n The skin was infiltrated with approximately 2 cc of 1% Xylocaine for local\n anesthesia at the anticipated needle puncture site. Uneventful retrograde\n one-wall venipuncture was achieved with a 22-gauge micropuncture needle.\n Subsequently, a guide wire was advanced by way of the basilic vein under\n fluoroscopic visualization to the level of superior vena cava. The\n intravascular length of the catheter to be placed was so determined at 34 cm.\n The catheter was tailored at the 34-cm mark and delivered using modified\n Seldinger technique to the level of superior vena cava. Both lumens of the\n catheter were flushed and heparinlocked per protocol. The catheter was\n secured in place with a StatLock device and then overlaid with a Tegaderm\n occlusive dressing. The patient tolerated procedure well without\n complication. Estimated blood loss was minimal.\n\n IMPRESSION: Status post successful placement of 5 French dual lumen PICC line\n placement via right basilic vein approach. Catheter is ready to employ. Post-\n procedural orders written.\n\n\n (Over)\n\n 12:42 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC. Failed attempt on floor\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2150-07-16 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":924436,"text":" 9:11 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: pre-xpl eval, looking at extension of clot in smv\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with liver cirrhosis, portal vein thrombus, ascites, s/p 7.5L\n paracentesis 2 days ago, reacumulated ascites, increasing abdominal pain, low\n hct\n REASON FOR THIS EXAMINATION:\n pre-xpl eval, looking at extension of clot in smv\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n 54-year-old male with cirrhosis and known portal vein thrombosis status post\n paracentesis now with rapid reaccumulation of ascites.\n\n TECHNIQUE: MDCT continuously acquired axial images of the abdomen and pelvis\n were obtained after oral and 130 mL Optiray IV contrast. A delayed portal\n venous phase as well as coronal and sagittal reformatted images were obtained.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a large right pleural effusion\n with associated atelectasis of the right lower lobe. The liver is shrunken\n and nodular consistent with cirrhosis. There is associated cavernous\n transformation of the portal vein and numerous portosystemic collaterals\n noted. There is a large amount of ascites. The spleen is enlarged. The\n gallbladder, pancreas, adrenal glands and kidneys are unremarkable. Small\n bowel is noted to be diffusely dilated up to 4.3 cm. Gas is distributed\n throughout normal caliber colon and there is no focal change in caliber of the\n small bowel suggesting that these findings are more likely due to ileus. There\n is no bowel wall thickening or pneumatosis intestinalis. The portal vein does\n not opacify and there is soft tissue density within the lumen consistent with\n thrombus. The thrombus extends 1-cm into the SMV and 1.5-cm into the splenic\n vein. The remainder of the mesenteric veins opacify well. There is no\n mesenteric venous gas or free intraperitoneal gas. A small chronic\n nonocclusive thrombus within the infrarenal IVC is similar to MR .\n\n CT OF THE PELVIS WITH IV CONTRAST: Ascites tracks into the pelvis. There is\n stool mixed with gas in the rectum and sigmoid colon. The urinary bladder is\n unremarkable.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are\n identified. Old rib fracture deformities are noted.\n\n IMPRESSION:\n 1. Cirrhosis.\n 2. Large amount of ascites.\n 3. Portal vein thrombosis extends 1-cm into the superior mesenteric vein and\n 1.5-cm into the splenic vein.\n 4. Large right pleural effusion with atelectasis of the right lower lobe.\n 5. Ileus.\n (Over)\n\n 9:11 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: pre-xpl eval, looking at extension of clot in smv\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2150-07-09 00:00:00.000","description":"NON-TUNNELED","row_id":923566,"text":" 3:14 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: please place 3-port temporary dialysis catheter on the left,\n Admitting Diagnosis: CIRRHOSIS\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1752 CATH,HEM/PERTI DIALYSIS SHORT *\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis and worsening ARF, will need HD\n REASON FOR THIS EXAMINATION:\n please place 3-port temporary dialysis catheter on the left, R IJ line to be\n pulled by team later today, INR 2.5- to get 4U FFP\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis and worsening renal failure, requires hemodialysis.\n\n TECHNIQUE/FINDINGS: After informed consent was obtained, the patient's left\n supraclavicular area was prepped and draped in a sterile fashion. Under\n ultrasound guidance, a micropuncture set was used to enter into the left\n internal jugular vein just above the clavicle. Hard copy ultrasound images\n were obtained before and after venous access documenting vessel patency. A\n 0.035 wire was advanced into the IVC under flouroscopic guidance. After\n which, the tract was dilated and a 16 cm triple lumen catheter advanced with\n its tip in the proximal atrium. Catheter has three ports, one for\n aspiration/infusion and arterial and venous ports for dialysis. The catheter\n was sewn in place with two times 0- silk sutures. There were no\n complications.\n\n IMPRESSION: Placement of a non-tunneled hemodialysis line via the left IJ\n without complication. Catheter tip is in the proximal right atrium and ready\n for use.\n\n"},{"category":"Radiology","chartdate":"2150-07-16 00:00:00.000","description":"TUNNELED W/O PORT","row_id":924323,"text":" 7:23 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: please place a tunnelled HD line\n Admitting Diagnosis: CIRRHOSIS\n ********************************* CPT Codes ********************************\n * TUNNELED W/O PORT *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL ADDENDUM\n MEDICATIONS: Moderate intravenous sedoanalgesia was employed in the course of\n the tunneled catheter placement. The patient received one dose of Versed 0.5\n mg IV as anxiolytic and 25 mcg of fentanyl IV as analgesic.\n\n\n 7:23 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: please place a tunnelled HD line\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with ETOH cirrhosis, Hepatorenal syndrome, currently on CVVH as\n a bridge to transplant.\n REASON FOR THIS EXAMINATION:\n please place a tunnelled HD line with an extra port to be used for blood draws\n and meds if needed\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: 14.5 French by 28 cm length Angiodynamics, EvenMore tunneled\n hemodialysis catheter placement in exchange for pre-positioned left internal\n jugular approach triple lumen temporary hemodialysis catheter; moderate\n intravenous pseudoanalgesia.\n\n CLINICAL INDICATION: Durable hemodialysis access requirement.\n\n INFORMED CONSENT: Procedural informed consent was obtained from the patient.\n Specifically discussed were the indications for the procedure as well as the\n attendant risk, potential complications and expected outcomes. The patient\n agreed to have the procedure performed and provided witnessed informed consent\n signature which in turn was placed in the medical record.\n\n OPERATORS: , M.D. (fellow).\n , M.D. (fellow).\n , M.D. (supervising staff).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, appropriate requisition,\n and appropriate informed consent. Once the above were verified, the patient\n was positioned in supine fashion on a special procedures table. This\n procedure was performed subsequent to an earlier performed right-sided PICC\n line placement. The latter procedure was dictated and reported under separate\n cover.\n\n The left upper anterior chest was prepped and draped in usual sterile fashion\n as was the external course of a pre-positioned temporary hemodialysis\n catheter. The hemodialysis catheter was accessed and aspirated free of the\n heparin content within the respected lumens. Subsequently, a 1.5 mm J, 0.035-\n inch wire was advanced through the catheter and steered using\n fluoroscopic visualization to the inferior vena cava. Subsequently,\n approximately 3 cc was infiltrated into the skin and subcutaneous tissues\n surrounding the entrance wound for this catheter. An additional 3 cc was\n infiltrated into the planned catheter exit site in the left upper anterior\n chest wall. An additional 10 cc was infiltrated subcutaneously along the\n planned tunnel to the entrance site of the temporary dialysis catheter.\n\n The angiodynamics 14.5 French by 28 cm catheter was then tunneled from an exit\n incision of the left upper anterior chest wall to the venipuncture/dermatotomy\n site in the left upper chest at the supraclavicular region. Subsequently, the\n (Over)\n\n 7:23 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: please place a tunnelled HD line\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n retention sutures on the temporary dialysis catheter were removed and the\n catheter itself delivered over the guidewire leaving the guidewire in situ.\n Subsequently, the peel-away sheath/dilator the tunneled dialysis catheter was\n advanced over the wire under fluoroscopic visualization carefully to the level\n of the superior vena cava. Subsequently, the inner dilator was removed as was\n the guidewire. The tunneled dialysis catheter was then delivered using\n modified Seldinger technique through the peel-away sheath to the right atrium\n level. The peel-away sheath was split and then removed.\n\n Hemostasis was achieved at both the venipuncture/dermatotomy site and the exit\n wound site using digital compression for approximately 5 minutes. The\n supraclavicular wound was then closed with dermatotomy and then overlaid with\n a 2 x 2 dressing, folded in quarters. Both wounds were then overlaid with a\n Tegaderm occlusive patch. Both lumens of the tunneled dialysis catheter were\n flushed and heparin locked per protocol. The patient tolerated the procedure\n well without incident.\n\n IMPRESSION:\n\n 1. Status post successful placement of tunneled hemodialysis catheter in\n exchange for a previous positioned left internal jugular post-temporary\n hemodialysis catheter. See above description. The catheter is ready to\n employ. Post-procedural orders written.\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2150-07-03 00:00:00.000","description":"CHEST (PA & LAT)","row_id":922832,"text":" 4:54 PM\n CHEST (PA & LAT) Clip # \n Reason: Pls evaluate for infiltrate\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man liver cirrhosis, portal vein thrombus awaiting liver transplant\n with rigors, leukopenia WBC 1\n REASON FOR THIS EXAMINATION:\n Pls evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old man with liver cirrhosis, portal vein thrombosis\n awaiting liver transplant, now with rigors, leukopenia. Evaluate for\n infiltrate.\n\n COMPARISON: AP upright portable chest x-ray dated .\n CT chest dated .\n\n PA AND LATERAL CHEST X-RAY: A right internal jugular central venous catheter\n terminates in unchanged position in the distal SVC. The cardiac silhouette,\n mediastinal and hilar contours are normal. The pulmonary vasculature is\n normal. Allowing for differences in technique, there is no significant\n interval change compared with prior study from . There is stable mild\n pulmonary edema and a small right- sided pleural effusion. Multiple old,\n healed right sided rib fractures are again noted.\n\n IMPRESSION: Stable mild pulmonary edema and small right pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2150-07-02 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":922698,"text":" 4:56 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assessment for liver metastasis\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man, cirrhotic, portal vein thrombus with 2cm mass adjacent to\n portal vein. Chest CT as work up for OLT to assess for possible metastatic\n disease.\n REASON FOR THIS EXAMINATION:\n assessment for liver metastasis\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis with hepatic lesions suspicious for hepatocellular\n carcinoma. Assess for metastatic disease.\n\n COMPARISON: Chest radiograph .\n\n TECHNIQUE: MDCT acquired contiguous axial images from the thoracic inlet to\n the upper abdomen were obtained without intravenous contrast.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: Poorly-defined, scattered, ground glass\n opacities in both upper lobes are either inflammatory or due to resolving\n pulmonary edema. 4 mm non-calcified solid nodule in the superior segment of\n the right lower lobe (series 4, image 27) is present. Small bilateral pleural\n effusions, right greater than left, are associated with dependent parenchymal\n opacities, likely atelectasis. A small dystrophic calcification involving the\n posterior inferior left pleura likely reflects prior pleural insult. Airways\n are patent to the subsegmental bronchi bilaterally.\n\n No pathologically enlarged mediastinal, hilar, or axillary lymph nodes are\n present. Coronary artery calcifications and focal calcified atherosclerotic\n plaque in the aortic arch are present. Heart, pericardium, and great vessels\n are otherwise unremarkable. Right internal jugular central venous catheter\n tip terminates in the distal SVC. Small mediastinal venous collaterals feed\n into a distended azygos vein.\n\n The liver is shrunken and nodular consistent with cirrhosis. Ill-defined\n hypodensity within segment VIII of the liver corresponds to the abnormality\n noted on recent MRI from . Splenomegaly with splenic and\n esophageal varices and ascites indicate portal hypertension.\n\n No osseous lesions are worrisome for malignancy.\n\n IMPRESSION:\n 1) 4 mm right lower lobe pulmonary nodule. 3 month follow up chest CT is\n recommended in this patient with possible hepatocellular carcinoma.\n\n 2) Small bilateral pleural effusions with associated mild compressive\n atelectasis.\n\n (Over)\n\n 4:56 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assessment for liver metastasis\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3) Bilateral upper lobe peripheral ground glass opacities are likely\n inflammatory in etiology or due to resolving pulmonary edema.\n\n 4) Cirrhosis with portal hypertension.\n DFDdp\n\n"},{"category":"Radiology","chartdate":"2150-07-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":923858,"text":" 7:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis currently on CVVH\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION PERFORMED: AP chest.\n\n INDICATION: A single AP view of the chest is obtained at 0813 hours\n and compared with a prior radiograph performed on . Significant\n improvement in the appearance of pulmonary edema has occurred. There is no\n evidence of acute infiltrate, pleural effusion, or pneumothorax on the current\n examination. Left-sided vascular catheter has been inserted with its tip\n overlying the expected location of the SVC. Multiple prior rib fractures are\n noted on the right side. No pneumothorax is visible.\n\n IMPRESSION:\n\n Improvement in the mild pulmonary edema since prior examination. Insertion of\n left- sided vascular catheter with no evidence of hemothorax or pneumothorax\n on the current examination.\n\n\n"},{"category":"Radiology","chartdate":"2150-07-02 00:00:00.000","description":"BONE SCAN","row_id":922588,"text":"BONE SCAN Clip # \n Reason: LIVER MASS, BEING EVALUATED FOR LIVER TRANSPLANT\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 26.3 mCi Tc-m MDP;\n HISTORY: 54 year old man with cirrhosis and liver mass, presenting for liver\n transplant work-up.\n\n INTERPRETATION:\n\n Whole body images of the skeleton were obtained in anterior and posterior\n projections. Mildly increased diffuse tracer activity over the soft tissue of\n the abdomen is consistent with ascites. There is asymmetric increased tracer\n activity in the region of the right sternoclavicular joint. There are no other\n worrisome foci of abnormal tracer activity.\n\n The kidneys and urinary bladder are visualized, the normal route of tracer\n excretion.\n\n There are no prior studies available for comparison.\n\n IMPRESSION: 1) Increased tracer activity in region of right sternoclavicular\n joint may be degenerative. If isolated osseous metastasis is considered, then\n correlation with CT may be of value. 2) Ascites. 3) If additional\n characterization of liver lesion is desired, then a blood pool study may be\n useful in evaluation of a possible hemangioma.\n\n\n , M.D.\n , M.D. Approved: FRI 8:19 AM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"},{"category":"Radiology","chartdate":"2150-07-01 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":922463,"text":" 10:27 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: pls evaluate flow with doppler to evaluate ?portal vein \n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis, ascites, ?portal vein thrombus\n REASON FOR THIS EXAMINATION:\n pls evaluate flow with doppler to evaluate ?portal vein thrombus\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Ultrasound abdomen.\n\n INDICATION: Examine portal vein.\n\n FINDINGS: In relation to the right lobe of liver, again note is made of the\n low echogenic area measuring 2.36 cm. This was previously identified on\n ultrasound and on MR and the appearances may be consistent with a\n hepatocellular CA. Note is made of significant ascites. No other focal\n lesion in relation to the liver. The extrahepatic portal vein is visualized,\n however, there is no flow within the intrahepatic portal vein. The hepatic\n artery is visualized and there is normal flow. The hepatic veins are patent\n and demonstrate flow. There is splenomegaly with the spleen measuring 16 cm.\n Note is made of splenic varices.\n\n IMPRESSION:\n\n No flow seen within the portal vein. It may represent thrombosis.\n\n Lesion in right lobe of liver, which may represent hepatocellular carcinoma\n and previously identified on ultrasound and MR.\n\n Ascites.\n\n Splenomegaly.\n\n Splenic varices.\n\n"},{"category":"Radiology","chartdate":"2150-06-26 00:00:00.000","description":"ABDOMEN U.S. (COMPLETE STUDY)","row_id":921804,"text":" 8:06 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: evaluate for ascites, please mark spot for paracentesis\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis, distended abdomen.\n REASON FOR THIS EXAMINATION:\n evaluate for ascites, please mark spot for paracentesis\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Abdominal ultrasound.\n\n CLINICAL HISTORY: 54-year-old man with cirrhosis, distended abdomen.\n Evaluate for ascites. Please mark spot for paracentesis.\n\n FINDINGS: There is extensive ascites. The liver is small, echogenic with an\n irregular contour, consistent with cirrhosis. In the left lobe of the liver,\n anterior to the portal vein, there is a 2.2 cm demarcated hypoechoic mass.\n Given the patient's history, this is concerning for the presence of\n hepatocellular carcinoma. Additional imaging, such as MR may be\n considered for further characterization of this finding. A mark was made over\n the right lower quadrant for paracentesis.\n\n There is sludge in the gallbladder, without evidence of stones. No intra - or\n extrahepatic biliary ductal dilatation. The spleen is enlarged, measuring up\n to 15.9 cm.\n\n The kidneys are normal in size and echotexture, with the right kidney\n measuring 11.9 cm and the left kidney measuring 11.3 cm.\n\n IMPRESSION:\n 1. 2.2 cm hypoechoic mass in left hepatic lobe that is concerning for\n hepatocellular carcinoma.\n 2. Ascites marked for paracentesis at right lower quadrant.\n 3. Splenomegaly.\n\n\n"},{"category":"Radiology","chartdate":"2150-06-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":921771,"text":" 9:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate central line placement.\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis, has R sided central line.\n REASON FOR THIS EXAMINATION:\n evaluate central line placement.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Evaluate central line placement. 54-year-old man with\n cirrhosis.\n\n COMPARISON: None.\n\n FINDINGS: Right internal jugular vein with tip in the inferior third of the\n SVC. There is no pneumothorax. The size of the heart is normal. The\n mediastinal contour is unremarkable. Small right pleural effusion. Discoid\n atelectasis is seen in the left lower lobe.\n\n IMPRESSION: No pneumothorax. Small right pleural effusion. Vascular line in\n adequate position.\n\n\n"},{"category":"Radiology","chartdate":"2150-06-27 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":921973,"text":" 11:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with hepatic encephalopathy, cirrhosis, and known gastric\n varices who presents with encephalopathy and altered MS.\n FOR THIS EXAMINATION:\n r/o bleed\n CONTRAINDICATIONS for IV CONTRAST:\n likely hepatorenal syndrome\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old man with hepatic encephalopathy, cirrhosis, and known\n gastric varices, who presents with encephalopathy and altered mental status.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, mass effect,\n hydrocephalus, shift of normally midline structures, or major vascular\n territorial infarction. Small foci of hypodensity in the frontal\n periventricular white matter are consistent with chronic microvascular\n ischemia. Osseous and soft tissue structures are unremarkable.\n\n IMPRESSION: No acute intracranial pathology identified, including no evidence\n of intracranial hemorrhage.\n\n\n"},{"category":"Radiology","chartdate":"2150-06-26 00:00:00.000","description":"DUPLEX DOPP ABD/PEL","row_id":921864,"text":" 2:01 PM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: Please assess patency of portal vasculature.\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with etoh cirrhosis, hepatic encephalopathy, varices, and acute\n renal failure.\n REASON FOR THIS EXAMINATION:\n Please assess patency of portal vasculature.\n ______________________________________________________________________________\n FINAL REPORT\n DUPLEX DOPPLER ULTRASOUND OF THE LIVER\n\n CLINICAL HISTORY: 54-year-old man with alcoholic cirrhosis, hepatic\n encephalopathy, varices, and acute renal failure. Please assess patency of\n portal vasculature.\n\n FINDINGS: Duplex Doppler ultrasound of the liver was performed on .\n Comparison made to prior study performed earlier in the day.\n\n The portal vein is patent and demonstrates normal hepatopetal flow. The left\n portal vein demonstrates slow velocity and occasional to and fro-type wave\n pattern suggesting stagnant flow. No echogenic material is seen within the\n portal system to suggest the presence of thrombus. The hepatic veins are\n patent. The main, right, and left hepatic arteries are patent and demonstrate\n normal arterial flow.\n\n IMPRESSION:\n 1. Patent portal vein, with waveforms suggestive of stagnant flow, without\n specific evidence of intraluminal thrombus.\n 2. Please see report from previous ultrasound regarding description of left\n hepatic mass.\n\n"},{"category":"Radiology","chartdate":"2150-07-17 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":924571,"text":" 8:37 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please evaluate for distention or evidence of bleeding.\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with history of cirrhosis and ascites, s/p paracentesis today.\n REASON FOR THIS EXAMINATION:\n Please evaluate for distention or evidence of bleeding.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis, ascites, status post paracentesis today. Evaluate for\n distention or evidence of bleeding.\n\n ABDOMEN, SINGLE AP SUPINE PORTABLE VIEW.\n\n The lateral aspects of the abdomen are not included on this film, nor are the\n obturator foramina. Residual oral contrast is present in portions of the\n colon. There are multiple air-filled dilated loops of small bowel in a\n stepladder configuration. Nonethe less, air is seen throughout much of the\n colon. No supine film evidence of free air is identified. No bowel wall\n thickening is detected and no intramural emphysema is seen. Note that many\n forms of hemorrhage would not be evident radiographically.\n\n There appear to be rib fractures in the left posterior ninth and tenth ribs\n and question eleventh rib near the costovertebral junction. The possibility\n of metastatic lesions in these areas cannot be excluded.\n\n Residual contrast is noted in the bladder.\n\n\n\n"},{"category":"Radiology","chartdate":"2150-07-03 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":922822,"text":" 3:30 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: pls evaluate flow, acute intraabdominal process\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis, ascites, portal vein thrombus s/p 7.5L para 2\n days ago, reacumulated fluid now w/increasing abdominal pain\n REASON FOR THIS EXAMINATION:\n pls evaluate flow, acute intraabdominal process\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Ultrasound abdomen.\n\n INDICATION: Cirrhosis, ascites, portal vein thrombosis.\n\n FINDINGS:\n\n Again note is made of the area of low echogenicity in the right lobe of the\n liver which measures 2.5 x 2 x 1.5 cm. Again, no evidence of any flow in\n relation to the portal vein. The hepatic veins demonstrate normal flow. The\n hepatic artery has a normal waveform.\n\n There is ascites noted.\n\n The right kidney is visualized and is normal.\n\n Splenomegaly is noted with the spleen measuring almost 16 cm.\n\n The left kidney is normal.\n\n CONCLUSION:\n\n Thrombosis of intrahepatic portal vein.\n\n Ascites.\n\n Approximately 2.5 cm area of low echogenicity in relation to the right lobe of\n liver which may represent a hepatocellular CA.\n\n Splenomegaly.\n\n Splenic varices.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566950,\n \"text\": \"NURSING NOTE 0700HRS-1600HRS\\n\\n\\n\\nEVENTS..B/P STABLE AWAIT HD.....IF TOLLERATES ? CALL OUT TO FLOOR...\\n\\n\\nNEURO..A/O X3, OOB TO CHAIR WITH X1 NURSE..C/O LOWER BACK PAIN RELIEVED WITH PO ANALAGESIA...\\n\\n\\nRESP..ROOM AIR SATS !@98%..CLERA UPPER DIMINSHED LOWER...\\n\\n\\nCVS...GOOD B/P, CONTINUES ON MIDIRINE, 100-110 SYSTOLIC..WAIT TO OBSERVE ON HD...HR STABLE 65-70BPM...\\nAFEBRILE, ALTHOUGH DID HAVE TEMP AT 100.1 LAST PM SO IF TEMP GOES UP AGAIN FOR B/ CULTS..VANC LAST PM WAS LAST DOSE...\\nB/S COVERED WITH S/S..\\nHCT @ 23.6 THIS AM , DOWN FROM YESTERDAY, FOR RE-CHECK THIS PM...PLTS REMAINS LOW @ 128, IS 1.5FLUID RESTRICTION\\n\\n\\nGI.. LARGE DISTENDED/ASCITES ..LAST TAP ..B/S PRESENT/GAS..TAJKEN SAMLL AMOUNT OF FOOD, NO BOWEL MOTION SO FAR TODAY..CONTINES ON LACTULOSE..\\nLIVER TEAM FOLLOWING..CT LAST FRIDAY SHOWED LARGE AMOUNT OF OLD CLOT IN PORTAL VEIN/MESENTERIC ARTERY...MEETING TOMORROW TO DISCUSS LIKELIHOOD OF GOING AHEAD WITH SURGERY GIVEN THIS INFORMATIONAS MAKES TRANSPLANT TECHNIQUELY VERY DIFFICULT\\n\\n\\nGU...FINISHED YESTERDAY @ 1300HRS...AM LABS SATBLE, AWAIT HD BOOKED FOR 1700HRS...NO URINE OUTPUT,NA, FLUID RESTRICTION AS ABOVE...\\n\\n\\nSKIN..ABRASION ON SACRUM, CREAM AAPPLIED..RELECTANT TO TURN ON SIDE..\\n\\n\\nLINES..PICC/DIALYSIS \\n\\n\\nSOCIAL..BROTHER TO VISIT PM..MEETING TOMORROW RE FINAL DECISION OF LIVER/KIDNEY TRANSPLANT...\\n\\n\\n\\nPLAN...TO ATTEMPT HD/OBSERVE B/P..TRANSFER WRITTEN IN PREP FOR C/O\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566951,\n \"text\": \"ADDENDUM..HCT STABLE, BUT PATIENT STOOLED THIS PM AND STREAKY BLOOD EVIDENT IN STOL..TEAM AWARE..CONTINUE AT PRESEENT AS HCT STABLE AND VITALS STABLE, REPEAT HCT @ 2200HRS\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566952,\n \"text\": \"7p to 7a Micu Progress Note\\n\\nOverview of Events - Pt underwent HD last eve. 02 sat dropped to 84% during procedure. 02 5 L NC applied temporarily with sats increasing to low 90's. HR slightly elevated to 105 ST during HD and lowest BP was 80/44.\\n\\nNeuro - Alert and oriented x 3. OOB to chair with minimal assist x 1. Lactulose for encephelopathy. Medicated with 5 mg oxycodone for back pain x 1 with good effect.\\n\\nResp - LS clear, diminished at bases. RR 11-19. Sats > 95% except for above mentioned incident during HD. Expectorating sm amts clear sputum with flecks of blood.\\n\\nC-V HR 60-110 ST. NBP 80-120/40-50. HR increased with HD and with exertion.\\n\\nF/E - HD administered over ~ 2 1/2 hrs. 500ccs fluid removed. BUN 24 CR 3.3. K 3.6. Pt remains hyponatremic at 127 despite 1000cc fluid restriction. Voided 30ccs amber colored urine. TFB + ~400ccs .\\n\\nGI - Abd + ascites +BS. Tolerating renal diet without n/v. Passed mod amt loose green stool on commode. Minute amt of BRB noted on tissue after pt defecated.\\n\\nHeme/Access- Hct stable throughout the night at 23.6. Transfuse hct < 21. Epogen given 3 x/wk. Pt bleeding from Dial LSC after instillation of heparin by dialysis R.N. Also bleeding from former skin tear site on RUE. Tegaderm dssg reapplied to RUE. Surgicel and DSD to LSC site and former line site above LSC with decrease in bleeding noted. INR 2.3\\n\\nID - Afeb. WBC 8.5. + contact precautions Vanco dosed by level for staph UTI. Cipro given for hx SBP.\\n\\nSocial - Brother visited with pt last eve.\\n\\nA+P - Continue to monitor for bleeding - follow hcts, INR. Pt stable during HD. ? call-out to floor today. Nsg transfer note updated. Surgery to make decision re ? liver transplant today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566949,\n \"text\": \"npn 7p-7a\\n\\n the pt remained off of crrt overnoc with the plan to attempt hd again later today. sbp remain stable ~90-100.\\n\\nreview of systems\\n\\nrespiratory-> lung sounds diminished bibasilarly. pt is maintaining sats >93% on room air. he denies c/o sob.\\n\\ncardiac-> hemodynamically stable. hr 60-70's, sr w/no noted ectopy. sbp @baseline ~90-100.\\n\\nneuro-> a&o x3. able to participate in care. oob to chair x several hours last noc, but he required a 2 person assist back to bed. mae x4 w/equal strength.\\n\\ngi-> abd w/+bs and significant ascites. denies c/o n/v. no bm overnoc.\\nneeds encouragement to take in more than po fluids. pt is aware that he is on a 1500cc free water fluid restriction.\\n\\ngu-> no void overnoc. anticipate attempt at hemodialysis again sometime later today.\\n\\nid-> tmax 100.1 orally earlier in the shift with no actual fever spike. received vancomycin x1 ~2100.\\n\\nendocrine-> received regular insulin coverage per sliding scale parameters.\\n\\naccess- right arm dl picc line and a left sc dialysis catheter are both patent and intact. peripheral iv was d/c'd this morning.\\n\\ndispo-> ?transfer back to floor if pt tolerates hemodialysis.\\n\\nsocial-> pt's brother was in visiting last evening. plan for family meeting on tues w/the transplant team re: final decision re: possible liver/kidney transplant.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566933,\n \"text\": \"7p to 7a Micu Progress Note\\n\\nNeuro - Pt remains alert and oriented x 3. MAE. Assists with self care. Jaundiced and fatigued appearing. c/o chronic back pain - . Medicated with 5 mg oxycodone x 2 with good results.\\n\\nResp - LS clear with few crackles. RR 10-16. 02 sat > 96% RA.\\n\\nC-V - HR 55 SB - 65 SR, no ectopy. NBP 86-100/40's. + Palp peripheral pulses. Hct stable at 26.8. No epistaxis or bleeding from lines noted. Transfuse hct< 25.\\n\\nGI - + Ascites. Pt not passing stool despite 3 doses of lactulose. + flatus. Tolerating renal diet although appetite is poor.\\n\\nF/E - Continues on CVVHD, with even fluid goal. System has clotted once and warning has appeared that system is clotting again as of this writing. TFB + 24ccs. Presently +16. No spontaneous voiding of urine. AM lytes pend but BUN/Cr improving to 53/3.2 with eve labs. Still hyponatremic with Na of 129 - on 1000cc fluid restriction. Ca and K infusing via sliding scale per CRRT protocol.\\n\\nID - Afeb. WBC 3.2. Lactic acid 2.6. + contact precautions.\\n\\nSocial - Brother and family members visited pm.\\n\\nA+P - Hemodynamically stable on CVVHD. Electrolye repletion as needed. ? nutrition consult to improve po intake.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566934,\n \"text\": \"Micu Nursing Progress Note\\nEvents: remains on CRRT, filter seems to be clotting ~12h.\\n\\nNeuro: Pt is awake, alert, pleasant and cooperative. Moving around in bed without difficulty. C/O back pain 1400 and was medicated with oxycodone 5mg given with good relief.\\n\\nCardiac: B/P 90-104/50's, HR 68-72, SR. K+ 4.3 at 10am and 3.9 at1700, potassium replacement gtt maintained at 20ml/hr, Ca+ 1.14 at 10a and calcium gtt increased to 30ml/hr then decreased to 25 at 1700 for Ca+ 1.25.\\n\\nResp: breath sounds clear, room air O2 sats 99-100%. RR 10-14.\\n\\nGI: taking renal diet well with good appetite. Pt taking lactulose tid as ordered. He had a mod amount of soft golden stool X1. Abd- distended with ascities (+) BS.\\n\\nEndo: BS slightly higher today with 12n 248, covered with 4u regular insulin and 1800 BS 174 covered with 2u insulin.\\n\\nGU: Pt voided ~300cc amber colored urine, specimen sent for U/A and C&S. CRRT continues, filter started to develope clots arounf 1300 and clotted off at 1700. Flow rate increased to 100 mg at 12n due to increasely positive. FLow rate decreased when access pressure alarming continueously, return and access lines also reversed to help stop the alarm. However due to decreased flow rates pt is currently 380cc positive.\\n\\nID: remains afebrile, not on any antibotics.\\n\\nSocial: no contact with pt's family today.\\n\\nPlan: continue CRRT, attempt to keep pt even. Lab review due at 2200.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566945,\n \"text\": \"7p to 7a Micu Progress Note\\n\\nNeuro - Pt remains oriented x 3. Lethargic and fatigued at times - easily arousable. MAE. Medicated wtih 5 mg oxycodone x 1 for back pain. Sleeping intermittently throughout the night.\\n\\nResp - LS clear. RR 10-16. 02 sat > 97%. + dry cough.\\n\\nC-V - HR 66-80 NSR. NBP 110-126/54-61. + palp peripheral pulses.\\n\\nGI - Abd + ascites. +BS. Pt s/p paracentesis on previous shift. Ate a couple of bites of a tuna after. c/o intermittent abd discomfort assoc with nausea and vomiting x 2. Pt vomiting bilious material with undigested food. MD notified. Abd soft on exam. Hct sent, which was stable at 28.6 KUB taken. Medicated with dolasteron mesylate iv x 2 and one dose of maalox po with fair results. Pt reports feeling better after vomiting and after moving his bowels. Passed a lg amt loose brown guiac neg stool on the bedpan.\\n\\nF/E - TFB neg ~5000 cc on . Continues on with goal fluid removal rate of neg 30ccs/hr. Presently neg 191. LOS + 345. Access and return lines remain reversed when prisma reaccessed due to fluctuating access pressures. Filter pressures elevated throughout the night to 150-176, despite changing system x 1. Ca and K infusing via sliding scale per protocol. BUN 18 Cr 2.0. Remain hyponatremic with Na 132 - on 1000cc fluid restriction. Pt voided 50ccs clear amber urine with urinal.\\n\\nHeme - Hct stable at 27.2 this am. s/p transfusion 2 units prbcs on eves. Anemia rx with epogen 3 x/wk. INR 1.8\\n\\nID - Afeb. WBC 3.6. + contact precautions. Vanco level pend. ? staph uti being empirically covered with vanco. Cipro 1x/wk for hx SBP.\\n\\nSkin - Barrier cream applied to reddened rectal area. Sarna lotion to pruritic back.\\n\\nA+P - Continue - replete lytes as indicated. ? gastroenteritis s/p eating tuna - continue to assess abd pain, ? abd CT should pain worsen.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566931,\n \"text\": \"7p to 7a Micu Progress Note\\n\\nNeuro - Pt alert and oriented x 3. MAE. Up to commode with minimal assist. Lactulose for encephelopathy prophylaxis. Denies any pain.\\n\\nResp - LS clear. RR 12-20. 02 sat > 96 on RA.\\n\\nC-V- HR 60's NSR, no ectopy noted. NBP 86-96/40's. Baseline SBP 90's per pt. No edema.\\n\\nGI - Abd + ascites. Tolerating renal diet without difficulty but po intake poor. Passed sm amt loose brown stool on commode. Carafate and PPI for varices.\\n\\nF/E - CVVHD initiated with fluid removal rate goal 0. Ca and K drips infusing per sliding scale protocol. K 3.9 Ionized ca 1.20. BUN and Cr slighlty improved - 88/5.3 respectively. Pt remains hyponatremic, Na 126 - on 1000ml fluid restriction. Pt oliguric but but voided 50ccs clear yellow urine with urinal.\\n\\nHeme - Pt s/p transfusion 2 units FFP and cryoprecipitate on previous shift. INR 2.1, previously 2.7. Hct 25.3. Transfuse hct < 25.\\n\\nID - Afeb, normothermic. WBC 3.0. + contact precautions for c-dif - completed course of flagyl.\\n\\nEndo - RISS\\n\\nAccess - RIJ TLC by MD. sent for cult. Pt has access port on LSC Quinton catheter. One peripheral #20 angio iv inserted into R forearm. Quinton site bleeding mod amt at onset of shift. Surgicel and new DSD applied with resolution of bleeding.\\n\\nSocial - Brother, who is HCP, visited with pt last eve.\\n\\nA+P - Pt tolerating CVVHD with marginal BP. Monitor for bleeding, FFP prior to invasive procedures. ? transfusion PRBCS if hct continues to decline. Na and fluid restriction for hyponatremia. Lyte repletion per sl scale.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566932,\n \"text\": \"MICU 6 NSG 7A-7PM\\nRESP--PT CONTS ON RA LUNGS STA WITH SOME INTERMITTENT RIGHT BASE CRACKLES. DENIES SOB OR RESP DISTRESS.\\n\\nCV--REMAINS IN SB 50-60'S, NO ECTOPY NOTED. BP 80'S-100/. TOL CRRT SO FAR THIS SHIFT. NO PERIPHERAL EDEMA NOTED. INTERMITTENTLY MILD EPISTAXIS NOTED. NO FURTHER BLEED ING FROM RIGHT NECK AT SITE OF PREVIOUS TLCL. HD LINE SITE ALSO WITHOUT BLEEDING. CLOT SENT FOR BLOOD BANK WITH REPEAT HCT THIS AFTERNOON.\\n\\nGI--TOL RENAL DIET WELL. LACTULOSE X1 DOSE WITH NO BM SO FAR THIS SHIFT, PT PASSING FLATUS. ABD REMAINS DISTENDED DUE TO ASCITIES.\\n\\nRENAL--PT WILL NEED UA NEXT TIME HE VOIDS. SO FAR THIS SHIFT PT IS ANURIC. CONTS ON CVVHDF, FLUID GOAL IS TO RUN PT EVEN, SO FAR TOL WELL. CONTS ON IV KCL AND CALCIUM INFUSIONS, TITRATED PER SS. CRRT SYSTEM CLOTTED X1 AND RESTARTED THIS SHIFT.\\n\\nNEURO--PT A&OX3. MAE WELL, AND REPSOITIONS SELF IN BED. PNEUMO BOOTS APPLIED FOPR DVT PREVENTION.\\n\\nSOCIAL--NO CONTACT WITH FAMILY SO FAR THIS SHIFT.\\n\\nPLAN--F/U HCT TRANSFUSE FOR HCT <25\\n--CONTS CRRT WITH FLUID GOAL NET EVEN\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566946,\n \"text\": \"MICU NURSING PROGRESS NOTE. 0700-1900\\n PLEASE SEE CAREVIEW FOR OBJECTIVE DATA.\\n\\n Events: Continues on cvvhdf, filter changed this pm. Medicated for nausea x 1. Emesis x 2. No c/o discomfort, reports feeling slightly better this pm.\\n\\n Neuro: Alert and oriented x 3. Is able to make needs known verbally in soft clear voice in full sentences. Intermittent napping throughout shift, easily arouses to verbal stimulus. Able to move all extrem. freely. Follows commands. Temperature max. 98.0 No c/o discomfort this shift.\\n\\n Respiratory: Lung sounds are clear throughout. RR 12-20 and non labored. O2 saturation on ra 97-100%. Cxr reportdly showed rll opacity.\\n\\n CV: Sinus rhythm with no ecopy noted, rate 60's to 70's. Nbp low 100's to 110's systolic. Rt ac picc line patent, site wnl. Lt sc hd line site wnl, remains patent with access reversed. Hct stable this pm at 26.6.\\n\\n GI/GU: Abdomen ascitic with +bs. Continues nausea although reporting feels better this pm, s/p 12.5mg anzemet i.v. Several episodes of green bilious emesis this am. Reports he is passing gas, no bm this shift. Continues on lactulose. No urine this shift.\\n\\n Cvvhdf: Continues on crrt, pfr at 90, goal is negative 30 per hr. Filter changed this pm at 1500 hrs with access and return lines reversed. Renal wants crrt to continue thru weekend despite pt being hemodynamically stable and a questionable transplant candidate r/t his large clot in his portal vein.\\n\\n Social: No social contacts this shift, has received calls in room.\\n\\n Integ: Skin remains grossly intact, sarna lotion applied to back.\\n\\n F/e/n: Pneumo boots. Renal diet.\\n\\n Plan: Continue on crrt. Monitor electorlytes per protocol, next set due at 2200, and adjust potassium, calcium drips accordingly. Medicate for nausea.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566947,\n \"text\": \"pmicu npn 7p-7a\\n\\n crrt clotted off again earlier this morning and was restarted w/o incident ~0230. he has met his fluid removal goal and is actually tfb negative for his los after having a large, liquid stool.\\n\\nreview of systems\\n\\nrespiratory-> lung sounds are course w/sats >97% on room air. pt denies c/o sob.\\n\\ncardiac-> sbp ranging 100-120's. hr 60-70's, sr w/no noted ectopy. pt is receiving continuous potassium and calcium repletion per ccrt sliding scales.\\n\\nneuro-> pt is alert and cooperative although he requires motivation to be repositioned. he is able to mae x4, ue >le's. c/o lower back pain and medicated w/oxycodeine x1 w/good effect.\\n\\ngi-> abd w/significant ascites despite recent paracentesis. he denies any n/v overnoc but refuses to eat. he did drink several cups of water and gingerale. he had 500cc of liquid stool x1.\\n\\ngu-> crrt continues to clot off at least 2-3x/24hrs. he was restarted again this morning. pt's inr is marginally elevated, ?need to start systemtic heparin. as noted above, he is tolerating a goal fluid loss of 30cc/hr and is currently tfb negative for his los. ?another attempt at hd soon since he has been hemodynamically stable.\\n\\nid-> afebrile w/a normal wbc. awaiting level before redosing w/vanco today.\\n\\naccess-> right arm dl picc line and a left sc tunneled dialysis catheter are both patent and intact.\\n\\nsocial-> no contact w/family overnoc. family meeting planned on tuesday w/liver team to discuss possibily of transplantation.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566930,\n \"text\": \"Nursing Progress Note.\\n\\nBriefly, this is a pleasant 51 yr old male transferred to MICU 6 West from 10 for the initiation of CVVHDF. Pt initially admitted on c confusion which responded well to PO Lactulose therapy. PMH includes; cirrhosis, portal vein thrombosis, varices, DM II, SBP, ETOH, cigs and now ARF. Pt had been doing well on 10 (ambulating, self ADL's, fair PO intake) but unfortunately unable to tol regular HD on floor c SBP dropping to low 80's (from a baseline SBP values in the 90's). Pt therefore transferred to MICU WEST 6 for initiation of CVVHDF. NKDA. The pt is a Full Code. Contact precautions in place.\\n\\nMS: AAO times three currently, follows commands, pleasant/cooperative and appropriate. Poor short term memory noted. Pt reports intermittent R eye pain, intermittent dental and belly pain. Pt currently denies pain, team to assess eye shortly. Pt reports poor PO intake and recent weight loss of 40 lbs in past year. Pt given call light c instruction.\\n\\nCV: Hemodynamically stable and afebrile. NSR c no ectopy. Pt c an INR value this AM of 2.9 c some minor bleeding around two central lines (RIJ TLC & LSC Quinton), pt received two units of FFP on floor f/b one unit Cryoprecipitate -- HO to d/c RIJ TLC shortly (placed @ an outside facility and deemed unessential @ this time). Nursing staff to place PIV shortly and LSC Quinton cath has a side port for central access needs.\\n\\nRESP: RA c nl sats, RR and resp effort @ rest in bed.\\n\\nGI: Pt reports poor PO appetite, will encourage PO supplements and cont to encourage good PO intake.\\n\\nGU: Oliguric per report from 10.\\n\\nDERM: Pt is jaundiced.\\n\\nSOC: Brother now visiting @ BS.\\n\\nOTHER: Please see CareVue for additional pt care data/comments.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566940,\n \"text\": \"Micu Nursing Progress Notes\\nEvents: CRRT continued, filter clotted at 12n and changed.\\n\\nGU: CRRT continued with fluid volume goal continues to be even. Problems with the access pressure continue contributing to the clotting difficulty. Pt will be NPO after MN for a tunnel catheter to be placed tomorrow. He continues to be acidotic so the replacement and dialysate were changed to compensate. Also the blood flow rate was increased to 150 (per Renal fellow Dr. ) to help with the clotting issue.\\nPt voided 250cc dark amber urine.\\nK+ at 12n 3.8 so gtt increased to 30ml/hr, at 1700 K+ 4.1 so Kcl gtt decreased to 20ml/hr, ionized Ca at 12n was 1.14 so calcium ftt increased to 30mg/hr, but at 1700 ionized Ca was 1.21 so rate decreased to 25ml/hr.\\n\\nCardiac: B/P 92-101/40's, HR 62-74.\\n\\nResp: remains on room air with RR 12-18, O2 sats 99-100. Breath sounds clear.\\n\\nGI: Appetite remains good. Pt receiving lactulose tid. He was transfered to the bedside commode when he had a moderate amount of golden soft stool. Abd remains distended with asities. (+) bowel sounds.\\n\\nEndo: Blood sugar 150 at 12n and 189 at 1800-received 2u regular insulin.\\n\\nNeuro: He remains alert and oriented, able to transfer to the bedside commode with minimal assistance.\\n\\nID: Pt received a one time dose of vanco at 12n for a low vanco level. He remains afebrile with temps 97.0-98.0.\\n\\nSocial: there is to be a family meeting tomorrow at 1500 with the liver team, transplant, renal and the Micu team to determine if pt will receive enough support if he receives a liver transplant. He will remain on CRRT.\\n\\nPlan: fluid balance goal is even, NPO after MN for tunnel catheter tomorrow, family meeting tomorrow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566941,\n \"text\": \"NURSING PROGRESS NOTE 1900-0700\\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVRIONMENT SECURED FOR SAFETY.\\n\\nTHIS IS A VERY PLEASANT 51 Y/O MALE PT TRANSFERRED TO THE MICU FROM 10 FOR INITIATION OF . PT INITIALLY ADMITTED ON FOR CONFUSION WHICH RESPONDED WELL TO PO LACTULOSE THERAPY. PMH SIGNIFICANT FOR CIRRHOSIS, PORTAL VEIN THROMBOSIS, VARICES, DMII, SBP, ETOH AND ARF. PT HAD BEEN DOING WELL ON 10 (AMBULATING, SELF ADL'S) BUT UNABLE TO TOLERATE HD. S/P ESOPHAGEAL VARICIES BANDING ON - ALSO FOUND TO HAVE NEW LIVER MASS.\\n\\nNEURO: ALERT AND ORIENTED X 3. SPEECH IS CLEAR, ABLE TO VERBALIZE NEEDS WITHOUT DIFFICULTY. SELF SUFFICIENT IN ADL'S FOR THE MOST PART. AFEBRILE. PERRLA, 3/BRISK. MAE X 4 WITHOUT DIFFICULTY. STEADY GAIT. NO SEIZURE ACTIVITY NOTED.\\n\\nRR: ROOM AIR. RR 15-20. BBS= ESSENTIALLY CTA X ALL LUNG FIELDS. STRONG COUGH EFFORT- NON-PRODUCTIVE. BILATERAL CHEST EXPANSION NOTED. DENIES ANY SOB OR DIFFICULTY BREATHING. SP02 > OR = TO 95%.\\n\\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, HR 60-70'S WITH NO SIGNS OF ECTOPY NOTED. SBP > OR = TO 90 WITH NO HYPER OR HYPOTENSIVE EPISODES NOTED. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. PT NOTED TO HAVE CRIT OF 22- DR/ MADE AWARE. DENIES ANY CHEST PAIN. ALSO NOTED TO HAVE INR OF 2.0.\\n\\nGI: ABD IS LARGE WITH ASCITES. PT ABLE TO TOLERATE PO'S WITH NO C/O N,V,D. PT HAS BEEN NPO SINCE MIDNIGHT FOR IMPENDING PROCEDURE TODAY. PT HAS BEEN ABLE TO USE THE BEDSIDE COMMODE FAIRLY INDEPENDTLY. I MEDIUM SIZED GOLDEN, SOFT STOOL NOTED. PASSING FLATUS.\\n\\nGU: PT VOIDS IN URINAL- ALTHOUGH HAS BEEN ANURIC THIS SHIFT. ONGOING AT BEDSIDE. GOAL IS TO RUN PT EVEN. FILTER HAS BEEN CHANGED TOTAL OF 3 TIMES. PLAN IS FOR PT TO HAVE HD TUNNEL CATHETER REPLCMT DONE TODAY. OF NOTE, ALTERNATING NORMAL SALINE AND REPLACEMENT FLUIDS.\\n\\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS. PT HAS SOME SKIN TEARS TO BILATERAL UPPER EXTREMITIES.\\n\\nLYTES: PT CURRENTLY ON K AND ION CA GTT. PT TO RECEIVE TOTAL OF 4GMS OF MAG AND 15MMOL OF K-PHOS BASED ON 0400 LABS.\\n\\nSOCIAL: NO CONTACT FROM FAMILY THIS SHIFT.\\n\\nPLAN: LABS AT 1000 AND 1600. WILL NEED TO CONSIDER PRBC AND FFP TX FOR DECREASED CRIT AND INCREASED INR. REPLETE LYTES PRN. PT TO HAVE HD TUNNEL CATHETER INSERTION TODAY. CONTINUE AS PT WILL EVENTUAL PLAN TO SWITCH TO HD. FAMILY MEETING TO DISCUSS POSSIBILITY OF LIVER TX. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566942,\n \"text\": \"Nursing Progress note 0700-1900\\nEvents: off @ 1115 for pt transport to IR for double lumen PICC and tunneled HD lines. Procedure tolerated well. On return to unit, family mtg with liver transplant team/MICU team took place. Pt then prepped for abd CT to check for ?SMV clot, as part of liver transplant check list. Pt also to have PFT's and stress test done before liver transplant team meets next Tuesday.\\n\\nReview of Systems:\\n\\nNeuro: Pt generally AAO X 3, cooperative, turning self STS in bed. He C/O back pain @ 1200 and rec'd Oxycodone 5mg X 1 with good results. Pt also rec'd small amts Fentanyl and Versed (0.5mg) in IR for procedure. He remains lethargic, but easily woken and appropriate.\\n\\nResp: O2 sat 99-100% on RA with RR 11-15 and regular. Lung snds clear throughout. Occas clears throat, but not expectorating sputum.\\n\\nCV: HR 63-77SR without VEA. BP 101/51-109/48. Infusion of K-Phos interrupted when pt off floor, now cont to infuse. Pt rec'd 1 bag platelets and 1 u FFP before going to IR, and 1 u FFP in IR. Post-procedure labs pndg, with K+ 4.2 and ionized Ca 1.08.\\n\\nGI: Pt remains NPO except for Baricat solution and ice chips. Abd with ascites, appears larger. Paracentesis planned, ? tomorrow. Bowel snds present and pt passing flatus, no stool.\\n\\nGU: stopped @ 1115 per above. 24hr fluid balance MN->1700 + 1300ml, LOS balance + 4liters.\\n\\nAccess: New HD and PICC lines with small amt blood @ sites. Periph IV inserted in L arm for contrast dye for Abd CT scan.\\n\\nSocial: Family mtg per above. See liver team social worker's note. Nurse re-stated to pt importance of compliance, as his roommate again brought in gum/candy that was not sugarfree.\\n\\nPlan: Abd CT tonight, PFT's and stress test in next few days if pt candidate for liver transplant. Cont to impress on pt and family necessity of complying with orders in order to qualify for liver transplant(ie. follow /renal diet, fluid restriction, etc.). Re-start this PM after abd CT scan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566943,\n \"text\": \"7p to 7a Micu Progress Note\\n\\nOverview of Events - pt went for abd/pelvic CT - results pend. restarted.\\n\\nNeuro - Pt oriented x 3, fatigued appearing. Slept most of the night. MAE. Medicated with 5 mg oxycodone x 1 for back pain () with good effect.\\n\\nResp - LS clear. RR 11-16. 02 sat > 96% RA.\\n\\nC-V - HR 60-80 NSR, no ectopy noted. NBP 100-110/50's.\\n\\nGI - Pt given barocat as prep for abd ct. c/o nausea and abd discomfort after ingesting 800ccs of barocat. Medicated with 12.5 mg dolasetron mesylate iv with good results. Abd/pelvic CT performed to R/o SMV clot - results pend. Abd + ascites. + BS. ? paracentesis to be performed today. Passing flatus, no stool.\\n\\nF/E - restarted ~2300 last eve. Goal even fluid balance. Pt + ~ 2750ccs ( barocat and blood products). Presently running - 13. Access and return lines reversed as access pressure extremely neg. Bld flow rate increased to 80 as filter and effluent pressures began to rise. Bld clots present in filter - anticipate system will need to be changed shortly despite infusion taking place via new tunnel dialysis catheter. Pt completed K phos infusion. Phos 2.8 Ca and K drips infusing on sliding scale per protocol ( most recent K 4.3 and ionized Ca 1.15). BUN 20 Creat 2.2. Pt on 1000cc fluid restriciton. Na decreasing to 132.\\n\\nHeme - Pt transfused 2 units PRBCS without incident for hct 19.5. Post transfusion hct 26.1. INR 1.7\\n\\nID - Afeb. WBC 3.8. Pt given one dose of vanco for staph UTI. Vanco level pend this am. Also being rx with cipro once a week for hx of SBP. Remains on contact precautions.\\n\\nSkin - Minor skin tears and ecchymotic areas to upper exts.\\n\\nEndo - RISS.\\n\\nAccess - Minor bleeding from HD LSC insertion site. PIC dssg D+I - line draws and flushes easily. #20 LLA peripheral iv patent.\\n\\nSocial - No contacts overnight.\\n\\nA+P - Continue - ? use of citrate as pt continues to clot off filters freq ( no heparin given hx of coagulopathy). ? run pt slightly neg as BP tolerates given lg + TFB . Plan is to proceed with w/u for liver transplant - PFTs and stress test today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566944,\n \"text\": \"Nursing Progress note 0700-1900\\nEvents: Pre liver transplant tests (PFT's and stress test) cancelled as abd CT revealed portal vein thrombus extends to SMV, making surgery very difficult. Final decision re transplant to be made Tuesday by committee. restarted @ 1230 with pressures high but machine running smoothly @ this time. Paracentesis done, taking off 5 liters fluid.\\n\\nReview of Systems:\\n\\nNeuro: Pt remains AAO X 3, occas dozing but woken easily. Rec'd Oxycodone 5mg X 1 for C/O back pain with good relief. When transferring bed to chair pt C/O bilat leg pain (length of legs) and required assist of 1. Tolerating alternating pressure sleeves well on legs.\\n\\nResp: O2 sat 97-100% on RA with RR 10-14 and regular. Lung snds clear throughout. Abd CT showed atelectasis of RLL. Non-productive cough.\\n\\nCV: HR 64-83SR without VEA. BP 108/68-118/61. Pt rec'ing Calcium Gluconate and KCL per sliding scale.\\n\\nGI: Pt with poor appetite which he attributes to increased ascites. Occas belching and flatus, no BM. Multivites changed to nephrocaps.\\n\\nGU: Pt voided 340ml amber/clear urine X 1. restarted @ 1230, with goal -30ml/hr. Filter pressure remains elevated after red/blue lines switched, but machine running well/continuously @ this time. Site of tunneled HD line C&D.\\n\\nAccess: Red port of PICC with heparin infused, blue port flushed with NS and good blood return.\\n\\nSocial: Liver team informed pt and his brother and proxy, , re low chance of transplant D/T clot.\\n\\nPlan: Cont . Await transplant committee decision on Tuesday.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566937,\n \"text\": \"Shift Note 1900-0700\\nCV: HR 70's, NSR with no ectopy. NIBP 90/40-60's. Pt was running on CVVH until yesterday afternoon when d/c. Hct down 24 (26.2)...transfuse for Hct <21. Coagulopathy; FFP/cryo if evidence of bleeding.\\n\\nResp: RR 10-17; sats >94% RA. BBS CTA.\\n\\nNeuro: A/Ox3. Pt c/o aching in back, relieved by repositioning until around 0500 when he awoke and having pain in back. Given prn oxycodone 5mg and currently asleep.\\n\\nGI/GU: Ascites. BS present. Tolerating renal diet; pt continually requesting PO fluids. Pt remains on strict I/O (1000cc fluid restriction);hyponatremic. Voided urinal for 50cc dark yellow/amber urine. Receiving lactulose; no BM this shift.\\n\\nID: low grade temp 99.5. BC sent with am labs. Contact precautions.\\n\\nPlan: ? need for dialysis; possible c/o to floor when okay with renal.\\n\\nSocial: brother to visit; copy of HCP in chart.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566938,\n \"text\": \"Nursing Progress note 0700-1900\\nEvents: Restarted on CVVHD @ 1745 in prep for liver transplant.\\n\\nReview of systems:\\n\\nNeuro: Pt remains AAO X 3, dozing less freq today. Did not require any pain med for back this shift. Moves self in bed, and amb to commode without assist.\\n\\nResp: O2 sat 99-100% on RA with RR 9-14 and regular. Lung snds clear throughout.\\n\\nCV: HR 64-76SR without VEA. BP 84/40-103/48. Hct stable @ 26.\\n\\nGI: Appetite cont good. Fluid restriction increased to 1200ml/day. Pt with loose brown stool X 2, lactulose and reglan held.\\n\\nGU: Pt voided 50ml amber urine X 1. CVVHD restarted @ 1745, with alternating replacement solutions of NA and Prismasate per order.\\n\\nID: Afebrile. Rec'd Vanco X 1.\\n\\nPlan: Cont CVVHD to stabilize pt for liver transplant.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566939,\n \"text\": \"Shift Note 1900-0700\\nPt 54 y/o M with ETOH cirrhosis, liver failure, renal failure on CVVH; placed on liver transplant.\\n\\nCV: HR 60-70's, NSR with no ectopy. NIBP 90's/40(baseline hypotension). Hct 25.5; Plt 53.\\n\\nAccess: PIV x1 20g right posterior forearm; flushes well\\nLSC dialysis with med port.\\n\\nResp: RR 12-15; sats >98% on RA. BBS CTA. Pt with strong congested cough.\\n\\nNeuro: Pt receiving lactulose TID; hepatic enceph. improved. A/O x3; pleasant and cooperative with care. c/o aching and pain in back and medicated last at 0200 with prn 5mg oxycodone with some relief. Back pain improves with frequent repositioning.\\n\\nGI/GU: Ascites, abdomen distended. No UO/BM this shift. BS hyperactive. Pt on renal diet; tolerating well. 1000cc fluid restriction.\\n\\nCVVH: Pt started on CVVH around 1800 yesterday. Filter clotted around 0100, requiring new set. Blood flow increased from 80 to 100. Goal to run patient even. Alternating replacement solution b/w NaCl and prismasate. Na 128. Following VBG's 7.34/42/30/21 last evening and 7.28/42/30/21 this am. KCL and CaGluconate replacement according to sliding scale. Continue to monitor lytes and VBG Q6hrs.\\n\\nSkin: Intact; skin cool/dry...jaundiced.\\n\\nEndo: SSC; BS elevated, monitor closely. need to adjust SSC.\\n\\nID: Afebrile. BC pnd. Additional set of peripheral BC sent this am with labs. Urine cx from with staph, ?UTI.\\n\\nSocial: brother to visit last evening.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566953,\n \"text\": \"0700-1900 NPN:\\n\\nPLEASE SEE CAREVUE FLOWSHEET AND TRANSFER NOTE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT ALERT AND ORIENTED X3. PLEASANT AND COOPERATIVE W/ CARE. FOLLOWS COMMANDS, MAE, PERLA. PT DENIES PAIN. OOB TO CHAIR W/ ASSIST X1 FOR MOST OF SHIFT. NSR @ 69-79, NO ECTOPY NOTED. NBP= 92-108/43-58. AM HCT= 23.6, MICU TEAM ORDERED HCT CHECKS DAILY W/ PARAMETERS TO TRANSFUSE IF BELOW 21. AFEBRILE. AM WBC= 8.5. CIPRO PO 1X/WEEK AND NO IV VANCO ORDERED THIS SHIFT. CONTACT PRECAUTIONS CONTINUE FOR STAPH UTI. LEFT DUAL LUMEN PICC INTACT. RIGHT SUBCLAV DIALYSIS INTACT, DRSG X2 THIS SHIFT R/T BLEEDING AT SITE. SURGICEL AND SURGIFOAM USED. AM INR=2.3. LS= CLEAR/DIM. 02 SAT 93-100%. RR=. PT TOLERATING RENAL DIET. PRESENT BS. LACTULOSE CONTINUES TID FOR ENCEPHALOPATHY. OCTREOTIDE SQ AND MIDODRINE PO CONTINUES. POSITIVE ASCITES. NO VOID THIS SHIFT. LAST DIAYLSIS TREATMENT COMPLETED LAST HS AT APPROX 2300, NEXT DUE WED . FS QID ON S/S COVERAGE 118-194. LIVER AND RENAL TEAM MET TODAY TO DISCUSS PLAN OF CARE AND POSSIBILITY OF LIVER TRANSPLANT. SURGICAL TEAM UNABLE TO ATTEND MEETING, DECISION WILL BE MADE TOMORROW REGARDING LIVER TRANSPLANT. PT MADE AWARE, EMOTIONAL SUPPORT PROVIDED R/T PT LOOKING FORWARD TO FINDING OUT SOME NEWS TODAY. PT SPOKE W/ BROTHER AND REPORTS FEELING BETTER. PT CALLED OUT TO FLOOR. PT STABLE, READY TO TRANSFER TO FLOOR WHEN PRIVATE BED AVAILABLE ON 10.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566954,\n \"text\": \"7p to 7a Micu Progress Note\\n\\nOverview of events - pt stable overnight but continued to ooze lg amt BRB from Dial LSC line. Surgicel, gelfoam and elastoplast pressure dssg applied without resolution. FFP to be given and IR consulted re: line.\\n\\nNeuro - Pt alert and oriented x 3. OOB to chair. Minimal assist with transfers. PT consult ordered as pt's overall strength has deconditioned. Pt declined any pain med for chronic back pain.\\n\\nResp - LS clear, diminished at bases. RR 11-16. 02 sat > 97% on RA.\\n\\nC-V - HR 70-80 NSR, no ectopy. NBP 85-114/40-50.\\n\\nGI - Abd + ascites. Tolerating renal diet without n/v, although intake poor. Nutrition has been consulted. Rx with lactulose tid for encephelopathy. Passed mod amt loose golden guiac + stool on bedpan. c/o pain from hemorrhoids. Hydrocortisone rectal cream to be ordered by MD.\\n\\nF/E - TFB + 1150ccs ( pt not dialzyed). To have HD today. BUN and Cr rising to 30/4.2 respectively. Phos 2.4 - Per renal, sucralfate should be dcd. Na 126 - remains on 1000cc fluid restriction. Pt voided 25ccs amber colored urine with urinal.\\n\\nHeme/Access - INR 2.0 at onset of shift. Rx with 5 mg vit K sc. As per above pt continued to bleed lg amt of blood from Dial LSC line despite surgicel, gelfoam and elastoplast pressure dssg. Hct 24.5 last eve, dropping to 22.2 this am. PT 19.5 PTT 57.4. INR 1.9. To be transfused one unit frozen plasma. IR to be consulted re Dialysis line. ? purse string sutures to be applied. Telfa pad applied to RUE skin tear which has also been bleeding.\\n\\nID - Afeb. WBC 4.5. + contact precautions. Vanco dosed per level for staph uti, no vanco administered. ? vanco to be dcd per transplant team recommendations.\\n\\nSocial - Brother and numerous family members visited with pt last eve. Liver and surgical service to meet with pt and brother at 3pm today.\\n\\nA+P - FFP to be administered. ? purse string sutures need to be utilized to prevent further bleeding from dialysis line. Pt to receive HD today. Pt called out - stable to go to floor once bleeding from RSC dialysis line is resolved.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566955,\n \"text\": \"0700-1900 NPN:\\n\\nPLEASE SEE CAREVUE FLOWSHEET AND TRANSFER NOTE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT CALLED OUT TO FLOOR, AWAIT AVAILABLE BED AND LEFT SUBCLAV BLEEDING TO RESOLVE. PT ALERT AND ORIENTED X3. PLEASANT AND COOPERATIVE W/ CARE. PT FOLLOWS COMMANDS, MAE, PERLA. PT DENIES PAIN AT THIS TIME. OOB TO CHAIR X 1 ASSIST. WHILE IN BED EARLIER IN SHIFT, PT C/O BACK PAIN AND MEDICATED W/ OXYCODONE 5MG PO X2 DOSES W/ GOOD EFFECTS. SB TO NSR 62-90. AFEBRILE. NBP=89-110/37-56. PT C/O SLIGHT PALPITATION DURING HEMODIALYSIS TODAY, HR UP TO 104 AND SBP DOWN TO 89. 02 SAT DROPPED TO 85%. 5L N/C AND FACE TENT APPLIED R/T PT ASLEEP AND MOUTH BREATHING. ALL RESOLVED AFTER HD COMPLETED. LS= CLEAR/DIM. RR=. 02 SAT 92-100% ON RA. PT TOLERATING RENAL DIET. PRESENT BS. POSITIVE ASCITES. LACTULOSE CONTINUES TID FOR ENCEPHALOPATHY. PT VOIDS , NONE THIS SHIFT. HEMODIALYSIS DONE FOR APPROX 1 HR TODAY, NO VOLUME REMOVED. LEFT SUBCLAV DIALYSIS LINE INTACT, BLEEDING FROM SITE CONTINUES SINCE LAST HD TREATMENT ON MON PM. HEPARIN GIVEN IN HD PORTS ON , CITRATE GIVEN IN HD PORTS INSTEAD TODAY. AM INR=1.9. AM HCT=22.2. PT RECEIVED K X2 DOSES YESTERDAY. 2 UNITS OF FFP TODAY. DDAVP THIS SHIFT AND MULTIPLE DRSG / SURGICEL AND SURGIFOAM TO AID CLOTTING. IR CONSULTED AND ASSESSED HD LINE FOR POSSIBLE PURSE STRING SUTURE. PLEASE SEE PROGRESS NOTES FOR RECOMM, NO SUTURE PLACED AT THIS TIME. MICU TEAM AWARE SITE STILL BLEEDING AND PM HCT DOWN TO 20.9 AND PM INR 1.7. AMINOCAPROIC ACID OR AMICAR RINSE ORDERED TO BE APPLIED DIRECTLY TO SITE. LIVER AND SURGICAL TEAM MADE FINAL DECISION THIS SHIFT. LIVER ATTENDING DR MET W/ PT AND BROTHER TO INFORM THEM THAT PT IS NO LONGER LIVER CANDIDATE. EMOTIONAL SUPPORT PROVIDED. PT HAS DECIDED AT THIS TIME THAT HE WOULD LIKE TO STOP DIALYSIS AND RETURN HOME. MICU TEAM AWARE AND WILL NEED TO GET PALLIATIVE CARE INVOLVED TOMORROW. PT CALLED BACK IN AND WILL STAY IN MICU TONIGHT DUE TO DROPPING HCT, DOWN 6 PTS SINCE . MICU TEAM ORDER UNITS OF PRBC FOR TONIGHT IF PT AGREES. FS QID ON S/S COVERAGE. FULL CODE. PT AND BROTHER UPDATING REST OF FAMILY R/T FINDINGS.\\n\\nPLAN- ASSESS DIALYSIS SITE FOR BLEEDING, ADMIN PRBC AND MONITOR HCT AS ORDERED. PROVIDE EMOTIONAL SUPPORT AND FOLLOW UP W/ PALLIATIVE CARE IN AM. SOCIAL WORK CONSULT AS NEEDED. POSSIBLE REMOVAL OF DIALYSIS LINE IN IR TOMORROW IF PT REQUESTS. CONTINUE ICU SUPPORTIVE CARE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566956,\n \"text\": \"MICU Nursing Note 1900-0700\\nEvents: Left SC Dialysis catheter continues to ooze during night with HCT down to 20.9. Transfused with 1 unit Cryoprecipitate, 1 unit FFP, and 1 unit pRBC's overnight with am labs to be sent.\\n\\nNeuro: A+OX3, pleasant and cooperative, verbalizing about plan to go home over next few days, Moves all extremities and follows all commands, OOB to chair until MN and rested in naps overnight. Denies lightheadedness or dizziness.\\n\\nCardiac: HR= 60-80's SR with no ectopy noted, BP= 95-110/50's, Right PICC site C/D/I with no oozing and ports patent, Left SC Dialysis catheter continued to ooze blood throughout evening---MICU team and Attending assessed pt, HCT down to 20.9, asymptomatic for blood loss, Thrombin dressing placed over site at MN with no further bleeding noted---dressing remains D/I, Transfused with 1 unit cryoprecipitate, 1 unit FFP, and 1 unit pRBC's---without evidence of reaction noted.\\n\\nResp: Lungs clear upper lobes and rales at bilat. bases, denies SOB, RR= with Sats= 97-99 on RA.\\n\\nGI: Abd with large amt. ascites, tolerating renal diet, taking sips during night, no N/V, no BM, + bowel sounds all quads.\\n\\nGU: no void\\n\\nSkin: no acute change noted.\\n\\nEndo: fingerstick 199 at MN---treated with 2 units SC insulin and am fingerstick 135.\\n\\nSocial: pt on phone with family members most of evening. No contact from family members or friends with nursing staff, MICU resident addressed code status with pt during evening and pt remains full code until he can discuss it further with his brother and have more time to think about his options. Stating that he would like to go home to as soon as possible.\\n\\nPlan: Monitor blood levels and transfuse if needed, Monitor Dialysis site for further bleeding and change dressing prn, ? of HD in future, Begin discharge plan to , If bleeding subsides transfer pt out to medical floor for further management, Support pt and family prn.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566957,\n \"text\": \"0700-1900 NPN:\\n\\nPLEASE SEE CAREVUE FLOWSHEET AND TRANSFER NOTE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT ALERT AND ORIENTED X3. PLEASANT AND COOPERATIVE W/ CARE. PT FOLLOWS COMMANDS, MAE, PERLA. PT DENIES PAIN AT THIS TIME, OOB TO CHAIR X 1 ASSIST. WHILE IN BED, C/O BACK PAIN AND MEDICATED W/ OXYCODONE 5MG PO X 2 DOSES PRN W/ GOOD EFFECTS. SB TO NSR @ 56-95. AFEBRILE. NBP=90-110/37-52. LS= CLEAR/DIM. 02 SAT 95-100% ON RA. PT DENIES SOB. NO INCREASED WOB NOTED. PT RECEIVED CRYO, 1U PRBC, AND 3U FFP OVER PAST 24HRS FOR BLEEDING DIALYSIS LINE. HCT DROPPED TO 20.9 FROM 22.2, FOR A TOTAL 6 PT HCT DROP FROM 26.2 ON . TOPICAL THROMBIN APPLIED LAST HS W/ GOOD EFFECTS, NO BLEEDING FOR APPROX 12HRS. PT RECEIVED HEMODIALYSIS TODAY FOR 3 HRS, NO FLUID REMOVED. 02 SAT DROP TO 87%, SBP TO 89, AND HR TO 100. 02 N/C 5L AND FACE TENT APPLIED, 02 SAT UP TO 93-94%. PT TOLERATED WELL, OVERALL ASYMPTOMATIC. BLEEDING FROM DIALYSIS LINE AFTER HD COMPLETE. TOPICAL THROMBIN APPLIED AGAIN W/ GOOD EFFECTS. DRSG AND AT THIS TIME. AM HCT=22.2 AND AM INR=1.6. WILL CONTINUE TO MONITOR DIALYSIS SITE. ABD MORE DISTENDED TODAY, INCREASING ASCITES. MICU TEAM PLANS TO DO PARACENTESIS BEFORE D/C HOME, PT AWARE AND AGREES. PRESENT BS. LOOSE BROWN STOOL W/ BRB DUE TO HEMORRHOIDS. RECTAL EXAM DONE BY LIVER/GI FELLOW TO CONFIRM BRB MOST LIKELY DUE TO HEMORRHOIDS. OINTMENT APPLIED BY NRSG. LACTULOSE CONTINUES TID FOR ENCEPHALOPATHY. PT VOIDS , APPROX 30CC DARK AMBER THIS SHIFT. PALPABLE PEDAL PULSES. FS QID ON S/S COVERAGE. FULL CODE. PT'S FAMILY VISITED AND UPDATED ON CONDITION. EMOTIONAL SUPPORT PROVIDED. MICU AND RENAL SOCIAL WORKER AS WELL AS CASE MANAGEMENT INVOLVED R/T END OF LIFE CARE.\\n\\n TRANSFER TO 10 WHEN BED AVAILABLE. PT REQUESTS TO BE D/C'D HOME W/ SERVICES ON FRIDAY. PLAN FOR DIALYSIS 3X/WEEK AT FACILITY IN . PROVIDE SUPPORT AND TEACHING R/T CHOICES INVOLVED IN END OF LIFE CARE. CODE STATUS TO BE RE-ADDRESSED BY MICU TEAM. POSSIBLE PARACENTESIS TONIGHT VS TOMORROW. CONTINUE ICU SUPPROTIVE CARE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566935,\n \"text\": \"7p to 7a Micu Progress Note\\n\\nNeuro - Pt remains alert and oriented x 3. MAE. Medicated with 5mg oxycodone x 2 for back pain with good effect. Lactulose for encephelopathy prophylaxis.\\n\\nResp - LS clear. + dry cough. RR 10-18. 02 sat > 96%.\\n\\nC-V - HR 66-80 NSR. NBP 90-110/40's. Hct stable at 26.2. INR increased to 2.7.\\n\\nGI - Abd + ascites. Tolerating renal diet. No n/v or abd pain. Passed lg amt loose brown stool on bedpan with minute amt of blood - pt reports bleeding from internal hemorrhoids in the past.\\n\\nF/E - Remains on CVVHD with even fluid rate goal. TFB + 41ccs . Currently + 18. System clotted x 1. Access and Return lines reversed due to high access pressures. Ca and K drips infusing via sliding scale per CCRT protocol. BUN/Cr improving - down to 29/2.5 respectively. Pt with persistant hyponatremia, Na dropping to 129 despite 1000cc fluid restriction. Phos 1.7 - ? replacement. Pt voided 125ccs amber colored urine in urinal.\\n\\nID - Afeb. WBC 3.9. + contact precautions - hx c-dif. ? VRE in urine - results pend.\\n\\nSocial - No visitors. Pt spoke with brother on phone.\\n\\nA+P - BP remains stable during CVVHD. BUN/CR improving. ? pt can return to HD soon.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566936,\n \"text\": \"Nursing Progress note 0700-1900\\nEvents: CVVHD D/C'd @ 1200. Pt voiding small amts.\\n\\nReview of systems:\\n\\nNeuro: Pt dozing intermit, otherwise AAO X 3. Pleasant, follows comands consistantly. Occas slurring of words. Requested pain med for back X 1, rec'd Oxycodone with good relief. Sucking almost continuously on lozanges or chew gum (smoker).\\n\\nResp: O2 sat 97-99% on RA with RR 8-14 and regular. Lung snds clear throughout.\\n\\nCV: HR 67-82SR without VEA. BP generally 86/39-103/57, with rare dips in SBP to high 70's. K+ and ionized Ca WNL @ 1100. Phos-lo D/C'd(phos 1.7) and pt started on epogen.\\n\\nGI: Pt with good appetite, tolerating renal/ diet well. Cont to receive Lactulose RTC, no BM this shift.\\n\\nGU: Filter of CVVHD clotted @ 1130 and dialysis was subsequently D/C'd. HD lines heparinized. Pt voided 75ml of amber urine with sed in am which was sent for U/A. 24hr fluid balance MN->1700 +555ml, with LOS balance +941ml. Pt cont to push limits of 1000ml/day fluid restriction.\\n\\nID: T max 99.0po@ 1600. Pt to receive Cipro Q week.\\n\\nPlan: Straight if pt without void this pm. Cont to monitor blood levels for ? restarting HD. Cont to enforce fluid restriction. Awaiting proxy papers from brother, .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1566948,\n \"text\": \"MICU NURSING PROGRESS NOTE. 0700-1900\\n PLEASE SEE CAREVIEW FOR OBJECTIVE DATA.\\n\\n Events: Crrt machine failed this pm, placed on hold by team. Minimal medication changes. Denies any nausea this shift but still only taking po liquids.\\n\\n Neuro: Alert and oriented x 3. Speach is clear and is able to make needs known verbally. Mae. Following commands. Denies discomfort as of this time. Temperature max. 97.5 oral.\\n\\n Resp: Lung sounds are clear throughout, diminished in rt base. RR 12-22 and non labored. O2 saturation 95-100% ra.\\n\\n CV: Sinus rhythm with no ectopy noted, rate 60-100's. Nbp 90's to 110's systolic. Picc line rt ac patent, site wnl. Lt sc dialysis line site wnl.\\n\\n GI/GU: Abdomen ascitic with + bs. Taking liquid po's. No bm this shift. No urine this shift.\\n\\n Social: No social contacts this shift.\\n\\n Crrt: Cvvhdf machine failed, failure code 0080. Team aware, crrt on hold as of this time. Catheter heparinized.\\n\\n Endo: Fs 122/135/156. This pm fs covered with 2 units regular insulin.\\n\\n ID: Awaiting ID approval for vancomycin dose.\\n\\n Plan: Start hd tomm. Monitor electrolytes and repleat as required. Medicate for discomfort. Encourage po intake with fluid restiction. Cipro dose tomm.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2150-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 82658,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. /Pre liver transplant. Portal thrombus.\\nHeight: (in) 66\\nWeight (lb): 200\\nBSA (m2): 2.00 m2\\nBP (mm Hg): 102/60\\nHR (bpm): 64\\nStatus: Inpatient\\nDate/Time: at 16:17\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Mild LA enlargement. Elongated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\\nregional LV systolic function. Overall normal LVEF (>55%).\\n\\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\\nsystolic function.\\n\\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\\naortic arch diameter.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality.\\n\\nConclusions:\\nSuboptimal study.\\n\\n1. The left atrium is mildly dilated. The left atrium is elongated.\\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\\nsize is normal. The LV is not well seen but limited views demonstrate normal\\nregional left ventricular wall motion.. Overall left ventricular systolic\\nfunction appears normal (LVEF>55%).\\n3. Right ventricular chamber size is normal. Right ventricular systolic\\nfunction is normal.\\n4.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation\\n5.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\\nis seen.\\n6.There is no pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-08 00:00:00.000\",\n \"description\": \"RENAL U.S.\",\n \"row_id\": 923388,\n \"text\": \" 12:48 PM\\n RENAL U.S. Clip # \\n Reason: please eval for hydronephrosis\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with cirrhosis, renal failure worsening after Foley removal\\n\\n REASON FOR THIS EXAMINATION:\\n please eval for hydronephrosis\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Worsening renal failure, cirrhosis.\\n\\n RENAL ULTRASOUND: The right kidney measures 10.3 cm, and the left kidney\\n measures 10.8 cm. There is limited evaluation of the lower pole of the right\\n kidney. There are no renal masses, stones, or hydronephrosis. The echogenicity\\n of the kidneys is normal. Ascites is noted in the right upper and lower\\n quadrants. The bladder is partially collapsed.\\n There is a small nodular liver consistent with known cirrhosis.\\n\\n IMPRESSION: No hydronephrosis. Ascites.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-06-29 00:00:00.000\",\n \"description\": \"MRI ABDOMEN W/O & W/CONTRAST\",\n \"row_id\": 922238,\n \"text\": \" 6:44 PM\\n MRI ABDOMEN W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \\n MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\\n Reason: please evaluate mass\\n Admitting Diagnosis: CIRRHOSIS\\n Contrast: MAGNEVIST Amt: 20\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with cirrhosis and new finding of liver mass\\n REASON FOR THIS EXAMINATION:\\n please evaluate mass\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: MRI of the abdomen with and without contrast \\n\\n COMPARISON: Abdominal ultrasound, .\\n\\n TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 Tesla\\n magnet including dynamic 3d imaging obtained prior to, during, and after the\\n uneventful intravenous administration of 0.1 millimole per kilogram of\\n gadolinium-DTPA.\\n Multiplanar reformats were essential in providing multiple perspectives for\\n the dynamic series.\\n\\n There is a small right pleural effusion and right lower lobe atelectasis.\\n There is a region of susceptibility artifact on the in-and-out-of-phase images\\n within the right lower lobe which may represent artifact from a granuloma.\\n Diffuse ascites is demonstrated within the abdomen. The liver contour is\\n nodular, the liver is shrunken consistent with cirrhosis. There is\\n splenomegaly and multiple portosplenic collaterals including paraesophageal\\n varices and spontaneous splenorenal shunt, consistent with portal\\n hypertension. Increased T1 signal is demonstrated within the portal vein on\\n the in-and-out-of-phase images with lack of enhancement on post-contrast\\n images suspicious for portal venous thrombosis. The liver lesion in question\\n on the ultrasound is seen within segment VIII and measures 1.8 cm and\\n demonstrates no evidence of early arterial enhancement, but does demonstrate\\n delayed enhancement, which may represent a pseudocapsule. There is an 8 mm\\n nodular focus of enhancement at the periphery of this lesion which is bright\\n on the in-phase image and drops out on the out-of-phase image consistent with\\n microscopic fat within the nodule. Although this is an atypical appearing\\n nodule, an early hepatocellular carcinoma cannot be excluded. No other\\n intrahepatic lesions are demonstrated. The pancreas, adrenal glands, and\\n kidneys are unremarkable. Small periportal lymph nodes are demonstrated, the\\n largest measuring 8 mm in short axis diameter.\\n\\n IMPRESSION:\\n\\n 1. Cirrhosis and evidence of portal hypertension given portosystemic\\n collaterals, splenomegaly, and large volume ascites.\\n\\n 2. 1.7 cm lesion within segment VIII with unusual enhancement\\n characteristics; however, which does contain an 8 mm peripheral nodule which\\n contains some microscopic fat, early hepatocellular carcinoma cannot be\\n (Over)\\n\\n 6:44 PM\\n MRI ABDOMEN W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \\n MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\\n Reason: please evaluate mass\\n Admitting Diagnosis: CIRRHOSIS\\n Contrast: MAGNEVIST Amt: 20\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n excluded. A hemangioma would be much less likely.\\n\\n 3. No portal venous enhancement on the post-contrast images, these findings\\n are suspicious for portal vein thrombosis.\\n\\n These findings were discussed with Dr. on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-16 00:00:00.000\",\n \"description\": \"PICC W/O PORT\",\n \"row_id\": 924370,\n \"text\": \" 12:42 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: Please place PICC. Failed attempt on floor\\n Admitting Diagnosis: CIRRHOSIS\\n ********************************* CPT Codes ********************************\\n * PICC W/O PORT -59 DISTINCT PROCEDURAL SERVICE *\\n * FLUOR GUID PLCT/REPLCT/REMOVE -59 DISTINCT PROCEDURAL SERVICE *\\n * C1751 CATH ,/CENT/MID(NOT D *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with ETOH cirrhosis, Hepatorenal syndrome, currently on CVVH as\\n a bridge to transplant. Needs PICC access\\n REASON FOR THIS EXAMINATION:\\n Please place PICC. Failed attempt on floor\\n ______________________________________________________________________________\\n FINAL REPORT\\n RIGHT-SIDED 5 FRENCH DUAL LUMEN PICC LINE PLACEMENT VIA RIGHT BASILIC VEIN\\n APPROACH; ULTRASOUND-GUIDED VENIPUNCTURE\\n\\n RADIOLOGISTS: and . Dr. , the Attending Radiologist,\\n was present throughout the entire procedure.\\n\\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\\n procedure to be performed, the site of the procedure, and appropriate\\n requisition. Once the above were verified, the patient was positioned in\\n supine fashion with the right arm abducted and externally rotated. The right\\n arm was then prepped and draped from the axilla to the antecubital fossa. A\\n tourniquet was applied to the upper arm. Ultrasound was employed to visualize\\n the right basilic vein which was noted to be widely patent and compressible.\\n The skin was infiltrated with approximately 2 cc of 1% Xylocaine for local\\n anesthesia at the anticipated needle puncture site. Uneventful retrograde\\n one-wall venipuncture was achieved with a 22-gauge micropuncture needle.\\n Subsequently, a guide wire was advanced by way of the basilic vein under\\n fluoroscopic visualization to the level of superior vena cava. The\\n intravascular length of the catheter to be placed was so determined at 34 cm.\\n The catheter was tailored at the 34-cm mark and delivered using modified\\n Seldinger technique to the level of superior vena cava. Both lumens of the\\n catheter were flushed and heparinlocked per protocol. The catheter was\\n secured in place with a StatLock device and then overlaid with a Tegaderm\\n occlusive dressing. The patient tolerated procedure well without\\n complication. Estimated blood loss was minimal.\\n\\n IMPRESSION: Status post successful placement of 5 French dual lumen PICC line\\n placement via right basilic vein approach. Catheter is ready to employ. Post-\\n procedural orders written.\\n\\n\\n (Over)\\n\\n 12:42 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: Please place PICC. Failed attempt on floor\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-16 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 924436,\n \"text\": \" 9:11 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: pre-xpl eval, looking at extension of clot in smv\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with liver cirrhosis, portal vein thrombus, ascites, s/p 7.5L\\n paracentesis 2 days ago, reacumulated ascites, increasing abdominal pain, low\\n hct\\n REASON FOR THIS EXAMINATION:\\n pre-xpl eval, looking at extension of clot in smv\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n 54-year-old male with cirrhosis and known portal vein thrombosis status post\\n paracentesis now with rapid reaccumulation of ascites.\\n\\n TECHNIQUE: MDCT continuously acquired axial images of the abdomen and pelvis\\n were obtained after oral and 130 mL Optiray IV contrast. A delayed portal\\n venous phase as well as coronal and sagittal reformatted images were obtained.\\n\\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a large right pleural effusion\\n with associated atelectasis of the right lower lobe. The liver is shrunken\\n and nodular consistent with cirrhosis. There is associated cavernous\\n transformation of the portal vein and numerous portosystemic collaterals\\n noted. There is a large amount of ascites. The spleen is enlarged. The\\n gallbladder, pancreas, adrenal glands and kidneys are unremarkable. Small\\n bowel is noted to be diffusely dilated up to 4.3 cm. Gas is distributed\\n throughout normal caliber colon and there is no focal change in caliber of the\\n small bowel suggesting that these findings are more likely due to ileus. There\\n is no bowel wall thickening or pneumatosis intestinalis. The portal vein does\\n not opacify and there is soft tissue density within the lumen consistent with\\n thrombus. The thrombus extends 1-cm into the SMV and 1.5-cm into the splenic\\n vein. The remainder of the mesenteric veins opacify well. There is no\\n mesenteric venous gas or free intraperitoneal gas. A small chronic\\n nonocclusive thrombus within the infrarenal IVC is similar to MR .\\n\\n CT OF THE PELVIS WITH IV CONTRAST: Ascites tracks into the pelvis. There is\\n stool mixed with gas in the rectum and sigmoid colon. The urinary bladder is\\n unremarkable.\\n\\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are\\n identified. Old rib fracture deformities are noted.\\n\\n IMPRESSION:\\n 1. Cirrhosis.\\n 2. Large amount of ascites.\\n 3. Portal vein thrombosis extends 1-cm into the superior mesenteric vein and\\n 1.5-cm into the splenic vein.\\n 4. Large right pleural effusion with atelectasis of the right lower lobe.\\n 5. Ileus.\\n (Over)\\n\\n 9:11 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: pre-xpl eval, looking at extension of clot in smv\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-09 00:00:00.000\",\n \"description\": \"NON-TUNNELED\",\n \"row_id\": 923566,\n \"text\": \" 3:14 PM\\n TEMP DIALYSIS LINE PLCT Clip # \\n Reason: please place 3-port temporary dialysis catheter on the left,\\n Admitting Diagnosis: CIRRHOSIS\\n ********************************* CPT Codes ********************************\\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\\n * US GUID FOR VAS. ACCESS C1752 CATH,HEM/PERTI DIALYSIS SHORT *\\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT C1769 GUID WIRES INCL INF *\\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with cirrhosis and worsening ARF, will need HD\\n REASON FOR THIS EXAMINATION:\\n please place 3-port temporary dialysis catheter on the left, R IJ line to be\\n pulled by team later today, INR 2.5- to get 4U FFP\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Cirrhosis and worsening renal failure, requires hemodialysis.\\n\\n TECHNIQUE/FINDINGS: After informed consent was obtained, the patient's left\\n supraclavicular area was prepped and draped in a sterile fashion. Under\\n ultrasound guidance, a micropuncture set was used to enter into the left\\n internal jugular vein just above the clavicle. Hard copy ultrasound images\\n were obtained before and after venous access documenting vessel patency. A\\n 0.035 wire was advanced into the IVC under flouroscopic guidance. After\\n which, the tract was dilated and a 16 cm triple lumen catheter advanced with\\n its tip in the proximal atrium. Catheter has three ports, one for\\n aspiration/infusion and arterial and venous ports for dialysis. The catheter\\n was sewn in place with two times 0- silk sutures. There were no\\n complications.\\n\\n IMPRESSION: Placement of a non-tunneled hemodialysis line via the left IJ\\n without complication. Catheter tip is in the proximal right atrium and ready\\n for use.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-16 00:00:00.000\",\n \"description\": \"TUNNELED W/O PORT\",\n \"row_id\": 924323,\n \"text\": \" 7:23 AM\\n TUNNELLED CATH PLACE SCH Clip # \\n Reason: please place a tunnelled HD line\\n Admitting Diagnosis: CIRRHOSIS\\n ********************************* CPT Codes ********************************\\n * TUNNELED W/O PORT *\\n ****************************************************************************\\n ______________________________________________________________________________\\n FINAL ADDENDUM\\n MEDICATIONS: Moderate intravenous sedoanalgesia was employed in the course of\\n the tunneled catheter placement. The patient received one dose of Versed 0.5\\n mg IV as anxiolytic and 25 mcg of fentanyl IV as analgesic.\\n\\n\\n 7:23 AM\\n TUNNELLED CATH PLACE SCH Clip # \\n Reason: please place a tunnelled HD line\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with ETOH cirrhosis, Hepatorenal syndrome, currently on CVVH as\\n a bridge to transplant.\\n REASON FOR THIS EXAMINATION:\\n please place a tunnelled HD line with an extra port to be used for blood draws\\n and meds if needed\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: 14.5 French by 28 cm length Angiodynamics, EvenMore tunneled\\n hemodialysis catheter placement in exchange for pre-positioned left internal\\n jugular approach triple lumen temporary hemodialysis catheter; moderate\\n intravenous pseudoanalgesia.\\n\\n CLINICAL INDICATION: Durable hemodialysis access requirement.\\n\\n INFORMED CONSENT: Procedural informed consent was obtained from the patient.\\n Specifically discussed were the indications for the procedure as well as the\\n attendant risk, potential complications and expected outcomes. The patient\\n agreed to have the procedure performed and provided witnessed informed consent\\n signature which in turn was placed in the medical record.\\n\\n OPERATORS: , M.D. (fellow).\\n , M.D. (fellow).\\n , M.D. (supervising staff).\\n\\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\\n procedure to be performed, the site of the procedure, appropriate requisition,\\n and appropriate informed consent. Once the above were verified, the patient\\n was positioned in supine fashion on a special procedures table. This\\n procedure was performed subsequent to an earlier performed right-sided PICC\\n line placement. The latter procedure was dictated and reported under separate\\n cover.\\n\\n The left upper anterior chest was prepped and draped in usual sterile fashion\\n as was the external course of a pre-positioned temporary hemodialysis\\n catheter. The hemodialysis catheter was accessed and aspirated free of the\\n heparin content within the respected lumens. Subsequently, a 1.5 mm J, 0.035-\\n inch wire was advanced through the catheter and steered using\\n fluoroscopic visualization to the inferior vena cava. Subsequently,\\n approximately 3 cc was infiltrated into the skin and subcutaneous tissues\\n surrounding the entrance wound for this catheter. An additional 3 cc was\\n infiltrated into the planned catheter exit site in the left upper anterior\\n chest wall. An additional 10 cc was infiltrated subcutaneously along the\\n planned tunnel to the entrance site of the temporary dialysis catheter.\\n\\n The angiodynamics 14.5 French by 28 cm catheter was then tunneled from an exit\\n incision of the left upper anterior chest wall to the venipuncture/dermatotomy\\n site in the left upper chest at the supraclavicular region. Subsequently, the\\n (Over)\\n\\n 7:23 AM\\n TUNNELLED CATH PLACE SCH Clip # \\n Reason: please place a tunnelled HD line\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n retention sutures on the temporary dialysis catheter were removed and the\\n catheter itself delivered over the guidewire leaving the guidewire in situ.\\n Subsequently, the peel-away sheath/dilator the tunneled dialysis catheter was\\n advanced over the wire under fluoroscopic visualization carefully to the level\\n of the superior vena cava. Subsequently, the inner dilator was removed as was\\n the guidewire. The tunneled dialysis catheter was then delivered using\\n modified Seldinger technique through the peel-away sheath to the right atrium\\n level. The peel-away sheath was split and then removed.\\n\\n Hemostasis was achieved at both the venipuncture/dermatotomy site and the exit\\n wound site using digital compression for approximately 5 minutes. The\\n supraclavicular wound was then closed with dermatotomy and then overlaid with\\n a 2 x 2 dressing, folded in quarters. Both wounds were then overlaid with a\\n Tegaderm occlusive patch. Both lumens of the tunneled dialysis catheter were\\n flushed and heparin locked per protocol. The patient tolerated the procedure\\n well without incident.\\n\\n IMPRESSION:\\n\\n 1. Status post successful placement of tunneled hemodialysis catheter in\\n exchange for a previous positioned left internal jugular post-temporary\\n hemodialysis catheter. See above description. The catheter is ready to\\n employ. Post-procedural orders written.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-03 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 922832,\n \"text\": \" 4:54 PM\\n CHEST (PA & LAT) Clip # \\n Reason: Pls evaluate for infiltrate\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man liver cirrhosis, portal vein thrombus awaiting liver transplant\\n with rigors, leukopenia WBC 1\\n REASON FOR THIS EXAMINATION:\\n Pls evaluate for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 54-year-old man with liver cirrhosis, portal vein thrombosis\\n awaiting liver transplant, now with rigors, leukopenia. Evaluate for\\n infiltrate.\\n\\n COMPARISON: AP upright portable chest x-ray dated .\\n CT chest dated .\\n\\n PA AND LATERAL CHEST X-RAY: A right internal jugular central venous catheter\\n terminates in unchanged position in the distal SVC. The cardiac silhouette,\\n mediastinal and hilar contours are normal. The pulmonary vasculature is\\n normal. Allowing for differences in technique, there is no significant\\n interval change compared with prior study from . There is stable mild\\n pulmonary edema and a small right- sided pleural effusion. Multiple old,\\n healed right sided rib fractures are again noted.\\n\\n IMPRESSION: Stable mild pulmonary edema and small right pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-02 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 922698,\n \"text\": \" 4:56 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: assessment for liver metastasis\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man, cirrhotic, portal vein thrombus with 2cm mass adjacent to\\n portal vein. Chest CT as work up for OLT to assess for possible metastatic\\n disease.\\n REASON FOR THIS EXAMINATION:\\n assessment for liver metastasis\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal failure\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Cirrhosis with hepatic lesions suspicious for hepatocellular\\n carcinoma. Assess for metastatic disease.\\n\\n COMPARISON: Chest radiograph .\\n\\n TECHNIQUE: MDCT acquired contiguous axial images from the thoracic inlet to\\n the upper abdomen were obtained without intravenous contrast.\\n\\n CT OF THE CHEST WITHOUT IV CONTRAST: Poorly-defined, scattered, ground glass\\n opacities in both upper lobes are either inflammatory or due to resolving\\n pulmonary edema. 4 mm non-calcified solid nodule in the superior segment of\\n the right lower lobe (series 4, image 27) is present. Small bilateral pleural\\n effusions, right greater than left, are associated with dependent parenchymal\\n opacities, likely atelectasis. A small dystrophic calcification involving the\\n posterior inferior left pleura likely reflects prior pleural insult. Airways\\n are patent to the subsegmental bronchi bilaterally.\\n\\n No pathologically enlarged mediastinal, hilar, or axillary lymph nodes are\\n present. Coronary artery calcifications and focal calcified atherosclerotic\\n plaque in the aortic arch are present. Heart, pericardium, and great vessels\\n are otherwise unremarkable. Right internal jugular central venous catheter\\n tip terminates in the distal SVC. Small mediastinal venous collaterals feed\\n into a distended azygos vein.\\n\\n The liver is shrunken and nodular consistent with cirrhosis. Ill-defined\\n hypodensity within segment VIII of the liver corresponds to the abnormality\\n noted on recent MRI from . Splenomegaly with splenic and\\n esophageal varices and ascites indicate portal hypertension.\\n\\n No osseous lesions are worrisome for malignancy.\\n\\n IMPRESSION:\\n 1) 4 mm right lower lobe pulmonary nodule. 3 month follow up chest CT is\\n recommended in this patient with possible hepatocellular carcinoma.\\n\\n 2) Small bilateral pleural effusions with associated mild compressive\\n atelectasis.\\n\\n (Over)\\n\\n 4:56 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: assessment for liver metastasis\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 3) Bilateral upper lobe peripheral ground glass opacities are likely\\n inflammatory in etiology or due to resolving pulmonary edema.\\n\\n 4) Cirrhosis with portal hypertension.\\n DFDdp\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 923858,\n \"text\": \" 7:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with cirrhosis currently on CVVH\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION PERFORMED: AP chest.\\n\\n INDICATION: A single AP view of the chest is obtained at 0813 hours\\n and compared with a prior radiograph performed on . Significant\\n improvement in the appearance of pulmonary edema has occurred. There is no\\n evidence of acute infiltrate, pleural effusion, or pneumothorax on the current\\n examination. Left-sided vascular catheter has been inserted with its tip\\n overlying the expected location of the SVC. Multiple prior rib fractures are\\n noted on the right side. No pneumothorax is visible.\\n\\n IMPRESSION:\\n\\n Improvement in the mild pulmonary edema since prior examination. Insertion of\\n left- sided vascular catheter with no evidence of hemothorax or pneumothorax\\n on the current examination.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-02 00:00:00.000\",\n \"description\": \"BONE SCAN\",\n \"row_id\": 922588,\n \"text\": \"BONE SCAN Clip # \\n Reason: LIVER MASS, BEING EVALUATED FOR LIVER TRANSPLANT\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n RADIOPHARMECEUTICAL DATA:\\n 26.3 mCi Tc-m MDP;\\n HISTORY: 54 year old man with cirrhosis and liver mass, presenting for liver\\n transplant work-up.\\n\\n INTERPRETATION:\\n\\n Whole body images of the skeleton were obtained in anterior and posterior\\n projections. Mildly increased diffuse tracer activity over the soft tissue of\\n the abdomen is consistent with ascites. There is asymmetric increased tracer\\n activity in the region of the right sternoclavicular joint. There are no other\\n worrisome foci of abnormal tracer activity.\\n\\n The kidneys and urinary bladder are visualized, the normal route of tracer\\n excretion.\\n\\n There are no prior studies available for comparison.\\n\\n IMPRESSION: 1) Increased tracer activity in region of right sternoclavicular\\n joint may be degenerative. If isolated osseous metastasis is considered, then\\n correlation with CT may be of value. 2) Ascites. 3) If additional\\n characterization of liver lesion is desired, then a blood pool study may be\\n useful in evaluation of a possible hemangioma.\\n\\n\\n , M.D.\\n , M.D. Approved: FRI 8:19 AM\\n\\n\\n\\n\\n RADLINE ; A radiology consult service.\\n To hear preliminary results, prior to transcription, call the\\n Radiology Listen Line .\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-01 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 922463,\n \"text\": \" 10:27 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOPP ABD/PEL\\n Reason: pls evaluate flow with doppler to evaluate ?portal vein \\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with cirrhosis, ascites, ?portal vein thrombus\\n REASON FOR THIS EXAMINATION:\\n pls evaluate flow with doppler to evaluate ?portal vein thrombus\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: Ultrasound abdomen.\\n\\n INDICATION: Examine portal vein.\\n\\n FINDINGS: In relation to the right lobe of liver, again note is made of the\\n low echogenic area measuring 2.36 cm. This was previously identified on\\n ultrasound and on MR and the appearances may be consistent with a\\n hepatocellular CA. Note is made of significant ascites. No other focal\\n lesion in relation to the liver. The extrahepatic portal vein is visualized,\\n however, there is no flow within the intrahepatic portal vein. The hepatic\\n artery is visualized and there is normal flow. The hepatic veins are patent\\n and demonstrate flow. There is splenomegaly with the spleen measuring 16 cm.\\n Note is made of splenic varices.\\n\\n IMPRESSION:\\n\\n No flow seen within the portal vein. It may represent thrombosis.\\n\\n Lesion in right lobe of liver, which may represent hepatocellular carcinoma\\n and previously identified on ultrasound and MR.\\n\\n Ascites.\\n\\n Splenomegaly.\\n\\n Splenic varices.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-06-26 00:00:00.000\",\n \"description\": \"ABDOMEN U.S. (COMPLETE STUDY)\",\n \"row_id\": 921804,\n \"text\": \" 8:06 AM\\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \\n Reason: evaluate for ascites, please mark spot for paracentesis\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with cirrhosis, distended abdomen.\\n REASON FOR THIS EXAMINATION:\\n evaluate for ascites, please mark spot for paracentesis\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Abdominal ultrasound.\\n\\n CLINICAL HISTORY: 54-year-old man with cirrhosis, distended abdomen.\\n Evaluate for ascites. Please mark spot for paracentesis.\\n\\n FINDINGS: There is extensive ascites. The liver is small, echogenic with an\\n irregular contour, consistent with cirrhosis. In the left lobe of the liver,\\n anterior to the portal vein, there is a 2.2 cm demarcated hypoechoic mass.\\n Given the patient's history, this is concerning for the presence of\\n hepatocellular carcinoma. Additional imaging, such as MR may be\\n considered for further characterization of this finding. A mark was made over\\n the right lower quadrant for paracentesis.\\n\\n There is sludge in the gallbladder, without evidence of stones. No intra - or\\n extrahepatic biliary ductal dilatation. The spleen is enlarged, measuring up\\n to 15.9 cm.\\n\\n The kidneys are normal in size and echotexture, with the right kidney\\n measuring 11.9 cm and the left kidney measuring 11.3 cm.\\n\\n IMPRESSION:\\n 1. 2.2 cm hypoechoic mass in left hepatic lobe that is concerning for\\n hepatocellular carcinoma.\\n 2. Ascites marked for paracentesis at right lower quadrant.\\n 3. Splenomegaly.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-06-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 921771,\n \"text\": \" 9:27 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate central line placement.\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with cirrhosis, has R sided central line.\\n REASON FOR THIS EXAMINATION:\\n evaluate central line placement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST.\\n\\n REASON FOR EXAM: Evaluate central line placement. 54-year-old man with\\n cirrhosis.\\n\\n COMPARISON: None.\\n\\n FINDINGS: Right internal jugular vein with tip in the inferior third of the\\n SVC. There is no pneumothorax. The size of the heart is normal. The\\n mediastinal contour is unremarkable. Small right pleural effusion. Discoid\\n atelectasis is seen in the left lower lobe.\\n\\n IMPRESSION: No pneumothorax. Small right pleural effusion. Vascular line in\\n adequate position.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-06-27 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 921973,\n \"text\": \" 11:22 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o bleed\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with hepatic encephalopathy, cirrhosis, and known gastric\\n varices who presents with encephalopathy and altered MS.\\n FOR THIS EXAMINATION:\\n r/o bleed\\n CONTRAINDICATIONS for IV CONTRAST:\\n likely hepatorenal syndrome\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 54-year-old man with hepatic encephalopathy, cirrhosis, and known\\n gastric varices, who presents with encephalopathy and altered mental status.\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n FINDINGS: There is no evidence of intracranial hemorrhage, mass effect,\\n hydrocephalus, shift of normally midline structures, or major vascular\\n territorial infarction. Small foci of hypodensity in the frontal\\n periventricular white matter are consistent with chronic microvascular\\n ischemia. Osseous and soft tissue structures are unremarkable.\\n\\n IMPRESSION: No acute intracranial pathology identified, including no evidence\\n of intracranial hemorrhage.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-06-26 00:00:00.000\",\n \"description\": \"DUPLEX DOPP ABD/PEL\",\n \"row_id\": 921864,\n \"text\": \" 2:01 PM\\n DUPLEX DOPP ABD/PEL Clip # \\n Reason: Please assess patency of portal vasculature.\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with etoh cirrhosis, hepatic encephalopathy, varices, and acute\\n renal failure.\\n REASON FOR THIS EXAMINATION:\\n Please assess patency of portal vasculature.\\n ______________________________________________________________________________\\n FINAL REPORT\\n DUPLEX DOPPLER ULTRASOUND OF THE LIVER\\n\\n CLINICAL HISTORY: 54-year-old man with alcoholic cirrhosis, hepatic\\n encephalopathy, varices, and acute renal failure. Please assess patency of\\n portal vasculature.\\n\\n FINDINGS: Duplex Doppler ultrasound of the liver was performed on .\\n Comparison made to prior study performed earlier in the day.\\n\\n The portal vein is patent and demonstrates normal hepatopetal flow. The left\\n portal vein demonstrates slow velocity and occasional to and fro-type wave\\n pattern suggesting stagnant flow. No echogenic material is seen within the\\n portal system to suggest the presence of thrombus. The hepatic veins are\\n patent. The main, right, and left hepatic arteries are patent and demonstrate\\n normal arterial flow.\\n\\n IMPRESSION:\\n 1. Patent portal vein, with waveforms suggestive of stagnant flow, without\\n specific evidence of intraluminal thrombus.\\n 2. Please see report from previous ultrasound regarding description of left\\n hepatic mass.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-17 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 924571,\n \"text\": \" 8:37 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: Please evaluate for distention or evidence of bleeding.\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with history of cirrhosis and ascites, s/p paracentesis today.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for distention or evidence of bleeding.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Cirrhosis, ascites, status post paracentesis today. Evaluate for\\n distention or evidence of bleeding.\\n\\n ABDOMEN, SINGLE AP SUPINE PORTABLE VIEW.\\n\\n The lateral aspects of the abdomen are not included on this film, nor are the\\n obturator foramina. Residual oral contrast is present in portions of the\\n colon. There are multiple air-filled dilated loops of small bowel in a\\n stepladder configuration. Nonethe less, air is seen throughout much of the\\n colon. No supine film evidence of free air is identified. No bowel wall\\n thickening is detected and no intramural emphysema is seen. Note that many\\n forms of hemorrhage would not be evident radiographically.\\n\\n There appear to be rib fractures in the left posterior ninth and tenth ribs\\n and question eleventh rib near the costovertebral junction. The possibility\\n of metastatic lesions in these areas cannot be excluded.\\n\\n Residual contrast is noted in the bladder.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-03 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 922822,\n \"text\": \" 3:30 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOPP ABD/PEL\\n Reason: pls evaluate flow, acute intraabdominal process\\n Admitting Diagnosis: CIRRHOSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old man with cirrhosis, ascites, portal vein thrombus s/p 7.5L para 2\\n days ago, reacumulated fluid now w/increasing abdominal pain\\n REASON FOR THIS EXAMINATION:\\n pls evaluate flow, acute intraabdominal process\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: Ultrasound abdomen.\\n\\n INDICATION: Cirrhosis, ascites, portal vein thrombosis.\\n\\n FINDINGS:\\n\\n Again note is made of the area of low echogenicity in the right lobe of the\\n liver which measures 2.5 x 2 x 1.5 cm. Again, no evidence of any flow in\\n relation to the portal vein. The hepatic veins demonstrate normal flow. The\\n hepatic artery has a normal waveform.\\n\\n There is ascites noted.\\n\\n The right kidney is visualized and is normal.\\n\\n Splenomegaly is noted with the spleen measuring almost 16 cm.\\n\\n The left kidney is normal.\\n\\n CONCLUSION:\\n\\n Thrombosis of intrahepatic portal vein.\\n\\n Ascites.\\n\\n Approximately 2.5 cm area of low echogenicity in relation to the right lobe of\\n liver which may represent a hepatocellular CA.\\n\\n Splenomegaly.\\n\\n Splenic varices.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":84,"cells":{"subject_id":{"kind":"number","value":19270,"string":"19,270"},"hadm_id":{"kind":"number","value":146196,"string":"146,196"},"target_text":{"kind":"string","value":"A/P: 82 yo W w/ h/o CVA, ESRD, DMII, CHF, rectal ca admitted w/ increased pedal edema, G+ stool, sent to the MICU after admission w/ respiratory arrest and is now s/p intubation. She is now extubated, doing well, and be sent back to the floor. * 1) Respiratory failure - On admission, Mrs. was breathing comfortably with no complaints of SOB. On morning of admission (as per HPI) she experienced acute SOB-->respiratory distress. This was thought to be to flash pulmonary edema vs. mucus plug vs. PNA. Given h/o noncompliant diet(s/p sardines) and incomplete dialysis 2 days prior to admit, flash pulm edema seems most likely diagnosis. 2 L fluid taken off at emergent HD upon transfer to MICU with symptomatic improvement. Also started patient on levo/flagyl for ? PNA - however, f/u CXR showed improvement and was thought to be more consistent with atelectasis. After extubation, patient was stable from respiratory standpoint, with no further SOB or need for supplemental oxygen. * 2) ESRD - DMII; aneuric; admitted with volume overload secondary to dietary noncompliance(ate can of sardines ). s/p emergent dialysis on (with 2 units of RBCs). She was then continued on her outpatient M/W/F dialysis schedule and followed by renal team without further complications. * 3) CAD - demand ischemia w/ trop elevated during this admission (to 0.4); likely high in the setting of renal failure. BB or ace-I were held while she was in the ICU and initially on tranfser to floor because low BP; however, BP normalized and medications were restarted at outpatient doses. Aspirin and plavix were continued throughout hospitalization and on discharge. She is to follow up with Dr. on discharge for further evaluation/treatment of cardiac disease. * 4) NEURO - On admission, Mrs did not demonstrate any residual defects from her previous strokes. However, at onset of respiratory distress there was concern for ? stroke as patient did not appear to be moving L side of body. Head CT negative and after intubation, she was alert and able to move all 4 extremities. Neuro evaluated patient and felt that the episode was likely due to her tenuous cardiorespiratory/fluid status and not CVA. * 5) GIB - G+ stool on admission. Patient was anticoagulated on admission (coumadin started 8 weeks ago after pt had stroke on asa/plavix). INR 2.5 on admission). Hct had dropped 10 points since earlier in the month. Case discussed with GI team who planned to get EGD/colnoscopy when Mrs. was stabalized on floor. Of note, she has a hx of rectal cancer, noted on excisional biopsy. She received to units of blood during emergency dialysis after episode of respiratory distress, which increased hct from 28.5 ->33.2. Hct was stable throughout the rest of admission with no further transfusions required. Coumadin was held during admission for GI procedures and there was discussion with PCP as to whether to continue coumadin on d/c given acute drop in HCT. However, given risk of repeat CVA, her coumadin was restarted on d/c at 2.5mg each evening. PPI was continued during admission and on d/c. Colonoscopy was performed on with polypectomy (adenoma per path report) diverticulae, but no other gross abnormalities. Bx of antrum of stomach on EGD on revealed chronic inactive gastritis. No evidence of active bleeding per GI studies. Hematocrit was stabalized and patient was discharged with close f/u with Dr. to trend cbc. * 6) L arm swelling: Per patient, there was some difficulty with palcement of dialysis needle on Fri with ? nerve damage. She c/o continued swelling, numbness, tingling, and inability to use L hand. She had discussed with outpt nephrologist last friday - who told her it was likely nerve damage. Seen by OT who recommended wrist splint which pt refused to wear. U/S on without evidence of DVT . Her fistula remained patent with no needle placement issues during admission. Likely to nerve damage, but considered sympathetic nerve dystrophy syndrome. Symptomatic improvement during admission and she is to f/u with nephrologist and report and new/worsening symptoms. * 7) OPHTHALMOLOGIC ISSUES: The patient with a history of glaucoma and cataracts. The patient was continued on her glaucoma eyedrops (per her home regimen). * 8) Full code * 10) Communication - daughters(very involved in patient care), granddaughter"},"extractive_notes_summ":{"kind":"string","value":"HD RN ON UNIT NOW PREPARING TO START.ACCESS- 2 PIV, LEFT UPPER ARM FISTULA. PT ARRIVED INTUBATED ON VENT AC MODE AND HYPOTENSION TO SBP 70'S. Resp Care: Pt intubated and ventilated with a/c, abg drawn from RRA, resp alkalosis/ good oxygenation, settings titrated; bs occ crackles, sxn thick blood tinged secretions, rsbi 70, will attempt sbt, wean to extubate. PT PLACED ON DOPAMINE BRIEFLY.NEURO- AROUSES TO VOICE. TEAM TO OBTAIN ABG FOR FIO2 AND VENT WEANING. TAKEN FOR STAT HEAD CT. PT STARTED ON PROPOFOL FOR SHORT TERM SEDATION WHILE INTUBATED.RESP- LS COARSE WITH RALES. MD GU: PT ANURIC AND HAVE HD TODAY TO PULL MORE FLUID OFFSKIN ; ABRASION NOTED ON LEFT ELBOW, AND ECCYMOTIC AREA NOTED AROUND LEFT FISTULA SITE, STAGE 2 DUCUBITUS NOTED ON RIGHT BUTTOCK DUODERM PLACED 1CM/ 1CMSOCIAL: 2 DAUGHTERS VERY INVOLVED W/ CAREENDO: PT ON FINGERSTICKS Q6HRS AND SSCCODE FULLPLAN:1. NURSING NOTE: ADMIT TO MICUPT ARRIVED FROM CC7 S/P RESP FAILURE AND EMERGENT INTUBATION LIKELY CHF AND FLASH PULMONARY EDEMA. OGT PLACED BY NURSING, CONFIRMED BY CXR BY DR . CONT FINGERSTICKS Q6HRS AND USE SSC SUCTIONING MINIMAL THIN TAN SECRETIONSCV: TELE SR 80S BP STABLE HRT SOUNDS S1S2 W/ MURMUR. FSBS 112.GU- ANURIC PER REPORT. AND TO REMAIN INTUBATED OVERNIGHT AND HAVE SBT IN AM FOR EARLY EXTUBATION. Pt intubated with 7.5 ETT, 23 cm at the left corner of her lip. CONT TO INFORM DAUGHTERS OF PT STATUS7. UPDATED BY NURSING AND DR .DISPO- FULL CODE PLAN IS TO HAVE HD WITH BLOOD TRANSFUSION TONIGHT. RADIAL PULSES +2 FINGERTIPS DUSKY HANDS COOL R> MD AWARE. EXTUBATE THIS AM AFTER 2. ? PUPILS SURGICAL. HCT REPORTED TO BE 28, ORDERED FOR 2UNITS PRBC'S TO BE GIVEN DURING HD.GI- ABD SOFT + BS NO STOOL. SUCTIONED FOR PINK FROTHY SPUTUM.CV- HR 80-100 SR WITH OCCAS PAC'S BP INITIALLY NEEDED DOPAMINE, SINCE WEANED OFF AND STILL TOLERATING PROPOFOL WELL. Respiratory CarePending respiratory failure, secondary to CHF. BP NOW 118/48. RSBI THIS AM 71 PT ON @0530 CPAP0 PS 5 FIO2 40% TV >300 RR18NEURO: PUPILS SURGICAL, MAE FOLLOWS COMMANDS, ALERT.RESP: AS ABOVE. +THRILL AND BRUIT.SOCIAL- DAUGHTERS AT BEDSIDE. Sinus rhythmAnterolateral ST-T changes suggest myocardial injury/ischemiaSince previous tracing of , ST-T wave abnormalities are more marked LS CLEAR UPPER LOBES W/ CRACKLES IN BASES. PEDAL PULSES +2LEFT ARM AV FISTULA + BRUIT AND THRILL.GI: OGT TO INTERMITTENT SUCTIONING DRAINING GREEN GASTRIC CONTENTS BS+ABD DISTENDED AND SOFT. VASCULAR US TO DO ARM US ? NURSING PROGRESS NOTESPT ENDED HER HD EARLY D/T LOW BP LAST EVENING 1.7 LITERS REMOVED 2 UNITS OF PRBC GIVEN FOR HCT 27 RECHECKED LAST NOC 31.5 THIS AM 32.CRT 7.3, BUN 97 BEFORE DIALYSIS CRT 6.0/ 68 BUN THIS AM. US OF LEFT ARM WAS CANCELLED WILL NEED VASCULAR US TO DO THE EXAM ? FOLLOW LYTES AND LABS6. ESRD. HD TODAY3. Sinus rhythmLateral ST-T changes are nonspecific, more pronounced than previousConsider ischemia Placed on mechanical ventilation, Assist Control mode, Tidal Volume 600cc, Set Rate 14 breaths per minute, FiO2 100%, Peep 5cm. CLOT4. SATS 100% ON VENT 600X14 100% +5. Breath sounds equal, diffuse rales. LEFT ARM TO HAVE ULTRASOUND THIS EVENING TO R/O CLOT.FISTULA SITE SWOLLEN WITH LARGE BRUISE. CLOT IN ARM. SATS 100% ALL SHIFT. PT RESTED COMFORTABLY LAST EVENING AND RECEIVED FENTANYL 50MCQS IV X3 DOSES. Pt to be closely monitored. MAE AND FOLLOWED SIMPLE COMMANDS."},"n_notes":{"kind":"number","value":6,"string":"6"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2171-11-04 00:00:00.000","description":"Report","row_id":1516455,"text":"NURSING PROGRESS NOTES\nPT ENDED HER HD EARLY D/T LOW BP LAST EVENING 1.7 LITERS REMOVED 2 UNITS OF PRBC GIVEN FOR HCT 27 RECHECKED LAST NOC 31.5 THIS AM 32.\nCRT 7.3, BUN 97 BEFORE DIALYSIS CRT 6.0/ 68 BUN THIS AM. PT RESTED COMFORTABLY LAST EVENING AND RECEIVED FENTANYL 50MCQS IV X3 DOSES. RSBI THIS AM 71 PT ON @0530 CPAP0 PS 5 FIO2 40% TV >300 RR18\n\nNEURO: PUPILS SURGICAL, MAE FOLLOWS COMMANDS, ALERT.\n\nRESP: AS ABOVE. LS CLEAR UPPER LOBES W/ CRACKLES IN BASES. SATS 100% ALL SHIFT. SUCTIONING MINIMAL THIN TAN SECRETIONS\n\nCV: TELE SR 80S BP STABLE HRT SOUNDS S1S2 W/ MURMUR. RADIAL PULSES +2 FINGERTIPS DUSKY HANDS COOL R> MD AWARE. PEDAL PULSES +2\nLEFT ARM AV FISTULA + BRUIT AND THRILL.\nGI: OGT TO INTERMITTENT SUCTIONING DRAINING GREEN GASTRIC CONTENTS BS+ABD DISTENDED AND SOFT. US OF LEFT ARM WAS CANCELLED WILL NEED VASCULAR US TO DO THE EXAM ? CLOT IN ARM. MD \n\nGU: PT ANURIC AND HAVE HD TODAY TO PULL MORE FLUID OFF\n\nSKIN ; ABRASION NOTED ON LEFT ELBOW, AND ECCYMOTIC AREA NOTED AROUND LEFT FISTULA SITE, STAGE 2 DUCUBITUS NOTED ON RIGHT BUTTOCK DUODERM PLACED 1CM/ 1CM\n\nSOCIAL: 2 DAUGHTERS VERY INVOLVED W/ CARE\n\nENDO: PT ON FINGERSTICKS Q6HRS AND SSC\n\nCODE FULL\n\nPLAN:\n1. EXTUBATE THIS AM AFTER \n2. ? HD TODAY\n3. VASCULAR US TO DO ARM US ? CLOT\n4. UNABLE TO RECHECK ABG ON D/T THERAPIST UNABLE TO DRAW\n5. FOLLOW LYTES AND LABS\n6. CONT TO INFORM DAUGHTERS OF PT STATUS\n7. CONT FINGERSTICKS Q6HRS AND USE SSC\n"},{"category":"Nursing/other","chartdate":"2171-11-03 00:00:00.000","description":"Report","row_id":1516452,"text":"Respiratory Care\nPending respiratory failure, secondary to CHF. Pt intubated with 7.5 ETT, 23 cm at the left corner of her lip. Breath sounds equal, diffuse rales. Placed on mechanical ventilation, Assist Control mode, Tidal Volume 600cc, Set Rate 14 breaths per minute, FiO2 100%, Peep 5cm. Pt to be closely monitored.\n"},{"category":"Nursing/other","chartdate":"2171-11-03 00:00:00.000","description":"Report","row_id":1516453,"text":"NURSING NOTE: ADMIT TO MICU\nPT ARRIVED FROM CC7 S/P RESP FAILURE AND EMERGENT INTUBATION LIKELY CHF AND FLASH PULMONARY EDEMA. PT ARRIVED INTUBATED ON VENT AC MODE AND HYPOTENSION TO SBP 70'S. PT PLACED ON DOPAMINE BRIEFLY.\n\nNEURO- AROUSES TO VOICE. MAE AND FOLLOWED SIMPLE COMMANDS. PUPILS SURGICAL. TAKEN FOR STAT HEAD CT. PT STARTED ON PROPOFOL FOR SHORT TERM SEDATION WHILE INTUBATED.\n\nRESP- LS COARSE WITH RALES. SATS 100% ON VENT 600X14 100% +5. TEAM TO OBTAIN ABG FOR FIO2 AND VENT WEANING. SUCTIONED FOR PINK FROTHY SPUTUM.\n\nCV- HR 80-100 SR WITH OCCAS PAC'S BP INITIALLY NEEDED DOPAMINE, SINCE WEANED OFF AND STILL TOLERATING PROPOFOL WELL. BP NOW 118/48. HCT REPORTED TO BE 28, ORDERED FOR 2UNITS PRBC'S TO BE GIVEN DURING HD.\n\nGI- ABD SOFT + BS NO STOOL. OGT PLACED BY NURSING, CONFIRMED BY CXR BY DR . FSBS 112.\n\nGU- ANURIC PER REPORT. ESRD. HD RN ON UNIT NOW PREPARING TO START.\n\nACCESS- 2 PIV, LEFT UPPER ARM FISTULA. LEFT ARM TO HAVE ULTRASOUND THIS EVENING TO R/O CLOT.FISTULA SITE SWOLLEN WITH LARGE BRUISE. +THRILL AND BRUIT.\n\nSOCIAL- DAUGHTERS AT BEDSIDE. UPDATED BY NURSING AND DR .\n\nDISPO- FULL CODE PLAN IS TO HAVE HD WITH BLOOD TRANSFUSION TONIGHT. AND TO REMAIN INTUBATED OVERNIGHT AND HAVE SBT IN AM FOR EARLY EXTUBATION.\n\n"},{"category":"Nursing/other","chartdate":"2171-11-04 00:00:00.000","description":"Report","row_id":1516454,"text":"Resp Care: Pt intubated and ventilated with a/c, abg drawn from RRA, resp alkalosis/ good oxygenation, settings titrated; bs occ crackles, sxn thick blood tinged secretions, rsbi 70, will attempt sbt, wean to extubate.\n"},{"category":"ECG","chartdate":"2171-11-03 00:00:00.000","description":"Report","row_id":274640,"text":"Sinus rhythm\nAnterolateral ST-T changes suggest myocardial injury/ischemia\nSince previous tracing of , ST-T wave abnormalities are more marked\n\n"},{"category":"ECG","chartdate":"2171-11-02 00:00:00.000","description":"Report","row_id":274641,"text":"Sinus rhythm\nLateral ST-T changes are nonspecific, more pronounced than previous\nConsider ischemia\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-11-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1516455,\n \"text\": \"NURSING PROGRESS NOTES\\nPT ENDED HER HD EARLY D/T LOW BP LAST EVENING 1.7 LITERS REMOVED 2 UNITS OF PRBC GIVEN FOR HCT 27 RECHECKED LAST NOC 31.5 THIS AM 32.\\nCRT 7.3, BUN 97 BEFORE DIALYSIS CRT 6.0/ 68 BUN THIS AM. PT RESTED COMFORTABLY LAST EVENING AND RECEIVED FENTANYL 50MCQS IV X3 DOSES. RSBI THIS AM 71 PT ON @0530 CPAP0 PS 5 FIO2 40% TV >300 RR18\\n\\nNEURO: PUPILS SURGICAL, MAE FOLLOWS COMMANDS, ALERT.\\n\\nRESP: AS ABOVE. LS CLEAR UPPER LOBES W/ CRACKLES IN BASES. SATS 100% ALL SHIFT. SUCTIONING MINIMAL THIN TAN SECRETIONS\\n\\nCV: TELE SR 80S BP STABLE HRT SOUNDS S1S2 W/ MURMUR. RADIAL PULSES +2 FINGERTIPS DUSKY HANDS COOL R> MD AWARE. PEDAL PULSES +2\\nLEFT ARM AV FISTULA + BRUIT AND THRILL.\\nGI: OGT TO INTERMITTENT SUCTIONING DRAINING GREEN GASTRIC CONTENTS BS+ABD DISTENDED AND SOFT. US OF LEFT ARM WAS CANCELLED WILL NEED VASCULAR US TO DO THE EXAM ? CLOT IN ARM. MD \\n\\nGU: PT ANURIC AND HAVE HD TODAY TO PULL MORE FLUID OFF\\n\\nSKIN ; ABRASION NOTED ON LEFT ELBOW, AND ECCYMOTIC AREA NOTED AROUND LEFT FISTULA SITE, STAGE 2 DUCUBITUS NOTED ON RIGHT BUTTOCK DUODERM PLACED 1CM/ 1CM\\n\\nSOCIAL: 2 DAUGHTERS VERY INVOLVED W/ CARE\\n\\nENDO: PT ON FINGERSTICKS Q6HRS AND SSC\\n\\nCODE FULL\\n\\nPLAN:\\n1. EXTUBATE THIS AM AFTER \\n2. ? HD TODAY\\n3. VASCULAR US TO DO ARM US ? CLOT\\n4. UNABLE TO RECHECK ABG ON D/T THERAPIST UNABLE TO DRAW\\n5. FOLLOW LYTES AND LABS\\n6. CONT TO INFORM DAUGHTERS OF PT STATUS\\n7. CONT FINGERSTICKS Q6HRS AND USE SSC\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-11-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1516452,\n \"text\": \"Respiratory Care\\nPending respiratory failure, secondary to CHF. Pt intubated with 7.5 ETT, 23 cm at the left corner of her lip. Breath sounds equal, diffuse rales. Placed on mechanical ventilation, Assist Control mode, Tidal Volume 600cc, Set Rate 14 breaths per minute, FiO2 100%, Peep 5cm. Pt to be closely monitored.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-11-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1516453,\n \"text\": \"NURSING NOTE: ADMIT TO MICU\\nPT ARRIVED FROM CC7 S/P RESP FAILURE AND EMERGENT INTUBATION LIKELY CHF AND FLASH PULMONARY EDEMA. PT ARRIVED INTUBATED ON VENT AC MODE AND HYPOTENSION TO SBP 70'S. PT PLACED ON DOPAMINE BRIEFLY.\\n\\nNEURO- AROUSES TO VOICE. MAE AND FOLLOWED SIMPLE COMMANDS. PUPILS SURGICAL. TAKEN FOR STAT HEAD CT. PT STARTED ON PROPOFOL FOR SHORT TERM SEDATION WHILE INTUBATED.\\n\\nRESP- LS COARSE WITH RALES. SATS 100% ON VENT 600X14 100% +5. TEAM TO OBTAIN ABG FOR FIO2 AND VENT WEANING. SUCTIONED FOR PINK FROTHY SPUTUM.\\n\\nCV- HR 80-100 SR WITH OCCAS PAC'S BP INITIALLY NEEDED DOPAMINE, SINCE WEANED OFF AND STILL TOLERATING PROPOFOL WELL. BP NOW 118/48. HCT REPORTED TO BE 28, ORDERED FOR 2UNITS PRBC'S TO BE GIVEN DURING HD.\\n\\nGI- ABD SOFT + BS NO STOOL. OGT PLACED BY NURSING, CONFIRMED BY CXR BY DR . FSBS 112.\\n\\nGU- ANURIC PER REPORT. ESRD. HD RN ON UNIT NOW PREPARING TO START.\\n\\nACCESS- 2 PIV, LEFT UPPER ARM FISTULA. LEFT ARM TO HAVE ULTRASOUND THIS EVENING TO R/O CLOT.FISTULA SITE SWOLLEN WITH LARGE BRUISE. +THRILL AND BRUIT.\\n\\nSOCIAL- DAUGHTERS AT BEDSIDE. UPDATED BY NURSING AND DR .\\n\\nDISPO- FULL CODE PLAN IS TO HAVE HD WITH BLOOD TRANSFUSION TONIGHT. AND TO REMAIN INTUBATED OVERNIGHT AND HAVE SBT IN AM FOR EARLY EXTUBATION.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-11-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1516454,\n \"text\": \"Resp Care: Pt intubated and ventilated with a/c, abg drawn from RRA, resp alkalosis/ good oxygenation, settings titrated; bs occ crackles, sxn thick blood tinged secretions, rsbi 70, will attempt sbt, wean to extubate.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-11-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 274640,\n \"text\": \"Sinus rhythm\\nAnterolateral ST-T changes suggest myocardial injury/ischemia\\nSince previous tracing of , ST-T wave abnormalities are more marked\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-11-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 274641,\n \"text\": \"Sinus rhythm\\nLateral ST-T changes are nonspecific, more pronounced than previous\\nConsider ischemia\\n\\n\"\n }\n]"}}},{"rowIdx":85,"cells":{"subject_id":{"kind":"number","value":47949,"string":"47,949"},"hadm_id":{"kind":"number","value":130852,"string":"130,852"},"target_text":{"kind":"string","value":""},"extractive_notes_summ":{"kind":"string","value":"FINDINGS: There is a left frontal superior frontal gyrus subarachnoid hemorrhage (series 2, image 14 and series 601B, image 26). The lung apices are clear.A partially calcified left thyroid nodule is seen. Chest clear on exam. Possible left atrial abnormality. TECHNIQUE: Contiguous MDCT images of the C-spine were obtained. FINDINGS: The height of the vertebral bodies of the C-spine is preserved. Clinically correlate. TECHNIQUE: Axial CT images of the head were obtained. chest pathology. Axial, coronal, and sagittal reformats were acquired. There is no acute fracture. IMPRESSION: Focus of left frontal subarachnoid hemorrhage without evidence of fractures, unchanged from the outside hospital CT earlier from today. Heart size and vascularity are normal. COMPARISON: Outside hospital CT of the C-spine from . Please assess for fracture. Coronal and sagittal reformats were acquired. No fracture. COMPARISON: Outside hospital CT of the head from . The ventricles and sulci are normal in size and configuration. There is no large neck hematoma. There are moderate-to-severe degenerative changes at C6-C7 with posterior osteophytes, uncal and facet hypertrophy and posterior disc bulging with moderate narrowing of the spinal canal and moderate-to-severe narrowing of the neural foramina bilaterally. No additional foci of intracranial hemorrhage are identified. Sinus rhythm. The paranasal sinuses and mastoids are clear. Soft tissue laceration is seen at the vertex with skin staples in place. Severe degenerative changes at C6-C7. The -white matter differentiation is well preserved. If concern for spinal cord injury, MRI might be considered. No fracture is identified. IMPRESSION: 1. The lungs are clear as are the pleural spaces. Moderate to severe degenerative changes at C6/7 with posterior disc protrusion narrowing the spinal canal. If there is concern for spinal cord injury, MRI might be considered. FINDINGS: There are multiple healed right rib fractures. IMPRESSION: No evidence for active cardiopulmonary disease. REASON FOR THIS EXAMINATION: ? COMPARISONS: None. 7:40 AM CHEST (PORTABLE AP) Clip # Reason: ? Left anterior fascicular block.Increased voltage in the precordial leads suggestive of left ventricularhypertrophy. No fx. WET READ VERSION #1 FINAL REPORT INDICATION: 66-year-old man with head injury. WET READ VERSION #1 FINAL REPORT INDICATION: 66-year-old man with head injury. No previous tracing available for comparison. 4:01 AM CT C-SPINE W/O CONTRAST Clip # Reason: fx MEDICAL CONDITION: 66 year old man s/p head injury REASON FOR THIS EXAMINATION: fx No contraindications for IV contrast WET READ: JBRe SAT 6:07 AM 1. chest pathology Admitting Diagnosis: INTRACRANIAL HEMORRHAGE MEDICAL CONDITION: 66 year old man with traumatic SAH ? 4:00 AM CT HEAD W/O CONTRAST Clip # Reason: bleed MEDICAL CONDITION: 66 year old man s/p head injury REASON FOR THIS EXAMINATION: bleed No contraindications for IV contrast WET READ: JBRe SAT 6:01 AM Small focus of left frontal SAH is unchanged from the OSH CT a few hours earlier. 2."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2199-09-21 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":1210669,"text":" 4:01 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p head injury\n REASON FOR THIS EXAMINATION:\n fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SAT 6:07 AM\n 1. No fx.\n 2. Moderate to severe degenerative changes at C6/7 with posterior disc\n protrusion narrowing the spinal canal. If concern for spinal cord injury, MRI\n might be considered.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with head injury. Please assess for fracture.\n\n TECHNIQUE: Contiguous MDCT images of the C-spine were obtained. Axial,\n coronal, and sagittal reformats were acquired.\n\n COMPARISON: Outside hospital CT of the C-spine from .\n\n FINDINGS: The height of the vertebral bodies of the C-spine is preserved.\n There is no acute fracture. There are moderate-to-severe degenerative changes\n at C6-C7 with posterior osteophytes, uncal and facet hypertrophy and posterior\n disc bulging with moderate narrowing of the spinal canal and\n moderate-to-severe narrowing of the neural foramina bilaterally.\n\n There is no large neck hematoma. The lung apices are clear.A partially\n calcified left thyroid nodule is seen. Clinically correlate.\n\n IMPRESSION:\n 1. No fracture. Severe degenerative changes at C6-C7. If there is concern\n for spinal cord injury, MRI might be considered.\n\n"},{"category":"Radiology","chartdate":"2199-09-21 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1210668,"text":" 4:00 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p head injury\n REASON FOR THIS EXAMINATION:\n bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SAT 6:01 AM\n Small focus of left frontal SAH is unchanged from the OSH CT a few hours\n earlier.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with head injury.\n\n TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal\n reformats were acquired.\n\n COMPARISON: Outside hospital CT of the head from .\n\n FINDINGS: There is a left frontal superior frontal gyrus subarachnoid\n hemorrhage (series 2, image 14 and series 601B, image 26). No additional foci\n of intracranial hemorrhage are identified. Soft tissue laceration is seen at\n the vertex with skin staples in place.\n\n The -white matter differentiation is well preserved. The ventricles and\n sulci are normal in size and configuration. The paranasal sinuses and\n mastoids are clear. No fracture is identified.\n\n IMPRESSION: Focus of left frontal subarachnoid hemorrhage without evidence of\n fractures, unchanged from the outside hospital CT earlier from today.\n\n"},{"category":"Radiology","chartdate":"2199-09-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1210673,"text":" 7:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? chest pathology\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with traumatic SAH ? chest pathology. Chest clear on exam.\n REASON FOR THIS EXAMINATION:\n ? chest pathology\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: 66-year-old man with traumatic SAH.\n\n COMPARISONS: None.\n\n FINDINGS: There are multiple healed right rib fractures. Heart size and\n vascularity are normal. The lungs are clear as are the pleural spaces.\n\n IMPRESSION: No evidence for active cardiopulmonary disease.\n\n\n"},{"category":"ECG","chartdate":"2199-09-21 00:00:00.000","description":"Report","row_id":251007,"text":"Sinus rhythm. Possible left atrial abnormality. Left anterior fascicular block.\nIncreased voltage in the precordial leads suggestive of left ventricular\nhypertrophy. No previous tracing available for comparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-09-21 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 1210669,\n \"text\": \" 4:01 AM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man s/p head injury\\n REASON FOR THIS EXAMINATION:\\n fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JBRe SAT 6:07 AM\\n 1. No fx.\\n 2. Moderate to severe degenerative changes at C6/7 with posterior disc\\n protrusion narrowing the spinal canal. If concern for spinal cord injury, MRI\\n might be considered.\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 66-year-old man with head injury. Please assess for fracture.\\n\\n TECHNIQUE: Contiguous MDCT images of the C-spine were obtained. Axial,\\n coronal, and sagittal reformats were acquired.\\n\\n COMPARISON: Outside hospital CT of the C-spine from .\\n\\n FINDINGS: The height of the vertebral bodies of the C-spine is preserved.\\n There is no acute fracture. There are moderate-to-severe degenerative changes\\n at C6-C7 with posterior osteophytes, uncal and facet hypertrophy and posterior\\n disc bulging with moderate narrowing of the spinal canal and\\n moderate-to-severe narrowing of the neural foramina bilaterally.\\n\\n There is no large neck hematoma. The lung apices are clear.A partially\\n calcified left thyroid nodule is seen. Clinically correlate.\\n\\n IMPRESSION:\\n 1. No fracture. Severe degenerative changes at C6-C7. If there is concern\\n for spinal cord injury, MRI might be considered.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-09-21 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1210668,\n \"text\": \" 4:00 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: bleed\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man s/p head injury\\n REASON FOR THIS EXAMINATION:\\n bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JBRe SAT 6:01 AM\\n Small focus of left frontal SAH is unchanged from the OSH CT a few hours\\n earlier.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 66-year-old man with head injury.\\n\\n TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal\\n reformats were acquired.\\n\\n COMPARISON: Outside hospital CT of the head from .\\n\\n FINDINGS: There is a left frontal superior frontal gyrus subarachnoid\\n hemorrhage (series 2, image 14 and series 601B, image 26). No additional foci\\n of intracranial hemorrhage are identified. Soft tissue laceration is seen at\\n the vertex with skin staples in place.\\n\\n The -white matter differentiation is well preserved. The ventricles and\\n sulci are normal in size and configuration. The paranasal sinuses and\\n mastoids are clear. No fracture is identified.\\n\\n IMPRESSION: Focus of left frontal subarachnoid hemorrhage without evidence of\\n fractures, unchanged from the outside hospital CT earlier from today.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-09-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1210673,\n \"text\": \" 7:40 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? chest pathology\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with traumatic SAH ? chest pathology. Chest clear on exam.\\n REASON FOR THIS EXAMINATION:\\n ? chest pathology\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST\\n\\n HISTORY: 66-year-old man with traumatic SAH.\\n\\n COMPARISONS: None.\\n\\n FINDINGS: There are multiple healed right rib fractures. Heart size and\\n vascularity are normal. The lungs are clear as are the pleural spaces.\\n\\n IMPRESSION: No evidence for active cardiopulmonary disease.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 251007,\n \"text\": \"Sinus rhythm. Possible left atrial abnormality. Left anterior fascicular block.\\nIncreased voltage in the precordial leads suggestive of left ventricular\\nhypertrophy. No previous tracing available for comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":86,"cells":{"subject_id":{"kind":"number","value":50596,"string":"50,596"},"hadm_id":{"kind":"number","value":118069,"string":"118,069"},"target_text":{"kind":"string","value":"32 yo F w/ depression hx and prior SA, admitted to the MICU for trazodone OD with EtOH intoxication; now transferred to the floor for further monitoring and recovery."},"extractive_notes_summ":{"kind":"string","value":"(#) DISPO: likely d/c to floor or the psych service in the am ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 06:34 PM Prophylaxis: DVT: SQ UF Heparin Stress ulcer: Not indicated VAP: Comments: Communication: ICU consent signed Comments: Code status: Full code Disposition: ICU In the ED, had some mild hypotension. In the ED, had some mild hypotension. Action: Maintained suicide precautions with 1:1 sitter. Action: Maintained suicide precautions with 1:1 sitter. Action: Maintained suicide precautions with 1:1 sitter. ICU Care Nutrition: Clear liqs Glycemic Control: Lines / Intubation: 18 Gauge - 06:34 PM Comments: Prophylaxis: DVT: SQ UF Heparin Stress ulcer: VAP: Comments: Not applicable. She denied nausea, HA, F/C, CP, SOB, abd pain; she was somnolent but easily arousable and conversant Hypotension (not Shock) Assessment: Recd one IVFB overnight for low BP, since BPs-98-104/60, HR-70s SR with no ectopy noted. She denied nausea, HA, F/C, CP, SOB, abd pain; she was somnolent but easily arousable and conversant Hypotension (not Shock) Assessment: Recd one IVFB overnight for low BP, since BPs-98-104/60, HR-70s SR with no ectopy noted. Imaging: no imagin Microbiology: UCx: pending ECG: EKG: (done at 3:15 pm on ) sinus at 94 BPM; QTC 450 Assessment and Plan 32 yoF w/ depression hx and prior SA, admitted from ED for trazodone OD with EtOH intoxication. Purse with pills was reported to be in ED safe per ED nurse. Purse with pills was reported to be in ED safe per ED nurse. Purse with pills was reported to be in ED safe per ED nurse. Sinus rhythmEarly precordial QRS transition may be normal variantSince previous tracing of , T wave changes decreased Elongated Qtc, hypotension, solmolence. Elongated Qtc, hypotension, solmolence. Elongated Qtc, hypotension, solmolence. -- will watch for hypotension; fluid boluses PRN for SBP < 90 -- monitor for somnolence, altered MS -- will check repeat lytes and EKG tonight; also in am -- will place on CIWA for possible EtOH withdrawal; denies in history but elevated EtOH on admission and unclear how reliable of a historian she is . (#) SUICIDE ATTTEMPT, DEPRESSION: -- will hold Celexa for now given trazodone OD -- will place SW consult -- 24 hour suicide watch -- will have psych see patient in the morning . History obtained from Patient Allergies: Last dose of Antibiotics: Infusions: Other ICU medications: Lorazepam (Ativan) - 03:22 AM Other medications: HSQ Changes to medical and family history: PMH, SH, FH and ROS are unchanged from Admission except where noted above and below Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 10:12 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 37.5C (99.5 Tcurrent: 37.5C (99.5 HR: 69 (69 - 88) bpm BP: 106/65(74) {86/44(55) - 113/68(78)} mmHg RR: 13 (13 - 20) insp/min SpO2: 97% Total In: 5,136 mL 2,079 mL PO: 500 mL 750 mL TF: IVF: 1,636 mL 1,329 mL Blood products: Total out: 1,360 mL 885 mL Urine: 760 mL 885 mL NG: Stool: Drains: Balance: 3,776 mL 1,194 mL Respiratory support O2 Delivery Device: None SpO2: 97% ABG: ///21/ Physical Examination General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended Extremities: Right: Absent, Left: Absent Skin: Not assessed, No(t) Rash: Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed Labs / Radiology 9.4 g/dL 236 K/uL 88 mg/dL 0.7 mg/dL 21 mEq/L 4.0 mEq/L 8 mg/dL 109 mEq/L 138 mEq/L 27.4 % 5.8 K/uL [image002.jpg] 04:32 AM WBC 5.8 Hct 27.4 Plt 236 Cr 0.7 Glucose 88 Other labs: PT / PTT / INR:14.0/30.2/1.2, ALT / AST:, Alk Phos / T Bili:35/0.4, Albumin:3.5 g/dL, Ca++:6.9 mg/dL, Mg++:1.5 mg/dL, PO4:3.2 mg/dL Fluid analysis / Other labs: Tox screen: etoh otherwise neg."},"n_notes":{"kind":"number","value":17,"string":"17"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2200-01-25 00:00:00.000","description":"Report","row_id":240140,"text":"Sinus rhythm\nEarly precordial QRS transition may be normal variant\nSince previous tracing of , T wave changes decreased\n\n"},{"category":"ECG","chartdate":"2200-01-24 00:00:00.000","description":"Report","row_id":240141,"text":"Sinus rhythm. Minor non-diagnostic T wave flattening. Compared to the\nprevious tracing no major change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2200-01-23 00:00:00.000","description":"Report","row_id":240142,"text":"Sinus rhythm with baseline artifact. Probably normal tracing. No previous\ntracing available for comparison.\nTRACING #1\n\n"},{"category":"Nursing","chartdate":"2200-01-24 00:00:00.000","description":"Nursing Transfer Note","row_id":655197,"text":"Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Suicidality / Suicide Attempt\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2200-01-24 00:00:00.000","description":"Nursing Transfer Note","row_id":655200,"text":"Ms. is a 32 yoF with h/o prior suicide attempts, who presents\n after taking trazodone in an attempt to kill herself. Around noon\n yesterday , she drank \"five drinks\" of vodka, and then around 2\n pm, she ingested 30 pills of 50 mg trazodone. Within the next hour,\n she called the ambulance herself. This was done at her apartment, and\n she reports that she did this because she was upset about her\n boyfriend.\n .\n Of note, she has had three prior SA since , two of which\n resulted in hospitalization at , at which point she was\n put on Celexa. She has a PCP (Dr. ?) but no psychiatrist\n or psychologist currently.\n .\n In the ED, VS were T 98.0, HR 94, BP 133/97, RR 22, 99 % RA. The\n toxicology team saw her; she was considered out fo the time window for\n activated charcoal; no stomach pumping was performed. while she was\n wiating for a bed, she became hypotensive with BP 70-80, which improved\n with 2 L NS. On arrival to the MICU, VS were T 97.6, HR 86, BP 90/51,\n 100% RA, RR 19. She denied nausea, HA, F/C, CP, SOB, abd pain; she was\n somnolent but easily arousable and conversant\n Hypotension (not Shock)\n Assessment:\n Rec\nd one IVFB overnight for low BP, since BP\ns-98-104/60, HR-70\ns SR\n with no ectopy noted.\n Action:\n Rec\ning IVF D51/2 @ 125hr\n Response:\n BP stable\n Plan:\n Monitor BP\ns administer IVFB if needed.\n Suicidality / Suicide Attempt\n Assessment:\n No Suicidal ideation noted very sleepy but easily arousable. Has \n in room. Awaiting Psych Evaluation. A&Ox3. Will also obtain SW consult\n in attempt to help her find other housing, due to that she lives with\n boyfriend.\n Action:\n in room. Has a Privacy laert in place.\n Response:\n Is calm, and cooperative but sleepy\n Plan:\n Await Psych eval, continue with sitters.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n OVERDOSE\n Code status:\n Full code\n Height:\n Admission weight:\n 63 kg\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Past suicide attempts.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:101\n D:52\n Temperature:\n 99.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 80 bpm\n Heart rhythm:\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 2,733 mL\n 24h total out:\n 1,165 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:32 AM\n Potassium:\n 4.0 mEq/L\n 04:32 AM\n Chloride:\n 109 mEq/L\n 04:32 AM\n CO2:\n 21 mEq/L\n 04:32 AM\n BUN:\n 8 mg/dL\n 04:32 AM\n Creatinine:\n 0.7 mg/dL\n 04:32 AM\n Glucose:\n 88 mg/dL\n 04:32 AM\n Hematocrit:\n 27.4 %\n 04:32 AM\n Valuables / Signature\n Patient valuables: Has red duffle bag and laundry bag with personal\n care items and clothes inside.\n Other valuables: In EU safe.\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: In EU safe.\n Jewelry:\n Transferred from: MICU-7\n Transferred to: CC7\n Date & time of Transfer: 1300\n"},{"category":"Physician ","chartdate":"2200-01-24 00:00:00.000","description":"Physician Attending Progress Note","row_id":655183,"text":"Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Admitted overnight from the ED after presenting with a suicide\n attmept/trazadone overdose as well as etoh intoxication. In the ED,\n had some mild hypotension. Was not given activated charcoal for NGT\n lavage as she was felt to be too far out from ingestion.\n In ICU, SBP's ranged in 90-110's, received total of 1 L of NS.\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:22 AM\n Other medications:\n HSQ\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 69 (69 - 88) bpm\n BP: 106/65(74) {86/44(55) - 113/68(78)} mmHg\n RR: 13 (13 - 20) insp/min\n SpO2: 97%\n Total In:\n 5,136 mL\n 2,079 mL\n PO:\n 500 mL\n 750 mL\n TF:\n IVF:\n 1,636 mL\n 1,329 mL\n Blood products:\n Total out:\n 1,360 mL\n 885 mL\n Urine:\n 760 mL\n 885 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,776 mL\n 1,194 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.4 g/dL\n 236 K/uL\n 88 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 8 mg/dL\n 109 mEq/L\n 138 mEq/L\n 27.4 %\n 5.8 K/uL\n [image002.jpg]\n 04:32 AM\n WBC\n 5.8\n Hct\n 27.4\n Plt\n 236\n Cr\n 0.7\n Glucose\n 88\n Other labs: PT / PTT / INR:14.0/30.2/1.2, ALT / AST:, Alk Phos / T\n Bili:35/0.4, Albumin:3.5 g/dL, Ca++:6.9 mg/dL, Mg++:1.5 mg/dL, PO4:3.2\n mg/dL\n Fluid analysis / Other labs: Tox screen: etoh otherwise neg.\n U/A: WBC\n Microbiology: UCx: Pending\n ECG: QT interval about 450ms\n Assessment and Plan\n 32 yo F with h/o depression admitted with suicide attempt (trazadone\n and etoh) complicated by mild hypotension.\n Hypotension: Likely related to trazadone ingestion. Now normalized.\n Suicide attempt:\n -Psychiatry consult\n -Social work eval to assist with home situation (reported abusive\n boyfriend)\n - for now.\n FEN: Regular diet.\n D/c foley\n Rest of plan per resident note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:34 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n"},{"category":"Nursing","chartdate":"2200-01-24 00:00:00.000","description":"Nursing Transfer Note","row_id":655169,"text":"Ms. is a 32 yoF with h/o prior suicide attempts, who presents\n after taking trazodone in an attempt to kill herself. Around noon\n yesterday , she drank \"five drinks\" of vodka, and then around 2\n pm, she ingested 30 pills of 50 mg trazodone. Within the next hour,\n she called the ambulance herself. This was done at her apartment, and\n she reports that she did this because she was upset about her\n boyfriend.\n .\n Of note, she has had three prior SA since , two of which\n resulted in hospitalization at , at which point she was\n put on Celexa. She has a PCP (Dr. ?) but no psychiatrist\n or psychologist currently.\n .\n In the ED, VS were T 98.0, HR 94, BP 133/97, RR 22, 99 % RA. The\n toxicology team saw her; she was considered out fo the time window for\n activated charcoal; no stomach pumping was performed. while she was\n wiating for a bed, she became hypotensive with BP 70-80, which improved\n with 2 L NS. On arrival to the MICU, VS were T 97.6, HR 86, BP 90/51,\n 100% RA, RR 19. She denied nausea, HA, F/C, CP, SOB, abd pain; she was\n somnolent but easily arousable and conversant\n Hypotension (not Shock)\n Assessment:\n Rec\nd one IVFB overnight for low BP, since BP\ns-98-104/60, HR-70\ns SR\n with no ectopy noted.\n Action:\n Rec\ning IVF D51/2 @ 125hr\n Response:\n BP stable\n Plan:\n Monitor BP\ns administer IVFB if needed.\n Suicidality / Suicide Attempt\n Assessment:\n No Suicidal ideation noted very sleepy but easily arousable. Has \n in room. Awaiting Psych Evaluation. A&Ox3. Will also obtain SW consult\n in attempt to help her find other housing, due to that she lives with\n boyfriend.\n Action:\n in room. Has a Privacy laert in place.\n Response:\n Is calm, and cooperative but sleepy\n Plan:\n Await Psych eval, continue with sitters.\n"},{"category":"Physician ","chartdate":"2200-01-24 00:00:00.000","description":"Physician Attending Progress Note","row_id":655174,"text":"Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Admitted overnight from the ED after presenting with a suicide\n attmept/trazadone overdose as well as etoh intoxication. In the ED,\n had some mild hypotension. Was not given activated charcoal for NGT\n lavage as she was felt to be too far out from ingestion.\n In ICU, SBP's ranged in 90-110's, received total of 1 L of NS.\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:22 AM\n Other medications:\n HSQ\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 69 (69 - 88) bpm\n BP: 106/65(74) {86/44(55) - 113/68(78)} mmHg\n RR: 13 (13 - 20) insp/min\n SpO2: 97%\n Total In:\n 5,136 mL\n 2,079 mL\n PO:\n 500 mL\n 750 mL\n TF:\n IVF:\n 1,636 mL\n 1,329 mL\n Blood products:\n Total out:\n 1,360 mL\n 885 mL\n Urine:\n 760 mL\n 885 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,776 mL\n 1,194 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.4 g/dL\n 236 K/uL\n 88 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 8 mg/dL\n 109 mEq/L\n 138 mEq/L\n 27.4 %\n 5.8 K/uL\n [image002.jpg]\n 04:32 AM\n WBC\n 5.8\n Hct\n 27.4\n Plt\n 236\n Cr\n 0.7\n Glucose\n 88\n Other labs: PT / PTT / INR:14.0/30.2/1.2, ALT / AST:, Alk Phos / T\n Bili:35/0.4, Albumin:3.5 g/dL, Ca++:6.9 mg/dL, Mg++:1.5 mg/dL, PO4:3.2\n mg/dL\n Fluid analysis / Other labs: Tox screen: etoh otherwise neg.\n U/A: WBC\n Microbiology: UCx: Pending\n ECG: QT interval about 450ms\n Assessment and Plan\n 32 yo F with h/o depression admitted with suicide attempt (trazadone\n and etoh) complicated by mild hypotension.\n Hypotension: Likely related to trazadone ingestion. Now normalized.\n Suicide attempt:\n -Psychiatry consult\n -Social work eval to assist with home situation (reported abusive\n boyfriend)\n - for now.\n FEN: Regular diet.\n D/c foley\n Rest of plan per resident note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:34 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n"},{"category":"Nursing","chartdate":"2200-01-23 00:00:00.000","description":"Nursing Progress Note","row_id":655084,"text":"32 yo female admitted from home with suicide attempt, took 30 pills of\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\n she had a fight with her boyfriend. had 2 other attempts since\n .-08. In EU BP was 90-100\ns/50 but became hypotensive to the\n 70\ns/40, required 3L\ns NS, and was sent to the MICU for monitoring.\n Suicidality / Suicide Attempt\n Assessment:\n BP-90-92/50 with HR-70\ns, is lethargic but is easily arousable and able\n to answer questions. Stated that she had a fight with her boyfriend,\n and that her has fear in her relationship so is on a Privacy alert.\n Is oriented times 2. PERL 2mm, moves all extremities. Is pleasant and\n cooperative, but stated that she still was to harm herself, but no\n attempts to, has sitters. Has not been seen by Pysch as yet.\n Action:\n Has sitters in room, rec\ning NS @ 125cc/hr.\n Response:\n Appears calm with stable BP\n Plan:\n Assess MS\ns and monitor BP\n"},{"category":"Physician ","chartdate":"2200-01-23 00:00:00.000","description":"Physician Attending Admission Note - MICU","row_id":655090,"text":"Chief Complaint: Trazadone overdose\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 32 year old woman. Hx of depression. This afternoon had problems with\n her boyfriend. She drank Vodka (?5 drinks) and then at 2 PM took 30\n pills (trazadone 50 mg). She called an ambulance and was brought to the\n ED. Vital signs: afebrile, HR 94, BP 133/97, RR 22. Sats 95% on RA.\n Over the course of several hours, BP dropped to 70-80; was given fluids\n and admitted to the ICU. Urine output has been brisk. In MICU, still\n afebrile. BP 90/60. Patient denied fever, headache, chest pain,\n abdominal pain. She was somnolent but arousable.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Depression\n Prior suicide attempts X 3 since . Had been started on\n Celexa and Trazadone.\n Home meds: celexa, trazadone\n Mother breast ca, father DM type II, sister with MS.\n Occupation: Teaches English as 2nd language\n Drugs: None\n Tobacco: social, not daily.\n Alcohol: Occasional\n Other: Lives with boyfriend; hx of abuse - physical and emotional\n Review of systems:\n Flowsheet Data as of 09:53 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 76 (76 - 86) bpm\n BP: 92/50(59) {90/50(59) - 92/51(61)} mmHg\n RR: 18 (18 - 19) insp/min\n SpO2: 98%\n Total In:\n 3,300 mL\n PO:\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 0 mL\n 700 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,600 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, Pupils dilated, No(t) Conjunctiva pale,\n No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: ),\n Good breath sounds throughout. I/E=\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent edema, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone:\n Not assessed\n Labs / Radiology\n 290\n 36.7\n 92\n 0.7\n 11\n 21\n 110\n 3.8\n 145\n 4.7\n [image002.jpg]\n Fluid analysis / Other labs: alcohol 281\n Tox negative for ASA, tylenol, benzo, barbiturates, TCA, opiates,\n cocaine, methadone\n UA: small leuk esterase, neg nitrites, WBC\n Assessment and Plan\n SUICIDALITY / SUICIDE ATTEMPT\n HYPOTENSION\n HYPERNATREMIA\n Patient with trazadone overdose and EtOH ingestion combining to depress\n her sensorium. She is more alert now. Would allow clear liquids,\n monitor ECG, and Oxygen saturations. Psychiatry consult in the AM.\n Patient states she was not trying to kill herself; was upset that her\n boyfriend slashed her tires. Patient to be observed with CIWA scale,\n although by hx is not a chronic drinker.\n Hypotension likely related to drug effect and some volume depletion.\n She has responded to fluid resuscitation. Remains free water depleted,\n which may have been exacerbated since admission by the volume\n resuscitation with NS. Would give free water; recheck Na.\n ICU Care\n Nutrition: Clear liqs\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 06:34 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2200-01-23 00:00:00.000","description":"Physician Resident Admission Note","row_id":655091,"text":"Chief Complaint: trazodone overdose, EtOH intoxication\n HPI:\n Ms. is a 32 yoF with h/o prior suicide attempts, who presents\n after taking trazodone in an attempt to kill herself. Around noon this\n afternoon, she drank \"five drinks\" (not \"shots\") of vodka, and then\n around 2 pm, she ingested 30 pills of 50 mg trazodone. Within the next\n hour, she called the ambulance herself. This was done at her\n apartment, and she reports that she did this because she was upset\n about her boyfriend.\n .\n Of note, she has had three prior SA since , two of which\n resulted in hospitalization at , at which point she was\n put on Celexa. She has a PCP (Dr. ?) but no psychiatrist\n or psychologist currently.\n .\n In the ED, VS were T 98.0, HR 94, BP 133/97, RR 22, 99 % RA. The\n toxicology team saw her; she was considered out fo the time window for\n activated charcoal; no stomach pumping was performed. while she was\n wiating for a bed, she became hypotensive with BP 70-80, which improved\n with 2 L NS. On arrival to the MICU, VS were T 97.6, HR 86, BP 90/51,\n 100% RA, RR 19. She denied nausea, HA, F/C, CP, SOB, abd pain; she was\n somnolent but easily arousable and conversant.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME MEDICATIONS:\n Celexa 40 mg QD\n Trazodone 50 mg QHS PRN (takes about two per month)\n Past medical history:\n Family history:\n Social History:\n Depression\n -- mother: breast CA\n -- father: , diet controlled\n -- older sister: MS\n -- older brother: healthy\n Occupation: works as an ESL instructor\n Drugs: denied IVDU, snorting drugs\n Tobacco: smokes cigarettes socially when she drinks; does not smoke\n daily\n Alcohol: drinks occ on weekends; denies having a \"drinking problems\" in\n teh past; denies drinking daily\n Other: -- has lived with her boyfriend 4 years; readily admits to\n emotional and physical abuse by boyfriend (he has put out cigarettes on\n her in the past; has been hit in the face before)\n -- originally from Western Mass\n Review of systems: see above\n Flowsheet Data as of 10:35 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 78 (73 - 88) bpm\n BP: 103/58(68) {90/50(59) - 103/58(68)} mmHg\n RR: 15 (15 - 20) insp/min\n SpO2: 99%\n Total In:\n 4,946 mL\n PO:\n 500 mL\n TF:\n IVF:\n 1,446 mL\n Blood products:\n Total out:\n 0 mL\n 1,320 mL\n Urine:\n 720 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,628 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n Physical Examination\n VS on arrival to the MICU: T 97.6, HR 86, BP 90/51, 100% RA, RR 19\n General: sleepy, but easily arousable; somewhat slurred speech but\n coherent and logical\n HEENT: MMM, 1 mm pupils R=L (PEERL)\n Lungs: CTA b/l, no wheezes or crackles\n Cardio: RRR, no m.r.g.\n Extremities: no LE edema\n Skin: no rashes, no track marks\n Neuro: sleeping when seen but easily arousable; Ox3, somewhat slurred\n speech; CN II - XII intact; normal muscle tone, normal strength\n throughout; gait deferred\n Labs / Radiology\n 290\n 92\n 0.7\n 11\n 21\n 110\n 3.8\n 145\n 36.7\n 4.7\n [image002.jpg]\n Fluid analysis / Other labs: EtOH 281; rest of urine/serum tox\n negative;\n UA WBC, Sm LE, neg nit.\n Imaging: no imagin\n Microbiology: UCx: pending\n ECG: EKG: (done at 3:15 pm on ) sinus at 94 BPM; QTC 450\n Assessment and Plan\n 32 yoF w/ depression hx and prior SA, admitted from ED for trazodone OD\n with EtOH intoxication.\n .\n (#) TRAZODONE OVERDOSE: risk of hypotension with anti-alpha1 effects;\n no evidence of serotonin syndrome currently. Curbsided tox fellow who\n said to look out for hypotension, CNS depression and Qtc prolongation.\n Recommended levophed if she needs pressors.\n -- will watch for hypotension; fluid boluses PRN for SBP < 90\n -- monitor for somnolence, altered MS\n -- will check repeat lytes and EKG tonight; also in am\n -- will place on CIWA for possible EtOH withdrawal; denies in history\n but elevated EtOH on admission and unclear how reliable of a historian\n she is\n .\n (#) SUICIDE ATTTEMPT, DEPRESSION:\n -- will hold Celexa for now given trazodone OD\n -- will place SW consult\n -- 24 hour suicide watch\n -- will have psych see patient in the morning\n .\n (#) NUTRITION: clear liquids o/n for possible GI upset with OD; will\n likely advance diet in the am; IVF for maintenance overnight\n .\n (#) PPX:\n -- SQH\n -- no need for protonix tonight; will consider starting in the am\n -- no need for bowel regimen tonight as patient just admitted\n .\n (#) CODE: full\n .\n (#) CONSENT: signed in chart\n .\n (#) COMMUNICATION: with patient\n .\n (#) DISPO: likely d/c to floor or the psych service in the am\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:34 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2200-01-24 00:00:00.000","description":"Nursing Progress Note","row_id":655148,"text":"32 yo female admitted from home with suicide attempt, took 30 pills of\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\n she had a fight with her boyfriend. had 2 other attempts since\n .-08. In EU BP was 90-100\ns/50 but became hypotensive to the\n 70\ns/40, required 3L\ns NS, and was sent to the MICU for monitoring.\n Suicidality / Suicide Attempt\n Assessment:\n Pt slightly lethargic overnight with C/O wanting to sleep but easily\n arousable and able to answer questions, assist with care and turn\n self. Stated that she had a fight with her boyfriend, and that her has\n fear in her relationship so is on a Privacy alert. A & O x3, PEARL\n 2mm, moves all extremities. Is pleasant and cooperative, has 1:1\n sitter at bedside. Has not been seen by Pysch as yet.\n Action:\n Maintained suicide precautions with 1:1 sitter. Went through personal\n belongings\nclothes, no pills. Purse with pills was reported to be in\n ED safe per ED nurse.\n Response:\n Appears calm. No attempts to harm self. No verbalization of SI.\n Plan:\n Assess MS\ns, monitor for side effects of trazadone, ei. Elongated Qtc,\n hypotension, solmolence.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2200-01-24 00:00:00.000","description":"Nursing Progress Note","row_id":655149,"text":"32 yo female admitted from home with suicide attempt, took 30 pills of\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\n she had a fight with her boyfriend. had 2 other attempts since\n .-08. In EU BP was 90-100\ns/50 but became hypotensive to the\n 70\ns/40, required 3L\ns NS, and was sent to the MICU for monitoring.\n Suicidality / Suicide Attempt\n Assessment:\n Pt slightly lethargic overnight with C/O wanting to sleep but easily\n arousable and able to answer questions, assist with care and turn\n self. Stated that she had a fight with her boyfriend, and that her has\n fear in her relationship so is on a Privacy alert. A & O x3, PEARL\n 2mm, moves all extremities. Is pleasant and cooperative, has 1:1\n sitter at bedside. Has not been seen by Pysch as yet.\n Action:\n Maintained suicide precautions with 1:1 sitter. Went through personal\n belongings\nclothes, no pills. Purse with pills was reported to be in\n ED safe per ED nurse.\n Response:\n Appears calm. No attempts to harm self. No verbalization of SI.\n Plan:\n Assess MS\ns, monitor for side effects of trazadone, ei. Elongated Qtc,\n hypotension, solmolence.\n Hypotension (not Shock)\n Assessment:\n BP 92-112 with maps predominantly over 60. Did have short period of\n time where MAP was 55. HR\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2200-01-24 00:00:00.000","description":"Nursing Progress Note","row_id":655150,"text":"32 yo female admitted from home with suicide attempt, took 30 pills of\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\n she had a fight with her boyfriend. had 2 other attempts since\n .-08. In EU BP was 90-100\ns/50 but became hypotensive to the\n 70\ns/40, required 3L\ns NS, and was sent to the MICU for monitoring.\n Suicidality / Suicide Attempt\n Assessment:\n Pt slightly lethargic overnight with C/O wanting to sleep but easily\n arousable and able to answer questions, assist with care and turn\n self. Stated that she had a fight with her boyfriend, and that her has\n fear in her relationship so is on a Privacy alert. A & O x3, PEARL\n 2mm, moves all extremities. Is pleasant and cooperative, has 1:1\n sitter at bedside. Has not been seen by Pysch as yet.\n Action:\n Maintained suicide precautions with 1:1 sitter. Went through personal\n belongings\nclothes, no pills. Purse with pills was reported to be in\n ED safe per ED nurse.\n Response:\n Appears calm. No attempts to harm self. No verbalization of SI.\n Plan:\n Assess MS\ns, monitor for side effects of trazadone, ei. Elongated Qtc,\n hypotension, solmolence. Social work and Psych to see pt. Cont 1:1\n sitter for safety.\n Hypotension (not Shock)\n Assessment:\n BP 92-112 with maps predominantly over 60. Did have short period of\n time where MAP was 55. HR 70\ns-80\ns. QTc = 0.45\n Action:\n Bolused with 500cc NS x 2 with good effect. NS at 125cc/hr changed to\n D51/2 NS at 125cc/hr. Pt also taking in adequate PO liquids.\n Response:\n BP\ns maintained with MAP >60. Pt A & O x3, asymptomatic. Denies any\n N/V or other GI symptoms.\n Plan:\n Cont to assess BP, maintenance fluid. EKG changes with Qtc.\n"},{"category":"Nursing","chartdate":"2200-01-24 00:00:00.000","description":"Nursing Progress Note","row_id":655146,"text":"32 yo female admitted from home with suicide attempt, took 30 pills of\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\n she had a fight with her boyfriend. had 2 other attempts since\n .-08. In EU BP was 90-100\ns/50 but became hypotensive to the\n 70\ns/40, required 3L\ns NS, and was sent to the MICU for monitoring.\n Suicidality / Suicide Attempt\n Assessment:\n BP-90-92/50 with HR-70\ns, is lethargic but is easily arousable and able\n to answer questions. Stated that she had a fight with her boyfriend,\n and that her has fear in her relationship so is on a Privacy alert.\n Is oriented times 2. PERL 2mm, moves all extremities. Is pleasant and\n cooperative, but stated that she still was to harm herself, but no\n attempts to, has sitters. Has not been seen by Pysch as yet.\n Action:\n Has sitters in room, rec\ning NS @ 125cc/hr.\n Response:\n Appears calm with stable BP\n Plan:\n Assess MS\ns and monitor BP\n"},{"category":"Physician ","chartdate":"2200-01-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":655131,"text":"Chief Complaint: admitted with trazodone overdose\n 24 Hour Events:\n None-- admitted\n Slept overnight, but easily arousable\n HD stable throughout the night\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:22 AM\n Other medications:\n SQH\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 85 (73 - 88) bpm\n BP: 113/68(78) {90/44(55) - 113/68(78)} mmHg\n RR: 17 (15 - 20) insp/min\n SpO2: 97%\n Total In:\n 5,136 mL\n 1,055 mL\n PO:\n 500 mL\n 500 mL\n TF:\n IVF:\n 1,636 mL\n 555 mL\n Blood products:\n Total out:\n 1,360 mL\n 270 mL\n Urine:\n 760 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,776 mL\n 785 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General: sleepy, but easily arousable; somewhat slurred speech but\n coherent and logical\n HEENT: MMM, 1 mm pupils R=L (PEERL)\n Lungs: CTA b/l, no wheezes or crackles\n Cardio: RRR, no m.r.g.\n Extremities: no LE edema\n Skin: no rashes, no track marks\n Neuro: sleeping when seen but easily arousable; Ox3, somewhat slurred\n speech; CN II - XII intact; normal muscle tone, normal strength\n throughout; gait deferred\n Labs / Radiology\n 236 K/uL\n 9.4 g/dL\n 88 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 8 mg/dL\n 109 mEq/L\n 138 mEq/L\n 27.4 %\n 5.8 K/uL\n [image002.jpg]\n 04:32 AM\n WBC\n 5.8\n Hct\n 27.4\n Plt\n 236\n Cr\n 0.7\n Glucose\n 88\n Other labs: PT / PTT / INR:14.0/30.2/1.2, ALT / AST:, Alk Phos / T\n Bili:35/0.4, Albumin:3.5 g/dL, Ca++:6.9 mg/dL, Mg++:1.5 mg/dL, PO4:3.2\n mg/dL\n Imaging: no new imaging\n Microbiology: UCx: pending\n Assessment and Plan\n 32 yoF w/ depression hx and prior SA, admitted from ED for trazodone OD\n with EtOH intoxication.\n (#) TRAZODONE OVERDOSE: risk of hypotension with anti-alpha1 effects;\n no evidence of serotonin syndrome currently. Curbsided tox fellow who\n said to look out for hypotension, CNS depression and Qtc prolongation.\n Recommended levophed if she needs pressors. Qtc unchanged on am EKG.\n -- will watch for hypotension; fluid boluses PRN for SBP < 90 (has not\n needed)\n -- monitor for somnolence, altered MS\n (#) SUICIDE ATTTEMPT, DEPRESSION:\n -- will hold Celexa for now given trazodone OD\n -- SW consult placed\n -- 24 hour suicide watch; will need sitter on the floor\n -- will have psych see patient in the morning\n (#) NUTRITION: clear liquids o/n for possible GI upset with OD; will\n likely advance diet in the am; IVF for maintenance overnight\n (#) PPX:\n -- SQH\n -- no need for protonix tonight; will consider starting in the am if\n not eating or admits to sx\n -- no need for bowel regimen tonight as patient just admitted\n (#) CODE: full\n (#) CONSENT: signed in chart\n (#) COMMUNICATION: with patient\n (#) DISPO: likely d/c to floor or the psych service later today; pn\n privacy alert b/c of boyfriend\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:34 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"},{"category":"Physician ","chartdate":"2200-01-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":655134,"text":"Chief Complaint: admitted with trazodone overdose\n 24 Hour Events:\n None-- admitted\n Slept overnight, but easily arousable\n HD stable throughout the night\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:22 AM\n Other medications:\n SQH\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 85 (73 - 88) bpm\n BP: 113/68(78) {90/44(55) - 113/68(78)} mmHg\n RR: 17 (15 - 20) insp/min\n SpO2: 97%\n Total In:\n 5,136 mL\n 1,055 mL\n PO:\n 500 mL\n 500 mL\n TF:\n IVF:\n 1,636 mL\n 555 mL\n Blood products:\n Total out:\n 1,360 mL\n 270 mL\n Urine:\n 760 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,776 mL\n 785 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General: sleepy, but easily arousable; somewhat slurred speech but\n coherent and logical\n HEENT: MMM, 1 mm pupils R=L (PEERL)\n Lungs: CTA b/l, no wheezes or crackles\n Cardio: RRR, no m.r.g.\n Extremities: no LE edema\n Skin: no rashes, no track marks\n Neuro: sleeping when seen but easily arousable; Ox3, somewhat slurred\n speech; CN II - XII intact; normal muscle tone, normal strength\n throughout; gait deferred\n Labs / Radiology\n 236 K/uL\n 9.4 g/dL\n 88 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 8 mg/dL\n 109 mEq/L\n 138 mEq/L\n 27.4 %\n 5.8 K/uL\n [image002.jpg]\n 04:32 AM\n WBC\n 5.8\n Hct\n 27.4\n Plt\n 236\n Cr\n 0.7\n Glucose\n 88\n Other labs: PT / PTT / INR:14.0/30.2/1.2, ALT / AST:, Alk Phos / T\n Bili:35/0.4, Albumin:3.5 g/dL, Ca++:6.9 mg/dL, Mg++:1.5 mg/dL, PO4:3.2\n mg/dL\n Imaging: no new imaging\n Microbiology: UCx: pending\n Assessment and Plan\n 32 yoF w/ depression hx and prior SA, admitted from ED for trazodone OD\n with EtOH intoxication.\n (#) TRAZODONE OVERDOSE: risk of hypotension with anti-alpha1 effects;\n no evidence of serotonin syndrome currently. Curbsided tox fellow who\n said to look out for hypotension, CNS depression and Qtc prolongation.\n Recommended levophed if she needs pressors. Qtc unchanged on am EKG.\n -- will watch for hypotension; fluid boluses PRN for SBP < 90 (has not\n needed)\n -- monitor for somnolence, altered MS\n (#) SUICIDE ATTTEMPT, DEPRESSION:\n -- will hold Celexa for now given trazodone OD\n -- SW consult placed\n -- 24 hour suicide watch; will need sitter on the floor\n -- will have psych see patient in the morning\n (#) NUTRITION: clear liquids o/n for possible GI upset with OD; will\n likely advance diet in the am; IVF for maintenance overnight\n (#) PPX:\n -- SQH\n -- no need for protonix tonight; will consider starting in the am if\n not eating or admits to sx\n -- no need for bowel regimen tonight as patient just admitted\n (#) CODE: full\n (#) CONSENT: signed in chart\n (#) COMMUNICATION: with patient\n (#) DISPO: likely d/c to floor or the psych service later today; pn\n privacy alert b/c of boyfriend\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:34 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n ------ Protected Section ------\n ADDENDUM:\n Drop in Hct overnight from 36\n 27 likely dilutional from aggressive\n IVF; no evidence of gross blood loss.\n Will recheck in the pm to ensure stable; will send with T&S to be\n cautious.\n ------ Protected Section Addendum Entered By: , MD\n on: 06:25 ------\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-01-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 240140,\n \"text\": \"Sinus rhythm\\nEarly precordial QRS transition may be normal variant\\nSince previous tracing of , T wave changes decreased\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-01-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 240141,\n \"text\": \"Sinus rhythm. Minor non-diagnostic T wave flattening. Compared to the\\nprevious tracing no major change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-01-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 240142,\n \"text\": \"Sinus rhythm with baseline artifact. Probably normal tracing. No previous\\ntracing available for comparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-01-24 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 655197,\n \"text\": \"Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Suicidality / Suicide Attempt\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-01-24 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 655200,\n \"text\": \"Ms. is a 32 yoF with h/o prior suicide attempts, who presents\\n after taking trazodone in an attempt to kill herself. Around noon\\n yesterday , she drank \\\"five drinks\\\" of vodka, and then around 2\\n pm, she ingested 30 pills of 50 mg trazodone. Within the next hour,\\n she called the ambulance herself. This was done at her apartment, and\\n she reports that she did this because she was upset about her\\n boyfriend.\\n .\\n Of note, she has had three prior SA since , two of which\\n resulted in hospitalization at , at which point she was\\n put on Celexa. She has a PCP (Dr. ?) but no psychiatrist\\n or psychologist currently.\\n .\\n In the ED, VS were T 98.0, HR 94, BP 133/97, RR 22, 99 % RA. The\\n toxicology team saw her; she was considered out fo the time window for\\n activated charcoal; no stomach pumping was performed. while she was\\n wiating for a bed, she became hypotensive with BP 70-80, which improved\\n with 2 L NS. On arrival to the MICU, VS were T 97.6, HR 86, BP 90/51,\\n 100% RA, RR 19. She denied nausea, HA, F/C, CP, SOB, abd pain; she was\\n somnolent but easily arousable and conversant\\n Hypotension (not Shock)\\n Assessment:\\n Rec\\nd one IVFB overnight for low BP, since BP\\ns-98-104/60, HR-70\\ns SR\\n with no ectopy noted.\\n Action:\\n Rec\\ning IVF D51/2 @ 125hr\\n Response:\\n BP stable\\n Plan:\\n Monitor BP\\ns administer IVFB if needed.\\n Suicidality / Suicide Attempt\\n Assessment:\\n No Suicidal ideation noted very sleepy but easily arousable. Has \\n in room. Awaiting Psych Evaluation. A&Ox3. Will also obtain SW consult\\n in attempt to help her find other housing, due to that she lives with\\n boyfriend.\\n Action:\\n in room. Has a Privacy laert in place.\\n Response:\\n Is calm, and cooperative but sleepy\\n Plan:\\n Await Psych eval, continue with sitters.\\n Demographics\\n Attending MD:\\n P.\\n Admit diagnosis:\\n OVERDOSE\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 63 kg\\n Daily weight:\\n Allergies/Reactions:\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history: Past suicide attempts.\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:101\\n D:52\\n Temperature:\\n 99.5\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 16 insp/min\\n Heart Rate:\\n 80 bpm\\n Heart rhythm:\\n O2 delivery device:\\n None\\n O2 saturation:\\n 99% %\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 2,733 mL\\n 24h total out:\\n 1,165 mL\\n Pertinent Lab Results:\\n Sodium:\\n 138 mEq/L\\n 04:32 AM\\n Potassium:\\n 4.0 mEq/L\\n 04:32 AM\\n Chloride:\\n 109 mEq/L\\n 04:32 AM\\n CO2:\\n 21 mEq/L\\n 04:32 AM\\n BUN:\\n 8 mg/dL\\n 04:32 AM\\n Creatinine:\\n 0.7 mg/dL\\n 04:32 AM\\n Glucose:\\n 88 mg/dL\\n 04:32 AM\\n Hematocrit:\\n 27.4 %\\n 04:32 AM\\n Valuables / Signature\\n Patient valuables: Has red duffle bag and laundry bag with personal\\n care items and clothes inside.\\n Other valuables: In EU safe.\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with: In EU safe.\\n Jewelry:\\n Transferred from: MICU-7\\n Transferred to: CC7\\n Date & time of Transfer: 1300\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2200-01-24 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 655183,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n 24 Hour Events:\\n Admitted overnight from the ED after presenting with a suicide\\n attmept/trazadone overdose as well as etoh intoxication. In the ED,\\n had some mild hypotension. Was not given activated charcoal for NGT\\n lavage as she was felt to be too far out from ingestion.\\n In ICU, SBP's ranged in 90-110's, received total of 1 L of NS.\\n History obtained from Patient\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Lorazepam (Ativan) - 03:22 AM\\n Other medications:\\n HSQ\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:12 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.5\\nC (99.5\\n HR: 69 (69 - 88) bpm\\n BP: 106/65(74) {86/44(55) - 113/68(78)} mmHg\\n RR: 13 (13 - 20) insp/min\\n SpO2: 97%\\n Total In:\\n 5,136 mL\\n 2,079 mL\\n PO:\\n 500 mL\\n 750 mL\\n TF:\\n IVF:\\n 1,636 mL\\n 1,329 mL\\n Blood products:\\n Total out:\\n 1,360 mL\\n 885 mL\\n Urine:\\n 760 mL\\n 885 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,776 mL\\n 1,194 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n ABG: ///21/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\\n (Murmur: No(t) Systolic, No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right: Absent, Left: Absent\\n Skin: Not assessed, No(t) Rash:\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 9.4 g/dL\\n 236 K/uL\\n 88 mg/dL\\n 0.7 mg/dL\\n 21 mEq/L\\n 4.0 mEq/L\\n 8 mg/dL\\n 109 mEq/L\\n 138 mEq/L\\n 27.4 %\\n 5.8 K/uL\\n [image002.jpg]\\n 04:32 AM\\n WBC\\n 5.8\\n Hct\\n 27.4\\n Plt\\n 236\\n Cr\\n 0.7\\n Glucose\\n 88\\n Other labs: PT / PTT / INR:14.0/30.2/1.2, ALT / AST:, Alk Phos / T\\n Bili:35/0.4, Albumin:3.5 g/dL, Ca++:6.9 mg/dL, Mg++:1.5 mg/dL, PO4:3.2\\n mg/dL\\n Fluid analysis / Other labs: Tox screen: etoh otherwise neg.\\n U/A: WBC\\n Microbiology: UCx: Pending\\n ECG: QT interval about 450ms\\n Assessment and Plan\\n 32 yo F with h/o depression admitted with suicide attempt (trazadone\\n and etoh) complicated by mild hypotension.\\n Hypotension: Likely related to trazadone ingestion. Now normalized.\\n Suicide attempt:\\n -Psychiatry consult\\n -Social work eval to assist with home situation (reported abusive\\n boyfriend)\\n - for now.\\n FEN: Regular diet.\\n D/c foley\\n Rest of plan per resident note\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:34 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Transfer to floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-01-24 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 655169,\n \"text\": \"Ms. is a 32 yoF with h/o prior suicide attempts, who presents\\n after taking trazodone in an attempt to kill herself. Around noon\\n yesterday , she drank \\\"five drinks\\\" of vodka, and then around 2\\n pm, she ingested 30 pills of 50 mg trazodone. Within the next hour,\\n she called the ambulance herself. This was done at her apartment, and\\n she reports that she did this because she was upset about her\\n boyfriend.\\n .\\n Of note, she has had three prior SA since , two of which\\n resulted in hospitalization at , at which point she was\\n put on Celexa. She has a PCP (Dr. ?) but no psychiatrist\\n or psychologist currently.\\n .\\n In the ED, VS were T 98.0, HR 94, BP 133/97, RR 22, 99 % RA. The\\n toxicology team saw her; she was considered out fo the time window for\\n activated charcoal; no stomach pumping was performed. while she was\\n wiating for a bed, she became hypotensive with BP 70-80, which improved\\n with 2 L NS. On arrival to the MICU, VS were T 97.6, HR 86, BP 90/51,\\n 100% RA, RR 19. She denied nausea, HA, F/C, CP, SOB, abd pain; she was\\n somnolent but easily arousable and conversant\\n Hypotension (not Shock)\\n Assessment:\\n Rec\\nd one IVFB overnight for low BP, since BP\\ns-98-104/60, HR-70\\ns SR\\n with no ectopy noted.\\n Action:\\n Rec\\ning IVF D51/2 @ 125hr\\n Response:\\n BP stable\\n Plan:\\n Monitor BP\\ns administer IVFB if needed.\\n Suicidality / Suicide Attempt\\n Assessment:\\n No Suicidal ideation noted very sleepy but easily arousable. Has \\n in room. Awaiting Psych Evaluation. A&Ox3. Will also obtain SW consult\\n in attempt to help her find other housing, due to that she lives with\\n boyfriend.\\n Action:\\n in room. Has a Privacy laert in place.\\n Response:\\n Is calm, and cooperative but sleepy\\n Plan:\\n Await Psych eval, continue with sitters.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2200-01-24 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 655174,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n Admitted overnight from the ED after presenting with a suicide\\n attmept/trazadone overdose as well as etoh intoxication. In the ED,\\n had some mild hypotension. Was not given activated charcoal for NGT\\n lavage as she was felt to be too far out from ingestion.\\n In ICU, SBP's ranged in 90-110's, received total of 1 L of NS.\\n History obtained from Patient\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Lorazepam (Ativan) - 03:22 AM\\n Other medications:\\n HSQ\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:12 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.5\\nC (99.5\\n HR: 69 (69 - 88) bpm\\n BP: 106/65(74) {86/44(55) - 113/68(78)} mmHg\\n RR: 13 (13 - 20) insp/min\\n SpO2: 97%\\n Total In:\\n 5,136 mL\\n 2,079 mL\\n PO:\\n 500 mL\\n 750 mL\\n TF:\\n IVF:\\n 1,636 mL\\n 1,329 mL\\n Blood products:\\n Total out:\\n 1,360 mL\\n 885 mL\\n Urine:\\n 760 mL\\n 885 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,776 mL\\n 1,194 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n ABG: ///21/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\\n (Murmur: No(t) Systolic, No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\\n Extremities: Right: Absent, Left: Absent\\n Skin: Not assessed, No(t) Rash:\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 9.4 g/dL\\n 236 K/uL\\n 88 mg/dL\\n 0.7 mg/dL\\n 21 mEq/L\\n 4.0 mEq/L\\n 8 mg/dL\\n 109 mEq/L\\n 138 mEq/L\\n 27.4 %\\n 5.8 K/uL\\n [image002.jpg]\\n 04:32 AM\\n WBC\\n 5.8\\n Hct\\n 27.4\\n Plt\\n 236\\n Cr\\n 0.7\\n Glucose\\n 88\\n Other labs: PT / PTT / INR:14.0/30.2/1.2, ALT / AST:, Alk Phos / T\\n Bili:35/0.4, Albumin:3.5 g/dL, Ca++:6.9 mg/dL, Mg++:1.5 mg/dL, PO4:3.2\\n mg/dL\\n Fluid analysis / Other labs: Tox screen: etoh otherwise neg.\\n U/A: WBC\\n Microbiology: UCx: Pending\\n ECG: QT interval about 450ms\\n Assessment and Plan\\n 32 yo F with h/o depression admitted with suicide attempt (trazadone\\n and etoh) complicated by mild hypotension.\\n Hypotension: Likely related to trazadone ingestion. Now normalized.\\n Suicide attempt:\\n -Psychiatry consult\\n -Social work eval to assist with home situation (reported abusive\\n boyfriend)\\n - for now.\\n FEN: Regular diet.\\n D/c foley\\n Rest of plan per resident note\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:34 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Transfer to floor\\n Total time spent: 30 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-01-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 655084,\n \"text\": \"32 yo female admitted from home with suicide attempt, took 30 pills of\\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\\n she had a fight with her boyfriend. had 2 other attempts since\\n .-08. In EU BP was 90-100\\ns/50 but became hypotensive to the\\n 70\\ns/40, required 3L\\ns NS, and was sent to the MICU for monitoring.\\n Suicidality / Suicide Attempt\\n Assessment:\\n BP-90-92/50 with HR-70\\ns, is lethargic but is easily arousable and able\\n to answer questions. Stated that she had a fight with her boyfriend,\\n and that her has fear in her relationship so is on a Privacy alert.\\n Is oriented times 2. PERL 2mm, moves all extremities. Is pleasant and\\n cooperative, but stated that she still was to harm herself, but no\\n attempts to, has sitters. Has not been seen by Pysch as yet.\\n Action:\\n Has sitters in room, rec\\ning NS @ 125cc/hr.\\n Response:\\n Appears calm with stable BP\\n Plan:\\n Assess MS\\ns and monitor BP\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2200-01-23 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 655090,\n \"text\": \"Chief Complaint: Trazadone overdose\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 32 year old woman. Hx of depression. This afternoon had problems with\\n her boyfriend. She drank Vodka (?5 drinks) and then at 2 PM took 30\\n pills (trazadone 50 mg). She called an ambulance and was brought to the\\n ED. Vital signs: afebrile, HR 94, BP 133/97, RR 22. Sats 95% on RA.\\n Over the course of several hours, BP dropped to 70-80; was given fluids\\n and admitted to the ICU. Urine output has been brisk. In MICU, still\\n afebrile. BP 90/60. Patient denied fever, headache, chest pain,\\n abdominal pain. She was somnolent but arousable.\\n Patient admitted from: ER\\n History obtained from Patient\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n Depression\\n Prior suicide attempts X 3 since . Had been started on\\n Celexa and Trazadone.\\n Home meds: celexa, trazadone\\n Mother breast ca, father DM type II, sister with MS.\\n Occupation: Teaches English as 2nd language\\n Drugs: None\\n Tobacco: social, not daily.\\n Alcohol: Occasional\\n Other: Lives with boyfriend; hx of abuse - physical and emotional\\n Review of systems:\\n Flowsheet Data as of 09:53 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.4\\nC (97.6\\n Tcurrent: 36.4\\nC (97.6\\n HR: 76 (76 - 86) bpm\\n BP: 92/50(59) {90/50(59) - 92/51(61)} mmHg\\n RR: 18 (18 - 19) insp/min\\n SpO2: 98%\\n Total In:\\n 3,300 mL\\n PO:\\n TF:\\n IVF:\\n 300 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 700 mL\\n Urine:\\n 100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 2,600 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 98%\\n ABG: ////\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, No(t) Overweight\\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, Pupils dilated, No(t) Conjunctiva pale,\\n No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: ),\\n Good breath sounds throughout. I/E=\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: Absent edema, Left: Absent, No(t) Cyanosis, No(t)\\n Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone:\\n Not assessed\\n Labs / Radiology\\n 290\\n 36.7\\n 92\\n 0.7\\n 11\\n 21\\n 110\\n 3.8\\n 145\\n 4.7\\n [image002.jpg]\\n Fluid analysis / Other labs: alcohol 281\\n Tox negative for ASA, tylenol, benzo, barbiturates, TCA, opiates,\\n cocaine, methadone\\n UA: small leuk esterase, neg nitrites, WBC\\n Assessment and Plan\\n SUICIDALITY / SUICIDE ATTEMPT\\n HYPOTENSION\\n HYPERNATREMIA\\n Patient with trazadone overdose and EtOH ingestion combining to depress\\n her sensorium. She is more alert now. Would allow clear liquids,\\n monitor ECG, and Oxygen saturations. Psychiatry consult in the AM.\\n Patient states she was not trying to kill herself; was upset that her\\n boyfriend slashed her tires. Patient to be observed with CIWA scale,\\n although by hx is not a chronic drinker.\\n Hypotension likely related to drug effect and some volume depletion.\\n She has responded to fluid resuscitation. Remains free water depleted,\\n which may have been exacerbated since admission by the volume\\n resuscitation with NS. Would give free water; recheck Na.\\n ICU Care\\n Nutrition: Clear liqs\\n Glycemic Control:\\n Lines / Intubation:\\n 18 Gauge - 06:34 PM\\n Comments:\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments: Not applicable.\\n Communication: Patient discussed on interdisciplinary rounds , ICU\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 40 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2200-01-23 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 655091,\n \"text\": \"Chief Complaint: trazodone overdose, EtOH intoxication\\n HPI:\\n Ms. is a 32 yoF with h/o prior suicide attempts, who presents\\n after taking trazodone in an attempt to kill herself. Around noon this\\n afternoon, she drank \\\"five drinks\\\" (not \\\"shots\\\") of vodka, and then\\n around 2 pm, she ingested 30 pills of 50 mg trazodone. Within the next\\n hour, she called the ambulance herself. This was done at her\\n apartment, and she reports that she did this because she was upset\\n about her boyfriend.\\n .\\n Of note, she has had three prior SA since , two of which\\n resulted in hospitalization at , at which point she was\\n put on Celexa. She has a PCP (Dr. ?) but no psychiatrist\\n or psychologist currently.\\n .\\n In the ED, VS were T 98.0, HR 94, BP 133/97, RR 22, 99 % RA. The\\n toxicology team saw her; she was considered out fo the time window for\\n activated charcoal; no stomach pumping was performed. while she was\\n wiating for a bed, she became hypotensive with BP 70-80, which improved\\n with 2 L NS. On arrival to the MICU, VS were T 97.6, HR 86, BP 90/51,\\n 100% RA, RR 19. She denied nausea, HA, F/C, CP, SOB, abd pain; she was\\n somnolent but easily arousable and conversant.\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n HOME MEDICATIONS:\\n Celexa 40 mg QD\\n Trazodone 50 mg QHS PRN (takes about two per month)\\n Past medical history:\\n Family history:\\n Social History:\\n Depression\\n -- mother: breast CA\\n -- father: , diet controlled\\n -- older sister: MS\\n -- older brother: healthy\\n Occupation: works as an ESL instructor\\n Drugs: denied IVDU, snorting drugs\\n Tobacco: smokes cigarettes socially when she drinks; does not smoke\\n daily\\n Alcohol: drinks occ on weekends; denies having a \\\"drinking problems\\\" in\\n teh past; denies drinking daily\\n Other: -- has lived with her boyfriend 4 years; readily admits to\\n emotional and physical abuse by boyfriend (he has put out cigarettes on\\n her in the past; has been hit in the face before)\\n -- originally from Western Mass\\n Review of systems: see above\\n Flowsheet Data as of 10:35 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.9\\nC (98.4\\n Tcurrent: 36.9\\nC (98.4\\n HR: 78 (73 - 88) bpm\\n BP: 103/58(68) {90/50(59) - 103/58(68)} mmHg\\n RR: 15 (15 - 20) insp/min\\n SpO2: 99%\\n Total In:\\n 4,946 mL\\n PO:\\n 500 mL\\n TF:\\n IVF:\\n 1,446 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 1,320 mL\\n Urine:\\n 720 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 3,628 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 99%\\n Physical Examination\\n VS on arrival to the MICU: T 97.6, HR 86, BP 90/51, 100% RA, RR 19\\n General: sleepy, but easily arousable; somewhat slurred speech but\\n coherent and logical\\n HEENT: MMM, 1 mm pupils R=L (PEERL)\\n Lungs: CTA b/l, no wheezes or crackles\\n Cardio: RRR, no m.r.g.\\n Extremities: no LE edema\\n Skin: no rashes, no track marks\\n Neuro: sleeping when seen but easily arousable; Ox3, somewhat slurred\\n speech; CN II - XII intact; normal muscle tone, normal strength\\n throughout; gait deferred\\n Labs / Radiology\\n 290\\n 92\\n 0.7\\n 11\\n 21\\n 110\\n 3.8\\n 145\\n 36.7\\n 4.7\\n [image002.jpg]\\n Fluid analysis / Other labs: EtOH 281; rest of urine/serum tox\\n negative;\\n UA WBC, Sm LE, neg nit.\\n Imaging: no imagin\\n Microbiology: UCx: pending\\n ECG: EKG: (done at 3:15 pm on ) sinus at 94 BPM; QTC 450\\n Assessment and Plan\\n 32 yoF w/ depression hx and prior SA, admitted from ED for trazodone OD\\n with EtOH intoxication.\\n .\\n (#) TRAZODONE OVERDOSE: risk of hypotension with anti-alpha1 effects;\\n no evidence of serotonin syndrome currently. Curbsided tox fellow who\\n said to look out for hypotension, CNS depression and Qtc prolongation.\\n Recommended levophed if she needs pressors.\\n -- will watch for hypotension; fluid boluses PRN for SBP < 90\\n -- monitor for somnolence, altered MS\\n -- will check repeat lytes and EKG tonight; also in am\\n -- will place on CIWA for possible EtOH withdrawal; denies in history\\n but elevated EtOH on admission and unclear how reliable of a historian\\n she is\\n .\\n (#) SUICIDE ATTTEMPT, DEPRESSION:\\n -- will hold Celexa for now given trazodone OD\\n -- will place SW consult\\n -- 24 hour suicide watch\\n -- will have psych see patient in the morning\\n .\\n (#) NUTRITION: clear liquids o/n for possible GI upset with OD; will\\n likely advance diet in the am; IVF for maintenance overnight\\n .\\n (#) PPX:\\n -- SQH\\n -- no need for protonix tonight; will consider starting in the am\\n -- no need for bowel regimen tonight as patient just admitted\\n .\\n (#) CODE: full\\n .\\n (#) CONSENT: signed in chart\\n .\\n (#) COMMUNICATION: with patient\\n .\\n (#) DISPO: likely d/c to floor or the psych service in the am\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:34 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: Not indicated\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-01-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 655148,\n \"text\": \"32 yo female admitted from home with suicide attempt, took 30 pills of\\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\\n she had a fight with her boyfriend. had 2 other attempts since\\n .-08. In EU BP was 90-100\\ns/50 but became hypotensive to the\\n 70\\ns/40, required 3L\\ns NS, and was sent to the MICU for monitoring.\\n Suicidality / Suicide Attempt\\n Assessment:\\n Pt slightly lethargic overnight with C/O wanting to sleep but easily\\n arousable and able to answer questions, assist with care and turn\\n self. Stated that she had a fight with her boyfriend, and that her has\\n fear in her relationship so is on a Privacy alert. A & O x3, PEARL\\n 2mm, moves all extremities. Is pleasant and cooperative, has 1:1\\n sitter at bedside. Has not been seen by Pysch as yet.\\n Action:\\n Maintained suicide precautions with 1:1 sitter. Went through personal\\n belongings\\nclothes, no pills. Purse with pills was reported to be in\\n ED safe per ED nurse.\\n Response:\\n Appears calm. No attempts to harm self. No verbalization of SI.\\n Plan:\\n Assess MS\\ns, monitor for side effects of trazadone, ei. Elongated Qtc,\\n hypotension, solmolence.\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-01-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 655149,\n \"text\": \"32 yo female admitted from home with suicide attempt, took 30 pills of\\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\\n she had a fight with her boyfriend. had 2 other attempts since\\n .-08. In EU BP was 90-100\\ns/50 but became hypotensive to the\\n 70\\ns/40, required 3L\\ns NS, and was sent to the MICU for monitoring.\\n Suicidality / Suicide Attempt\\n Assessment:\\n Pt slightly lethargic overnight with C/O wanting to sleep but easily\\n arousable and able to answer questions, assist with care and turn\\n self. Stated that she had a fight with her boyfriend, and that her has\\n fear in her relationship so is on a Privacy alert. A & O x3, PEARL\\n 2mm, moves all extremities. Is pleasant and cooperative, has 1:1\\n sitter at bedside. Has not been seen by Pysch as yet.\\n Action:\\n Maintained suicide precautions with 1:1 sitter. Went through personal\\n belongings\\nclothes, no pills. Purse with pills was reported to be in\\n ED safe per ED nurse.\\n Response:\\n Appears calm. No attempts to harm self. No verbalization of SI.\\n Plan:\\n Assess MS\\ns, monitor for side effects of trazadone, ei. Elongated Qtc,\\n hypotension, solmolence.\\n Hypotension (not Shock)\\n Assessment:\\n BP 92-112 with maps predominantly over 60. Did have short period of\\n time where MAP was 55. HR\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-01-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 655150,\n \"text\": \"32 yo female admitted from home with suicide attempt, took 30 pills of\\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\\n she had a fight with her boyfriend. had 2 other attempts since\\n .-08. In EU BP was 90-100\\ns/50 but became hypotensive to the\\n 70\\ns/40, required 3L\\ns NS, and was sent to the MICU for monitoring.\\n Suicidality / Suicide Attempt\\n Assessment:\\n Pt slightly lethargic overnight with C/O wanting to sleep but easily\\n arousable and able to answer questions, assist with care and turn\\n self. Stated that she had a fight with her boyfriend, and that her has\\n fear in her relationship so is on a Privacy alert. A & O x3, PEARL\\n 2mm, moves all extremities. Is pleasant and cooperative, has 1:1\\n sitter at bedside. Has not been seen by Pysch as yet.\\n Action:\\n Maintained suicide precautions with 1:1 sitter. Went through personal\\n belongings\\nclothes, no pills. Purse with pills was reported to be in\\n ED safe per ED nurse.\\n Response:\\n Appears calm. No attempts to harm self. No verbalization of SI.\\n Plan:\\n Assess MS\\ns, monitor for side effects of trazadone, ei. Elongated Qtc,\\n hypotension, solmolence. Social work and Psych to see pt. Cont 1:1\\n sitter for safety.\\n Hypotension (not Shock)\\n Assessment:\\n BP 92-112 with maps predominantly over 60. Did have short period of\\n time where MAP was 55. HR 70\\ns-80\\ns. QTc = 0.45\\n Action:\\n Bolused with 500cc NS x 2 with good effect. NS at 125cc/hr changed to\\n D51/2 NS at 125cc/hr. Pt also taking in adequate PO liquids.\\n Response:\\n BP\\ns maintained with MAP >60. Pt A & O x3, asymptomatic. Denies any\\n N/V or other GI symptoms.\\n Plan:\\n Cont to assess BP, maintenance fluid. EKG changes with Qtc.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2200-01-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 655146,\n \"text\": \"32 yo female admitted from home with suicide attempt, took 30 pills of\\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\\n she had a fight with her boyfriend. had 2 other attempts since\\n .-08. In EU BP was 90-100\\ns/50 but became hypotensive to the\\n 70\\ns/40, required 3L\\ns NS, and was sent to the MICU for monitoring.\\n Suicidality / Suicide Attempt\\n Assessment:\\n BP-90-92/50 with HR-70\\ns, is lethargic but is easily arousable and able\\n to answer questions. Stated that she had a fight with her boyfriend,\\n and that her has fear in her relationship so is on a Privacy alert.\\n Is oriented times 2. PERL 2mm, moves all extremities. Is pleasant and\\n cooperative, but stated that she still was to harm herself, but no\\n attempts to, has sitters. Has not been seen by Pysch as yet.\\n Action:\\n Has sitters in room, rec\\ning NS @ 125cc/hr.\\n Response:\\n Appears calm with stable BP\\n Plan:\\n Assess MS\\ns and monitor BP\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2200-01-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 655131,\n \"text\": \"Chief Complaint: admitted with trazodone overdose\\n 24 Hour Events:\\n None-- admitted\\n Slept overnight, but easily arousable\\n HD stable throughout the night\\n History obtained from Patient\\n Allergies:\\n History obtained from Patient\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Lorazepam (Ativan) - 03:22 AM\\n Other medications:\\n SQH\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 37\\nC (98.6\\n HR: 85 (73 - 88) bpm\\n BP: 113/68(78) {90/44(55) - 113/68(78)} mmHg\\n RR: 17 (15 - 20) insp/min\\n SpO2: 97%\\n Total In:\\n 5,136 mL\\n 1,055 mL\\n PO:\\n 500 mL\\n 500 mL\\n TF:\\n IVF:\\n 1,636 mL\\n 555 mL\\n Blood products:\\n Total out:\\n 1,360 mL\\n 270 mL\\n Urine:\\n 760 mL\\n 270 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,776 mL\\n 785 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n ABG: ///21/\\n Physical Examination\\n General: sleepy, but easily arousable; somewhat slurred speech but\\n coherent and logical\\n HEENT: MMM, 1 mm pupils R=L (PEERL)\\n Lungs: CTA b/l, no wheezes or crackles\\n Cardio: RRR, no m.r.g.\\n Extremities: no LE edema\\n Skin: no rashes, no track marks\\n Neuro: sleeping when seen but easily arousable; Ox3, somewhat slurred\\n speech; CN II - XII intact; normal muscle tone, normal strength\\n throughout; gait deferred\\n Labs / Radiology\\n 236 K/uL\\n 9.4 g/dL\\n 88 mg/dL\\n 0.7 mg/dL\\n 21 mEq/L\\n 4.0 mEq/L\\n 8 mg/dL\\n 109 mEq/L\\n 138 mEq/L\\n 27.4 %\\n 5.8 K/uL\\n [image002.jpg]\\n 04:32 AM\\n WBC\\n 5.8\\n Hct\\n 27.4\\n Plt\\n 236\\n Cr\\n 0.7\\n Glucose\\n 88\\n Other labs: PT / PTT / INR:14.0/30.2/1.2, ALT / AST:, Alk Phos / T\\n Bili:35/0.4, Albumin:3.5 g/dL, Ca++:6.9 mg/dL, Mg++:1.5 mg/dL, PO4:3.2\\n mg/dL\\n Imaging: no new imaging\\n Microbiology: UCx: pending\\n Assessment and Plan\\n 32 yoF w/ depression hx and prior SA, admitted from ED for trazodone OD\\n with EtOH intoxication.\\n (#) TRAZODONE OVERDOSE: risk of hypotension with anti-alpha1 effects;\\n no evidence of serotonin syndrome currently. Curbsided tox fellow who\\n said to look out for hypotension, CNS depression and Qtc prolongation.\\n Recommended levophed if she needs pressors. Qtc unchanged on am EKG.\\n -- will watch for hypotension; fluid boluses PRN for SBP < 90 (has not\\n needed)\\n -- monitor for somnolence, altered MS\\n (#) SUICIDE ATTTEMPT, DEPRESSION:\\n -- will hold Celexa for now given trazodone OD\\n -- SW consult placed\\n -- 24 hour suicide watch; will need sitter on the floor\\n -- will have psych see patient in the morning\\n (#) NUTRITION: clear liquids o/n for possible GI upset with OD; will\\n likely advance diet in the am; IVF for maintenance overnight\\n (#) PPX:\\n -- SQH\\n -- no need for protonix tonight; will consider starting in the am if\\n not eating or admits to sx\\n -- no need for bowel regimen tonight as patient just admitted\\n (#) CODE: full\\n (#) CONSENT: signed in chart\\n (#) COMMUNICATION: with patient\\n (#) DISPO: likely d/c to floor or the psych service later today; pn\\n privacy alert b/c of boyfriend\\n ICU \\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:34 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: Not indicated\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition:Transfer to floor\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2200-01-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 655134,\n \"text\": \"Chief Complaint: admitted with trazodone overdose\\n 24 Hour Events:\\n None-- admitted\\n Slept overnight, but easily arousable\\n HD stable throughout the night\\n History obtained from Patient\\n Allergies:\\n History obtained from Patient\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Lorazepam (Ativan) - 03:22 AM\\n Other medications:\\n SQH\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37\\nC (98.6\\n Tcurrent: 37\\nC (98.6\\n HR: 85 (73 - 88) bpm\\n BP: 113/68(78) {90/44(55) - 113/68(78)} mmHg\\n RR: 17 (15 - 20) insp/min\\n SpO2: 97%\\n Total In:\\n 5,136 mL\\n 1,055 mL\\n PO:\\n 500 mL\\n 500 mL\\n TF:\\n IVF:\\n 1,636 mL\\n 555 mL\\n Blood products:\\n Total out:\\n 1,360 mL\\n 270 mL\\n Urine:\\n 760 mL\\n 270 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 3,776 mL\\n 785 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n ABG: ///21/\\n Physical Examination\\n General: sleepy, but easily arousable; somewhat slurred speech but\\n coherent and logical\\n HEENT: MMM, 1 mm pupils R=L (PEERL)\\n Lungs: CTA b/l, no wheezes or crackles\\n Cardio: RRR, no m.r.g.\\n Extremities: no LE edema\\n Skin: no rashes, no track marks\\n Neuro: sleeping when seen but easily arousable; Ox3, somewhat slurred\\n speech; CN II - XII intact; normal muscle tone, normal strength\\n throughout; gait deferred\\n Labs / Radiology\\n 236 K/uL\\n 9.4 g/dL\\n 88 mg/dL\\n 0.7 mg/dL\\n 21 mEq/L\\n 4.0 mEq/L\\n 8 mg/dL\\n 109 mEq/L\\n 138 mEq/L\\n 27.4 %\\n 5.8 K/uL\\n [image002.jpg]\\n 04:32 AM\\n WBC\\n 5.8\\n Hct\\n 27.4\\n Plt\\n 236\\n Cr\\n 0.7\\n Glucose\\n 88\\n Other labs: PT / PTT / INR:14.0/30.2/1.2, ALT / AST:, Alk Phos / T\\n Bili:35/0.4, Albumin:3.5 g/dL, Ca++:6.9 mg/dL, Mg++:1.5 mg/dL, PO4:3.2\\n mg/dL\\n Imaging: no new imaging\\n Microbiology: UCx: pending\\n Assessment and Plan\\n 32 yoF w/ depression hx and prior SA, admitted from ED for trazodone OD\\n with EtOH intoxication.\\n (#) TRAZODONE OVERDOSE: risk of hypotension with anti-alpha1 effects;\\n no evidence of serotonin syndrome currently. Curbsided tox fellow who\\n said to look out for hypotension, CNS depression and Qtc prolongation.\\n Recommended levophed if she needs pressors. Qtc unchanged on am EKG.\\n -- will watch for hypotension; fluid boluses PRN for SBP < 90 (has not\\n needed)\\n -- monitor for somnolence, altered MS\\n (#) SUICIDE ATTTEMPT, DEPRESSION:\\n -- will hold Celexa for now given trazodone OD\\n -- SW consult placed\\n -- 24 hour suicide watch; will need sitter on the floor\\n -- will have psych see patient in the morning\\n (#) NUTRITION: clear liquids o/n for possible GI upset with OD; will\\n likely advance diet in the am; IVF for maintenance overnight\\n (#) PPX:\\n -- SQH\\n -- no need for protonix tonight; will consider starting in the am if\\n not eating or admits to sx\\n -- no need for bowel regimen tonight as patient just admitted\\n (#) CODE: full\\n (#) CONSENT: signed in chart\\n (#) COMMUNICATION: with patient\\n (#) DISPO: likely d/c to floor or the psych service later today; pn\\n privacy alert b/c of boyfriend\\n ICU \\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:34 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: Not indicated\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition:Transfer to floor\\n ------ Protected Section ------\\n ADDENDUM:\\n Drop in Hct overnight from 36\\n 27 likely dilutional from aggressive\\n IVF; no evidence of gross blood loss.\\n Will recheck in the pm to ensure stable; will send with T&S to be\\n cautious.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 06:25 ------\\n\"\n }\n]"}}},{"rowIdx":87,"cells":{"subject_id":{"kind":"number","value":25415,"string":"25,415"},"hadm_id":{"kind":"number","value":139671,"string":"139,671"},"target_text":{"kind":"string","value":"A/P: yo f with HTN, DM II, OA, h/o UTI's, who now presents with hematemesis, UTI, and pan-colitis. . #) Hematemesis: Upon admission, the patient was reported to have approximately 50cc of hematemsis. She was admitted to in hemodynamically stable condition. Her Hct upon admission was 50.0, thought to represent hemoconcentration severe dehydration in the setting of pan-colitis. This returned to her baseline around 28-30 after IVF hydration and then remained stable. GI was made aware of pt, however plan for EGD was deferred as pt/family wish to avoid aggressive invasive measures. The patient had no further episodes of hematemesis and her Hct remained stable. ASA, NSAIDS were avoided and she was put on Protonix. . #) Pan-colitis: An abdominal CT scan with contrast upon admission showed a pan-colitis. The differential included infectious (? C dif), inflammatory, or ischemic causes. An infectious etiology was thought to be most likely given fever, elevated WBC count, and was guaiac negative. Ischemia was thought to be less likely given pan colitis distribution. Stool cultures were sent and were negative (C dif x 3 was negative as well as Campylobacter, O&P and stool culture. She was treated with flagyl, and meropenem for 6 days. Pain control acheived with fentanyl patch + prn morphine. After three negative C difs and clinical improvement in her abdominal exam, her antibiotics were discontinued. . #) Respiratory distress/Hypoxia: While in the ICU, the patient was noted to have one episode of mild respiratory distress with pulmonary edema after getting IVF hydration. She was approximately +7 Liters at the time after aggressive IVF hydration for pan-colitis. Her respiratory distress was volume overload and mild CHF from diastolic dysfunction. She was gently diuresed with excellent response to Lasix 10mg IV and got daily Lasix. She will be discharged on daily PO Lasix which will need to be titrated based on daily weights, monitoring Cr and UOP (this was discussed with patient's PCP before discharge). . #) Acute Renal Failure: Upon admission, the patient's Cr was 1.0 (near her baseline 0.9-1.3). Her Cr climbed to as high as 1.4 after gentle diuresis for volume overload with Lasix. Her creatinine trended down and was 1.2 upon discharge. Her volume status and creatinine will need to be monitored as an outpatient as she will be going home on daily Lasix 10mg daily (this may need to be titrated, possibly qday or QOD). . #) UTI: The patient has a long history of multiple Klebsiella UTIs that are multi-drug resistant (ESBL, extended spectrum beta-lactamase producing). Her urine culture upon admission showed Klebsiella (again ESBL but sensitive to Meropenem, pt cannot take cephaloporins or PCN, Klebsiella was resistant to Cipro, Bactrim, Nitrofurantoin and Levofloxacin). She completed a 6 day course of Meropenem. . #) Tachycardia: The patient was admitted with tachycardia to the 120s thought to be intravascular volume depletion/dehydration as well as from diffuse abdominal pain. After volume resuscitation upon admission and resolution of pain, the patient's HR improved. She appears to run between 90s-105 at baseline. . #) Hypertension: Pt has a h/o of HTN, which was treated with metoprolol and initially with prn hydral and nitropaste. Her blood pressure improved during her hospital stay and she required only Metoprolol to control her BP during the remainder of her hospital stay. . #) Fever: Thought to be secondary to UTI and colitis. She completed 6 days of Meropenem for resistent Klebsiella UTI and Flagyl for colitis of unclear etiology (C dif x 3 negative). Her fevers trended down during this admission and she was afebrile before discharge. . #) Mental status change: Thought to be likely secondary to infection and hypovolemia superimposed on mild dementia. On HD #2, her MS improved significantly after IVFs. She was restarted on Remeron and Neurontin after her mental status returned to baseline. . #) Arthritis: Stable. She was continued on her outpatient low-dose prednisone, and fentanyl patch. . #) DM II: Her diabetes was reportedly diet controlled (thought possibly to be steroids). Finger sticks were elevated on admission likely due to infection. She was maintained on an insulin sliding scale and required minimal coverage. . #) FEN: Patient was maintained on a regular diet with thickened liquids. . #) Comm: son , HCP (cell: , office: , home: , admin assistant Ms. ), grandson () . #) Code: DNR/DNI (discussed with son, ); Son requesting no aggressive procedures preferring instead for medical management ."},"extractive_notes_summ":{"kind":"string","value":"pt became wheezy-was given atrovent neb and 10mg iv lasix with brisk response of diuresis. K and Mg have been replaced.Resp: LS with rales in the bases, 02 SAT in the mid to upper 90s on 2 L NC. U/O HAD SLOWED DOWN AND PT WAS GIVEN LASIX 10MG IV AT MN WHICH HAD A GOOD EFFECT. NARRATIVE NOTE:PLEASE SEE ADM H&P FOR BACKGROUND INFORMATION.CV: B/P HAS RANGED FORM A LOW OF 116/62 WHEN PT ASLEEP, TO 185/122. Breathing improved to rr 12-14, LS c crackles at bases, occ wheezes on R. Sats 96-99 on 2L nc.CV: HR up to 114 c incr wob above, later 80s-90s, nsr. Fine expiratory wheezing on rt (pt turned to rt)Atrovent neb given some improvement in aeration no change in sats or WOB. PT IS PRESENTLY STILL HAVING A GOOD U/O.GI: ABD SOFT WITH + BS. nsg note addendum: 19:00-7:00t max 100.3po. sbp 100-130, altho had one dip to 90.GI: +BS, nt, nd. sob cleared entirely after 10mg iv lasix was given with brisk diuresis. WOB eventually resolve and spo2 remained in the mid 90's 2L nc. pt has been on 2lnc overnoc (not 4lnc as stated in above note). follows simple commands.cv: hr ranging 90s sr with no ectopy noted. urine was sent for cx.skin: r hip with pink area ota and ll leg with duoderm intact.lines: l w #22g piv and l brac. 2+ PERIPH EDEMA IN THE ARMS.RESP: LUNGS WITH CRACKLES IN THE BASES, UPPER LOBES CLEAR. hr 130s-140s with htn up to 220/130, diaphoretic. fld balance neg 240mls last 24 hrs, but 7.9L up los.Plan: F/u on am . PT HAS 1L OF LR BOLUS WITH LITTLE EFFECT. NPN 1900-0700Neuro: A&Ox2, c/o pain in lower legs, morphine 1mg x2 c good effect.Pt slept most of noc.Resp: Increased wob on eves c tachycard and RR up to 22. PRESENTLY HR HAS DECREASED TO THE 97-103 RANGE WHILE PT ASLEEP. medicated with 650mg po tylenol with temp down to 99.3po. Respiratory TherapyPt presents on 2L n/c Increased WOB after position change. 02 SATs have been in the mid to upper 90s on 5 L NC.GI: Tolerating food with almost no diarrhea today. sp02 ranging 96-100% on 4lnc.gi/gu: abd soft, nt, +bs, medium loose brown bm last eve. PT BRIGHT EYED THIS AM AND TALKING.GU: VERY POOR U/O. PPP BILAT.RESP: ON 2L N/C. 10mg lasix given c mod diuresis followed by usual dose of metoprolol and morphine 1mg. BS+ X4 SLOW. PT DX WITH PAN COLITIS AND HAS ONLY HAD PO MEDS OTHERWISE NPO FOR POSSIBLE SCOPE IF FURTHER GIB. SAO2 95-98% ON 2L N/C. CURRENTLY IVF AT 75CC/HR X 500CC.GI: PT ARRIVED WITH MOD AMT OF LIGHT BROWN SOFT STOOL. BUN 18/CREAT 1, WILL RECHECK IN AM. She has been given nebs for the wheezing with good effect. NARRATIVE NOTE:CV: B/P HAS RANGED FROM 90/39-161/74. medicated with total of 2mg iv morphine and repositioned back to r side with good effect. Cardiomegaly with a tortuous aorta is again seen and unchanged. Low attenuation splenic foci, which are incompletely characterized on this exam. CT ABDOMEN: There is mild dependent atelectasis. Sinus tachycardiaModest nonspecific ST-T wave changesSince previous tracing of , sinus tachycardia present and P-R intervalshorter Severe atherosclerotic disease; however, the mesenteric vessels appear patent. FINDINGS: Compared with 11/14 at 2:43 p.m., even allowing for a lighter radiographic technique, it appears that there has been interval engorgement and some upper zone redistribution of the pulmonary vessels consistent with mild CHF. Admitting Diagnosis: COLITIS ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. PROCEDURE AND FINDINGS: Since no suitable veins were visible, ultrasound was used to identify the left brachial vein, which was patent and compressible. Multiple small low attenuation splenic foci are noted. DOES NOT MOVE EXTREMITIES.RESP: LUNGS WITH BASE RALES AND EXP WHEEZES WHICH WERE INTERMITTENT. IMPRESSION: AP chest compared to through 19: Lung volumes remain quite low. There is low attenuation material within the bladder, which could represent blood clot. Heavy atherosclerotic disease but the mesenteric vessels are patent. REASON FOR THIS EXAMINATION: evaluate for edema, infiltrate. There is colonic diverticulosis. There is a fundal adenomyosis. A 0.018 guidewire was then advanced through the needle into the distal part of the SVC under fluoroscopic guidance. (Over) 4:38 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: HEMATEMASIS X1 TACHCARDIA,R/O PERF Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) Evaluate for edema, infiltrate. There is tortuosity of the aortic contour with wall calcifications. Tip of the left PIC catheter projects over the mid SVC. 2L N/C WAS STARTED AT HS AS SAO2 WOULD DECREASE WITH REST. Left renal cysts and additional low attenuation foci, which may represent cysts but are too small to be fully characterized are identified. REASON FOR THIS EXAMINATION: please eval for interval change FINAL REPORT INDICATION: Abdominal pain, fever, pancolitis. SAO2 WAS LOW 90'S ON R/A. She was given IV lasix and nitroglycerine paste and her BP has decreased to the 100s-120s., her HR was in the 100s and has dropped to the 80s after tylenol for a temp of 101.3. Gas-distended fundus of the stomach is noted. 8:10 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for edema, infiltrate."},"n_notes":{"kind":"number","value":22,"string":"22"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2127-11-21 00:00:00.000","description":"Report","row_id":1593937,"text":"Resp Care\n\nPt had episode of increased WOB; audible wheezing and desaturation this am. Pt received atrovent neb as well as lasix and nitro paste. WOB eventually resolve and spo2 remained in the mid 90's 2L nc.\n"},{"category":"Nursing/other","chartdate":"2127-11-22 00:00:00.000","description":"Report","row_id":1593938,"text":" nsg note: 19:00- 7:00\nthis is a y.o. woman adm from nsg home with coffee ground emesis, sob, abd pain. hr 130s-140s with htn up to 220/130, diaphoretic. tx'd with morphine but remained htn and tachy. ct revealed colitis and uti. dev. pulm edema -tx'd with lasix 10mg iv, nitropaste, and morphine with brisk u.o. overnight pt developed another episode of sob at 12am precipitated by repositioning. pt became wheezy-was given atrovent neb and 10mg iv lasix with brisk response of diuresis. sob resolved.\n\nneuro: a&ox3, legs remained contracted and painful with repositioning. doesn't move upper ext. but able to straighten them easily except hands contracted. follows simple commands.\n\ncv: hr ranging 90s sr with no ectopy noted. bp ranging 100s-150s/50s-60s. +pp. troponin ck yesterday was 300 with troponin back at .11. am pending.\n\nresp: acutely sob at 12am as described above with movement with diffuse wheezing settling after at rest and given atrovent neb. sob cleared entirely after 10mg iv lasix was given with brisk diuresis. sp02 ranging 96-100% on 4lnc.\n\ngi/gu: abd soft, nt, +bs, medium loose brown bm last eve. ate fried chicken without difficulty that her niece brought in to her last eve. taking pills crushed with raspberry ice without difficulty. foley patent with poor u.o. approx 20cc/hr at beginning of shift with inc. brisk u.o. s/o 10mg iv lasix. urine was sent for cx.\n\nskin: r hip with pink area ota and ll leg with duoderm intact.\n\nlines: l w #22g piv and l brac. picc line patent.\n\nsocial: neice was in to visit last eve. pt remains dnr/dni.\n\nplan: continue to monitor u.o., lung exam and need for more lasix, continue iv abx, follow ck, mb, troponin/am , need k, phos. repletion- did receive neutraphos last eve. send stool for o&p and cdiff w/a.\n"},{"category":"Nursing/other","chartdate":"2127-11-22 00:00:00.000","description":"Report","row_id":1593939,"text":" nsg note addendum: 19:00-7:00\nt max 100.3po. medicated with 650mg po tylenol with temp down to 99.3po. c/o bilat leg pain at 6:40am with hr as high as 120 and sbp 130s-160. medicated with total of 2mg iv morphine and repositioned back to r side with good effect. u.o. dropping down to 23cc/hr by 7am. may need more lasix. 02 sat currently 98% on 2lnc. pt has been on 2lnc overnoc (not 4lnc as stated in above note). pt denies sob at this time and resting comfortably.\n"},{"category":"Nursing/other","chartdate":"2127-11-22 00:00:00.000","description":"Report","row_id":1593940,"text":"NPN\n\nNeuro: Pt is alert and oriented x2, she has been dozing on and off through the day, in much part do to the morphine that she needed for pain.\n\nCV: BP has been stable, her HR has been 90s to the low 100s, she conts on lopressor 12.5 mg which she has been tolerating, it has not lowered her BP significantly (~ 10 points).\n\nResp: She has rales up from the bases, she becomes SOB and wheezy with any activity including eating. She has been given nebs for the wheezing with good effect. 02 SATs have been in the mid to upper 90s on 5 L NC.\n\nGI: Tolerating food with almost no diarrhea today. The flagyl was changed back to PO.\n\nGU: Her u/o has been 20-70cc/hr, she is presently ~ 200cc pos since MN and 8 liters pos since admit, she has not been given further lasix today.\n\nPain: She has been c/o L leg pain, she calls it a cramping pain, she has been given 1 mg of MS04 at a time with good effect though it makes her lethargic causing her to sleep most of the day.\n"},{"category":"Nursing/other","chartdate":"2127-11-23 00:00:00.000","description":"Report","row_id":1593941,"text":"Respiratory Therapy\nPt presents on 2L n/c Increased WOB after position change. Fine expiratory wheezing on rt (pt turned to rt)Atrovent neb given some improvement in aeration no change in sats or WOB. Pt remains 8L positive.\n"},{"category":"Nursing/other","chartdate":"2127-11-23 00:00:00.000","description":"Report","row_id":1593942,"text":"NPN 1900-0700\nNeuro: A&Ox2, c/o pain in lower legs, morphine 1mg x2 c good effect.\nPt slept most of noc.\n\nResp: Increased wob on eves c tachycard and RR up to 22. 10mg lasix given c mod diuresis followed by usual dose of metoprolol and morphine 1mg. Breathing improved to rr 12-14, LS c crackles at bases, occ wheezes on R. Sats 96-99 on 2L nc.\n\nCV: HR up to 114 c incr wob above, later 80s-90s, nsr. sbp 100-130, altho had one dip to 90.\n\nGI: +BS, nt, nd. Tol thickened flds well for meds. Had mod sized soft,formed, golden brown stool, ob neg. spec sent to lab.\n\nGu: duiuresed ~ 500mls from 10mg lasix, not as much as previous noc. Breathing improved. fld balance neg 240mls last 24 hrs, but 7.9L up los.\n\nPlan: F/u on am . cont to monitor u/o, resp status, ls, sats, rr, VS. Cont to medicate for pain.\n"},{"category":"Nursing/other","chartdate":"2127-11-23 00:00:00.000","description":"Report","row_id":1593943,"text":"NPN\n\nNeuro: Pt slept until 10:30, she was groggy until 11:30 but has been awake and alert, talking with her niece.\n\nCV: BP 100-120s/60s, HR 80s-100s, conts on lopressor but it is not lowering her HR very much\n\nResp: Still has periods of audible rales, given 10 mg of IV lasix with 150cc out in 2 hours. 02 SAT has been 94-95% on 2 L.\n\nGI: She had a very large amount of diarrhea - brown in color, poor appitite today, no abdominal pain.\n\nGU: Low u/o ~ 10cc/hr and amber, her urine has been 80-70cc/hr with the lasix.\n\nSoc: Her niece came in to visit, she wants to be called if she gets a bed tonight.\n"},{"category":"Nursing/other","chartdate":"2127-11-19 00:00:00.000","description":"Report","row_id":1593931,"text":"NARRATIVE NOTE:\n\nPLEASE SEE ADM H&P FOR BACKGROUND INFORMATION.\n\nCV: B/P HAS RANGED FORM A LOW OF 116/62 WHEN PT ASLEEP, TO 185/122. PT A LOPRESSOR 5MG IVP DOSE WHICH WAS NOT EFFECTIVE AND HYDRALAZINE 5MG IVP X2 WHICH WAS MUCH MORE EFFECTIVE IN DECREASING THE B/P. PT ALSO ARRIVED TACHYCARDIC AT 125-139 RANGE. PRESENTLY HR HAS DECREASED TO THE 97-103 RANGE WHILE PT ASLEEP. NO ECTOPY NOTED. PPP BILAT. PT HAS SLIGHT PERIPH EDEMA IN THE ARMS. HCT HAS INCREASED TO 50 AFTER APPROX 3L OF IVF, WILL RECHECK LABS IN AM. WBC 16.5.\n\nNEURO: PT IS USUALLY A&O X3, \"SHARP AS A TACK\" PER SON. UNABLE TO STATE WHERE SHE IS CONSISTANTLY BUT DOES RECALL THAT IT IS , HER 95TH BIRTHDAY. DOES FOLLOW SIMPLE COMMANDS TO SQUEEZE HANDS AND OPEN MOUTH ETC. PT HAS CHRONIC PAIN FROM ARTHRITIS. LEGS ARE CONTRACTED. PT WAS MED WITH MORPHINE 2MG IV X2 SO FAR FOR ABD PAIN. PT WILL CRY OUT AND MOAN WITH PAIN.\n\nRESP: PT HAS HAD BIL DIM BASES WITH RALES. SAO2 95-98% ON 2L N/C. NO RESP DISTRESS NOTED.\n\nGU: FOLEY CATH PATENT DRAINING SM AMTS OF DARK YELLOW TO AMBER URINE. PT HAS 2 NS BOLUSES OF 250CC OVER 1 HOUR EACH TO HELP INCREASE U/O WITH MARGINAL RESULTS. BUN 18/CREAT 1, WILL RECHECK IN AM. CURRENTLY IVF AT 75CC/HR X 500CC.\n\nGI: PT ARRIVED WITH MOD AMT OF LIGHT BROWN SOFT STOOL. BS+ X4 SLOW. PT DX WITH PAN COLITIS AND HAS ONLY HAD PO MEDS OTHERWISE NPO FOR POSSIBLE SCOPE IF FURTHER GIB. CT SCAN DID SHOW PAN COLITIS PRIOR TO MICU ADM.\n\nID: PT ON VANCO, FLAGYL, MEROPENEM, TEMP IN EW WAS 101.6 WBC'S AT MIDNIGHT 16.5.\n\nENDO: PT IS NIDDM. HAS SSIC.\n\nPLAN: CONT WITH ATB AND FOLLOW TEMPS. BLOOD CX IF TEMPS SPIKE. MONITOR VS AND LABS, REPLENISH LYTES AS NEEDED. SON IS HCP AND UPDATE WITH ANY CHANGES. PT IS DNR/DNI BUT OTHERWISE TREAT WITH IVF OR PRESSORS AS NEEDED. FAMILY FRIEND COME TO VISIT AND BE UPDATED PER HCP.\n"},{"category":"Nursing/other","chartdate":"2127-11-19 00:00:00.000","description":"Report","row_id":1593932,"text":"NPN\n\nNeuro: Pt has been lethargic for most of the day, more awake this afternoon, able to tell me her first name, when asked, \"Who is ?\". She said \"Me\". She has been deniing pain today though she is on 150mcg fent patch.\n\nCV: SBP 90s-low 100s, HR 80s-90s, she was not given her lopressor today due to her lowish BP. K and Mg have been replaced.\n\nResp: LS with rales in the bases, 02 SAT in the mid to upper 90s on 2 L NC. She has been given 2 liters IVF this shift and she is 5800cc pos for LOS.\n\nGI: ABD soft, she has been deniing ABD pain, she has had a small amount of loose mustard colored stool, a HCT will be sent after her KCl finishes.\n\nGU: She has had a poor u/o all day, 0-20cc/hr, her foley was flushed and then replaced due to the sedament in her urine but this did not improve her u/o nor did fluid boluses. We will check lytes and BUN/creat with the HTC - she did receive dye for the CT yesterday.\n\nSkin: She has a stage 2 decub on her shin as well as her R hip, her chest is also red - this was true this morning? if this is from vanco.\n\n"},{"category":"Nursing/other","chartdate":"2127-11-24 00:00:00.000","description":"Report","row_id":1593944,"text":"NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 111/55-165/73. NSR/ST WITH HR RANGING FROM 73-112, NO ECTOPY NOTED. PPP BILAT.\n\nRESP: ON 2L N/C. SAO2 HAS RANGED FROM 96-100%. RR 10-21. LUNGS HAVE VARIED DEPENDING ON ACTIVITY. DURING PERIODS OF REST LUNGS ARE CLEAR WITH RALES NOTED IN THE LOWER LOBES. WHEN PT IS EATING OR TALKING LUNGS TEND TO GET WHEEZY WITH OFTEN WHEEZES AUDIBLE WITHOUT STETHESCOPE. PT DENIES SOB OR ANY DIFFICULTY BREATHING EVEN WHEN WHEEZES ARE AUDIBLE.\n\nNEURO: A&O, MOSTLY X3 BUT DOES OCC FORGET THE DAY. PT HAS CONT TO TALK APPROPRIATELY AND AND FOLLOWS SIMPLE COMMANDS. DOES NOT MOVE EXT MUCH. LOWER EXT ARE CONTRACTED AND PT DOES NOT MOVE UPPER EXT MUCH OTHER THAN HER HANDS.\n\nGU: FOLEY CATH PATENT DRAINING CLEAR YELLOW URINE. U/O HAD SLOWED DOWN AND PT WAS GIVEN LASIX 10MG IV AT MN WHICH HAD A GOOD EFFECT. PT IS PRESENTLY STILL HAVING A GOOD U/O.\n\nGI: ABD SOFT WITH + BS. APPETITE IS FAIR TO GOOD. PT REQUIRES HELP WITH MEALS. NO STOOL THIS SHIFT.\n\nPLAN: PT IS CALLED OUT AND COUSILN WOULD LIKE TO BE NOTIFIED WHEN PT IS . PLAN IS TO MOVE PT WITH ROOM CLOSE TO NSG STATION SO PT IS ABLE TO CALL FOR NURSE EASILY IF SHE NEEDS. UPDATE FAMILY WITH ANY CHANGES IN PT CONDITION.\n"},{"category":"Nursing/other","chartdate":"2127-11-20 00:00:00.000","description":"Report","row_id":1593933,"text":"NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 90/39-161/74. SR/ST WITH HR RANGING FROM 71-105, NO ECTOPY NOTED. PPP BILAT. 2+ PERIPH EDEMA IN THE ARMS.\n\nRESP: LUNGS WITH CRACKLES IN THE BASES, UPPER LOBES CLEAR. SAO2 HAS RANGED FSROM 92-100%. RR 5-23. NO SOB NOTED.\n\nNEURO: ALERT AND SOMEWHAT ORIENTED. DOES NOT HAVE DATE AND LOCATION BUT DOES KNOW HER FAMILY AND ABOUT HER LIFE. PT BRIGHT EYED THIS AM AND TALKING.\n\nGU: VERY POOR U/O. PT HAS 1L OF LR BOLUS WITH LITTLE EFFECT. URINE IS YELLOW WITH SEDIMENT.\n\nGI: NPO. HAS HAD NO C/O ABD PAIN.\n\nPLAN: CONT TO MONITOR LYTES AND REPLEAT AS NEEDED. LYTES PENDINA PRESIENTLY IF THERE IS ENOUGH BLOOD AS PT IS A HARD STICK. UPDATE FAMILY WITH ANY CHANGES IN PT CONDITION\n"},{"category":"Nursing/other","chartdate":"2127-11-20 00:00:00.000","description":"Report","row_id":1593934,"text":"NPN\n\nNeuro: Pt is alert, oriented to name and a hospital, asking to eat since she is thirsty, she did well eating jello and nectar thickened fluid.\n\nCV: Her BP has been 100s-120s/50s-60s, HR 80s, her lopressor dose was deceases to 12.5 mg .\n\nResp: LS with rales 2/3 up from the bases, her 02 SAT on RA has been in the mid to upper 90s. She is over 8 liters pos for LOS and is putting out ~ 10-20cc/hr of urine.\n\nGI: She denies abd pain, she has been tolerating a clear liquid diet. No stool to send for clx.\n\nGU: U/O 10-20cc/hr, her urine is still cloudy, remains on miropenim.\n\nSoc: She has been numerous visitors.\n\nAccess: Both of her periferal IVs infiltrated, a bedside PIC was unsuccessful, to have PIC placed in IR tomorrow, she has a periferal line in until then.\n"},{"category":"Nursing/other","chartdate":"2127-11-21 00:00:00.000","description":"Report","row_id":1593935,"text":"NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 119/67-154/74. NSR/ST WITH HR RNGING FROM 88-108, NO ECTOPY NOTED. PPP BILAT.\n\nNEURO: A&OX3. PT WAS QUITE TALKATIVE THROUGHOUT THE SHIFT. FOLLOWS SIMPLE COMMANDS. DOES NOT MOVE EXTREMITIES.\n\nRESP: LUNGS WITH BASE RALES AND EXP WHEEZES WHICH WERE INTERMITTENT. SAO2 WAS LOW 90'S ON R/A. 2L N/C WAS STARTED AT HS AS SAO2 WOULD DECREASE WITH REST. RR 14-29.\n\nGU: FOLEY CATH PATENT DRAINING LESS THAN ADEQUATE AMTS OF CLOUDY YELLOW URINE WITH SEDIMENT.\n\nGI: PT HAD A SM STOOL GREENISH IN COLOR, SPEC SENT TO THE LAB FOR O&P AND C-DIFF.\n\nPLAN: PT WILL GO TO IR FOR A PICC PLACEMENT TODAY. CONT TO MONITOR LYTES AND REPLENISH AS NEEDED.\n"},{"category":"Nursing/other","chartdate":"2127-11-21 00:00:00.000","description":"Report","row_id":1593936,"text":"NPN\n\nNeuro: Pt is alert and oriented to name and a hospital, she has been tired today and has been sleeping on and off.\n\nCV: She had a period of hypertention to the 180s when she was having respiratory distress. She was given IV lasix and nitroglycerine paste and her BP has decreased to the 100s-120s., her HR was in the 100s and has dropped to the 80s after tylenol for a temp of 101.3. Her CPK is 300, the top and MB are pending.\n\nResp: She became acutely SOB this morning, she had audible wheezes, she was 9000cc pos, hypertensive, RR was in the mid 20s and labored, 02 SAT mid 90s on 4 L NC. She was given IV lasix, nitroglycerine paste. Her respirations became less labored, her BP decreased and she has put out ~ 700cc of urine so far today.\n\nGI: She has started to have diarrea today - 3 times since this morning, a stool spec was sent ealier today.\n\nGU: Good u/o from the lasix, her creat was 1.2 today.\n\nID: She spiked today to 101.3, blood clx were sent, urine to be sent, she does not have cough.\n\nAccess: A single lumen PIC was placed today.\n"},{"category":"ECG","chartdate":"2127-11-18 00:00:00.000","description":"Report","row_id":311310,"text":"Sinus tachycardia\nModest nonspecific ST-T wave changes\nSince previous tracing of , sinus tachycardia present and P-R interval\nshorter\n\n"},{"category":"Radiology","chartdate":"2127-11-21 00:00:00.000","description":"PICC W/O PORT","row_id":936336,"text":" 11:59 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC.\n Admitting Diagnosis: COLITIS\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with UTI, pan-colitis, hemetemesis, needs PICC for meropenem\n for ESBL klebsiella\n REASON FOR THIS EXAMINATION:\n please place PICC.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: This is a 75-year-old woman with UTI, pancolitis that\n needs PICC line to be placed for antibiotic therapy.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. , the\n attending radiologist, who was present and supervising throughout the\n procedure.\n\n PROCEDURE AND FINDINGS: Since no suitable veins were visible, ultrasound was\n used to identify the left brachial vein, which was patent and compressible.\n The left arm of the patient was then prepped and draped in standard sterile\n fashion. After injection of 5 cc of 1% lidocaine, a 21 gauge needle was\n advanced into the left brachial vein under ultrasonographic guidance. Hard\n copies of the images before and after the venipuncture were obtained. A 0.018\n guidewire was then advanced through the needle into the distal part of the SVC\n under fluoroscopic guidance. The needle was then exchanged for a 5 French\n micropuncture sheath. Based on the markers in the guidewire, it was decided\n that a length of 41 cm would be suitable. The line was then trimmed to this\n length and advanced over the wire into the distal part of the SVC under\n fluoroscopic guidance. The wire and the peel-away sheath was then removed and\n the line was flushed, heplocked and statlocked. Final fluoroscopic image of\n the chest demonstrates the tip of the catheter to be located in the distal\n part of the SVC. The patient tolerated the procedure well.\n\n IMPRESSION: Successful placement of 41 cm long single lumen line placed via\n the left brachial vein with the tip in the distal part of the SVC. The line\n is ready for use.\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2127-11-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":935956,"text":" 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for edema, infiltrate.\n Admitting Diagnosis: COLITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abd pain, pan-colitis, low-grade fever, and crackles on\n exam.\n REASON FOR THIS EXAMINATION:\n evaluate for edema, infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 8:37 A.M. ON \n\n INDICATION: Pancolitis. Fever. Crackles. Evaluate for edema, infiltrate.\n\n FINDINGS: Compared with 11/14 at 2:43 p.m., even allowing for a lighter\n radiographic technique, it appears that there has been interval engorgement\n and some upper zone redistribution of the pulmonary vessels consistent with\n mild CHF.\n\n No confluent infiltrates or sizable pleural effusions are appreciated. The\n decreased lung volumes are about the same.\n\n"},{"category":"Radiology","chartdate":"2127-11-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":936664,"text":" 6:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: COLITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abd pain, pan-colitis, low-grade fever, and increased\n crackles on exam.\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:40 A.M., .\n\n HISTORY: Abdominal pain, pancolitis, low-grade fever and increased crackles.\n\n IMPRESSION: AP chest compared to through 19:\n\n Lung volumes remain quite low. There is no focal pulmonary abnormality. I\n doubt that pulmonary edema is present. Heart size is normal. Thoracic aorta\n is generally large and unchanged. No pneumothorax or pleural effusion is\n seen. Tip of the left PIC catheter projects over the mid SVC.\n\n\n"},{"category":"Radiology","chartdate":"2127-11-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":936539,"text":" 5:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: COLITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abd pain, pan-colitis, low-grade fever, and increased\n crackles on exam.\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Abdominal pain, low-grade fever.\n\n CHEST:\n\n There has been no significant change since the prior chest x-ray of . Some upper zone redistribution is present, but no infiltrates or other\n evidence of failure is seen.\n\n IMPRESSION: No change.\n\n\n"},{"category":"Radiology","chartdate":"2127-11-18 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":935875,"text":" 4:38 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: HEMATEMASIS X1 TACHCARDIA,R/O PERF\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hematemasis x1, tachcardia\n\n REASON FOR THIS EXAMINATION:\n eval for perforation, ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JCT TUE 5:27 PM\n Pancolitis which could be infectious, inflammatory or ischemic.\n Heavy atherosclerotic disease but the mesenteric vessels are patent.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old woman with hematemesis and tachycardia.\n\n COMPARISON: .\n\n TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained\n with 100 cc Optiray IV contrast. A small amount of oral contrast was also\n given. Coronal and sagittal reformatted images were obtained.\n\n CT ABDOMEN: There is mild dependent atelectasis. The liver is unremarkable.\n The gallbladder is not distended. There is a fundal adenomyosis. The\n pancreas is unremarkable. Multiple small low attenuation splenic foci are\n noted. The adrenal glands are unremarkable. Left renal cysts and additional\n low attenuation foci, which may represent cysts but are too small to be fully\n characterized are identified. Stomach and small bowel loops are unremarkable.\n The colon is decompressed, but the wall is diffusely thickened. This is most\n prominent in the right colon and sigmoid colon. There is colonic\n diverticulosis. There is no free air. No mesenteric or retroperitoneal\n lymphadenopathy is identified. There is severe atherosclerotic disease\n including a large plaque in the proximal SMA. The mesenteric vessels do\n appear patent.\n\n CT PELVIS: Foley catheter is noted in the bladder. There is low attenuation\n material within the bladder, which could represent blood clot. The sigmoid\n colon and rectum are diffusely thickened. There is mild surrounding\n inflammatory stranding.\n\n BONE WINDOWS: There is severe osteopenia and degenerative changes of the\n lumbar spine and pelvis. Right hip prosthesis is noted.\n\n IMPRESSION:\n 1. Pancolitis. The appearance is nonspecific and could be secondary to\n infection, an inflammatory process, or ischemia. Severe atherosclerotic\n disease; however, the mesenteric vessels appear patent.\n 2. Gallbladder fundal adenomyosis.\n 3. Low attenuation splenic foci, which are incompletely characterized on this\n exam.\n (Over)\n\n 4:38 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: HEMATEMASIS X1 TACHCARDIA,R/O PERF\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2127-11-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":935858,"text":" 2:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o free air\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abd pain\n REASON FOR THIS EXAMINATION:\n r/o free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain. Rule out free air.\n\n COMPARISON: CXR .\n\n FINDINGS: Upright plain radiograph of the chest. Cardiomegaly with a\n tortuous aorta is again seen and unchanged. Pulmonary vascularity is\n unremarkable. No infiltrate or consolidation is identified within the lung.\n No pleural effusion is seen. No intraperitoneal free air is identified.\n Gas-distended fundus of the stomach is noted.\n\n IMPRESSION: No intraperitoneal free air.\n\n\n"},{"category":"Radiology","chartdate":"2127-11-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":936273,"text":" 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: COLITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abd pain, pan-colitis, low-grade fever, and increased\n crackles on exam.\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain, fever, pancolitis.\n\n COMPARISONS: .\n\n SINGLE VIEW CHEST, AP SEMI-ERECT: Allowing for technique, there is no\n significant change compared to the previous exam. There is no change in mild\n pulmonary edema. There is tortuosity of the aortic contour with wall\n calcifications. Degenerative changes are seen within both shoulder joints.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-11-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1593937,\n \"text\": \"Resp Care\\n\\nPt had episode of increased WOB; audible wheezing and desaturation this am. Pt received atrovent neb as well as lasix and nitro paste. WOB eventually resolve and spo2 remained in the mid 90's 2L nc.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-11-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1593938,\n \"text\": \" nsg note: 19:00- 7:00\\nthis is a y.o. woman adm from nsg home with coffee ground emesis, sob, abd pain. hr 130s-140s with htn up to 220/130, diaphoretic. tx'd with morphine but remained htn and tachy. ct revealed colitis and uti. dev. pulm edema -tx'd with lasix 10mg iv, nitropaste, and morphine with brisk u.o. overnight pt developed another episode of sob at 12am precipitated by repositioning. pt became wheezy-was given atrovent neb and 10mg iv lasix with brisk response of diuresis. sob resolved.\\n\\nneuro: a&ox3, legs remained contracted and painful with repositioning. doesn't move upper ext. but able to straighten them easily except hands contracted. follows simple commands.\\n\\ncv: hr ranging 90s sr with no ectopy noted. bp ranging 100s-150s/50s-60s. +pp. troponin ck yesterday was 300 with troponin back at .11. am pending.\\n\\nresp: acutely sob at 12am as described above with movement with diffuse wheezing settling after at rest and given atrovent neb. sob cleared entirely after 10mg iv lasix was given with brisk diuresis. sp02 ranging 96-100% on 4lnc.\\n\\ngi/gu: abd soft, nt, +bs, medium loose brown bm last eve. ate fried chicken without difficulty that her niece brought in to her last eve. taking pills crushed with raspberry ice without difficulty. foley patent with poor u.o. approx 20cc/hr at beginning of shift with inc. brisk u.o. s/o 10mg iv lasix. urine was sent for cx.\\n\\nskin: r hip with pink area ota and ll leg with duoderm intact.\\n\\nlines: l w #22g piv and l brac. picc line patent.\\n\\nsocial: neice was in to visit last eve. pt remains dnr/dni.\\n\\nplan: continue to monitor u.o., lung exam and need for more lasix, continue iv abx, follow ck, mb, troponin/am , need k, phos. repletion- did receive neutraphos last eve. send stool for o&p and cdiff w/a.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-11-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1593939,\n \"text\": \" nsg note addendum: 19:00-7:00\\nt max 100.3po. medicated with 650mg po tylenol with temp down to 99.3po. c/o bilat leg pain at 6:40am with hr as high as 120 and sbp 130s-160. medicated with total of 2mg iv morphine and repositioned back to r side with good effect. u.o. dropping down to 23cc/hr by 7am. may need more lasix. 02 sat currently 98% on 2lnc. pt has been on 2lnc overnoc (not 4lnc as stated in above note). pt denies sob at this time and resting comfortably.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-11-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1593940,\n \"text\": \"NPN\\n\\nNeuro: Pt is alert and oriented x2, she has been dozing on and off through the day, in much part do to the morphine that she needed for pain.\\n\\nCV: BP has been stable, her HR has been 90s to the low 100s, she conts on lopressor 12.5 mg which she has been tolerating, it has not lowered her BP significantly (~ 10 points).\\n\\nResp: She has rales up from the bases, she becomes SOB and wheezy with any activity including eating. She has been given nebs for the wheezing with good effect. 02 SATs have been in the mid to upper 90s on 5 L NC.\\n\\nGI: Tolerating food with almost no diarrhea today. The flagyl was changed back to PO.\\n\\nGU: Her u/o has been 20-70cc/hr, she is presently ~ 200cc pos since MN and 8 liters pos since admit, she has not been given further lasix today.\\n\\nPain: She has been c/o L leg pain, she calls it a cramping pain, she has been given 1 mg of MS04 at a time with good effect though it makes her lethargic causing her to sleep most of the day.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-11-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1593941,\n \"text\": \"Respiratory Therapy\\nPt presents on 2L n/c Increased WOB after position change. Fine expiratory wheezing on rt (pt turned to rt)Atrovent neb given some improvement in aeration no change in sats or WOB. Pt remains 8L positive.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-11-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1593942,\n \"text\": \"NPN 1900-0700\\nNeuro: A&Ox2, c/o pain in lower legs, morphine 1mg x2 c good effect.\\nPt slept most of noc.\\n\\nResp: Increased wob on eves c tachycard and RR up to 22. 10mg lasix given c mod diuresis followed by usual dose of metoprolol and morphine 1mg. Breathing improved to rr 12-14, LS c crackles at bases, occ wheezes on R. Sats 96-99 on 2L nc.\\n\\nCV: HR up to 114 c incr wob above, later 80s-90s, nsr. sbp 100-130, altho had one dip to 90.\\n\\nGI: +BS, nt, nd. Tol thickened flds well for meds. Had mod sized soft,formed, golden brown stool, ob neg. spec sent to lab.\\n\\nGu: duiuresed ~ 500mls from 10mg lasix, not as much as previous noc. Breathing improved. fld balance neg 240mls last 24 hrs, but 7.9L up los.\\n\\nPlan: F/u on am . cont to monitor u/o, resp status, ls, sats, rr, VS. Cont to medicate for pain.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-11-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1593943,\n \"text\": \"NPN\\n\\nNeuro: Pt slept until 10:30, she was groggy until 11:30 but has been awake and alert, talking with her niece.\\n\\nCV: BP 100-120s/60s, HR 80s-100s, conts on lopressor but it is not lowering her HR very much\\n\\nResp: Still has periods of audible rales, given 10 mg of IV lasix with 150cc out in 2 hours. 02 SAT has been 94-95% on 2 L.\\n\\nGI: She had a very large amount of diarrhea - brown in color, poor appitite today, no abdominal pain.\\n\\nGU: Low u/o ~ 10cc/hr and amber, her urine has been 80-70cc/hr with the lasix.\\n\\nSoc: Her niece came in to visit, she wants to be called if she gets a bed tonight.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-11-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1593931,\n \"text\": \"NARRATIVE NOTE:\\n\\nPLEASE SEE ADM H&P FOR BACKGROUND INFORMATION.\\n\\nCV: B/P HAS RANGED FORM A LOW OF 116/62 WHEN PT ASLEEP, TO 185/122. PT A LOPRESSOR 5MG IVP DOSE WHICH WAS NOT EFFECTIVE AND HYDRALAZINE 5MG IVP X2 WHICH WAS MUCH MORE EFFECTIVE IN DECREASING THE B/P. PT ALSO ARRIVED TACHYCARDIC AT 125-139 RANGE. PRESENTLY HR HAS DECREASED TO THE 97-103 RANGE WHILE PT ASLEEP. NO ECTOPY NOTED. PPP BILAT. PT HAS SLIGHT PERIPH EDEMA IN THE ARMS. HCT HAS INCREASED TO 50 AFTER APPROX 3L OF IVF, WILL RECHECK LABS IN AM. WBC 16.5.\\n\\nNEURO: PT IS USUALLY A&O X3, \\\"SHARP AS A TACK\\\" PER SON. UNABLE TO STATE WHERE SHE IS CONSISTANTLY BUT DOES RECALL THAT IT IS , HER 95TH BIRTHDAY. DOES FOLLOW SIMPLE COMMANDS TO SQUEEZE HANDS AND OPEN MOUTH ETC. PT HAS CHRONIC PAIN FROM ARTHRITIS. LEGS ARE CONTRACTED. PT WAS MED WITH MORPHINE 2MG IV X2 SO FAR FOR ABD PAIN. PT WILL CRY OUT AND MOAN WITH PAIN.\\n\\nRESP: PT HAS HAD BIL DIM BASES WITH RALES. SAO2 95-98% ON 2L N/C. NO RESP DISTRESS NOTED.\\n\\nGU: FOLEY CATH PATENT DRAINING SM AMTS OF DARK YELLOW TO AMBER URINE. PT HAS 2 NS BOLUSES OF 250CC OVER 1 HOUR EACH TO HELP INCREASE U/O WITH MARGINAL RESULTS. BUN 18/CREAT 1, WILL RECHECK IN AM. CURRENTLY IVF AT 75CC/HR X 500CC.\\n\\nGI: PT ARRIVED WITH MOD AMT OF LIGHT BROWN SOFT STOOL. BS+ X4 SLOW. PT DX WITH PAN COLITIS AND HAS ONLY HAD PO MEDS OTHERWISE NPO FOR POSSIBLE SCOPE IF FURTHER GIB. CT SCAN DID SHOW PAN COLITIS PRIOR TO MICU ADM.\\n\\nID: PT ON VANCO, FLAGYL, MEROPENEM, TEMP IN EW WAS 101.6 WBC'S AT MIDNIGHT 16.5.\\n\\nENDO: PT IS NIDDM. HAS SSIC.\\n\\nPLAN: CONT WITH ATB AND FOLLOW TEMPS. BLOOD CX IF TEMPS SPIKE. MONITOR VS AND LABS, REPLENISH LYTES AS NEEDED. SON IS HCP AND UPDATE WITH ANY CHANGES. PT IS DNR/DNI BUT OTHERWISE TREAT WITH IVF OR PRESSORS AS NEEDED. FAMILY FRIEND COME TO VISIT AND BE UPDATED PER HCP.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-11-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1593932,\n \"text\": \"NPN\\n\\nNeuro: Pt has been lethargic for most of the day, more awake this afternoon, able to tell me her first name, when asked, \\\"Who is ?\\\". She said \\\"Me\\\". She has been deniing pain today though she is on 150mcg fent patch.\\n\\nCV: SBP 90s-low 100s, HR 80s-90s, she was not given her lopressor today due to her lowish BP. K and Mg have been replaced.\\n\\nResp: LS with rales in the bases, 02 SAT in the mid to upper 90s on 2 L NC. She has been given 2 liters IVF this shift and she is 5800cc pos for LOS.\\n\\nGI: ABD soft, she has been deniing ABD pain, she has had a small amount of loose mustard colored stool, a HCT will be sent after her KCl finishes.\\n\\nGU: She has had a poor u/o all day, 0-20cc/hr, her foley was flushed and then replaced due to the sedament in her urine but this did not improve her u/o nor did fluid boluses. We will check lytes and BUN/creat with the HTC - she did receive dye for the CT yesterday.\\n\\nSkin: She has a stage 2 decub on her shin as well as her R hip, her chest is also red - this was true this morning? if this is from vanco.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-11-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1593944,\n \"text\": \"NARRATIVE NOTE:\\n\\nCV: B/P HAS RANGED FROM 111/55-165/73. NSR/ST WITH HR RANGING FROM 73-112, NO ECTOPY NOTED. PPP BILAT.\\n\\nRESP: ON 2L N/C. SAO2 HAS RANGED FROM 96-100%. RR 10-21. LUNGS HAVE VARIED DEPENDING ON ACTIVITY. DURING PERIODS OF REST LUNGS ARE CLEAR WITH RALES NOTED IN THE LOWER LOBES. WHEN PT IS EATING OR TALKING LUNGS TEND TO GET WHEEZY WITH OFTEN WHEEZES AUDIBLE WITHOUT STETHESCOPE. PT DENIES SOB OR ANY DIFFICULTY BREATHING EVEN WHEN WHEEZES ARE AUDIBLE.\\n\\nNEURO: A&O, MOSTLY X3 BUT DOES OCC FORGET THE DAY. PT HAS CONT TO TALK APPROPRIATELY AND AND FOLLOWS SIMPLE COMMANDS. DOES NOT MOVE EXT MUCH. LOWER EXT ARE CONTRACTED AND PT DOES NOT MOVE UPPER EXT MUCH OTHER THAN HER HANDS.\\n\\nGU: FOLEY CATH PATENT DRAINING CLEAR YELLOW URINE. U/O HAD SLOWED DOWN AND PT WAS GIVEN LASIX 10MG IV AT MN WHICH HAD A GOOD EFFECT. PT IS PRESENTLY STILL HAVING A GOOD U/O.\\n\\nGI: ABD SOFT WITH + BS. APPETITE IS FAIR TO GOOD. PT REQUIRES HELP WITH MEALS. NO STOOL THIS SHIFT.\\n\\nPLAN: PT IS CALLED OUT AND COUSILN WOULD LIKE TO BE NOTIFIED WHEN PT IS . PLAN IS TO MOVE PT WITH ROOM CLOSE TO NSG STATION SO PT IS ABLE TO CALL FOR NURSE EASILY IF SHE NEEDS. UPDATE FAMILY WITH ANY CHANGES IN PT CONDITION.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-11-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1593933,\n \"text\": \"NARRATIVE NOTE:\\n\\nCV: B/P HAS RANGED FROM 90/39-161/74. SR/ST WITH HR RANGING FROM 71-105, NO ECTOPY NOTED. PPP BILAT. 2+ PERIPH EDEMA IN THE ARMS.\\n\\nRESP: LUNGS WITH CRACKLES IN THE BASES, UPPER LOBES CLEAR. SAO2 HAS RANGED FSROM 92-100%. RR 5-23. NO SOB NOTED.\\n\\nNEURO: ALERT AND SOMEWHAT ORIENTED. DOES NOT HAVE DATE AND LOCATION BUT DOES KNOW HER FAMILY AND ABOUT HER LIFE. PT BRIGHT EYED THIS AM AND TALKING.\\n\\nGU: VERY POOR U/O. PT HAS 1L OF LR BOLUS WITH LITTLE EFFECT. URINE IS YELLOW WITH SEDIMENT.\\n\\nGI: NPO. HAS HAD NO C/O ABD PAIN.\\n\\nPLAN: CONT TO MONITOR LYTES AND REPLEAT AS NEEDED. LYTES PENDINA PRESIENTLY IF THERE IS ENOUGH BLOOD AS PT IS A HARD STICK. UPDATE FAMILY WITH ANY CHANGES IN PT CONDITION\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-11-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1593934,\n \"text\": \"NPN\\n\\nNeuro: Pt is alert, oriented to name and a hospital, asking to eat since she is thirsty, she did well eating jello and nectar thickened fluid.\\n\\nCV: Her BP has been 100s-120s/50s-60s, HR 80s, her lopressor dose was deceases to 12.5 mg .\\n\\nResp: LS with rales 2/3 up from the bases, her 02 SAT on RA has been in the mid to upper 90s. She is over 8 liters pos for LOS and is putting out ~ 10-20cc/hr of urine.\\n\\nGI: She denies abd pain, she has been tolerating a clear liquid diet. No stool to send for clx.\\n\\nGU: U/O 10-20cc/hr, her urine is still cloudy, remains on miropenim.\\n\\nSoc: She has been numerous visitors.\\n\\nAccess: Both of her periferal IVs infiltrated, a bedside PIC was unsuccessful, to have PIC placed in IR tomorrow, she has a periferal line in until then.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-11-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1593935,\n \"text\": \"NARRATIVE NOTE:\\n\\nCV: B/P HAS RANGED FROM 119/67-154/74. NSR/ST WITH HR RNGING FROM 88-108, NO ECTOPY NOTED. PPP BILAT.\\n\\nNEURO: A&OX3. PT WAS QUITE TALKATIVE THROUGHOUT THE SHIFT. FOLLOWS SIMPLE COMMANDS. DOES NOT MOVE EXTREMITIES.\\n\\nRESP: LUNGS WITH BASE RALES AND EXP WHEEZES WHICH WERE INTERMITTENT. SAO2 WAS LOW 90'S ON R/A. 2L N/C WAS STARTED AT HS AS SAO2 WOULD DECREASE WITH REST. RR 14-29.\\n\\nGU: FOLEY CATH PATENT DRAINING LESS THAN ADEQUATE AMTS OF CLOUDY YELLOW URINE WITH SEDIMENT.\\n\\nGI: PT HAD A SM STOOL GREENISH IN COLOR, SPEC SENT TO THE LAB FOR O&P AND C-DIFF.\\n\\nPLAN: PT WILL GO TO IR FOR A PICC PLACEMENT TODAY. CONT TO MONITOR LYTES AND REPLENISH AS NEEDED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-11-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1593936,\n \"text\": \"NPN\\n\\nNeuro: Pt is alert and oriented to name and a hospital, she has been tired today and has been sleeping on and off.\\n\\nCV: She had a period of hypertention to the 180s when she was having respiratory distress. She was given IV lasix and nitroglycerine paste and her BP has decreased to the 100s-120s., her HR was in the 100s and has dropped to the 80s after tylenol for a temp of 101.3. Her CPK is 300, the top and MB are pending.\\n\\nResp: She became acutely SOB this morning, she had audible wheezes, she was 9000cc pos, hypertensive, RR was in the mid 20s and labored, 02 SAT mid 90s on 4 L NC. She was given IV lasix, nitroglycerine paste. Her respirations became less labored, her BP decreased and she has put out ~ 700cc of urine so far today.\\n\\nGI: She has started to have diarrea today - 3 times since this morning, a stool spec was sent ealier today.\\n\\nGU: Good u/o from the lasix, her creat was 1.2 today.\\n\\nID: She spiked today to 101.3, blood clx were sent, urine to be sent, she does not have cough.\\n\\nAccess: A single lumen PIC was placed today.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2127-11-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 311310,\n \"text\": \"Sinus tachycardia\\nModest nonspecific ST-T wave changes\\nSince previous tracing of , sinus tachycardia present and P-R interval\\nshorter\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-11-21 00:00:00.000\",\n \"description\": \"PICC W/O PORT\",\n \"row_id\": 936336,\n \"text\": \" 11:59 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: please place PICC.\\n Admitting Diagnosis: COLITIS\\n ********************************* CPT Codes ********************************\\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\\n * C1769 GUID WIRES INCL INF *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old woman with UTI, pan-colitis, hemetemesis, needs PICC for meropenem\\n for ESBL klebsiella\\n REASON FOR THIS EXAMINATION:\\n please place PICC.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION FOR EXAM: This is a 75-year-old woman with UTI, pancolitis that\\n needs PICC line to be placed for antibiotic therapy.\\n\\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. , the\\n attending radiologist, who was present and supervising throughout the\\n procedure.\\n\\n PROCEDURE AND FINDINGS: Since no suitable veins were visible, ultrasound was\\n used to identify the left brachial vein, which was patent and compressible.\\n The left arm of the patient was then prepped and draped in standard sterile\\n fashion. After injection of 5 cc of 1% lidocaine, a 21 gauge needle was\\n advanced into the left brachial vein under ultrasonographic guidance. Hard\\n copies of the images before and after the venipuncture were obtained. A 0.018\\n guidewire was then advanced through the needle into the distal part of the SVC\\n under fluoroscopic guidance. The needle was then exchanged for a 5 French\\n micropuncture sheath. Based on the markers in the guidewire, it was decided\\n that a length of 41 cm would be suitable. The line was then trimmed to this\\n length and advanced over the wire into the distal part of the SVC under\\n fluoroscopic guidance. The wire and the peel-away sheath was then removed and\\n the line was flushed, heplocked and statlocked. Final fluoroscopic image of\\n the chest demonstrates the tip of the catheter to be located in the distal\\n part of the SVC. The patient tolerated the procedure well.\\n\\n IMPRESSION: Successful placement of 41 cm long single lumen line placed via\\n the left brachial vein with the tip in the distal part of the SVC. The line\\n is ready for use.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-11-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 935956,\n \"text\": \" 8:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for edema, infiltrate.\\n Admitting Diagnosis: COLITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old woman with abd pain, pan-colitis, low-grade fever, and crackles on\\n exam.\\n REASON FOR THIS EXAMINATION:\\n evaluate for edema, infiltrate.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST AT 8:37 A.M. ON \\n\\n INDICATION: Pancolitis. Fever. Crackles. Evaluate for edema, infiltrate.\\n\\n FINDINGS: Compared with 11/14 at 2:43 p.m., even allowing for a lighter\\n radiographic technique, it appears that there has been interval engorgement\\n and some upper zone redistribution of the pulmonary vessels consistent with\\n mild CHF.\\n\\n No confluent infiltrates or sizable pleural effusions are appreciated. The\\n decreased lung volumes are about the same.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-11-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 936664,\n \"text\": \" 6:05 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for interval change\\n Admitting Diagnosis: COLITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old woman with abd pain, pan-colitis, low-grade fever, and increased\\n crackles on exam.\\n REASON FOR THIS EXAMINATION:\\n please evaluate for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 6:40 A.M., .\\n\\n HISTORY: Abdominal pain, pancolitis, low-grade fever and increased crackles.\\n\\n IMPRESSION: AP chest compared to through 19:\\n\\n Lung volumes remain quite low. There is no focal pulmonary abnormality. I\\n doubt that pulmonary edema is present. Heart size is normal. Thoracic aorta\\n is generally large and unchanged. No pneumothorax or pleural effusion is\\n seen. Tip of the left PIC catheter projects over the mid SVC.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-11-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 936539,\n \"text\": \" 5:44 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? interval change\\n Admitting Diagnosis: COLITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old woman with abd pain, pan-colitis, low-grade fever, and increased\\n crackles on exam.\\n REASON FOR THIS EXAMINATION:\\n ? interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Abdominal pain, low-grade fever.\\n\\n CHEST:\\n\\n There has been no significant change since the prior chest x-ray of . Some upper zone redistribution is present, but no infiltrates or other\\n evidence of failure is seen.\\n\\n IMPRESSION: No change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-11-18 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 935875,\n \"text\": \" 4:38 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: HEMATEMASIS X1 TACHCARDIA,R/O PERF\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old woman with hematemasis x1, tachcardia\\n\\n REASON FOR THIS EXAMINATION:\\n eval for perforation, ischemia\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JCT TUE 5:27 PM\\n Pancolitis which could be infectious, inflammatory or ischemic.\\n Heavy atherosclerotic disease but the mesenteric vessels are patent.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: -year-old woman with hematemesis and tachycardia.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained\\n with 100 cc Optiray IV contrast. A small amount of oral contrast was also\\n given. Coronal and sagittal reformatted images were obtained.\\n\\n CT ABDOMEN: There is mild dependent atelectasis. The liver is unremarkable.\\n The gallbladder is not distended. There is a fundal adenomyosis. The\\n pancreas is unremarkable. Multiple small low attenuation splenic foci are\\n noted. The adrenal glands are unremarkable. Left renal cysts and additional\\n low attenuation foci, which may represent cysts but are too small to be fully\\n characterized are identified. Stomach and small bowel loops are unremarkable.\\n The colon is decompressed, but the wall is diffusely thickened. This is most\\n prominent in the right colon and sigmoid colon. There is colonic\\n diverticulosis. There is no free air. No mesenteric or retroperitoneal\\n lymphadenopathy is identified. There is severe atherosclerotic disease\\n including a large plaque in the proximal SMA. The mesenteric vessels do\\n appear patent.\\n\\n CT PELVIS: Foley catheter is noted in the bladder. There is low attenuation\\n material within the bladder, which could represent blood clot. The sigmoid\\n colon and rectum are diffusely thickened. There is mild surrounding\\n inflammatory stranding.\\n\\n BONE WINDOWS: There is severe osteopenia and degenerative changes of the\\n lumbar spine and pelvis. Right hip prosthesis is noted.\\n\\n IMPRESSION:\\n 1. Pancolitis. The appearance is nonspecific and could be secondary to\\n infection, an inflammatory process, or ischemia. Severe atherosclerotic\\n disease; however, the mesenteric vessels appear patent.\\n 2. Gallbladder fundal adenomyosis.\\n 3. Low attenuation splenic foci, which are incompletely characterized on this\\n exam.\\n (Over)\\n\\n 4:38 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: HEMATEMASIS X1 TACHCARDIA,R/O PERF\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-11-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 935858,\n \"text\": \" 2:23 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o free air\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old woman with abd pain\\n REASON FOR THIS EXAMINATION:\\n r/o free air\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Abdominal pain. Rule out free air.\\n\\n COMPARISON: CXR .\\n\\n FINDINGS: Upright plain radiograph of the chest. Cardiomegaly with a\\n tortuous aorta is again seen and unchanged. Pulmonary vascularity is\\n unremarkable. No infiltrate or consolidation is identified within the lung.\\n No pleural effusion is seen. No intraperitoneal free air is identified.\\n Gas-distended fundus of the stomach is noted.\\n\\n IMPRESSION: No intraperitoneal free air.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-11-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 936273,\n \"text\": \" 5:14 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for interval change\\n Admitting Diagnosis: COLITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old woman with abd pain, pan-colitis, low-grade fever, and increased\\n crackles on exam.\\n REASON FOR THIS EXAMINATION:\\n please eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Abdominal pain, fever, pancolitis.\\n\\n COMPARISONS: .\\n\\n SINGLE VIEW CHEST, AP SEMI-ERECT: Allowing for technique, there is no\\n significant change compared to the previous exam. There is no change in mild\\n pulmonary edema. There is tortuosity of the aortic contour with wall\\n calcifications. Degenerative changes are seen within both shoulder joints.\\n\\n\"\n }\n]"}}},{"rowIdx":88,"cells":{"subject_id":{"kind":"number","value":40287,"string":"40,287"},"hadm_id":{"kind":"number","value":103847,"string":"103,847"},"target_text":{"kind":"string","value":"In summary, this is a 58 year-old man presenting s/p ventricular fibrillation arrest, now intubated, sedated and paralyzed on cooling protocol, back in normal sinus rhythm. The period between onset of cardiac arrest and restoration of sinus pulse was approximately 6 minutes, per EMS report. .. # RHYTHM / VF ARREST: Shortly after presentation to the emergency room he went to the cath lab where there was evidence of coronary vasospasm of the LAD; there were no fixed lesions requiring stenting, only a 30% fixed stenosis of the LAD (see full catheterization report above). Urine toxicology was negative. Echo showed severe aortic regurgitation and mild symmetric LVH with preserved global systolic function. He was started on a nitro drip for vasospasm and afterload reduction in the setting of known AI. He was cooled per neuroprotective protocol post cardiac arrest and maintained in a hypothermic state for 24 hours. He was sedated throughout with Fentanyl and midazolam and paralyzed with vecuronium to minimize shivering. . Twenty-four hours after beginning cooling, his core body temperature was slowly warmed. He became increasingly agitated overnight and on the morning of HD 2, his sedation was weaned and he was extubated. Telemetry showed no further episodes of ventricular dysrhythmia. The presumed cause for his VF arrest is coronary artery vasospasm. It is unclear at this time whether the (exertional) anginal-type symptoms he describes in the weeks leading up to this event are also due to vasospasm. . During the hospital course, his nitro drip was switched over to long acting nitro and calcium channel blocker. An ICD was placed several days prior to discharge. He will have follow-up with his cardiologist at as well as follow-up in the clinic at . .. # PUMP / VALVES: An echocardiogram performed in the ED showed normal EF with severe AI and moderate LV dilation. Although he was initially hypotensive in the ED requiring neosynephrine he became hypertensive in cath lab and his pressor was discontinued. As above, there was no significant coronary artery disease and no regional wall motion abnormalities. A repeat TTE performed two days after admission showed normal LV function with EF of >55% and an aortic valve with three leaflets but functionally bileaflet; AR was 3+. It is unclear at this time whether his aortic insufficiency is at all related to his VF arrest. . As above, he was continued on afterload reducing agents. He will follow-up at with Dr. . Aortic valve replacement is being considered. .. # ISCHEMIA / CAD: As above, coronary angiography showed a 30% fixed stenosis of his proximal LAD. LCx and RCA were unremarkable. The LAD coronary vasospasm that likely caused his cardiac arrest was treated with Imdur and amlodipine. We continued his home dose of aspirin 81 mg qday. . # RESPIRATORY STATUS / PNEUMONIA: He was intubated in the field secondary to his cardiac arrest and continued on ventilation throughout the cooling and rewarming period. On HD 2, sedation was weaned and he was extubated on the morning of HD 3. . The night before extubation, he spiked a fever. Differential at that time included VAP, aspiration pna, pulmonary embolus, and endocarditis (given his known valvular disease). blood cultures grew gram positive cocci (later speciated as coag neg staph), and he was started empirically on IV vanco. A tranesophageal echo was done while he was still intubated that was negative for valvular vegetations. CXR came back showing bibasilar consolidations c/w aspiration pna. We started him empirically on Zosyn and continued the vanco. When blood culture speciation returned and he began tolerating PO, IV vanco and Zosyn were stopped and he was started on levo and flagyl to complete a seven day course of antibiotics. . Unfortunately, on day 7 of his antibiotic course he spiked a low-grade fever to 100.6, then on day 8 to 101.1. Repeat CXR, PA and lateral, showed worsening RLL pneumonia. Blood and urine cultures were negative. Infectious disease consultation recommended increasing dose of levo to 750 QDAY. We made this change and decided to treat for an additional 7 days for presumptive hospital acquired pneiumonia. He had no more fever over the next 24 hours. O2 sats were excellent on RA and there was no cough or sputum production. He is discharged with five days of PO levo remaining to complete a seven day course. .. # PLEURITIC CHEST PAIN / STATUS POST CHEST COMPRESSIONS: Chest pain was treated with IV morphine, switched over to oxycodone post-extubation. This was suppplemented by a lidocaine patch. At time of discharge, he is taking vicodin, lidocaine patch, and NSAIDs with adequate pain control. Narcotic-related constipation is treated with senna and docusate. .. # MENTAL STATUS: There was concern after extubation that he may have memory deficits s/p arrest. CT-head was ordered at admission and negative for acute intracranial process. Over the course of the hospitalization, he became increasingly alert and oriented. His MS at time of discharge is fully recovered and back to baseline pre-arrest. .. # ANEMIA: During hospital course, he had hematocrit in mid twenties that rose to 30 at time of discharge. Kidney function was normal; iron studies WNL and hemolysis labs negative. Unclear why this otherwise healthy man who runs 20 mi/wk should have anemia, other than possibly d/t marrow suppression in the setting of acute illness. This will need follow-up as outpatient. .. # After extubation, he was started on a regular diet. DVT prophylaxis with subcutaneous heparin. GI ulcer prophylaxis with an H2 blocker while intubated which was stopped after extubation. Code status was full throughout."},"extractive_notes_summ":{"kind":"string","value":"Pulmonary edema and cardiomegaly cleared. Pulmonary edema and cardiomegaly cleared. FINDINGS: There are bilateral opacifications in the lung base, with air bronchograms seen, and obscure hemidiaphragm. FINDINGS: There is a single chamber pacer/AICD in place with lead terminating in the region of the right ventricle. There has been interval removal of the endotracheal tube and nasogastric tube. Interval removal of endotracheal and nasogastric tubes. PROVISIONAL FINDINGS IMPRESSION (PFI): IPf 12:26 PM Bilateral opacifications in the lung base with evident air bronchograms and obscured diaphragm. FINAL REPORT STUDY: PA and lateral chest radiographs. PFI REPORT Bilateral opacifications in the lung base with evident air bronchograms and obscured diaphragm. FINDINGS: There are unchanged bibasilar opacities with air bronchograms. Removal of endotracheal and nasogastric tubes. Removal of endotracheal and nasogastric tubes. TECHNIQUE: Non-contrast head CT was obtained. Interval progression of right lung base opacity, likely pneumonia. Bilateral minimal pleural effusions. 9:07 AM ABDOMEN (SUPINE & ERECT) PORT Clip # Reason: evaluate for acute intraabdominal pathology. FINAL REPORT SUPINE AND DUCUBITUS ABDOMINAL RADIOGRAPHS: INDICATION: Abdominal discomfort, status post cardiac arrest. pulmonary edema? pulmonary edema? pulmonary edema? pulmonary edema? IMPRESSION: AP chest compared to :23 a.m.: Gastric distension has resolved following placement of an orogastric tube in the upper stomach. , E. 9:07 AM ABDOMEN (SUPINE & ERECT) PORT Clip # Reason: evaluate for acute intraabdominal pathology. 8:03 AM CHEST (PORTABLE AP) Clip # Reason: Intubated. These findings likely represent a right pleural effusion and given the chronicity of findings adjacent right lung base pneumonia. Visualized paranasal sinuses and mastoid air cells are otherwise well aerated. The endotracheal tube and nasogastric tube placements are unchanged compared to . There is mild thoracic scoliosis. , E. 8:03 AM CHEST (PORTABLE AP) Clip # Reason: Intubated. Mildly thickened aortic valve leaflets.Cannot exclude AS. Noatheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion.IMPRESSION: Mildly thickened bicuspid aortic valve with severe eccentricaortic regurgitation directed toward the anterior mitral leaflet. Right ventricular chamber size and free wall motion arenormal. Mildly dilated ascending aorta. Mildly dilated ascending aorta. Mildsymmetric left ventricular hypertrophy with dilated left ventricular andpreserved regional/global systolic function. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Functionally bicuspid aortic valve withthickened leaflets and eccentric, moderate to severe aortic regurgitation.Mildly dilated thoracic aorta.Dr. Sinus bradycardiaProlonged QT intervalInferior/lateral ST-T changes are nonspecificPoor R wave progressionrsr' in lead V1Since previous tracing of , sinus bradycardia present and leftventricular hypertrophy by voltage absent No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:There is mild symmetric left ventricular hypertrophy. Normalaortic arch diameter.AORTIC VALVE: Bicuspid aortic valve. Mild to moderate [+] TR.Borderline PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. The aortic root is mildly dilated at the sinus level. The left ventricularcavity is moderately dilated. Sinus rhythmPremature ventricular contractionsrsr' in lead V1Possible left ventricular hypertrophySince previous tracing of , ventricular premature complexes new; ST-Twave abnormalities are less An eccentric jet of moderate tosevere (3+) aortic regurgitation is seen. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Compared to the previous tracing of atrial ectopyis absent. The aortic root is moderately dilated at the sinus level.The ascending aorta is mildly dilated. There is normal regional and globalbiventricular systolic function. Mild mitralannular calcification. Normalregional LV systolic function.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Moderately dilated aortic sinus. Moderate to severe (3+) AR.MITRAL VALVE: Normal mitral valve leaflets. The aortic valve is bicuspid. Moderately dilated aortic root.Borderline pulmonary hypertension. PATIENT/TEST INFORMATION:Indication: Aortic valve disease.BP (mm Hg): 160/71HR (bpm): 72Status: InpatientDate/Time: at 16:02Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH. There is borderlinepulmonary artery systolic hypertension. The ascendingaorta is mildly dilated. Good (>20 cm/s) LAA ejectionvelocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: No mass or thrombus in the RA or RAA. Mild thickening of mitral valve chordae. Sinus rhythmPossible left atrial abnormalityLeft ventricular hypertrophyExtensive ST-T changes may be due to ventricular hypertrophy or ischemiarsr' in leads V1 and V2Since previous tracing of the same date, left atrial abnormality seen, T wavesmore prominent, sinus bradycardia absent Moderately dilated LV cavity. Overall left ventricular systolicfunction is normal. Sinus rhythm with atrial premature beats. The left lung is incompletely evaluated. FINDINGS: A single portable supine AP view of the chest was obtained. There has been interval advancement of the endotracheal tube, which now lies at the level of the inferior aspect of the clavicles, 4.8 cm above the carina. FINDINGS: A single portable AP supine view of the chest was obtained. MiniorST-T wave abnormalities. No ASDby 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness and cavity size."},"n_notes":{"kind":"number","value":22,"string":"22"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2170-08-10 00:00:00.000","description":"P ABDOMEN (SUPINE & ERECT) PORT","row_id":1033649,"text":" 9:07 AM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: evaluate for acute intraabdominal pathology.\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with persistent abdominal discomfort s/p out of hospital\n cardiac arrest and resuscitation.\n REASON FOR THIS EXAMINATION:\n evaluate for acute intraabdominal pathology.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CHgc FRI 10:16 AM\n No ileus or obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n SUPINE AND DUCUBITUS ABDOMINAL RADIOGRAPHS:\n\n INDICATION: Abdominal discomfort, status post cardiac arrest.\n\n COMPARISON: None available.\n\n FINDINGS: There is no evidence of ileus or obstruction. There is no evidence\n of free air. A radiopaque metallic wire projects over the expected location\n of the rectum, of unclear clinical significance.\n\n IMPRESSION: No evidence of ileus, obstruction or free air.\n\n"},{"category":"Radiology","chartdate":"2170-08-10 00:00:00.000","description":"P ABDOMEN (SUPINE & ERECT) PORT","row_id":1033650,"text":", E. 9:07 AM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: evaluate for acute intraabdominal pathology.\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with persistent abdominal discomfort s/p out of hospital\n cardiac arrest and resuscitation.\n REASON FOR THIS EXAMINATION:\n evaluate for acute intraabdominal pathology.\n ______________________________________________________________________________\n PFI REPORT\n No ileus or obstruction.\n\n"},{"category":"Radiology","chartdate":"2170-08-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1033647,"text":" 9:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: INfection\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with s/p extubation, fever, last Xray concerning for PNA.\n REASON FOR THIS EXAMINATION:\n INfection\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc FRI 8:56 PM\n Bibasilar opacities suggesting pneumonia. Removal of endotracheal and\n nasogastric tubes.\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: Comparison is made to chest radiograph from .\n\n FINDINGS: There are unchanged bibasilar opacities with air bronchograms.\n Given the persistence of these findings since the previous study, these likely\n represent foci of infection. The lungs are otherwise clear. There is a small\n right pleural effusion.\n\n There has been interval removal of the endotracheal tube and nasogastric tube.\n There is mild thoracic scoliosis. The cardiac contours suggest left\n ventricular enlargement.\n\n IMPRESSION:\n 1. Persistent bibasilar opacities suggesting pneumonia.\n 2. Interval removal of endotracheal and nasogastric tubes.\n\n"},{"category":"Radiology","chartdate":"2170-08-07 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1032948,"text":" 10:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 1102\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p cardiac arrest\n REASON FOR THIS EXAMINATION:\n r/o bleed or mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl TUE 11:14 AM\n no intracranial bleed or mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITHOUT CONTRAST.\n\n HISTORY: 50-year-old male status post cardiac arrest. Rule out bleed or\n mass.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS: There is no intra-axial or extra-axial hemorrhage, mass effect,\n shift of normally midline structures, or hydrocephalus. -white matter\n differentiation is preserved. Ventricles, sulci and basal cisterns are\n unremarkable. Structures within the posterior fossa are unremarkable.\n\n No suspicious lytic or blastic osseous lesion is identified. There is\n scattered opacification of ethmoid air cells, and thickening of the posterior\n aspect of the left maxillary sinus. Visualized paranasal sinuses and mastoid\n air cells are otherwise well aerated.\n\n IMPRESSION: No acute intracranial abnormality identified.\n\n"},{"category":"Radiology","chartdate":"2170-08-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1033648,"text":", E. 9:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: INfection\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with s/p extubation, fever, last Xray concerning for PNA.\n REASON FOR THIS EXAMINATION:\n INfection\n ______________________________________________________________________________\n PFI REPORT\n Bibasilar opacities suggesting pneumonia. Removal of endotracheal and\n nasogastric tubes.\n\n"},{"category":"Radiology","chartdate":"2170-08-14 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1034290,"text":", E. 9:22 AM\n CHEST (PA & LAT) Clip # \n Reason: lead placement\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p single chamber ICD\n REASON FOR THIS EXAMINATION:\n lead placement\n ______________________________________________________________________________\n PFI REPORT\n Significant progression of right lung base opacity, likely pneumonia.\n Interval placement of single chamber pacer/AICD with lead in good position.\n\n"},{"category":"Radiology","chartdate":"2170-08-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1033412,"text":" 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated.\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p VF arrest, now intubated.\n REASON FOR THIS EXAMINATION:\n Intubated.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf 12:26 PM\n Bilateral opacifications in the lung base with evident air bronchograms and\n obscured diaphragm. This finding might suggest bilateral pneumonia in the\n lung bases. Please correlate clinically. Minimal bilateral pleural\n effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50-year-old man, status post cardiac arrest, now intubated.\n\n TECHNIQUE: AP semiupright portable chest radiograph.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: There are bilateral opacifications in the lung base, with air\n bronchograms seen, and obscure hemidiaphragm. This might be consistent with\n consolidation within the lung base bilaterally. There is minimal bilateral\n pleural effusion. The endotracheal tube and nasogastric tube placements are\n unchanged compared to . The mediastinal and cardiac silhouettes\n are unchanged compared to .\n\n IMPRESSION: Bilateral opacifications in the lung base, likely consistent with\n pneumonia. Please correlate clinically. Bilateral minimal pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2170-08-14 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1034289,"text":" 9:22 AM\n CHEST (PA & LAT) Clip # \n Reason: lead placement\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p single chamber ICD\n REASON FOR THIS EXAMINATION:\n lead placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc TUE 11:55 AM\n Significant progression of right lung base opacity, likely pneumonia.\n Interval placement of single chamber pacer/AICD with lead in good position.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest radiographs.\n\n HISTORY: 58-year-old man status post single chamber ICD placement.\n\n COMPARISON: Comparison is made to chest radiograph from .\n\n FINDINGS: There is a single chamber pacer/AICD in place with lead terminating\n in the region of the right ventricle. There is no pneumothorax.\n\n There is significant interval increase in right lung base opacity. This\n appears to be progressive since . There is blunting of the\n right costophrenic angle. These findings likely represent a right pleural\n effusion and given the chronicity of findings adjacent right lung base\n pneumonia. The left lung is unchanged from past studies. There is a large\n cardiac silhouette, and mediastinal contours are unremarkable.\n\n IMPRESSION:\n 1. Interval progression of right lung base opacity, likely pneumonia.\n 2. Interval placement of single chamber pacer/AICD with lead in good\n position.\n\n"},{"category":"Radiology","chartdate":"2170-08-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1033413,"text":", E. 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated.\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p VF arrest, now intubated.\n REASON FOR THIS EXAMINATION:\n Intubated.\n ______________________________________________________________________________\n PFI REPORT\n Bilateral opacifications in the lung base with evident air bronchograms and\n obscured diaphragm. This finding might suggest bilateral pneumonia in the\n lung bases. Please correlate clinically. Minimal bilateral pleural\n effusions.\n\n"},{"category":"Radiology","chartdate":"2170-08-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1033131,"text":" 6:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: OG tube placement? pulmonary edema?\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with vfib arrest intubated in the field\n REASON FOR THIS EXAMINATION:\n OG tube placement? pulmonary edema?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 1:35 PM\n OG tube okay in stomach, no gastric distention. Pulmonary edema and\n cardiomegaly cleared. ET tube okay.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:51 A.M. ON \n\n HISTORY: A-fib arrest. Check ET and orogastric tube.\n\n IMPRESSION: AP chest compared to :23 a.m.:\n\n Gastric distension has resolved following placement of an orogastric tube in\n the upper stomach. Previous mild pulmonary edema has improved and cardiac\n size returned to . No pneumothorax. ET tube in standard placement.\n\n\n"},{"category":"Radiology","chartdate":"2170-08-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1033132,"text":", E. 6:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: OG tube placement? pulmonary edema?\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with vfib arrest intubated in the field\n REASON FOR THIS EXAMINATION:\n OG tube placement? pulmonary edema?\n ______________________________________________________________________________\n PFI REPORT\n OG tube okay in stomach, no gastric distention. Pulmonary edema and\n cardiomegaly cleared. ET tube okay.\n\n\n"},{"category":"Radiology","chartdate":"2170-08-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1032943,"text":" 10:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ETT placement, cardiomeg\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with vfib arrest, intubated\n REASON FOR THIS EXAMINATION:\n assess ETT placement, cardiomeg\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE PORTABLE VIEW OF THE CHEST\n\n HISTORY: 50-year-old male with v fib arrest, intubated. Assess for ET tube\n placement, cardiomegaly.\n\n COMPARISON: None.\n\n FINDINGS: A single portable supine AP view of the chest was obtained. Trauma\n stabilization hardware overlies the lateral aspect of the chest bilaterally,\n limiting evaluation. The lateral left lung is not included on this study.\n\n The endotracheal tube tip terminates above the clavicles, 10.2 cm above the\n carina. Cardiac size is difficult to assess on this frontal view due to\n magnification. The right lung is clear. The left lung is incompletely\n evaluated. Note is made of an air distended loop of bowel or stomach in the\n left upper quadrant.\n\n IMPRESSION: ET tube terminates 10.2 cm above the carina and should be\n advanced. Limited study.\n\n"},{"category":"Radiology","chartdate":"2170-08-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1032957,"text":" 11:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ETT advancment\n REASON FOR THIS EXAMINATION:\n assess for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST\n\n HISTORY: 50-year-old male with ET tube advancement. Assess for ET tube\n placement.\n\n COMPARISON: Portable chest x-ray from today () at 10:31 a.m.\n\n FINDINGS: A single portable AP supine view of the chest was obtained. There\n has been interval advancement of the endotracheal tube, which now lies at the\n level of the inferior aspect of the clavicles, 4.8 cm above the carina. There\n is no focal airspace consolidation.\n\n Bilateral upper lobe ill defined opacities likely relate to cephalization of\n vessels and pulmonary edema. The cardiac silhousette is enlarged, with a left\n ventricular configuration. The stomach is air distended.\n\n IMPRESSION:\n 1. Endotracheal tube tip now lies 4.8 cm above the carina.\n 2. Findings consistent with pulmonary edema, although developing infiltrates\n cannot be excluded. Repeat radiographs following diruesis recommended.\n 3. Air distention of the stomach. The patient may benefit from nasogatric\n tube placement.\n\n"},{"category":"Echo","chartdate":"2170-08-09 00:00:00.000","description":"Report","row_id":87765,"text":"PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Endocarditis. Ventricular ectopy.\nHeight: (in) 71\nWeight (lb): 152\nBSA (m2): 1.88 m2\nBP (mm Hg): 115/47\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 10:22\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: No mass/thrombus in the LAA. Good (>20 cm/s) LAA ejection\nvelocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No mass or thrombus in the RA or RAA. No ASD\nby 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. No\natheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No masses or vegetations\non aortic valve. Moderate to severe (3+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nNo mass/thrombus is seen in the left atrium or left atrial appendage. No mass\nor thrombus is seen in the right atrium or right atrial appendage. No atrial\nseptal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses and cavity size are normal. Overall left ventricular systolic\nfunction is normal. Right ventricular chamber size and free wall motion are\nnormal. The aortic root is mildly dilated at the sinus level. The ascending\naorta is mildly dilated. The aortic valve has three leaflets but is\nfunctionally bileaflet. Leaflets are thickened and deformed. No masses or\nvegetations are seen on the aortic valve. An eccentric jet of moderate to\nsevere (3+) aortic regurgitation is seen. The mitral valve leaflets are\nstructurally normal. No mass or vegetation is seen on the mitral valve.\nTrivial mitral regurgitation is seen.\n\nIMPRESSION: No vegetations seen. Functionally bicuspid aortic valve with\nthickened leaflets and eccentric, moderate to severe aortic regurgitation.\nMildly dilated thoracic aorta.\n\nDr. was notified in person of the results on at 11:00 AM.\n\n\n"},{"category":"Echo","chartdate":"2170-08-07 00:00:00.000","description":"Report","row_id":87766,"text":"PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease.\nBP (mm Hg): 160/71\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 16:02\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Normal\nregional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic sinus. Mildly dilated ascending aorta. Normal\naortic arch diameter.\n\nAORTIC VALVE: Bicuspid aortic valve. Mildly thickened aortic valve leaflets.\nCannot exclude AS. Severe (4+) AR. Eccentric AR jet directed toward the\nanterior mitral leaflet.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nBorderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity is moderately dilated. There is normal regional and global\nbiventricular systolic function. Right ventricular chamber size and free wall\nmotion are normal. The aortic root is moderately dilated at the sinus level.\nThe ascending aorta is mildly dilated. The aortic valve is bicuspid. The\naortic valve leaflets are mildly thickened. The study is inadequate to exclude\nsignificant aortic valve stenosis. Severe (4+) aortic regurgitation is seen.\nThe aortic regurgitation jet is eccentric, directed toward the anterior mitral\nleaflet. The mitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Mildly thickened bicuspid aortic valve with severe eccentric\naortic regurgitation directed toward the anterior mitral leaflet. Mild\nsymmetric left ventricular hypertrophy with dilated left ventricular and\npreserved regional/global systolic function. Moderately dilated aortic root.\nBorderline pulmonary hypertension.\n\n\n"},{"category":"ECG","chartdate":"2170-08-07 00:00:00.000","description":"Report","row_id":220972,"text":"Sinus bradycardia\nBorderline prolonged QT interval\nrsr' in leads V1 and V2 - consider incomplete right bundle branch block\nLeft ventricular hypertrophy\nExtensive ST-T changes may be due to hypertrophy and/or ischemia\nNo previous tracing available for comparison\n\n"},{"category":"ECG","chartdate":"2170-08-14 00:00:00.000","description":"Report","row_id":220966,"text":"Sinus rhythm\nPremature ventricular contractions\nrsr' in lead V1\nPossible left ventricular hypertrophy\nSince previous tracing of , ventricular premature complexes new; ST-T\nwave abnormalities are less\n\n"},{"category":"ECG","chartdate":"2170-08-13 00:00:00.000","description":"Report","row_id":220967,"text":"Sinus bradycardia.\nrSr'(V1) - probable normal variant\nLeft ventricular hypertrophy\nInferior/lateral ST-T changes are probably due to ventricular hypertrophy\nQT interval prolonged for rate\nSince previous tracing of , increased QRS voltage\n\n"},{"category":"ECG","chartdate":"2170-08-10 00:00:00.000","description":"Report","row_id":220968,"text":"Sinus bradycardia with slowing of the rate as compared with prior tracing\nof . Delayed precordial R wave transition and diffuse non-specific\nST-T wave changes. Compared to the previous tracing of atrial ectopy\nis absent. Otherwise, no diagnostic interim change.\n\n"},{"category":"ECG","chartdate":"2170-08-09 00:00:00.000","description":"Report","row_id":220969,"text":"Sinus rhythm with atrial premature beats. RSR' pattern in lead V1. Minior\nST-T wave abnormalities. Since the previous tracing of the rate is\nfaster. ST-T wave abnormalities may be less prominent.\n\n"},{"category":"ECG","chartdate":"2170-08-09 00:00:00.000","description":"Report","row_id":220970,"text":"Sinus bradycardia\nProlonged QT interval\nInferior/lateral ST-T changes are nonspecific\nPoor R wave progression\nrsr' in lead V1\nSince previous tracing of , sinus bradycardia present and left\nventricular hypertrophy by voltage absent\n\n"},{"category":"ECG","chartdate":"2170-08-07 00:00:00.000","description":"Report","row_id":220971,"text":"Sinus rhythm\nPossible left atrial abnormality\nLeft ventricular hypertrophy\nExtensive ST-T changes may be due to ventricular hypertrophy or ischemia\nrsr' in leads V1 and V2\nSince previous tracing of the same date, left atrial abnormality seen, T waves\nmore prominent, sinus bradycardia absent\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2170-08-10 00:00:00.000\",\n \"description\": \"P ABDOMEN (SUPINE & ERECT) PORT\",\n \"row_id\": 1033649,\n \"text\": \" 9:07 AM\\n ABDOMEN (SUPINE & ERECT) PORT Clip # \\n Reason: evaluate for acute intraabdominal pathology.\\n Admitting Diagnosis: CARDIAC ARREST\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with persistent abdominal discomfort s/p out of hospital\\n cardiac arrest and resuscitation.\\n REASON FOR THIS EXAMINATION:\\n evaluate for acute intraabdominal pathology.\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): CHgc FRI 10:16 AM\\n No ileus or obstruction.\\n ______________________________________________________________________________\\n FINAL REPORT\\n SUPINE AND DUCUBITUS ABDOMINAL RADIOGRAPHS:\\n\\n INDICATION: Abdominal discomfort, status post cardiac arrest.\\n\\n COMPARISON: None available.\\n\\n FINDINGS: There is no evidence of ileus or obstruction. There is no evidence\\n of free air. A radiopaque metallic wire projects over the expected location\\n of the rectum, of unclear clinical significance.\\n\\n IMPRESSION: No evidence of ileus, obstruction or free air.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2170-08-10 00:00:00.000\",\n \"description\": \"P ABDOMEN (SUPINE & ERECT) PORT\",\n \"row_id\": 1033650,\n \"text\": \", E. 9:07 AM\\n ABDOMEN (SUPINE & ERECT) PORT Clip # \\n Reason: evaluate for acute intraabdominal pathology.\\n Admitting Diagnosis: CARDIAC ARREST\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with persistent abdominal discomfort s/p out of hospital\\n cardiac arrest and resuscitation.\\n REASON FOR THIS EXAMINATION:\\n evaluate for acute intraabdominal pathology.\\n ______________________________________________________________________________\\n PFI REPORT\\n No ileus or obstruction.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2170-08-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1033647,\n \"text\": \" 9:07 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: INfection\\n Admitting Diagnosis: CARDIAC ARREST\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with s/p extubation, fever, last Xray concerning for PNA.\\n REASON FOR THIS EXAMINATION:\\n INfection\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc FRI 8:56 PM\\n Bibasilar opacities suggesting pneumonia. Removal of endotracheal and\\n nasogastric tubes.\\n ______________________________________________________________________________\\n FINAL REPORT\\n COMPARISON: Comparison is made to chest radiograph from .\\n\\n FINDINGS: There are unchanged bibasilar opacities with air bronchograms.\\n Given the persistence of these findings since the previous study, these likely\\n represent foci of infection. The lungs are otherwise clear. There is a small\\n right pleural effusion.\\n\\n There has been interval removal of the endotracheal tube and nasogastric tube.\\n There is mild thoracic scoliosis. The cardiac contours suggest left\\n ventricular enlargement.\\n\\n IMPRESSION:\\n 1. Persistent bibasilar opacities suggesting pneumonia.\\n 2. Interval removal of endotracheal and nasogastric tubes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2170-08-07 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1032948,\n \"text\": \" 10:48 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: 1102\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man with s/p cardiac arrest\\n REASON FOR THIS EXAMINATION:\\n r/o bleed or mass\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JXRl TUE 11:14 AM\\n no intracranial bleed or mass effect.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT OF THE HEAD WITHOUT CONTRAST.\\n\\n HISTORY: 50-year-old male status post cardiac arrest. Rule out bleed or\\n mass.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Non-contrast head CT was obtained.\\n\\n FINDINGS: There is no intra-axial or extra-axial hemorrhage, mass effect,\\n shift of normally midline structures, or hydrocephalus. -white matter\\n differentiation is preserved. Ventricles, sulci and basal cisterns are\\n unremarkable. Structures within the posterior fossa are unremarkable.\\n\\n No suspicious lytic or blastic osseous lesion is identified. There is\\n scattered opacification of ethmoid air cells, and thickening of the posterior\\n aspect of the left maxillary sinus. Visualized paranasal sinuses and mastoid\\n air cells are otherwise well aerated.\\n\\n IMPRESSION: No acute intracranial abnormality identified.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2170-08-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1033648,\n \"text\": \", E. 9:07 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: INfection\\n Admitting Diagnosis: CARDIAC ARREST\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with s/p extubation, fever, last Xray concerning for PNA.\\n REASON FOR THIS EXAMINATION:\\n INfection\\n ______________________________________________________________________________\\n PFI REPORT\\n Bibasilar opacities suggesting pneumonia. Removal of endotracheal and\\n nasogastric tubes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2170-08-14 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1034290,\n \"text\": \", E. 9:22 AM\\n CHEST (PA & LAT) Clip # \\n Reason: lead placement\\n Admitting Diagnosis: CARDIAC ARREST\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man s/p single chamber ICD\\n REASON FOR THIS EXAMINATION:\\n lead placement\\n ______________________________________________________________________________\\n PFI REPORT\\n Significant progression of right lung base opacity, likely pneumonia.\\n Interval placement of single chamber pacer/AICD with lead in good position.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2170-08-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1033412,\n \"text\": \" 8:03 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Intubated.\\n Admitting Diagnosis: CARDIAC ARREST\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man s/p VF arrest, now intubated.\\n REASON FOR THIS EXAMINATION:\\n Intubated.\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf 12:26 PM\\n Bilateral opacifications in the lung base with evident air bronchograms and\\n obscured diaphragm. This finding might suggest bilateral pneumonia in the\\n lung bases. Please correlate clinically. Minimal bilateral pleural\\n effusions.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 50-year-old man, status post cardiac arrest, now intubated.\\n\\n TECHNIQUE: AP semiupright portable chest radiograph.\\n\\n COMPARISON: Chest radiograph from .\\n\\n FINDINGS: There are bilateral opacifications in the lung base, with air\\n bronchograms seen, and obscure hemidiaphragm. This might be consistent with\\n consolidation within the lung base bilaterally. There is minimal bilateral\\n pleural effusion. The endotracheal tube and nasogastric tube placements are\\n unchanged compared to . The mediastinal and cardiac silhouettes\\n are unchanged compared to .\\n\\n IMPRESSION: Bilateral opacifications in the lung base, likely consistent with\\n pneumonia. Please correlate clinically. Bilateral minimal pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2170-08-14 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1034289,\n \"text\": \" 9:22 AM\\n CHEST (PA & LAT) Clip # \\n Reason: lead placement\\n Admitting Diagnosis: CARDIAC ARREST\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man s/p single chamber ICD\\n REASON FOR THIS EXAMINATION:\\n lead placement\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc TUE 11:55 AM\\n Significant progression of right lung base opacity, likely pneumonia.\\n Interval placement of single chamber pacer/AICD with lead in good position.\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: PA and lateral chest radiographs.\\n\\n HISTORY: 58-year-old man status post single chamber ICD placement.\\n\\n COMPARISON: Comparison is made to chest radiograph from .\\n\\n FINDINGS: There is a single chamber pacer/AICD in place with lead terminating\\n in the region of the right ventricle. There is no pneumothorax.\\n\\n There is significant interval increase in right lung base opacity. This\\n appears to be progressive since . There is blunting of the\\n right costophrenic angle. These findings likely represent a right pleural\\n effusion and given the chronicity of findings adjacent right lung base\\n pneumonia. The left lung is unchanged from past studies. There is a large\\n cardiac silhouette, and mediastinal contours are unremarkable.\\n\\n IMPRESSION:\\n 1. Interval progression of right lung base opacity, likely pneumonia.\\n 2. Interval placement of single chamber pacer/AICD with lead in good\\n position.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2170-08-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1033413,\n \"text\": \", E. 8:03 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Intubated.\\n Admitting Diagnosis: CARDIAC ARREST\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man s/p VF arrest, now intubated.\\n REASON FOR THIS EXAMINATION:\\n Intubated.\\n ______________________________________________________________________________\\n PFI REPORT\\n Bilateral opacifications in the lung base with evident air bronchograms and\\n obscured diaphragm. This finding might suggest bilateral pneumonia in the\\n lung bases. Please correlate clinically. Minimal bilateral pleural\\n effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2170-08-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1033131,\n \"text\": \" 6:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: OG tube placement? pulmonary edema?\\n Admitting Diagnosis: CARDIAC ARREST\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with vfib arrest intubated in the field\\n REASON FOR THIS EXAMINATION:\\n OG tube placement? pulmonary edema?\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 1:35 PM\\n OG tube okay in stomach, no gastric distention. Pulmonary edema and\\n cardiomegaly cleared. ET tube okay.\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 6:51 A.M. ON \\n\\n HISTORY: A-fib arrest. Check ET and orogastric tube.\\n\\n IMPRESSION: AP chest compared to :23 a.m.:\\n\\n Gastric distension has resolved following placement of an orogastric tube in\\n the upper stomach. Previous mild pulmonary edema has improved and cardiac\\n size returned to . No pneumothorax. ET tube in standard placement.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2170-08-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1033132,\n \"text\": \", E. 6:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: OG tube placement? pulmonary edema?\\n Admitting Diagnosis: CARDIAC ARREST\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with vfib arrest intubated in the field\\n REASON FOR THIS EXAMINATION:\\n OG tube placement? pulmonary edema?\\n ______________________________________________________________________________\\n PFI REPORT\\n OG tube okay in stomach, no gastric distention. Pulmonary edema and\\n cardiomegaly cleared. ET tube okay.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2170-08-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1032943,\n \"text\": \" 10:30 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess ETT placement, cardiomeg\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man with vfib arrest, intubated\\n REASON FOR THIS EXAMINATION:\\n assess ETT placement, cardiomeg\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE PORTABLE VIEW OF THE CHEST\\n\\n HISTORY: 50-year-old male with v fib arrest, intubated. Assess for ET tube\\n placement, cardiomegaly.\\n\\n COMPARISON: None.\\n\\n FINDINGS: A single portable supine AP view of the chest was obtained. Trauma\\n stabilization hardware overlies the lateral aspect of the chest bilaterally,\\n limiting evaluation. The lateral left lung is not included on this study.\\n\\n The endotracheal tube tip terminates above the clavicles, 10.2 cm above the\\n carina. Cardiac size is difficult to assess on this frontal view due to\\n magnification. The right lung is clear. The left lung is incompletely\\n evaluated. Note is made of an air distended loop of bowel or stomach in the\\n left upper quadrant.\\n\\n IMPRESSION: ET tube terminates 10.2 cm above the carina and should be\\n advanced. Limited study.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2170-08-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1032957,\n \"text\": \" 11:19 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for ETT placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 50 year old man with ETT advancment\\n REASON FOR THIS EXAMINATION:\\n assess for ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE VIEW OF THE CHEST\\n\\n HISTORY: 50-year-old male with ET tube advancement. Assess for ET tube\\n placement.\\n\\n COMPARISON: Portable chest x-ray from today () at 10:31 a.m.\\n\\n FINDINGS: A single portable AP supine view of the chest was obtained. There\\n has been interval advancement of the endotracheal tube, which now lies at the\\n level of the inferior aspect of the clavicles, 4.8 cm above the carina. There\\n is no focal airspace consolidation.\\n\\n Bilateral upper lobe ill defined opacities likely relate to cephalization of\\n vessels and pulmonary edema. The cardiac silhousette is enlarged, with a left\\n ventricular configuration. The stomach is air distended.\\n\\n IMPRESSION:\\n 1. Endotracheal tube tip now lies 4.8 cm above the carina.\\n 2. Findings consistent with pulmonary edema, although developing infiltrates\\n cannot be excluded. Repeat radiographs following diruesis recommended.\\n 3. Air distention of the stomach. The patient may benefit from nasogatric\\n tube placement.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2170-08-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 87765,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Aortic valve disease. Endocarditis. Ventricular ectopy.\\nHeight: (in) 71\\nWeight (lb): 152\\nBSA (m2): 1.88 m2\\nBP (mm Hg): 115/47\\nHR (bpm): 60\\nStatus: Inpatient\\nDate/Time: at 10:22\\nTest: Portable TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: No mass/thrombus in the LAA. Good (>20 cm/s) LAA ejection\\nvelocity.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No mass or thrombus in the RA or RAA. No ASD\\nby 2D or color Doppler.\\n\\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Overall normal LVEF\\n(>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. No\\natheroma in descending aorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No masses or vegetations\\non aortic valve. Moderate to severe (3+) AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\\nvalve. Trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\\n(normal) PR.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was monitored\\nby a nurse throughout the procedure. The patient was under\\ngeneral anesthesia throughout the procedure. No TEE related complications. The\\npatient appears to be in sinus rhythm. Results were personally reviewed with\\nthe MD caring for the patient.\\n\\nConclusions:\\nNo mass/thrombus is seen in the left atrium or left atrial appendage. No mass\\nor thrombus is seen in the right atrium or right atrial appendage. No atrial\\nseptal defect is seen by 2D or color Doppler. Left ventricular wall\\nthicknesses and cavity size are normal. Overall left ventricular systolic\\nfunction is normal. Right ventricular chamber size and free wall motion are\\nnormal. The aortic root is mildly dilated at the sinus level. The ascending\\naorta is mildly dilated. The aortic valve has three leaflets but is\\nfunctionally bileaflet. Leaflets are thickened and deformed. No masses or\\nvegetations are seen on the aortic valve. An eccentric jet of moderate to\\nsevere (3+) aortic regurgitation is seen. The mitral valve leaflets are\\nstructurally normal. No mass or vegetation is seen on the mitral valve.\\nTrivial mitral regurgitation is seen.\\n\\nIMPRESSION: No vegetations seen. Functionally bicuspid aortic valve with\\nthickened leaflets and eccentric, moderate to severe aortic regurgitation.\\nMildly dilated thoracic aorta.\\n\\nDr. was notified in person of the results on at 11:00 AM.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2170-08-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 87766,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Aortic valve disease.\\nBP (mm Hg): 160/71\\nHR (bpm): 72\\nStatus: Inpatient\\nDate/Time: at 16:02\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Normal\\nregional LV systolic function.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Moderately dilated aortic sinus. Mildly dilated ascending aorta. Normal\\naortic arch diameter.\\n\\nAORTIC VALVE: Bicuspid aortic valve. Mildly thickened aortic valve leaflets.\\nCannot exclude AS. Severe (4+) AR. Eccentric AR jet directed toward the\\nanterior mitral leaflet.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\\nannular calcification. Mild thickening of mitral valve chordae. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\\nBorderline PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\\ncavity is moderately dilated. There is normal regional and global\\nbiventricular systolic function. Right ventricular chamber size and free wall\\nmotion are normal. The aortic root is moderately dilated at the sinus level.\\nThe ascending aorta is mildly dilated. The aortic valve is bicuspid. The\\naortic valve leaflets are mildly thickened. The study is inadequate to exclude\\nsignificant aortic valve stenosis. Severe (4+) aortic regurgitation is seen.\\nThe aortic regurgitation jet is eccentric, directed toward the anterior mitral\\nleaflet. The mitral valve leaflets are mildly thickened. There is no mitral\\nvalve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline\\npulmonary artery systolic hypertension. There is no pericardial effusion.\\n\\nIMPRESSION: Mildly thickened bicuspid aortic valve with severe eccentric\\naortic regurgitation directed toward the anterior mitral leaflet. Mild\\nsymmetric left ventricular hypertrophy with dilated left ventricular and\\npreserved regional/global systolic function. Moderately dilated aortic root.\\nBorderline pulmonary hypertension.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2170-08-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 220972,\n \"text\": \"Sinus bradycardia\\nBorderline prolonged QT interval\\nrsr' in leads V1 and V2 - consider incomplete right bundle branch block\\nLeft ventricular hypertrophy\\nExtensive ST-T changes may be due to hypertrophy and/or ischemia\\nNo previous tracing available for comparison\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2170-08-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 220966,\n \"text\": \"Sinus rhythm\\nPremature ventricular contractions\\nrsr' in lead V1\\nPossible left ventricular hypertrophy\\nSince previous tracing of , ventricular premature complexes new; ST-T\\nwave abnormalities are less\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2170-08-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 220967,\n \"text\": \"Sinus bradycardia.\\nrSr'(V1) - probable normal variant\\nLeft ventricular hypertrophy\\nInferior/lateral ST-T changes are probably due to ventricular hypertrophy\\nQT interval prolonged for rate\\nSince previous tracing of , increased QRS voltage\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2170-08-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 220968,\n \"text\": \"Sinus bradycardia with slowing of the rate as compared with prior tracing\\nof . Delayed precordial R wave transition and diffuse non-specific\\nST-T wave changes. Compared to the previous tracing of atrial ectopy\\nis absent. Otherwise, no diagnostic interim change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2170-08-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 220969,\n \"text\": \"Sinus rhythm with atrial premature beats. RSR' pattern in lead V1. Minior\\nST-T wave abnormalities. Since the previous tracing of the rate is\\nfaster. ST-T wave abnormalities may be less prominent.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2170-08-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 220970,\n \"text\": \"Sinus bradycardia\\nProlonged QT interval\\nInferior/lateral ST-T changes are nonspecific\\nPoor R wave progression\\nrsr' in lead V1\\nSince previous tracing of , sinus bradycardia present and left\\nventricular hypertrophy by voltage absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2170-08-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 220971,\n \"text\": \"Sinus rhythm\\nPossible left atrial abnormality\\nLeft ventricular hypertrophy\\nExtensive ST-T changes may be due to ventricular hypertrophy or ischemia\\nrsr' in leads V1 and V2\\nSince previous tracing of the same date, left atrial abnormality seen, T waves\\nmore prominent, sinus bradycardia absent\\n\\n\"\n }\n]"}}},{"rowIdx":89,"cells":{"subject_id":{"kind":"number","value":17554,"string":"17,554"},"hadm_id":{"kind":"number","value":192233,"string":"192,233"},"target_text":{"kind":"string","value":"The pt was admitted after his procedure which he tolerated well. Please see the dictated operative note for further details. While in the PACU, he was noted to have brief apneic periods, and so was transfered to the ICU for extended PACU recovery when the APCU closed for the evening. His stay in the ICU was unremarkable, and by the morning of POD#1, all of his apneic issues had resolved, and he was transfered out to the regular floor. The Physical Therapy service began working with the pt on POD#1 and continued to work with him throughout his hospitalization. The pt was started on Lovenox on POD#1 as well. On POD#2, the pt was transitioned to oral pain medications and his Foley catheter was removed. Xrays obtained demonstrated the hip to be located with all components in good position. The pt was transfused 1 unit of PRBC on POD#3 for a Hct=26.2 with an appropriate elevation of his hematocrit to 28.1. By the day of discharge he was tolerating a regular diet with his pain well controlled on oral pain medication. He was discharged to home with home PT with instructions to follow up with Dr. in the office in ~2 weeks."},"extractive_notes_summ":{"kind":"string","value":"INDICATION: Revision right hip. ABDUCTOR PILLOW IN PLACE.RESP: LUNGS CLEAR THROUGHOUT. RIGHT HIP PORTABLE AP IN THE OR : Since , there is a new drain over the right total hip replacement, incompletely imaged. The heart size, mediastinal and hilar contours are within normal limits and stable compared to the previous study. RR 11-14, VERY SHORT PERIODS OF APNEA NOTED. FINDINGS: Three views of the right hip show a well-positioned right total hip prosthesis with a noncemented femoral component and subcutaneous gas adjacent to the recent surgical site. RIGHT Clip # Reason: RIGHT TOTAL HIP REVISION Admitting Diagnosis: FAILED TOTAL HIP REPLACEMENT/SDA FINAL REPORT Right hip in the operating room. MONITOR V/S AND LYTES, REPLENISH PRN. Small bilateral pleural effusions. NO RESP DISTRESS NOTED.NEURO: A&O X3. Underlying subcutaneous edema and emphysema are postoperative. BS SLOW X4 QUADS. C/O MILD PAIN ON ARRIVAL, USING PCA MORPHINE WITH RELIEF NOTED.GU/GI: ABD SOFT, NON-TENDER. B/P HAS RANGED FROM 119/49-135/62. NARRATIVE NOTE:CV: PP EASILY PALPABLE X4. 2 views were obtained from the C-arm videoscope demonstrating normal positioning of the hip prosthesis in image 1 and posterior dislocation of the prosthetic head in image 2. Additionally, there are apparent small bilateral pleural effusions on the lateral view. OPENS EYES SPONTANEOULY. ; -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: TOTAL HIP REPLACEMENT Admitting Diagnosis: FAILED TOTAL HIP REPLACEMENT/SDA FINAL REPORT CLINICAL HISTORY: Total hip replacement. The lungs reveal a subtle area of increased opacity in the left lower lobe posteriorly, new in the interval. INDICATION: Asthma and productive cough. PT TO USE PCA TO PREVENT PAIN. KEEP ABDUCTOR PILLOW IN PLACE. PT ABLE TO MOVE ALL TOES ON COMMAND. SAO2 98-100% ON 2L N/C. Degenerative changes are observed in the spine. IN O.R. D51/2NS WITH 20KCL INFUSING AT 100CC/HR.PLAN: CONT TO MONITOR R LEG FOR GOOD PEDAL PULSES AND MOVEMENT. Surgical clips are present within the pelvis. SB WITH H/R RANGING FROM 53-59, NO ECTOPY NOTED. FOLEY CATH PATENT, DRAINING CLEAR YELLOW URINE IN ADEQUATE AMTS. Several clips are present in the pelvis. IMPRESSION: Subtle left lower lobe opacity, concerning for an early focus of pneumonia. 9:59 AM HIP UNILAT MIN 2 VIEWS RIGHT Clip # Reason: evaluate hardware position MEDICAL CONDITION: 61 year old man s/p R THA REASON FOR THIS EXAMINATION: evaluate hardware position FINAL REPORT INDICATION: Right hip prosthesis placement. Follow up radiographs may be helpful to document resolution following appropriate therapy. BOTH FEET COOL TO TOUCH. 4:56 PM HIP UNILAT MIN 2 VIEWS IN O.R. PT WILL MOVE OUT TO THE FLOOR TODAY. FOLLOWS ALL COMMANDS CONSISTANTLY. TOOK SIPS OF WATER WITH NO N/V. NO NUMBNESS OR TINGLING IN LOWER EXTREMITIES. 6:55 PM HIP 1 VIEW IN O.R. 9:59 AM CHEST (PA & LAT) Clip # Reason: r/o infiltrate MEDICAL CONDITION: 61 year old man with asthma, now w/ productive cough and decreased spirometry REASON FOR THIS EXAMINATION: r/o infiltrate FINAL REPORT 2 VIEWS CHEST: COMPARISON: . AT HOME PT STRAIGHT CATH SELF . EASILY AROUSED WITH VERBAL STIMULI."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2154-06-21 00:00:00.000","description":"CHEST (PA & LAT)","row_id":868605,"text":" 9:59 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with asthma, now w/ productive cough and decreased spirometry\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n 2 VIEWS CHEST:\n\n COMPARISON: .\n\n INDICATION: Asthma and productive cough.\n\n The heart size, mediastinal and hilar contours are within normal limits and\n stable compared to the previous study. The lungs reveal a subtle area of\n increased opacity in the left lower lobe posteriorly, new in the interval.\n Additionally, there are apparent small bilateral pleural effusions on the\n lateral view. Degenerative changes are observed in the spine.\n\n IMPRESSION: Subtle left lower lobe opacity, concerning for an early focus of\n pneumonia. Follow up radiographs may be helpful to document resolution\n following appropriate therapy.\n\n Small bilateral pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2154-06-19 00:00:00.000","description":"OO HIP 1 VIEW IN O.R. IN O.R.","row_id":868415,"text":" 6:55 PM\n HIP 1 VIEW IN O.R. IN O.R.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: TOTAL HIP REPLACEMENT\n Admitting Diagnosis: FAILED TOTAL HIP REPLACEMENT/SDA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Total hip replacement.\n\n RIGHT HIP PORTABLE AP IN THE OR :\n\n Since , there is a new drain over the right total hip replacement,\n incompletely imaged. Several clips are present in the pelvis. Underlying\n subcutaneous edema and emphysema are postoperative.\n\n"},{"category":"Radiology","chartdate":"2154-06-19 00:00:00.000","description":"OR HIP UNILAT MIN 2 VIEWS IN O.R. RIGHT","row_id":868401,"text":" 4:56 PM\n HIP UNILAT MIN 2 VIEWS IN O.R. RIGHT Clip # \n Reason: RIGHT TOTAL HIP REVISION\n Admitting Diagnosis: FAILED TOTAL HIP REPLACEMENT/SDA\n ______________________________________________________________________________\n FINAL REPORT\n Right hip in the operating room.\n\n INDICATION: Revision right hip.\n\n 2 views were obtained from the C-arm videoscope demonstrating normal\n positioning of the hip prosthesis in image 1 and posterior dislocation of the\n prosthetic head in image 2.\n\n\n"},{"category":"Radiology","chartdate":"2154-06-21 00:00:00.000","description":"R HIP UNILAT MIN 2 VIEWS RIGHT","row_id":868604,"text":" 9:59 AM\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n Reason: evaluate hardware position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p R THA\n\n REASON FOR THIS EXAMINATION:\n evaluate hardware position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right hip prosthesis placement.\n\n FINDINGS: Three views of the right hip show a well-positioned right total hip\n prosthesis with a noncemented femoral component and subcutaneous gas adjacent\n to the recent surgical site. No bone destruction, bone erosion, acute\n fracture, dislocation, or radiopaque foreign bodies seen. Surgical clips are\n present within the pelvis.\n\n\n"},{"category":"Nursing/other","chartdate":"2154-06-20 00:00:00.000","description":"Report","row_id":1492256,"text":"NARRATIVE NOTE:\n\nCV: PP EASILY PALPABLE X4. PT ABLE TO MOVE ALL TOES ON COMMAND. BOTH FEET COOL TO TOUCH. NO NUMBNESS OR TINGLING IN LOWER EXTREMITIES. B/P HAS RANGED FROM 119/49-135/62. SB WITH H/R RANGING FROM 53-59, NO ECTOPY NOTED. ABDUCTOR PILLOW IN PLACE.\n\nRESP: LUNGS CLEAR THROUGHOUT. RR 11-14, VERY SHORT PERIODS OF APNEA NOTED. SAO2 98-100% ON 2L N/C. NO RESP DISTRESS NOTED.\n\nNEURO: A&O X3. FOLLOWS ALL COMMANDS CONSISTANTLY. EASILY AROUSED WITH VERBAL STIMULI. OPENS EYES SPONTANEOULY. C/O MILD PAIN ON ARRIVAL, USING PCA MORPHINE WITH RELIEF NOTED.\n\nGU/GI: ABD SOFT, NON-TENDER. BS SLOW X4 QUADS. TOOK SIPS OF WATER WITH NO N/V. FOLEY CATH PATENT, DRAINING CLEAR YELLOW URINE IN ADEQUATE AMTS. AT HOME PT STRAIGHT CATH SELF . D51/2NS WITH 20KCL INFUSING AT 100CC/HR.\n\nPLAN: CONT TO MONITOR R LEG FOR GOOD PEDAL PULSES AND MOVEMENT. KEEP ABDUCTOR PILLOW IN PLACE. MONITOR V/S AND LYTES, REPLENISH PRN. PT WILL MOVE OUT TO THE FLOOR TODAY. PT TO USE PCA TO PREVENT PAIN.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-06-21 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 868605,\n \"text\": \" 9:59 AM\\n CHEST (PA & LAT) Clip # \\n Reason: r/o infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with asthma, now w/ productive cough and decreased spirometry\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n 2 VIEWS CHEST:\\n\\n COMPARISON: .\\n\\n INDICATION: Asthma and productive cough.\\n\\n The heart size, mediastinal and hilar contours are within normal limits and\\n stable compared to the previous study. The lungs reveal a subtle area of\\n increased opacity in the left lower lobe posteriorly, new in the interval.\\n Additionally, there are apparent small bilateral pleural effusions on the\\n lateral view. Degenerative changes are observed in the spine.\\n\\n IMPRESSION: Subtle left lower lobe opacity, concerning for an early focus of\\n pneumonia. Follow up radiographs may be helpful to document resolution\\n following appropriate therapy.\\n\\n Small bilateral pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-06-19 00:00:00.000\",\n \"description\": \"OO HIP 1 VIEW IN O.R. IN O.R.\",\n \"row_id\": 868415,\n \"text\": \" 6:55 PM\\n HIP 1 VIEW IN O.R. IN O.R.; -59 DISTINCT PROCEDURAL SERVICE Clip # \\n Reason: TOTAL HIP REPLACEMENT\\n Admitting Diagnosis: FAILED TOTAL HIP REPLACEMENT/SDA\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Total hip replacement.\\n\\n RIGHT HIP PORTABLE AP IN THE OR :\\n\\n Since , there is a new drain over the right total hip replacement,\\n incompletely imaged. Several clips are present in the pelvis. Underlying\\n subcutaneous edema and emphysema are postoperative.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-06-19 00:00:00.000\",\n \"description\": \"OR HIP UNILAT MIN 2 VIEWS IN O.R. RIGHT\",\n \"row_id\": 868401,\n \"text\": \" 4:56 PM\\n HIP UNILAT MIN 2 VIEWS IN O.R. RIGHT Clip # \\n Reason: RIGHT TOTAL HIP REVISION\\n Admitting Diagnosis: FAILED TOTAL HIP REPLACEMENT/SDA\\n ______________________________________________________________________________\\n FINAL REPORT\\n Right hip in the operating room.\\n\\n INDICATION: Revision right hip.\\n\\n 2 views were obtained from the C-arm videoscope demonstrating normal\\n positioning of the hip prosthesis in image 1 and posterior dislocation of the\\n prosthetic head in image 2.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-06-21 00:00:00.000\",\n \"description\": \"R HIP UNILAT MIN 2 VIEWS RIGHT\",\n \"row_id\": 868604,\n \"text\": \" 9:59 AM\\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \\n Reason: evaluate hardware position\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man s/p R THA\\n\\n REASON FOR THIS EXAMINATION:\\n evaluate hardware position\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Right hip prosthesis placement.\\n\\n FINDINGS: Three views of the right hip show a well-positioned right total hip\\n prosthesis with a noncemented femoral component and subcutaneous gas adjacent\\n to the recent surgical site. No bone destruction, bone erosion, acute\\n fracture, dislocation, or radiopaque foreign bodies seen. Surgical clips are\\n present within the pelvis.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1492256,\n \"text\": \"NARRATIVE NOTE:\\n\\nCV: PP EASILY PALPABLE X4. PT ABLE TO MOVE ALL TOES ON COMMAND. BOTH FEET COOL TO TOUCH. NO NUMBNESS OR TINGLING IN LOWER EXTREMITIES. B/P HAS RANGED FROM 119/49-135/62. SB WITH H/R RANGING FROM 53-59, NO ECTOPY NOTED. ABDUCTOR PILLOW IN PLACE.\\n\\nRESP: LUNGS CLEAR THROUGHOUT. RR 11-14, VERY SHORT PERIODS OF APNEA NOTED. SAO2 98-100% ON 2L N/C. NO RESP DISTRESS NOTED.\\n\\nNEURO: A&O X3. FOLLOWS ALL COMMANDS CONSISTANTLY. EASILY AROUSED WITH VERBAL STIMULI. OPENS EYES SPONTANEOULY. C/O MILD PAIN ON ARRIVAL, USING PCA MORPHINE WITH RELIEF NOTED.\\n\\nGU/GI: ABD SOFT, NON-TENDER. BS SLOW X4 QUADS. TOOK SIPS OF WATER WITH NO N/V. FOLEY CATH PATENT, DRAINING CLEAR YELLOW URINE IN ADEQUATE AMTS. AT HOME PT STRAIGHT CATH SELF . D51/2NS WITH 20KCL INFUSING AT 100CC/HR.\\n\\nPLAN: CONT TO MONITOR R LEG FOR GOOD PEDAL PULSES AND MOVEMENT. KEEP ABDUCTOR PILLOW IN PLACE. MONITOR V/S AND LYTES, REPLENISH PRN. PT WILL MOVE OUT TO THE FLOOR TODAY. PT TO USE PCA TO PREVENT PAIN.\\n\"\n }\n]"}}},{"rowIdx":90,"cells":{"subject_id":{"kind":"number","value":16650,"string":"16,650"},"hadm_id":{"kind":"number","value":176541,"string":"176,541"},"target_text":{"kind":"string","value":"Patient seen in ED where U/S and CT studies confirmed all wounds were superficial to deep structures. Initially 0-silk sutures were placed in chest wounds to control hematoma. On Day 2 these were removed and deep monocryl and superficial nylon sutures were placed. Patient was seen by psychiatry who deemed him section 12 and requiring of psychiatric hospitaliztion. Patient was kept on a 1:1 sitter as a precaution for his own safety until a psychiatric bed could obtained. Please monitor for wound infection. Patient was kept on surgical floor with 1:1 sitter through weekend because of psychiatric team's concern of hematocrit, however HCT was deemed to be stable and on HD4 he was cleared for discharge to psychiatric bed."},"extractive_notes_summ":{"kind":"string","value":"free air under diaphragm or pneumothorax. On RA with clear and equal but diminished BS. Low attenuation renal lesions, likely cysts, but incompletely characterized. There is a small calcified granuloma in the right lung base. Mild-moderate coronary artery calcifications are present. HISTORY: Trauma, otherwise unspecified. Limited views of the upper abdomen demonstrate bilateral low attenuation renal lesions, likely cysts, but incompletely characterized on current study. CT OF THE CHEST WITH CONTRAST: The heart, pericardium, and great vessels are unremarkable. Few small foci of subcutaneous air, and tiny amount of air in anterior abdominal fat. Abd soft, obese with +BS. Few small foci of subcutaneous air and air in the anterior abdominal fat. Skin w/d/i except for stab wound. COMPARISON: No prior radiographs are obtained. 4:38 PM CT CHEST W/CONTRAST Clip # Reason: free air under diaphragm? There are a few small foci of subcutaneous air, and air within the anterior abdominal fat, but there is no free intraperitoneal air seen. A few small mediastinal lymph nodes are seen, but do not meet CT criteria for pathologic enlargement. SR, normotensive. After arrival to EW pt scanned and no injury to major organs. (Over) 4:38 PM CT CHEST W/CONTRAST Clip # Reason: free air under diaphragm? No definite pleural effusion or pneumothorax is seen. Foley patent with good UO. The central bronchi are patent to the subsegmental level. Contrast: OPTIRAY Amt: 75 FINAL REPORT (Cont) Hemodynamically stable. cont to have sitter at bedside as pt has active SI but no HI. IMPRESSION: No definite radiographic evidence of traumatic injury to the chest. Pt denies any pain in area. Meds- Prozac and glucophage (Has not been taking them recently because of care coverage). BG in 300s now slowly decreasing. Lung volumes are diminished but otherwise the lungs remain clear. Lopressor held at 2am for SBP<110. The cardiac silhouette remains normal in size. ptx? ptx? ptx? IMPRESSION: 1. No evidence of pneumothorax or free intraperitoneal air. No BM.Plan- Seen by psychiatry and will be section 12 after medically cleared. Afebrile. In the setting of trauma, however mediastinal vascular injury cannot be entirely excluded. HCT on arrival 29.3. COMPARISON: None. There are old right posterior rib fractures. No significant axillary, hilar, or mediastinal lymphadenopathy is seen. MAEs well. No displaced fractures are noted. Left chest wall hematoma, approximately 9 x 5 cm. Left chest wall hematoma, approximately 9 x 5 cm. No pneumothorax, diaphramatic injury or free air in abd. No contraindications for IV contrast WET READ: DSsd FRI 5:25 PM No pneumothorax or free intraperitoneal air. Wounds covered with DSD and at 4am noted small amt bleeding. No focal areas of consolidation are seen. Large L chest hematoma. FINDINGS: Trauma backboard artifact is evident. There is hematoma in the left lower chest wall and upper abdominal wall, overlying the left rectus abdominis muscle, measuring approximately 9.5 x 5.6 cm. HCT at 2300 25.6 and am labs pending. Ativan 2 mg given with good effect. There is no pulmonary embolism, pleural effusion, or pneumothorax. IVF at 125cc/h with good UO. TECHNIQUE: MDCT-acquired axial imaging from the thoracic inlet to the upper abdomen after 75 cc Optiray intravenous contrast. Area marked and timed. PMHx- Depression with h/o of suicide attempt in and , DM. PIV x 1, TLC in L groin. 3. ? ROS Pt is alert and orientated x 3. 2. This study, however, was made available for my review after a chest CT had been acquired and has already been dictated separately. The mediastinum is widened likely secondary to positioning, habitus, and AP portable technique. Renal ultrasound is recommended for further characterization. Was feeling \"little edgy\" being in the hospital and unable to sleep. 3:52 PM CHEST (PORTABLE AP) Clip # Reason: TRAUMA FINAL REPORT AP PORTABLE CHEST AT 1603 HOURS. Admitted to ICU for close monitoring. Married 2 years, seperated in and divorced . Multiplanar reformatted images obtained and reviewed. Sats > 95%. Contrast: OPTIRAY Amt: 75 MEDICAL CONDITION: 60 year old man with multiple stab wounds to left chest, hemodynamically stable REASON FOR THIS EXAMINATION: free air under diaphragm? Calm, cooperative and very pleasant. Strained relationship with father and not very close to his 2 sisters. Slept most of the night. Pt from upstate NY. He was found by passerbys who called 911. FINAL REPORT HISTORY: 60-year-old male with multiple stab wounds to the left chest. Figured he had enough money to live off of for 6 weeks, quit his job, tried to do the things he enjoyed and then when the money ran out kill himself. Pt has impressive educational backround and has had several careers including a teaching position at and in biology."},"n_notes":{"kind":"number","value":3,"string":"3"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2122-02-20 00:00:00.000","description":"CT CHEST W/CONTRAST","row_id":953845,"text":" 4:38 PM\n CT CHEST W/CONTRAST Clip # \n Reason: free air under diaphragm? ptx?\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with multiple stab wounds to left chest, hemodynamically stable\n REASON FOR THIS EXAMINATION:\n free air under diaphragm? ptx?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd FRI 5:25 PM\n No pneumothorax or free intraperitoneal air. Left chest wall hematoma,\n approximately 9 x 5 cm. Few small foci of subcutaneous air, and tiny amount\n of air in anterior abdominal fat.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old male with multiple stab wounds to the left chest.\n Hemodynamically stable. ? free air under diaphragm or pneumothorax.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired axial imaging from the thoracic inlet to the upper\n abdomen after 75 cc Optiray intravenous contrast. Multiplanar reformatted\n images obtained and reviewed.\n\n CT OF THE CHEST WITH CONTRAST: The heart, pericardium, and great vessels are\n unremarkable. There is no pulmonary embolism, pleural effusion, or\n pneumothorax. No focal areas of consolidation are seen. The central bronchi\n are patent to the subsegmental level. No significant axillary, hilar, or\n mediastinal lymphadenopathy is seen. There is a small calcified granuloma in\n the right lung base. Mild-moderate coronary artery calcifications are\n present. A few small mediastinal lymph nodes are seen, but do not meet CT\n criteria for pathologic enlargement.\n\n There is hematoma in the left lower chest wall and upper abdominal wall,\n overlying the left rectus abdominis muscle, measuring approximately 9.5 x 5.6\n cm. There are a few small foci of subcutaneous air, and air within the\n anterior abdominal fat, but there is no free intraperitoneal air seen.\n\n Limited views of the upper abdomen demonstrate bilateral low attenuation renal\n lesions, likely cysts, but incompletely characterized on current study. There\n are old right posterior rib fractures.\n\n IMPRESSION:\n 1. No evidence of pneumothorax or free intraperitoneal air.\n\n 2. Left chest wall hematoma, approximately 9 x 5 cm. Few small foci of\n subcutaneous air and air in the anterior abdominal fat.\n\n 3. Low attenuation renal lesions, likely cysts, but incompletely\n characterized. Renal ultrasound is recommended for further characterization.\n\n (Over)\n\n 4:38 PM\n CT CHEST W/CONTRAST Clip # \n Reason: free air under diaphragm? ptx?\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2122-02-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":953842,"text":" 3:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 1603 HOURS.\n\n HISTORY: Trauma, otherwise unspecified.\n\n COMPARISON: No prior radiographs are obtained. This study, however, was made\n available for my review after a chest CT had been acquired and has already\n been dictated separately.\n\n FINDINGS: Trauma backboard artifact is evident. Lung volumes are diminished\n but otherwise the lungs remain clear. The mediastinum is widened likely\n secondary to positioning, habitus, and AP portable technique. In the setting\n of trauma, however mediastinal vascular injury cannot be entirely excluded.\n The cardiac silhouette remains normal in size. No definite pleural effusion\n or pneumothorax is seen. No displaced fractures are noted.\n\n IMPRESSION: No definite radiographic evidence of traumatic injury to the\n chest.\n\n"},{"category":"Nursing/other","chartdate":"2122-02-21 00:00:00.000","description":"Report","row_id":1480072,"text":"NPN 2300-0700\n Pt is a 60 male BIBA after suicide attempt in Yard. Pt used a 5 inch paring knife and stabbed himself 4 times in chest area. Figured he had enough money to live off of for 6 weeks, quit his job, tried to do the things he enjoyed and then when the money ran out kill himself. He was found by passerbys who called 911. After arrival to EW pt scanned and no injury to major organs. No pneumothorax, diaphramatic injury or free air in abd. Large L chest hematoma. HCT on arrival 29.3. Admitted to ICU for close monitoring.\n\n PMHx- Depression with h/o of suicide attempt in and , DM.\n\n Meds- Prozac and glucophage (Has not been taking them recently because of care coverage).\n\n Pt from upstate NY. Strained relationship with father and not very close to his 2 sisters. Married 2 years, seperated in and divorced . Pt has impressive educational backround and has had several careers including a teaching position at and in biology.\n\n ROS\n Pt is alert and orientated x 3. MAEs well. Calm, cooperative and very pleasant. Was feeling \"little edgy\" being in the hospital and unable to sleep. Ativan 2 mg given with good effect. Slept most of the night.\n On RA with clear and equal but diminished BS. Sats > 95%.\n SR, normotensive. Lopressor held at 2am for SBP<110. Afebrile. BG in 300s now slowly decreasing. HCT at 2300 25.6 and am labs pending. PIV x 1, TLC in L groin. IVF at 125cc/h with good UO. Skin w/d/i except for stab wound. Wounds covered with DSD and at 4am noted small amt bleeding. Area marked and timed. Pt denies any pain in area.\n Abd soft, obese with +BS. Foley patent with good UO. No BM.\n\nPlan- Seen by psychiatry and will be section 12 after medically cleared. cont to have sitter at bedside as pt has active SI but no HI.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-02-20 00:00:00.000\",\n \"description\": \"CT CHEST W/CONTRAST\",\n \"row_id\": 953845,\n \"text\": \" 4:38 PM\\n CT CHEST W/CONTRAST Clip # \\n Reason: free air under diaphragm? ptx?\\n Contrast: OPTIRAY Amt: 75\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with multiple stab wounds to left chest, hemodynamically stable\\n REASON FOR THIS EXAMINATION:\\n free air under diaphragm? ptx?\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: DSsd FRI 5:25 PM\\n No pneumothorax or free intraperitoneal air. Left chest wall hematoma,\\n approximately 9 x 5 cm. Few small foci of subcutaneous air, and tiny amount\\n of air in anterior abdominal fat.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 60-year-old male with multiple stab wounds to the left chest.\\n Hemodynamically stable. ? free air under diaphragm or pneumothorax.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: MDCT-acquired axial imaging from the thoracic inlet to the upper\\n abdomen after 75 cc Optiray intravenous contrast. Multiplanar reformatted\\n images obtained and reviewed.\\n\\n CT OF THE CHEST WITH CONTRAST: The heart, pericardium, and great vessels are\\n unremarkable. There is no pulmonary embolism, pleural effusion, or\\n pneumothorax. No focal areas of consolidation are seen. The central bronchi\\n are patent to the subsegmental level. No significant axillary, hilar, or\\n mediastinal lymphadenopathy is seen. There is a small calcified granuloma in\\n the right lung base. Mild-moderate coronary artery calcifications are\\n present. A few small mediastinal lymph nodes are seen, but do not meet CT\\n criteria for pathologic enlargement.\\n\\n There is hematoma in the left lower chest wall and upper abdominal wall,\\n overlying the left rectus abdominis muscle, measuring approximately 9.5 x 5.6\\n cm. There are a few small foci of subcutaneous air, and air within the\\n anterior abdominal fat, but there is no free intraperitoneal air seen.\\n\\n Limited views of the upper abdomen demonstrate bilateral low attenuation renal\\n lesions, likely cysts, but incompletely characterized on current study. There\\n are old right posterior rib fractures.\\n\\n IMPRESSION:\\n 1. No evidence of pneumothorax or free intraperitoneal air.\\n\\n 2. Left chest wall hematoma, approximately 9 x 5 cm. Few small foci of\\n subcutaneous air and air in the anterior abdominal fat.\\n\\n 3. Low attenuation renal lesions, likely cysts, but incompletely\\n characterized. Renal ultrasound is recommended for further characterization.\\n\\n (Over)\\n\\n 4:38 PM\\n CT CHEST W/CONTRAST Clip # \\n Reason: free air under diaphragm? ptx?\\n Contrast: OPTIRAY Amt: 75\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-02-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 953842,\n \"text\": \" 3:52 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: TRAUMA\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP PORTABLE CHEST AT 1603 HOURS.\\n\\n HISTORY: Trauma, otherwise unspecified.\\n\\n COMPARISON: No prior radiographs are obtained. This study, however, was made\\n available for my review after a chest CT had been acquired and has already\\n been dictated separately.\\n\\n FINDINGS: Trauma backboard artifact is evident. Lung volumes are diminished\\n but otherwise the lungs remain clear. The mediastinum is widened likely\\n secondary to positioning, habitus, and AP portable technique. In the setting\\n of trauma, however mediastinal vascular injury cannot be entirely excluded.\\n The cardiac silhouette remains normal in size. No definite pleural effusion\\n or pneumothorax is seen. No displaced fractures are noted.\\n\\n IMPRESSION: No definite radiographic evidence of traumatic injury to the\\n chest.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2122-02-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1480072,\n \"text\": \"NPN 2300-0700\\n Pt is a 60 male BIBA after suicide attempt in Yard. Pt used a 5 inch paring knife and stabbed himself 4 times in chest area. Figured he had enough money to live off of for 6 weeks, quit his job, tried to do the things he enjoyed and then when the money ran out kill himself. He was found by passerbys who called 911. After arrival to EW pt scanned and no injury to major organs. No pneumothorax, diaphramatic injury or free air in abd. Large L chest hematoma. HCT on arrival 29.3. Admitted to ICU for close monitoring.\\n\\n PMHx- Depression with h/o of suicide attempt in and , DM.\\n\\n Meds- Prozac and glucophage (Has not been taking them recently because of care coverage).\\n\\n Pt from upstate NY. Strained relationship with father and not very close to his 2 sisters. Married 2 years, seperated in and divorced . Pt has impressive educational backround and has had several careers including a teaching position at and in biology.\\n\\n ROS\\n Pt is alert and orientated x 3. MAEs well. Calm, cooperative and very pleasant. Was feeling \\\"little edgy\\\" being in the hospital and unable to sleep. Ativan 2 mg given with good effect. Slept most of the night.\\n On RA with clear and equal but diminished BS. Sats > 95%.\\n SR, normotensive. Lopressor held at 2am for SBP<110. Afebrile. BG in 300s now slowly decreasing. HCT at 2300 25.6 and am labs pending. PIV x 1, TLC in L groin. IVF at 125cc/h with good UO. Skin w/d/i except for stab wound. Wounds covered with DSD and at 4am noted small amt bleeding. Area marked and timed. Pt denies any pain in area.\\n Abd soft, obese with +BS. Foley patent with good UO. No BM.\\n\\nPlan- Seen by psychiatry and will be section 12 after medically cleared. cont to have sitter at bedside as pt has active SI but no HI.\\n\"\n }\n]"}}},{"rowIdx":91,"cells":{"subject_id":{"kind":"number","value":14197,"string":"14,197"},"hadm_id":{"kind":"number","value":170569,"string":"170,569"},"target_text":{"kind":"string","value":"61-year-old man with a history of cirrhosis secondary to NASH with complication of esophageal varices, diabetes, atrial fibrillation, AVR, hypertension, diastolic CHF who presents with GI bleed and episode of hemetemesis in the ED, found to have volume overload on cath and difficult to control anticoagulation. #. Upper GI bleed, secondary to esophageal varices: Patient has previous admission in for esophageal bleeding. Liver performed endoscopy and found three actively bleeding varices in the fundus of the stomach, which where glued and appeared to have stopped bleeding. Endoscopy demonstrated varices at the lower third of the esophagus with old blood in the stomach. patient was kept on a PPI drip as well as an octreotide drip and transitioned to PO PPI and off octreotide. We actively followed the patient's hematocrit after the pRBC transfusions. Patient's hct was stable. total of 3uPRBC were transfused. Received 5 days zosyn antibiotics. He was discharged on sucralfate and PPI . . On transfer to the - service, the patient received 4U PRBC, as well as 2U FFP and his crits and INR remained stable. Cardiology was consulted, as patient had UGIB in the context of supratherapeutic INR for AVR and atrial fibrillation. After discussing the risks and benefits of anticoagulation in his situation, the patient's INR goal was decreased to . While on the floor, the patient was initially on octreotide and protonix drips. He was also started on Zosyn for SBP ppx and completed 5 days of treatment. Zosyn was started because the patient is allergic to cephalosporins. He was restarted on coumadin at 5 mg daily once all active bleeding had stopped. His home nadolol was held during the acute setting of bleeding, but was then restarted. . # Protection of airway: The patient had been intubated to protect his airway because of significant hemetemesis. After stabilization the patient was extubated without difficulty. . # Supratherapeutic INR: INR on admission was 5.4. Patient received 2 units of fresh frozen plasma. there was transient improvement in his INR. . On the floor, the patient was given another two units of FFP. After consulting cardiology it was decided (after discussion of risk/benefit with patient) that INR goal should be , given the high risk this patient has for bleeding. He was also restarted on coumadin, once it was sure that his hematocrits were stable and he was no longer bleeding. He was started on a heparin drip and warfarin was uptitrated over a longer than usual period of time to 10mg daily. This had been his home dose that he had come in on supratherapeutic and he denied med noncompliance or change in diet/meds. He likely has a narrow therapeutic window for INR and needs to be closely monitored. Home INR monitoring was set up and will be delivered to patient after discharge. He will follow up for INR check 1 and 3 days after discharge and results to be faxed to PCP, plan was discussed with by phone. . # Atrial fibrillation: Patient appeared to be in sinus rhythm on monitor on admission. CHADS score would be at least 3. Remained stable in the MICU. . On the floor, the patient was given another 2U FFP. Once his crits were stable, the patient was restarted on coumadin, with new INR goal of . While on the floor, the patient was still in sinus and continued on his home dronedarone . #. Aortic valve replacement: Holding anticoagulation in setting of upper GI bleed. Once his crits were stable, the patient was restarted on coumadin. Cardiolgy was also consulted, and it was decided that his INR goal should be . . # Diastolic congestive heart failure: Patient with history of diastolic CHF, last EF >55% in 5/. The patient appears to have interstitial pulonary edema on chest X-ray. Holding furosemide and spironolactone due to GI bleed. Stopping hemorrhage will take precedence over diuresis, especially as patient is intubated. . While on the floor, the patient appeared somewhat overloaded, especially in the setting of received blood product. He was restarted on diuresis with IV Lasix 40 mg , as well as spironlactone 50 mg daily. He was transitioned to PO dosing but creatinine did not tolerate higher than 40mg PO dose. Additional fluid should be diuresed as outpatient. . # Diabetes: Patient had good glycemic control on 20mg Lantus daily with minimal SSI coverage. BS should be closely monitored by PCP as . and dose increased as needed. . # cirrhosis: likely Etoh; the patient has not had alcohol since 5/. The patient was evaluated for TIPS on his last admission and on hepatic venogram, did not have elevated portosystemic pressure. Given the patient's abstinence from etoh and tenuous situation given need for anticoagulation superimposed with elevated bleeding risk with varices, liver transplantation is an option. He had a R heart cath this admission to assess for pulmonary hypertension. On R heart cath, the patient had elevated wedge and pulmonary pressures could not be assessed. He was then started on aggressive diueresis, IV Lasix 40 mg , as well as spironlactone 50 mg daily and transitioned to 40mg PO daily, limited by creatinine. The patient will have to pursue this as an outpatient, as he will need repeat R heart cath once his volume status is optimized. . # depression/anxiety: The patient was also continued on his duloxetine 30 mg daily. He affect seemed somewhat depressed during admission. . . Transitional issues: -repeat right heart cath as outpatient once volume status optimized -trend creatiniine while diuresing -close INR monitoring, including home monitor as outpatient -INR check by VNA and "},"extractive_notes_summ":{"kind":"string","value":"Unchanged moderate cardiomegaly with mild fluid overload, bilateral areas of basal atelectasis, and a small left pleural effusion. Unchanged moderate cardiomegaly with signs of mild fluid overload. No larger pleural effusions. Probable sinus rhythm. Otherwise, normaltracing. Q-T interval prolongation. Otherwise, normal tracing. The monitoring and support devices are in constant position, except for the nasogastric tube that has been removed in the interval. Compared to theprevious tracing of sinus bradycardia is new. Low amplitude P wave. Otherwise, unchanged. Left atrial abnormality.Leftward axis. Sinus bradycardia. No interval appearance of other parenchymal opacities. FINDINGS: As compared to the previous radiograph, there is no relevant change. No pneumonia, mild retrocardiac atelectasis. COMPARISON: . COMPARISON: . Known sternotomy wires after valvular repair. Leftward axis. Evaluation for interval change. FINDINGS: As compared to the previous radiograph, the patient has been intubated. QTc interval is longer. The patient has also received a nasogastric tube, the course of the tube is unremarkable, the tip of the tube projects over the distal parts of the stomach. Since the previous tracingof the rate is faster. The tip of the endotracheal tube projects 4 cm above the carina. 9:46 PM CHEST (PORTABLE AP) Clip # Reason: Eval ETT and NGT placement Admitting Diagnosis: UPPER GI BLEED MEDICAL CONDITION: 61 year old man with UGIB s/p intubation REASON FOR THIS EXAMINATION: Eval ETT and NGT placement FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post intubation, evaluation for nasogastric tube placement."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2173-01-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1221122,"text":" 9:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval ETT and NGT placement\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with UGIB s/p intubation\n REASON FOR THIS EXAMINATION:\n Eval ETT and NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post intubation, evaluation for nasogastric tube\n placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n intubated. The tip of the endotracheal tube projects 4 cm above the carina.\n The patient has also received a nasogastric tube, the course of the tube is\n unremarkable, the tip of the tube projects over the distal parts of the\n stomach.\n\n Known sternotomy wires after valvular repair.\n\n Unchanged moderate cardiomegaly with signs of mild fluid overload. No larger\n pleural effusions. No pneumonia, mild retrocardiac atelectasis.\n\n\n"},{"category":"Radiology","chartdate":"2173-01-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1221133,"text":" 3:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with upper GI bleed, history of diastolic\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Upper gastrointestinal bleed, history of diastolic disease.\n Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The monitoring and support devices are in constant position, except\n for the nasogastric tube that has been removed in the interval. Unchanged\n moderate cardiomegaly with mild fluid overload, bilateral areas of basal\n atelectasis, and a small left pleural effusion. No interval appearance of\n other parenchymal opacities.\n\n\n"},{"category":"ECG","chartdate":"2173-01-27 00:00:00.000","description":"Report","row_id":197630,"text":"Sinus bradycardia. Leftward axis. Otherwise, normal tracing. Compared to the\nprevious tracing of sinus bradycardia is new. Otherwise, normal\ntracing.\n\n"},{"category":"ECG","chartdate":"2173-01-23 00:00:00.000","description":"Report","row_id":197631,"text":"Low amplitude P wave. Probable sinus rhythm. Left atrial abnormality.\nLeftward axis. Q-T interval prolongation. Since the previous tracing\nof the rate is faster. QTc interval is longer. Otherwise, unchanged.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-01-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1221122,\n \"text\": \" 9:46 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval ETT and NGT placement\\n Admitting Diagnosis: UPPER GI BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with UGIB s/p intubation\\n REASON FOR THIS EXAMINATION:\\n Eval ETT and NGT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Status post intubation, evaluation for nasogastric tube\\n placement.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, the patient has been\\n intubated. The tip of the endotracheal tube projects 4 cm above the carina.\\n The patient has also received a nasogastric tube, the course of the tube is\\n unremarkable, the tip of the tube projects over the distal parts of the\\n stomach.\\n\\n Known sternotomy wires after valvular repair.\\n\\n Unchanged moderate cardiomegaly with signs of mild fluid overload. No larger\\n pleural effusions. No pneumonia, mild retrocardiac atelectasis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-01-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1221133,\n \"text\": \" 3:36 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Interval change\\n Admitting Diagnosis: UPPER GI BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with upper GI bleed, history of diastolic\\n REASON FOR THIS EXAMINATION:\\n Interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Upper gastrointestinal bleed, history of diastolic disease.\\n Evaluation for interval change.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, there is no relevant\\n change. The monitoring and support devices are in constant position, except\\n for the nasogastric tube that has been removed in the interval. Unchanged\\n moderate cardiomegaly with mild fluid overload, bilateral areas of basal\\n atelectasis, and a small left pleural effusion. No interval appearance of\\n other parenchymal opacities.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2173-01-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 197630,\n \"text\": \"Sinus bradycardia. Leftward axis. Otherwise, normal tracing. Compared to the\\nprevious tracing of sinus bradycardia is new. Otherwise, normal\\ntracing.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2173-01-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 197631,\n \"text\": \"Low amplitude P wave. Probable sinus rhythm. Left atrial abnormality.\\nLeftward axis. Q-T interval prolongation. Since the previous tracing\\nof the rate is faster. QTc interval is longer. Otherwise, unchanged.\\n\\n\"\n }\n]"}}},{"rowIdx":92,"cells":{"subject_id":{"kind":"number","value":27331,"string":"27,331"},"hadm_id":{"kind":"number","value":104786,"string":"104,786"},"target_text":{"kind":"string","value":"A/P 67-year-old gentleman with metastatic colon CA presenting with AMS . # Respiratory distress: CTA negative for large PE, though could not r/o small PE. CXR showed RLL atelectasis. PNA could not be completely ruled out. Exam and CXR dont support pulm edema. No echo in the system. LENIs were negative. He was given vanc and levo as well as albuterol and atrovent nebs. All cultures were negative. He was stabilized in the and transfered to the floor. . # AMS - His mental status waxed and waned during his stay. He was minimally interactive by the time he was called out of the to OMED. He had no intracranial disease by CT. His AMS was likely from hepatic encephalopathy vs infection, though there was little evidence of infection. He was given antibiotics as above as well as lactulose for possible hepatic encephalopathy. Mr. also showed evidence of seizure activity in the final days of his stay. Given his poor prognosis and acute decline, his family decided to transition to CMO status. All non-comfort meds were decreased. Palliative care was consulted. He passed on . . # ONCOLOGIC - Patient with widely metastatic colon CA s/p failed first and second-line chemotherapy, most recently started on Erbitux. Imaging as above. He was transitioned to CMO as above. . # LE edema: stable and chronic. d/c'd lasix with CMO status. . # ELEVATED LFTs - Likely related to progression of widely metastic colon CA with known involvement of liver. No acute intra-abdominal pathology seen on Abdominal CT; cholecystitis is on differential and HIDA or U/S more sensitive for cholecystitis, but given comorbidities, patient was not a candidate for surgical intervention. . # osteoarthritis - comfort care as above . # CODE - CMO"},"extractive_notes_summ":{"kind":"string","value":"There is sigmoid diverticulosis, without evidence of diverticulitis. Unchanged appearance of widespread intrahepatic metastatic disease. COMPARISON: Non-contrast head CT, . FINDINGS: Evaluation is limited secondary to severe edema bilaterally. TECHNIQUE: Non-contrast head CT. BS+, pt unable to hold lactulose enema, pt w/poor rectal tone. Widespread ill-defined intrahepatic nodules and masses are grossly unchanged when compared to , and remain consistent with metastatic disease. Mild atelectasis at the right base and elevation of the right hemidiaphragm are unchanged. C/o discomfort during ultrasound, prelim report no DVT.RESP: tachypnic, RR 30s. A previously identified subcentimeter right lower lobe pulmonary nodule is not well evaluated as it is present in the region of consolidated lung. There is some linear opacity at the right base representing mild atelectasis. Non-diagnostic small Q waves in the inferior leads.Anterolateral ST-T wave changes which are non-specific. There are a few small mediastinal lymph nodes not pathologic by CT size criteria. Pt w/gross sacral and bilateral lower extremity. Visualized lung apices are unremarkable. HR tachy 110-120s ST, no VEA noted. Right paracentral disc bulge at C5/6 without significant canal narrowing. TECHNIQUE: MDCT axial images of the head pre and post a bolus of Optiray IV contrast with multiplanar reformats. Small bilateral pleural effusions and consolidation of a portion of the dependent lower lobes, right worse than left. There is minimal periventricular white matter hypodensity, most consistent with chronic small vessel ischemic disease. The visualized brain parenchyma is unremarkable. Low QRS voltagein the precordial leads. IMPRESSION: No acute intracranial process. IMPRESSION: No acute intracranial process. Visualized paranasal sinuses are normally aerated. Allowing for these limitations, the common femoral, superficial femoral, and popliteal veins on both right and left lower extremities demonstrated normal flow, augmentation, compressibility, and waveforms. Broad-based posterior disc bulges at C3/4 and C4/5 result in mild-to-moderate central canal stenosis. Mild atelectasis at the right lung base. IMPRESSION: No relevant change as compared to . CT OF THE HEAD WITHOUT AND WITH IV CONTRAST: There is no evidence of hemorrhage, shift of normally midline structures, mass effect, hydrocephalus or infarction. Multilevel degenerative changes, as described above, with mild-moderate ventral canal narrowing at C3/4 and C4/5 levels. FINDINGS: In comparison with the previous examination, there are no major relevant changes. CT OF THE CHEST WITH IV CONTRAST: There is no evidence of pulmonary embolism, although assessment of the small segmental and subsegmental pulmonary arterial branches is somewhat limited by patient respiratory motion and contrast timing. TECHNIQUE: MDCT axial images of the chest after rapid bolus of Optiray IV contrast with multiplanar reformats. Limited evaluation of the upper abdomen demonstrates a large amount of ascites. There is mild periventricular white matter hypodensity consistent with mild chronic microvascular infarction. Numerous small mesenteric lymph nodes are not significantly changed. IMPRESSION: Limited exam, but no evidence to suggest DVT. OSSEOUS STRUCTURES: Multilevel thoracolumbar degenerative changes are similar, and there is no sign of suspicious osteolytic or sclerotic lesion. Clinical correlation issuggested. Additionally, the exam was limited given patient discomfort and the right tibials and peroneals on the right were not visualized. There are small bilateral pleural effusions and associated dependent consolidation of the lower lobes, right greater than left. In ICU, immediately started on heparin drip, then sent to CT scan of chest that showed no PE, heparin D/Ced, and CT of head was negative. No evidence of substantial pleural effusions. TECHNIQUE: MDCT acquired axial imaging was performed of the abdomen and pelvis after administration of intravenous contrast only. Prevertebral and paraspinal soft tissues are normal. The visualized osseous structures are unremarkable. LS: coarse upper, deminished bases. TECHNIQUE: MDCT-acquired axial imaging was performed through the cervical spine without intravenous contrast. No acute intrathoracic process. No opacity suggestive of pneumonia. IMPRESSION: No acute cervical spine fracture or malalignment. Facet osteophytes result in mild neural foraminal narrowing on the left at C4/5, on the right at C5/6, and also on the left at C5/6. COMPARISON: CT from . CT ABDOMEN: Visualized lung bases demonstrate small bilateral pleural effusions, and minor bibasilar atelectasis. MICU NPNNEURO: VERY LETHARGIC AND DISORIENTATED, RESPONDS TO PAIN.RESP: SATS ARE FINE ON ROOM AIR, TACHYPNEIC AT TIMES AND STOKE BREATHIGN AT TIMES. No signs of hyperhydration. No intraluminal luminal thrombus was identified. There is some interval worsening in the right mid and lower lobe atelectasis and pulmonary edema. There is no acute aortic abnormality. NGT placed as patient appeared to fail bedside swallow eval, clearing of throat after POs. NPN 1900-0700:Neuro: lethargic and dozing most og the time, oriented only to his name, pulling at tubes, restrained for safety, denied pain.Resp: On RA sating in 90s, LS CTA to coarse in upper lobes, diminished at bases, nonproductive cough.CV: SEE carevieu for details, tachycardiac, given 3 boluses of a total of 1.5 L NS, with a PIV line, difficult to palpate peripheral pulses.GI?GU: ascites, with NGT for meds, lactulose for encephalopathy, passed loose BM, diaper applied, with foley, icteric U/O, was low imporoved after NS boluses (see carevieu).Integ: T 98.6, restrained for safety.Social: DNI/DNR, wife and daughter visited and updated on .Plan: called out to a floor, monitor mental status, U/O, HR, bolus as needed, administer lactulose for encephalopathy, update family on any chamnges in pt's condition, still DNI/DNR. CTA unable to rule out small subsegmental PE due to motion artifact. IMPRESSION: Standard position of NG tube. No pulmonary embolism. No oral contrast was administered. No evidence of intracranial metastatic disease. There is no free intraperitoneal air. No new nodules are identified. Mild degenerative change is seen at the atlantodental interface anteriorly and superiorly, likely calcification of the apical dental ligament. CHEST PORTABLE: Comparison is made to a prior examination of . The gallbladder, pancreas, spleen, and adrenal glands are unremarkable. COMPARISON: CT torso . Interval worsening in atelectasis and pulmonary edema."},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2121-12-13 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":994967,"text":" 4:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for mass, bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with altered mental status s/p fall, metastatic colon ca\n REASON FOR THIS EXAMINATION:\n eval for mass, bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with altered mental status, status post fall.\n History of metastatic colon cancer. Please evaluate for mass or bleed.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intracranial hemorrhage, mass, mass effect, or evidence\n of acute vascular territorial infarction. There is minimal periventricular\n white matter hypodensity, most consistent with chronic small vessel ischemic\n disease. The ventricles and sulci are normal in size and configuration.\n There is no fracture. Visualized paranasal sinuses are normally aerated.\n\n IMPRESSION: No acute intracranial process.\n\n"},{"category":"Radiology","chartdate":"2121-12-13 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":994968,"text":" 4:34 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with altered mental status s/p fall, metastatic colon ca\n REASON FOR THIS EXAMINATION:\n eval for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd SAT 6:47 PM\n no fx or malalignment\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with altered mental status, metastatic colon\n cancer, status post multiple falls.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired axial imaging was performed through the cervical\n spine without intravenous contrast. Multiplanar reformatted images were\n obtained and reviewed.\n\n CT CERVICAL SPINE: There is no fracture, or acute cervical spine\n malalignment. Prevertebral and paraspinal soft tissues are normal. There is\n no lytic or sclerotic bony lesion.\n\n Mild degenerative change is seen at the atlantodental interface anteriorly and\n superiorly, likely calcification of the apical dental ligament. Facet\n osteophytes result in mild neural foraminal narrowing on the left at C4/5, on\n the right at C5/6, and also on the left at C5/6. Broad-based posterior disc\n bulges at C3/4 and C4/5 result in mild-to-moderate central canal stenosis.\n Right paracentral disc bulge at C5/6 without significant canal narrowing.\n\n Visualized lung apices are unremarkable. The visualized brain parenchyma is\n unremarkable.\n\n IMPRESSION: No acute cervical spine fracture or malalignment. Multilevel\n degenerative changes, as described above, with mild-moderate ventral canal\n narrowing at C3/4 and C4/5 levels.\n\n"},{"category":"Radiology","chartdate":"2121-12-13 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":994969,"text":" 4:35 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: abscess? bloody mass? free fluid?\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with colon CA now with abd distention and altered mental status\n REASON FOR THIS EXAMINATION:\n abscess? bloody mass? free fluid?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with colon cancer, now with abdominal distension\n and altered mental status.\n\n COMPARISON: CT from .\n\n TECHNIQUE: MDCT acquired axial imaging was performed of the abdomen and\n pelvis after administration of intravenous contrast only. No oral contrast\n was administered.\n\n CT ABDOMEN: Visualized lung bases demonstrate small bilateral pleural\n effusions, and minor bibasilar atelectasis.\n\n Widespread ill-defined intrahepatic nodules and masses are grossly unchanged\n when compared to , and remain consistent with metastatic disease. As\n before, some of these masses are situated near the liver capsule, and deform\n the liver surface. The overall amount of ascites within the abdomen has\n increased.\n\n The gallbladder, pancreas, spleen, and adrenal glands are unremarkable.\n Kidneys enhance and excrete contrast symmetrically. There is no\n hydronephrosis. There is no free intraperitoneal air. Numerous small\n mesenteric lymph nodes are not significantly changed.\n\n CT PELVIS: Free fluid extends into the pelvis, and within the\n processus vaginalis, through an inguinal hernia into the left hemiscrotum. The\n urinary bladder is decompressed with a Foley catheter balloon in place. There\n is sigmoid diverticulosis, without evidence of diverticulitis.\n\n OSSEOUS STRUCTURES: Multilevel thoracolumbar degenerative changes are\n similar, and there is no sign of suspicious osteolytic or sclerotic lesion.\n Note is again made of prior left hip surgery.\n\n IMPRESSION:\n\n 1. Unchanged appearance of widespread intrahepatic metastatic disease.\n\n 2. Increased ascites.\n (Over)\n\n 4:35 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: abscess? bloody mass? free fluid?\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2121-12-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":994963,"text":" 4:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with metastatic ca, change in mental status, sob\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE.\n\n INDICATION: 67-year-old man with metastatic carcinoma, change in mental\n status, shortness of breath. Evaluate for infiltrate.\n\n CHEST PORTABLE: Comparison is made to a prior examination of . The\n heart is normal in size. There is an elevated hemidiaphragm. There is some\n linear opacity at the right base representing mild atelectasis. The pulmonary\n vasculature is normal. The lungs are otherwise clear. Port-A-Cath is\n identified with its tip in the right atrium. There are no pleural effusions.\n\n IMPRESSION:\n\n 1. No acute intrathoracic process. No evidence for pneumonia.\n\n 2. Mild atelectasis at the right base and elevation of the right\n hemidiaphragm are unchanged.\n\n\n"},{"category":"Radiology","chartdate":"2121-12-15 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":995195,"text":" 4:36 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: evaluate for DVT's\n Admitting Diagnosis: DEHYDRATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with bilateral lower extremity edema, metastatic colon ca, CTA\n unable to rule out small subsegmental PE due to motion artifact\n REASON FOR THIS EXAMINATION:\n evaluate for DVT's\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral lower extremity edema with metastatic colon cancer. CTA\n unable to rule out small subsegmental PE due to motion artifact. Please\n evaluate for DVTs.\n\n FINDINGS: Evaluation is limited secondary to severe edema bilaterally. The\n SVC in the mid and distal portions on the left were difficult to visualize,\n though the color flow in these sections appeared normal. Additionally, the\n exam was limited given patient discomfort and the right tibials and peroneals\n on the right were not visualized. Allowing for these limitations, the common\n femoral, superficial femoral, and popliteal veins on both right and left lower\n extremities demonstrated normal flow, augmentation, compressibility, and\n waveforms. No intraluminal luminal thrombus was identified.\n\n IMPRESSION: Limited exam, but no evidence to suggest DVT.\n\n"},{"category":"Radiology","chartdate":"2121-12-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":995075,"text":" 6:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for intrathrocic pathology.\n Admitting Diagnosis: DEHYDRATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with respiratory alkylosis, bronchial breath sounds, and desats\n to 80s on 4L.\n REASON FOR THIS EXAMINATION:\n please eval for intrathrocic pathology.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n COMPARISON: .\n\n INDICATION: Desaturation, followup.\n\n FINDINGS: In comparison with the previous examination, there are no major\n relevant changes. Due to projection, the pre-existing slight elevation of the\n hemidiaphragms is a little more visible. No evidence of substantial pleural\n effusions. The size of the cardiac silhouette is within the upper range of\n normal. No signs of hyperhydration. Mild atelectasis at the right lung base.\n No opacity suggestive of pneumonia. The Port-A-Cath is in standard position.\n\n IMPRESSION: No relevant change as compared to . No cardiac\n decompensation, no overhydration, no pneumonia.\n\n\n DR. \n"},{"category":"Radiology","chartdate":"2121-12-15 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":995086,"text":" 12:34 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please doa CTA chest to eval for PE\n Admitting Diagnosis: DEHYDRATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with CA colon now w/ acute onset SOB, tachypnea, droppig satts,\n tachycardia\n REASON FOR THIS EXAMINATION:\n please doa CTA chest to eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with metastatic colon cancer, now with acute onset\n of difficulty breathing, tachypnea and tachycardia with concern for pulmonary\n embolism.\n\n COMPARISON: CT torso .\n\n TECHNIQUE: MDCT axial images of the chest after rapid bolus of Optiray IV\n contrast with multiplanar reformats.\n\n CT OF THE CHEST WITH IV CONTRAST: There is no evidence of pulmonary embolism,\n although assessment of the small segmental and subsegmental pulmonary arterial\n branches is somewhat limited by patient respiratory motion and contrast\n timing. There is no acute aortic abnormality. There are a few small\n mediastinal lymph nodes not pathologic by CT size criteria. There are small\n bilateral pleural effusions and associated dependent consolidation of the\n lower lobes, right greater than left. A previously identified subcentimeter\n right lower lobe pulmonary nodule is not well evaluated as it is present in\n the region of consolidated lung. No new nodules are identified.\n\n Limited evaluation of the upper abdomen demonstrates a large amount of\n ascites. Most of the visualized liver is occupied by confluent hypodense\n metastatic lesions.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are\n identified.\n\n IMPRESSION:\n\n 1. No pulmonary embolism. However, there is poor filling of the segmental\n branches for the left lower lobe. If clinically indicated, a repeated CTA\n coould be performed for better evaluation.\n\n 2. Small bilateral pleural effusions and consolidation of a portion of the\n dependent lower lobes, right worse than left.\n\n 3. Large amount of ascites and evidence of significant hepatic metastatic\n disease.\n\n These findings, including the need for further imaging if high clinical\n (Over)\n\n 12:34 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please doa CTA chest to eval for PE\n Admitting Diagnosis: DEHYDRATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n suspicion for PE were discussed with Dr. at 12:30PM on \n by Dr. .\n\n"},{"category":"Radiology","chartdate":"2121-12-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":995187,"text":" 3:58 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval ngt position\n Admitting Diagnosis: DEHYDRATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with metastatic Colon Ca s/p ngt placement\n REASON FOR THIS EXAMINATION:\n please eval ngt position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n INDICATION: Metastatic colon cancer, NG tube placement. There is comparison\n with the prior from at 2:42 p.m. The NG tube is in the\n proximal stomach. There is some interval worsening in the right mid and lower\n lobe atelectasis and pulmonary edema. No other interval change.\n\n IMPRESSION: Standard position of NG tube. Interval worsening in atelectasis\n and pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2121-12-15 00:00:00.000","description":"CT HEAD W/ & W/O CONTRAST","row_id":995085,"text":" 12:33 AM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: ?METS, BLEED\n Admitting Diagnosis: DEHYDRATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with metastatic CA colon now w/ acute onset SOB, and change in\n mental status\n REASON FOR THIS EXAMINATION:\n please eval for brain mets\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with metastatic colon cancer, now with difficulty\n breathing and change of mental status with concern for intracranial metastatic\n disease.\n\n COMPARISON: Non-contrast head CT, .\n\n TECHNIQUE: MDCT axial images of the head pre and post a bolus of Optiray IV\n contrast with multiplanar reformats.\n\n CT OF THE HEAD WITHOUT AND WITH IV CONTRAST: There is no evidence\n of hemorrhage, shift of normally midline structures, mass effect,\n hydrocephalus or infarction. There is mild periventricular white matter\n hypodensity consistent with mild chronic microvascular infarction. There is\n no evidence of abnormal brain parenchymal enhancement or focal mass lesion.\n The paranasal sinuses and mastoid air cells are clear. The visualized osseous\n structures are unremarkable.\n\n IMPRESSION: No acute intracranial process. No evidence of intracranial\n metastatic disease.\n\n\n\n"},{"category":"Radiology","chartdate":"2121-12-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":995177,"text":" 2:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evalute NG tube\n Admitting Diagnosis: DEHYDRATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with metastatic Colon CA s/p NG tube placement\n REASON FOR THIS EXAMINATION:\n please evalute NG tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube placement.\n\n FINDINGS: In comparison with the study of , the patient has taken a\n slightly better inspiration. The Dobbhoff tube extends to the lower body of\n the stomach.\n\n\n"},{"category":"Nursing/other","chartdate":"2121-12-15 00:00:00.000","description":"Report","row_id":1619961,"text":"NPN 0700-1900\nNeuro: difficult to arouse patient to painful stimulation this morning, however, after lactulose enema able to arouse patient to voice. Pt oriented to self only. AFebrile. Pt pulled out NGT necessitating hand mitts to prevent pulling of NGT. NGT placed as patient appeared to fail bedside swallow eval, clearing of throat after POs. Pt c/o discomfort on coccyx after lying of stretcher for ultrasound, repositioned on side and verbalized comfort.\nCV: b/p 95-120/50-60s, restarted PO lasix once NGT placement reconfirmed after pulling out 1st NGT. HR tachy 110-120s ST, no VEA noted. Pt given one 500cc IVF bolus and appeared to have increase in abdominal discomfort during bolus. Bolus given for lactate level of 5.2. Pt w/gross sacral and bilateral lower extremity. C/o discomfort during ultrasound, prelim report no DVT.\nRESP: tachypnic, RR 30s. LS: coarse upper, deminished bases. O2 sats RA 95%+ when pleth appears accurate.\nGI: ABD distended d/t ascites. BS+, pt unable to hold lactulose enema, pt w/poor rectal tone. Pt passing watery enema w/blood tinge x 2 today.\nGU: foley patent, restarted lasix PO @ 1800, monitor response.\nSocial: dtr and wife called, updated on care. Wife spoke w/MD @ length RE: status and consent for ICU.\n\n\n"},{"category":"Nursing/other","chartdate":"2121-12-16 00:00:00.000","description":"Report","row_id":1619962,"text":"NPN 1900-0700:\nNeuro: lethargic and dozing most og the time, oriented only to his name, pulling at tubes, restrained for safety, denied pain.\n\nResp: On RA sating in 90s, LS CTA to coarse in upper lobes, diminished at bases, nonproductive cough.\n\nCV: SEE carevieu for details, tachycardiac, given 3 boluses of a total of 1.5 L NS, with a PIV line, difficult to palpate peripheral pulses.\n\nGI?GU: ascites, with NGT for meds, lactulose for encephalopathy, passed loose BM, diaper applied, with foley, icteric U/O, was low imporoved after NS boluses (see carevieu).\n\nInteg: T 98.6, restrained for safety.\n\nSocial: DNI/DNR, wife and daughter visited and updated on .\n\nPlan: called out to a floor, monitor mental status, U/O, HR, bolus as needed, administer lactulose for encephalopathy, update family on any chamnges in pt's condition, still DNI/DNR.\n"},{"category":"Nursing/other","chartdate":"2121-12-16 00:00:00.000","description":"Report","row_id":1619963,"text":"MICU NPN\nNEURO: VERY LETHARGIC AND DISORIENTATED, RESPONDS TO PAIN.\n\nRESP: SATS ARE FINE ON ROOM AIR, TACHYPNEIC AT TIMES AND STOKE BREATHIGN AT TIMES. APPEARS COMFORTABLE.\n\nCV: HR AND BP STABLE\n\nGI: CONTINUES TO HAVE LOOSE DIARRHEA MUSHROOM CATH INSERTED, DRAINING WELL. CONTINUES TO BE NPO USING NGT FOR MEDS.\n\nGU: SEE CAREVUE FORMOST UP TO DATE URINE OUTPUT.\n\nSOCIAL: WIFE IN TODAY STATED CONCERNS ABOUT PT'S NEEDS AND HOW SHE WOULD LIKE HOSPICE TO GET INVOLVED, PALLIATIVE CARE CONSULT REQUESTED.\n\nPLAN: PT. IS CALLED OUT TO 7 SOUTH IS GOING TO BED 740.\n"},{"category":"Nursing/other","chartdate":"2121-12-15 00:00:00.000","description":"Report","row_id":1619960,"text":"Admission and NPN 2100-0700:\n67 yo male pt with hx of metastatic colonic CA, s/p 1st and 2nd line chemotherapy who was admitted to ED via EMS on with altered mental status and hallucinations when pt was noted by family to be incoherent, and more somnolent, talking to people who were not present and to deceased pets; no trauma or fall prior to this onset, he had been lethargic for several days and staying in bed, had anorexia and poor PO intake for several days. In ED CT was negative for bleeding, labs showed elevated LFTs, leukocytosis and dehydration, given fluids and antibiotics and admitted to 11 , where he developed deterioration in his mental status and occasional desaturatiopn, started on non0rebreather 100%, and transferred to for CT scans of chest and brain, ? PE. In ICU, immediately started on heparin drip, then sent to CT scan of chest that showed no PE, heparin D/Ced, and CT of head was negative. HO attributed the mental changes to encephalopathy, given lactulose enema, which didn't seem to work well.\n\nROS:\nNeuro: very lethargic, barely responsive to verbal stimuli, oriented only to his name, at times agitated in bed especially when he was on the CT table, got very restless, localizes pain, not follows commands, denied pain though he had bilateral knee replacement, which cause pain as per family, didn't recognize daughter or wife, very confused, .\n\nResp: received on NRB, then was on RA sating well, when in CT placed on NRB again, Sat 93-100%, LS coarse in upper lobes to diminished at bases, nonproductive cough.\n\nCV: ST HR 107-127, BP 107-129/72-101, with portocath on left chest area, heparin D/Ced, on levaquin and vancomycin, weak peripheral pulses, given bicarb pre and post CT scan wiuth contrast, cool extremities.\n\nGI/GU: with diffused ascites, paracentesis done and specimen sent for cx, NPO, passed loose stool, with foley icteric U/O.\n\nInteg: T max 98, icteric skin, with left heal blister, yellow base, cleaned and open to air, washed up.\n\nPlan: monitor mental status closely, monitor respiratory status and saturation, O2 as needed, pulmonary toileting, ? insert NG tube and administer Lactulose for encephalopathy.\n"},{"category":"ECG","chartdate":"2121-12-13 00:00:00.000","description":"Report","row_id":251687,"text":"Sinus rhythm. Non-diagnostic small Q waves in the inferior leads.\nAnterolateral ST-T wave changes which are non-specific. Low QRS voltage\nin the precordial leads. Compared to the previous tracing of \nanterolateral ST-T wave abnormalities are new. Clinical correlation is\nsuggested.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-12-13 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 994967,\n \"text\": \" 4:34 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for mass, bleed\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old man with altered mental status s/p fall, metastatic colon ca\\n REASON FOR THIS EXAMINATION:\\n eval for mass, bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 67-year-old male with altered mental status, status post fall.\\n History of metastatic colon cancer. Please evaluate for mass or bleed.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n FINDINGS: There is no intracranial hemorrhage, mass, mass effect, or evidence\\n of acute vascular territorial infarction. There is minimal periventricular\\n white matter hypodensity, most consistent with chronic small vessel ischemic\\n disease. The ventricles and sulci are normal in size and configuration.\\n There is no fracture. Visualized paranasal sinuses are normally aerated.\\n\\n IMPRESSION: No acute intracranial process.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-12-13 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 994968,\n \"text\": \" 4:34 PM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: eval for fracture\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old man with altered mental status s/p fall, metastatic colon ca\\n REASON FOR THIS EXAMINATION:\\n eval for fracture\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: DSsd SAT 6:47 PM\\n no fx or malalignment\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 67-year-old male with altered mental status, metastatic colon\\n cancer, status post multiple falls.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: MDCT-acquired axial imaging was performed through the cervical\\n spine without intravenous contrast. Multiplanar reformatted images were\\n obtained and reviewed.\\n\\n CT CERVICAL SPINE: There is no fracture, or acute cervical spine\\n malalignment. Prevertebral and paraspinal soft tissues are normal. There is\\n no lytic or sclerotic bony lesion.\\n\\n Mild degenerative change is seen at the atlantodental interface anteriorly and\\n superiorly, likely calcification of the apical dental ligament. Facet\\n osteophytes result in mild neural foraminal narrowing on the left at C4/5, on\\n the right at C5/6, and also on the left at C5/6. Broad-based posterior disc\\n bulges at C3/4 and C4/5 result in mild-to-moderate central canal stenosis.\\n Right paracentral disc bulge at C5/6 without significant canal narrowing.\\n\\n Visualized lung apices are unremarkable. The visualized brain parenchyma is\\n unremarkable.\\n\\n IMPRESSION: No acute cervical spine fracture or malalignment. Multilevel\\n degenerative changes, as described above, with mild-moderate ventral canal\\n narrowing at C3/4 and C4/5 levels.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-12-13 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 994969,\n \"text\": \" 4:35 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: abscess? bloody mass? free fluid?\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old man with colon CA now with abd distention and altered mental status\\n REASON FOR THIS EXAMINATION:\\n abscess? bloody mass? free fluid?\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 67-year-old male with colon cancer, now with abdominal distension\\n and altered mental status.\\n\\n COMPARISON: CT from .\\n\\n TECHNIQUE: MDCT acquired axial imaging was performed of the abdomen and\\n pelvis after administration of intravenous contrast only. No oral contrast\\n was administered.\\n\\n CT ABDOMEN: Visualized lung bases demonstrate small bilateral pleural\\n effusions, and minor bibasilar atelectasis.\\n\\n Widespread ill-defined intrahepatic nodules and masses are grossly unchanged\\n when compared to , and remain consistent with metastatic disease. As\\n before, some of these masses are situated near the liver capsule, and deform\\n the liver surface. The overall amount of ascites within the abdomen has\\n increased.\\n\\n The gallbladder, pancreas, spleen, and adrenal glands are unremarkable.\\n Kidneys enhance and excrete contrast symmetrically. There is no\\n hydronephrosis. There is no free intraperitoneal air. Numerous small\\n mesenteric lymph nodes are not significantly changed.\\n\\n CT PELVIS: Free fluid extends into the pelvis, and within the\\n processus vaginalis, through an inguinal hernia into the left hemiscrotum. The\\n urinary bladder is decompressed with a Foley catheter balloon in place. There\\n is sigmoid diverticulosis, without evidence of diverticulitis.\\n\\n OSSEOUS STRUCTURES: Multilevel thoracolumbar degenerative changes are\\n similar, and there is no sign of suspicious osteolytic or sclerotic lesion.\\n Note is again made of prior left hip surgery.\\n\\n IMPRESSION:\\n\\n 1. Unchanged appearance of widespread intrahepatic metastatic disease.\\n\\n 2. Increased ascites.\\n (Over)\\n\\n 4:35 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: abscess? bloody mass? free fluid?\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-12-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 994963,\n \"text\": \" 4:52 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old man with metastatic ca, change in mental status, sob\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST PORTABLE.\\n\\n INDICATION: 67-year-old man with metastatic carcinoma, change in mental\\n status, shortness of breath. Evaluate for infiltrate.\\n\\n CHEST PORTABLE: Comparison is made to a prior examination of . The\\n heart is normal in size. There is an elevated hemidiaphragm. There is some\\n linear opacity at the right base representing mild atelectasis. The pulmonary\\n vasculature is normal. The lungs are otherwise clear. Port-A-Cath is\\n identified with its tip in the right atrium. There are no pleural effusions.\\n\\n IMPRESSION:\\n\\n 1. No acute intrathoracic process. No evidence for pneumonia.\\n\\n 2. Mild atelectasis at the right base and elevation of the right\\n hemidiaphragm are unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-12-15 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 995195,\n \"text\": \" 4:36 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: evaluate for DVT's\\n Admitting Diagnosis: DEHYDRATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old man with bilateral lower extremity edema, metastatic colon ca, CTA\\n unable to rule out small subsegmental PE due to motion artifact\\n REASON FOR THIS EXAMINATION:\\n evaluate for DVT's\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Bilateral lower extremity edema with metastatic colon cancer. CTA\\n unable to rule out small subsegmental PE due to motion artifact. Please\\n evaluate for DVTs.\\n\\n FINDINGS: Evaluation is limited secondary to severe edema bilaterally. The\\n SVC in the mid and distal portions on the left were difficult to visualize,\\n though the color flow in these sections appeared normal. Additionally, the\\n exam was limited given patient discomfort and the right tibials and peroneals\\n on the right were not visualized. Allowing for these limitations, the common\\n femoral, superficial femoral, and popliteal veins on both right and left lower\\n extremities demonstrated normal flow, augmentation, compressibility, and\\n waveforms. No intraluminal luminal thrombus was identified.\\n\\n IMPRESSION: Limited exam, but no evidence to suggest DVT.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-12-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 995075,\n \"text\": \" 6:57 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for intrathrocic pathology.\\n Admitting Diagnosis: DEHYDRATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old man with respiratory alkylosis, bronchial breath sounds, and desats\\n to 80s on 4L.\\n REASON FOR THIS EXAMINATION:\\n please eval for intrathrocic pathology.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n COMPARISON: .\\n\\n INDICATION: Desaturation, followup.\\n\\n FINDINGS: In comparison with the previous examination, there are no major\\n relevant changes. Due to projection, the pre-existing slight elevation of the\\n hemidiaphragms is a little more visible. No evidence of substantial pleural\\n effusions. The size of the cardiac silhouette is within the upper range of\\n normal. No signs of hyperhydration. Mild atelectasis at the right lung base.\\n No opacity suggestive of pneumonia. The Port-A-Cath is in standard position.\\n\\n IMPRESSION: No relevant change as compared to . No cardiac\\n decompensation, no overhydration, no pneumonia.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-12-15 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 995086,\n \"text\": \" 12:34 AM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: please doa CTA chest to eval for PE\\n Admitting Diagnosis: DEHYDRATION\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old man with CA colon now w/ acute onset SOB, tachypnea, droppig satts,\\n tachycardia\\n REASON FOR THIS EXAMINATION:\\n please doa CTA chest to eval for PE\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 67-year-old male with metastatic colon cancer, now with acute onset\\n of difficulty breathing, tachypnea and tachycardia with concern for pulmonary\\n embolism.\\n\\n COMPARISON: CT torso .\\n\\n TECHNIQUE: MDCT axial images of the chest after rapid bolus of Optiray IV\\n contrast with multiplanar reformats.\\n\\n CT OF THE CHEST WITH IV CONTRAST: There is no evidence of pulmonary embolism,\\n although assessment of the small segmental and subsegmental pulmonary arterial\\n branches is somewhat limited by patient respiratory motion and contrast\\n timing. There is no acute aortic abnormality. There are a few small\\n mediastinal lymph nodes not pathologic by CT size criteria. There are small\\n bilateral pleural effusions and associated dependent consolidation of the\\n lower lobes, right greater than left. A previously identified subcentimeter\\n right lower lobe pulmonary nodule is not well evaluated as it is present in\\n the region of consolidated lung. No new nodules are identified.\\n\\n Limited evaluation of the upper abdomen demonstrates a large amount of\\n ascites. Most of the visualized liver is occupied by confluent hypodense\\n metastatic lesions.\\n\\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are\\n identified.\\n\\n IMPRESSION:\\n\\n 1. No pulmonary embolism. However, there is poor filling of the segmental\\n branches for the left lower lobe. If clinically indicated, a repeated CTA\\n coould be performed for better evaluation.\\n\\n 2. Small bilateral pleural effusions and consolidation of a portion of the\\n dependent lower lobes, right worse than left.\\n\\n 3. Large amount of ascites and evidence of significant hepatic metastatic\\n disease.\\n\\n These findings, including the need for further imaging if high clinical\\n (Over)\\n\\n 12:34 AM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: please doa CTA chest to eval for PE\\n Admitting Diagnosis: DEHYDRATION\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n suspicion for PE were discussed with Dr. at 12:30PM on \\n by Dr. .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-12-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 995187,\n \"text\": \" 3:58 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: please eval ngt position\\n Admitting Diagnosis: DEHYDRATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old man with metastatic Colon Ca s/p ngt placement\\n REASON FOR THIS EXAMINATION:\\n please eval ngt position\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST\\n\\n INDICATION: Metastatic colon cancer, NG tube placement. There is comparison\\n with the prior from at 2:42 p.m. The NG tube is in the\\n proximal stomach. There is some interval worsening in the right mid and lower\\n lobe atelectasis and pulmonary edema. No other interval change.\\n\\n IMPRESSION: Standard position of NG tube. Interval worsening in atelectasis\\n and pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-12-15 00:00:00.000\",\n \"description\": \"CT HEAD W/ & W/O CONTRAST\",\n \"row_id\": 995085,\n \"text\": \" 12:33 AM\\n CT HEAD W/ & W/O CONTRAST Clip # \\n Reason: ?METS, BLEED\\n Admitting Diagnosis: DEHYDRATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old man with metastatic CA colon now w/ acute onset SOB, and change in\\n mental status\\n REASON FOR THIS EXAMINATION:\\n please eval for brain mets\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 67-year-old male with metastatic colon cancer, now with difficulty\\n breathing and change of mental status with concern for intracranial metastatic\\n disease.\\n\\n COMPARISON: Non-contrast head CT, .\\n\\n TECHNIQUE: MDCT axial images of the head pre and post a bolus of Optiray IV\\n contrast with multiplanar reformats.\\n\\n CT OF THE HEAD WITHOUT AND WITH IV CONTRAST: There is no evidence\\n of hemorrhage, shift of normally midline structures, mass effect,\\n hydrocephalus or infarction. There is mild periventricular white matter\\n hypodensity consistent with mild chronic microvascular infarction. There is\\n no evidence of abnormal brain parenchymal enhancement or focal mass lesion.\\n The paranasal sinuses and mastoid air cells are clear. The visualized osseous\\n structures are unremarkable.\\n\\n IMPRESSION: No acute intracranial process. No evidence of intracranial\\n metastatic disease.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-12-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 995177,\n \"text\": \" 2:36 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evalute NG tube\\n Admitting Diagnosis: DEHYDRATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old man with metastatic Colon CA s/p NG tube placement\\n REASON FOR THIS EXAMINATION:\\n please evalute NG tube\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: NG tube placement.\\n\\n FINDINGS: In comparison with the study of , the patient has taken a\\n slightly better inspiration. The Dobbhoff tube extends to the lower body of\\n the stomach.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1619961,\n \"text\": \"NPN 0700-1900\\nNeuro: difficult to arouse patient to painful stimulation this morning, however, after lactulose enema able to arouse patient to voice. Pt oriented to self only. AFebrile. Pt pulled out NGT necessitating hand mitts to prevent pulling of NGT. NGT placed as patient appeared to fail bedside swallow eval, clearing of throat after POs. Pt c/o discomfort on coccyx after lying of stretcher for ultrasound, repositioned on side and verbalized comfort.\\nCV: b/p 95-120/50-60s, restarted PO lasix once NGT placement reconfirmed after pulling out 1st NGT. HR tachy 110-120s ST, no VEA noted. Pt given one 500cc IVF bolus and appeared to have increase in abdominal discomfort during bolus. Bolus given for lactate level of 5.2. Pt w/gross sacral and bilateral lower extremity. C/o discomfort during ultrasound, prelim report no DVT.\\nRESP: tachypnic, RR 30s. LS: coarse upper, deminished bases. O2 sats RA 95%+ when pleth appears accurate.\\nGI: ABD distended d/t ascites. BS+, pt unable to hold lactulose enema, pt w/poor rectal tone. Pt passing watery enema w/blood tinge x 2 today.\\nGU: foley patent, restarted lasix PO @ 1800, monitor response.\\nSocial: dtr and wife called, updated on care. Wife spoke w/MD @ length RE: status and consent for ICU.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1619962,\n \"text\": \"NPN 1900-0700:\\nNeuro: lethargic and dozing most og the time, oriented only to his name, pulling at tubes, restrained for safety, denied pain.\\n\\nResp: On RA sating in 90s, LS CTA to coarse in upper lobes, diminished at bases, nonproductive cough.\\n\\nCV: SEE carevieu for details, tachycardiac, given 3 boluses of a total of 1.5 L NS, with a PIV line, difficult to palpate peripheral pulses.\\n\\nGI?GU: ascites, with NGT for meds, lactulose for encephalopathy, passed loose BM, diaper applied, with foley, icteric U/O, was low imporoved after NS boluses (see carevieu).\\n\\nInteg: T 98.6, restrained for safety.\\n\\nSocial: DNI/DNR, wife and daughter visited and updated on .\\n\\nPlan: called out to a floor, monitor mental status, U/O, HR, bolus as needed, administer lactulose for encephalopathy, update family on any chamnges in pt's condition, still DNI/DNR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1619963,\n \"text\": \"MICU NPN\\nNEURO: VERY LETHARGIC AND DISORIENTATED, RESPONDS TO PAIN.\\n\\nRESP: SATS ARE FINE ON ROOM AIR, TACHYPNEIC AT TIMES AND STOKE BREATHIGN AT TIMES. APPEARS COMFORTABLE.\\n\\nCV: HR AND BP STABLE\\n\\nGI: CONTINUES TO HAVE LOOSE DIARRHEA MUSHROOM CATH INSERTED, DRAINING WELL. CONTINUES TO BE NPO USING NGT FOR MEDS.\\n\\nGU: SEE CAREVUE FORMOST UP TO DATE URINE OUTPUT.\\n\\nSOCIAL: WIFE IN TODAY STATED CONCERNS ABOUT PT'S NEEDS AND HOW SHE WOULD LIKE HOSPICE TO GET INVOLVED, PALLIATIVE CARE CONSULT REQUESTED.\\n\\nPLAN: PT. IS CALLED OUT TO 7 SOUTH IS GOING TO BED 740.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1619960,\n \"text\": \"Admission and NPN 2100-0700:\\n67 yo male pt with hx of metastatic colonic CA, s/p 1st and 2nd line chemotherapy who was admitted to ED via EMS on with altered mental status and hallucinations when pt was noted by family to be incoherent, and more somnolent, talking to people who were not present and to deceased pets; no trauma or fall prior to this onset, he had been lethargic for several days and staying in bed, had anorexia and poor PO intake for several days. In ED CT was negative for bleeding, labs showed elevated LFTs, leukocytosis and dehydration, given fluids and antibiotics and admitted to 11 , where he developed deterioration in his mental status and occasional desaturatiopn, started on non0rebreather 100%, and transferred to for CT scans of chest and brain, ? PE. In ICU, immediately started on heparin drip, then sent to CT scan of chest that showed no PE, heparin D/Ced, and CT of head was negative. HO attributed the mental changes to encephalopathy, given lactulose enema, which didn't seem to work well.\\n\\nROS:\\nNeuro: very lethargic, barely responsive to verbal stimuli, oriented only to his name, at times agitated in bed especially when he was on the CT table, got very restless, localizes pain, not follows commands, denied pain though he had bilateral knee replacement, which cause pain as per family, didn't recognize daughter or wife, very confused, .\\n\\nResp: received on NRB, then was on RA sating well, when in CT placed on NRB again, Sat 93-100%, LS coarse in upper lobes to diminished at bases, nonproductive cough.\\n\\nCV: ST HR 107-127, BP 107-129/72-101, with portocath on left chest area, heparin D/Ced, on levaquin and vancomycin, weak peripheral pulses, given bicarb pre and post CT scan wiuth contrast, cool extremities.\\n\\nGI/GU: with diffused ascites, paracentesis done and specimen sent for cx, NPO, passed loose stool, with foley icteric U/O.\\n\\nInteg: T max 98, icteric skin, with left heal blister, yellow base, cleaned and open to air, washed up.\\n\\nPlan: monitor mental status closely, monitor respiratory status and saturation, O2 as needed, pulmonary toileting, ? insert NG tube and administer Lactulose for encephalopathy.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2121-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 251687,\n \"text\": \"Sinus rhythm. Non-diagnostic small Q waves in the inferior leads.\\nAnterolateral ST-T wave changes which are non-specific. Low QRS voltage\\nin the precordial leads. Compared to the previous tracing of \\nanterolateral ST-T wave abnormalities are new. Clinical correlation is\\nsuggested.\\n\\n\"\n }\n]"}}},{"rowIdx":93,"cells":{"subject_id":{"kind":"number","value":98227,"string":"98,227"},"hadm_id":{"kind":"number","value":165553,"string":"165,553"},"target_text":{"kind":"string","value":"The patient was brought to the Operating Room on where the patient underwent CABG x 5. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. He received a unit of PRBC on POD 3 for hct 22%. Hct would rise to 28%. He was started on Flomax and Foley was re-placed for failure to void. The foley was discontinued again and he was able to void without difficulty. The patient was evaluated by the physical therapy service for assistance with strength and mobility. On POD 4 he developed tachycardia in the 110s and hypotension with SBP in the 90s and 80s. He remained stable and was monitored overnight. Heart rate remained in the low 100s and BP would dip to the 90s. He is asymptomatic and medications were titrated accordingly. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to Rehab in good condition with appropriate follow up instructions. Expected length of stay at rehab is less than 30 days."},"extractive_notes_summ":{"kind":"string","value":"Cardiomediastinal silhouette has a normal postoperative appearance. Right jugular line ends low in the SVC. The left ventricular cavity sizeis normal. Mild regionalLV systolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; midinferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo;inferior apex - hypo; remaining LV segments contract normally.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.Simple atheroma in ascending aorta. There are simpleatheroma in the ascending and descending thoracic aorta.The aortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic stenosis or aortic regurgitation.The mitral valve appears structurally normal with trivial mitralregurgitation.Post bypass:Intact thoracic aorta.Normal RV and LV systolic function. Right IJ catheter is in unchanged position. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.GENERAL COMMENTS: Written informed consent was obtained from the patient. Left pleural effusion and atelectasis are small. Minimal atelectasis is seen at the bases. Simple atheroma in descending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). There is mild regional left ventricular systolic dysfunction withhypokinesis in the inferior and inferoseptal region. Good (>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. Left pleural tube has been removed and there may be a very small left apical pneumothorax but no appreciable left pleural effusion is collected. Compared to the previoustracing of no diagnostic interval change. Moderate left basal atelectasis is stable, moderate right basal atelectasis is worsened. No spontaneous echo contrast or thrombus isseen in the body of the left atrium/left atrial appendage or the body of theright atrium/right atrial appendage.Left ventricular wall thicknesses are normal. Hypertension.Status: InpatientDate/Time: at 15:41Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. Normal sinus rhythm. Lower lobe atelectasis is minimal. Left pleural effusion is probably small. IMPRESSION: AP chest compared to and : Since , the patient has been extubated and lung volumes are accordingly lower. Normal LV cavity size. FINDINGS: In comparison with study of , the lateral projection shows small bilateral pleural effusions. Borderline low voltage in thelimb leads. Non-specific ST-T wave abnormalities. Estimated LVEF is 50-55%.The remaining left ventricular segments contract normally.Right ventricular chamber size and free wall motion are normal.The diameters of aorta at the sinus, ascending and arch levels are normal.There are complex (>4mm) atheroma in the aortic arch. Right-sided jugular line is in mid SVC. There is no pulmonary edema. Results were personally reviewed with the MD caring forthe patient.Conclusions:Pre-BypassThe left atrium is normal in size. No TEE related complications. Chest tube discontinued. No spontaneous echo contrast or thrombus in theLA/LAA or the RA/RAA. FINDINGS: ET tube ends at 5.9 cm above carina. Overall LVEF 55%.No new valvular findings.Previously hypokinetic inferior wall is moving better. The patient was under general anesthesiathroughout the procedure. The patient appears tobe in sinus rhythm. CONCLUSION: The patient had recent CABG surgery. There is no pneumothorax. I certify I was present incompliance with HCFA regulations. No evidence of acute vascular congestion, pneumothorax, or pneumonia. Right bundle-branch block. No AS. Tube and lines are in adequate position. Coronary artery disease. Complex (>4mm) atheroma in the aorticarch. The NG tube is in the stomach. 7:37 PM CHEST PORT. PATIENT/TEST INFORMATION:Indication: Chest pain. ATEE was performed in the location listed above. COMPARISON: . 1:37 PM CHEST (PA & LAT) Clip # Reason: eval for effusion Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 73 year old man s/p cabg REASON FOR THIS EXAMINATION: eval for effusion FINAL REPORT HISTORY: CABG. 10:36 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for ptx Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 73 year old man with s/p CABG, CTs d/c'd REASON FOR THIS EXAMINATION: evaluate for ptx FINAL REPORT AP CHEST, 10:53 A.M. . LINE PLACEMENT Clip # Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 73 year old man s/p CABG REASON FOR THIS EXAMINATION: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY FINAL REPORT PORTABLE AP CHEST X-RAY INDICATION: CABG, fast track early extubation."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2196-09-21 00:00:00.000","description":"Report","row_id":67096,"text":"PATIENT/TEST INFORMATION:\nIndication: Chest pain. Coronary artery disease. Hypertension.\nStatus: Inpatient\nDate/Time: at 15:41\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mild regional\nLV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid\ninferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo;\ninferior apex - hypo; remaining LV segments contract normally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\nSimple atheroma in ascending aorta. Complex (>4mm) atheroma in the aortic\narch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. A\nTEE was performed in the location listed above. I certify I was present in\ncompliance with HCFA regulations. The patient was under general anesthesia\nthroughout the procedure. No TEE related complications. The patient appears to\nbe in sinus rhythm. Results were personally reviewed with the MD caring for\nthe patient.\n\nConclusions:\nPre-Bypass\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. There is mild regional left ventricular systolic dysfunction with\nhypokinesis in the inferior and inferoseptal region. Estimated LVEF is 50-55%.\nThe remaining left ventricular segments contract normally.\nRight ventricular chamber size and free wall motion are normal.\nThe diameters of aorta at the sinus, ascending and arch levels are normal.\nThere are complex (>4mm) atheroma in the aortic arch. There are simple\natheroma in the ascending and descending thoracic aorta.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis or aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nPost bypass:\nIntact thoracic aorta.\nNormal RV and LV systolic function. Overall LVEF 55%.\nNo new valvular findings.\nPreviously hypokinetic inferior wall is moving better.\n\n\n"},{"category":"ECG","chartdate":"2196-09-21 00:00:00.000","description":"Report","row_id":143717,"text":"Normal sinus rhythm. Right bundle-branch block. Borderline low voltage in the\nlimb leads. Non-specific ST-T wave abnormalities. Compared to the previous\ntracing of no diagnostic interval change.\n\n"},{"category":"Radiology","chartdate":"2196-09-21 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1253257,"text":" 7:37 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST X-RAY\n\n INDICATION: CABG, fast track early extubation.\n\n COMPARISON: .\n\n FINDINGS:\n\n ET tube ends at 5.9 cm above carina. Right-sided jugular line is in mid SVC.\n Lower lobe atelectasis is minimal. There is no pneumothorax. Left pleural\n effusion is probably small. The NG tube is in the stomach.\n\n CONCLUSION:\n\n The patient had recent CABG surgery. Tube and lines are in adequate position.\n Left pleural effusion and atelectasis are small.\n\n"},{"category":"Radiology","chartdate":"2196-09-24 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1253597,"text":" 1:37 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n FINDINGS: In comparison with study of , the lateral projection shows small\n bilateral pleural effusions. Minimal atelectasis is seen at the bases. Right\n IJ catheter is in unchanged position.\n\n No evidence of acute vascular congestion, pneumothorax, or pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2196-09-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1253462,"text":" 10:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p CABG, CTs d/c'd\n REASON FOR THIS EXAMINATION:\n evaluate for ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:53 A.M. .\n\n HISTORY: 73-year-old man after CABG. Chest tube discontinued.\n\n IMPRESSION: AP chest compared to and :\n\n Since , the patient has been extubated and lung volumes are\n accordingly lower. Left pleural tube has been removed and there may be a very\n small left apical pneumothorax but no appreciable left pleural effusion is\n collected. Moderate left basal atelectasis is stable, moderate right basal\n atelectasis is worsened. There is no pulmonary edema. Cardiomediastinal\n silhouette has a normal postoperative appearance. Right jugular line ends low\n in the SVC.\n\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2196-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 67096,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Chest pain. Coronary artery disease. Hypertension.\\nStatus: Inpatient\\nDate/Time: at 15:41\\nTest: TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\\nLA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mild regional\\nLV systolic dysfunction.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\\ninferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid\\ninferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo;\\ninferior apex - hypo; remaining LV segments contract normally.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\\nSimple atheroma in ascending aorta. Complex (>4mm) atheroma in the aortic\\narch. Simple atheroma in descending aorta.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nGENERAL COMMENTS: Written informed consent was obtained from the patient. A\\nTEE was performed in the location listed above. I certify I was present in\\ncompliance with HCFA regulations. The patient was under general anesthesia\\nthroughout the procedure. No TEE related complications. The patient appears to\\nbe in sinus rhythm. Results were personally reviewed with the MD caring for\\nthe patient.\\n\\nConclusions:\\nPre-Bypass\\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\\nseen in the body of the left atrium/left atrial appendage or the body of the\\nright atrium/right atrial appendage.\\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\\nis normal. There is mild regional left ventricular systolic dysfunction with\\nhypokinesis in the inferior and inferoseptal region. Estimated LVEF is 50-55%.\\nThe remaining left ventricular segments contract normally.\\nRight ventricular chamber size and free wall motion are normal.\\nThe diameters of aorta at the sinus, ascending and arch levels are normal.\\nThere are complex (>4mm) atheroma in the aortic arch. There are simple\\natheroma in the ascending and descending thoracic aorta.\\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\\nexcursion and no aortic stenosis or aortic regurgitation.\\nThe mitral valve appears structurally normal with trivial mitral\\nregurgitation.\\n\\nPost bypass:\\nIntact thoracic aorta.\\nNormal RV and LV systolic function. Overall LVEF 55%.\\nNo new valvular findings.\\nPreviously hypokinetic inferior wall is moving better.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2196-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 143717,\n \"text\": \"Normal sinus rhythm. Right bundle-branch block. Borderline low voltage in the\\nlimb leads. Non-specific ST-T wave abnormalities. Compared to the previous\\ntracing of no diagnostic interval change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-09-21 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1253257,\n \"text\": \" 7:37 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man s/p CABG\\n REASON FOR THIS EXAMINATION:\\n FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE AP CHEST X-RAY\\n\\n INDICATION: CABG, fast track early extubation.\\n\\n COMPARISON: .\\n\\n FINDINGS:\\n\\n ET tube ends at 5.9 cm above carina. Right-sided jugular line is in mid SVC.\\n Lower lobe atelectasis is minimal. There is no pneumothorax. Left pleural\\n effusion is probably small. The NG tube is in the stomach.\\n\\n CONCLUSION:\\n\\n The patient had recent CABG surgery. Tube and lines are in adequate position.\\n Left pleural effusion and atelectasis are small.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-09-24 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1253597,\n \"text\": \" 1:37 PM\\n CHEST (PA & LAT) Clip # \\n Reason: eval for effusion\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man s/p cabg\\n REASON FOR THIS EXAMINATION:\\n eval for effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: CABG.\\n\\n FINDINGS: In comparison with study of , the lateral projection shows small\\n bilateral pleural effusions. Minimal atelectasis is seen at the bases. Right\\n IJ catheter is in unchanged position.\\n\\n No evidence of acute vascular congestion, pneumothorax, or pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2196-09-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1253462,\n \"text\": \" 10:36 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for ptx\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with s/p CABG, CTs d/c'd\\n REASON FOR THIS EXAMINATION:\\n evaluate for ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 10:53 A.M. .\\n\\n HISTORY: 73-year-old man after CABG. Chest tube discontinued.\\n\\n IMPRESSION: AP chest compared to and :\\n\\n Since , the patient has been extubated and lung volumes are\\n accordingly lower. Left pleural tube has been removed and there may be a very\\n small left apical pneumothorax but no appreciable left pleural effusion is\\n collected. Moderate left basal atelectasis is stable, moderate right basal\\n atelectasis is worsened. There is no pulmonary edema. Cardiomediastinal\\n silhouette has a normal postoperative appearance. Right jugular line ends low\\n in the SVC.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":94,"cells":{"subject_id":{"kind":"number","value":43323,"string":"43,323"},"hadm_id":{"kind":"number","value":156689,"string":"156,689"},"target_text":{"kind":"string","value":"69 year old male with history of emphysema, SCC diagnosed in s/p left upper lobectomy and s/p neoadjuvant chemoradiation, PE/DVT in , pericardial effusion w/ tamponade requiring pericardial window in , s/p IVC filter placement who presented from clinic with SOB and CTA showing multiple PEs and multifocal right sided pneumonia. . Pt was initially admitted to OMED service and started on heparin drip for the PEs, and given ceftriaxone, vanco and levoflox for the pneumonia. He then became hypoxic and was transferred to the ICU for further monitoring. He required intubation for worsening respiratory status, which was initially felt to be mostly related to pneumonia. There was also a concern for diffuse alveolar hemorrhage so he underwent a bronchoscopy showing minimial bleeding. Heparin drip was stopped as it was felt his bleeding risk was higher than PE risk given his filter. His respiratory status and chest xray began to improve initially on broad spectrum antibiotics. On the evening of , he became acutely tachycardic up to 140s, felt to be in atrial flutter. An echo was obtained showing a severe amount of tricuspid regurg. Overnight his clinical status worsened significantly, with rising lactate and worsening electrolytes. A ferritin level was checked and found to be , then > on recheck. Unclear etiology but likely due to some systemic inflammatory process that was contributing to underlying shock. Her family was updated on the poor prognosis and the decision was made to withdraw treatment and make the patient CMO. He passed away with family at bedside."},"extractive_notes_summ":{"kind":"string","value":"Mildly dilated aortic root. Left upper lung opacities which are due to combination of loculated fluid and collapsed adjacent lung and elevation of the left hemidiaphragm and left hilus are unchanged in appearance. Rule out pulmonary embolus.Diffuse T wave abnormalities. Moderatepulmonary systolic hypertension.Compared with the findings of the prior study (images reviewed) of ,the rhythm is now sinus (without ectopy) and the left ventricular ejectionfraction appears normal. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is normal in size. There is moderate pulmonary artery systolichypertension. There is a trivial/physiologic pericardial effusion.IMPRESSION: Suboptimal image quality. No MS.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. There is moderate pulmonaryartery systolic hypertension. The gallbladder is within normal limits. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. EndocarditisHeight: (in) 71Weight (lb): 187BSA (m2): 2.05 m2BP (mm Hg): 102/64HR (bpm): 119Status: InpatientDate/Time: at 16:05Test: Portable TTE (Complete)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: Mild symmetric LVH. Left upper lung opacities from loculated pleural fluid and collapse of the adjacent lung as suggested from the chest CT dated is unchanged. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Moderate tosevere [3+] tricuspid regurgitation is seen. The mitral valve appears structurally normal withtrivial mitral regurgitation. Mild mitralannular calcification. Unchanged small pericardial effusion. Left atrial abnormality. Left atrial abnormality. 6. low density of the intravascular space consistent with anemia. Evidence of left upper lobe resection, elevation of the left hilum and cardiomediastinal silhouette are unchanged. Unchanged small amount of pericardial effusion that is mainly concentrated on the left side. The aorticvalve leaflets (3) are mildly thickened but aortic stenosis is not present.The mitral valve leaflets are mildly thickened. Extensive pneumonic consolidations in the right lung are unchanged. Suboptimal image quality - ventilator. PATIENT/TEST INFORMATION:Indication: Worsening hupoxia.Height: (in) 71Weight (lb): 187BSA (m2): 2.05 m2BP (mm Hg): 108/59HR (bpm): 77Status: OutpatientDate/Time: at 11:18Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildy dilated aortic root. T Admitting Diagnosis: PULMONARY EMBOLISM FINAL REPORT (Cont) Few prominent mediastinal lymph nodes are identified, for example, a right paratracheal lymph node that measures 11 mm and a subcarinal lymph node with punctate calcifications that measures 12.4 mm on its short axis (2:30). Small pleural effusions bilaterally are unchanged. Diverticulosis is seen along the course of the colon without signs of diverticulitis. The right ventricular free wall is hypertrophied. Probable prior inferior myocardialinfarction of indeterminate age. FINDINGS: CHEST: A central line is seen with its tip in the inferior margin of the superior vena cava. Mild thickening of mitral valve chordae. The aortic root ismildly dilated at the sinus level. The left ventricularcavity is unusually small. Typical atrial flutter is present again. Colon diverticulosis without signs of diverticulitis. Overall left ventricular systolic function isnormal (LVEF 60%). Status post left upper lobectomy. Note is made to a calcified right hilar node and a calcified nodule in the right lower lobe, most consistent with old granulomatous disease. Inferior ST segment elevationraises concern for myocardial ischemia. Otherwise, the large and small bowel is within normal limits. Sinus rhythm with ventricular premature beats. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality as the patient was difficult toposition. If clinically indicated, a transesophagealechocardiographic examination is recommended.Conclusions:There is mild symmetric left ventricular hypertrophy. Normal ascending aorta diameter.AORTIC VALVE: Normal aortic valve leaflets (3). Small left pleural effusion that was not seen on prior examination. Prolonged (>250ms)transmitral E-wave decel time.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. e/o occult infection. e/o occult infection. e/o occult infection. e/o occult infection. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Abnormal diastolic septalmotion/position consistent with RV volume overload.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Possible prior myocardial infarction ofindeterminate age with residual ST segment elevations suggesting possibleaneurysm. The rightventricular cavity is dilated There is abnormal diastolic septalmotion/position consistent with right ventricular volume overload. given rapidity, infection and possible additional edema are likely 2. stable appearance of left hemithorax with post-surgical and radiation changes. Reidentified are ground-glass opacities in the right upper, middle and lower lobes as well as in the superior segment of the left lower lobe. Small amount of ascites is seen. ST segment depressions in leads I and aVL andT wave flattening in leads V2-V6 persist when compared to the previous tracingof . Normal biventricular systolic function.No significant valvular disease. Compared to theprevious tracing of ST segment elevation in the inferior leads was seenon the prior tracing suggesting that these findings may be chronic and may beassociated with an aneurysm. Sinus rhythm. Sinus rhythm. Normal mainPA. FINDINGS: Endotracheal tube ends approximately 5.2 cm above the carina and is appropriate. An orogastric tube is seen to course below the diaphragm and ends into the stomach; however, the distal end is beyond the radiograph view. Normal tricuspidvalve supporting structures. COMPARISON: Prior CT of the chest from . FINDINGS: In comparison with the earlier study of this date, the tip of the endotracheal tube lies just above the clavicles, approximately 6.8 cm above the carina. Free fluid is seen within the pelvis. S1-Q3-T3 is present as well as theanterolateral T wave changes noted previously, all compatible with acutepulmonary embolism.TRACING #2 The heart is within normal limits regarding size and configuration. TOTAL EXAM DLP: 1308.95 mGy-cm. FINDINGS: In comparison with the earlier study of this date, there has been placement of a right IJ catheter that extends to the cavoatrial junction or possibly into the upper portion of the right atrium."},"n_notes":{"kind":"number","value":12,"string":"12"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2130-02-04 00:00:00.000","description":"DISTINCT PROCEDURAL SERVICE","row_id":1225737,"text":" 3:28 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Please evaluate for worsening infiltrate, effusion, fluid ov\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with PE/DVT, s/p LUL lobectomy with hypoxia\n REASON FOR THIS EXAMINATION:\n Please evaluate for worsening infiltrate, effusion, fluid overload,\n pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Worsening hypoxia.\n\n Comparison is made with prior study performed 5 hours earlier.\n\n There appears to be increase in left pleural effusion that is loculated in the\n left apex. Otherwise, there are no interval changes. No pneumothorax or\n overt pulmonary edema. Extensive pneumonic consolidations in the right lung\n are unchanged. Evidence of left upper lobe resection, elevation of the left\n hilum and cardiomediastinal silhouette are unchanged.\n\n"},{"category":"Radiology","chartdate":"2130-02-08 00:00:00.000","description":"BY DIFFERENT PHYSICIAN","row_id":1226250,"text":" 12:28 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: desaturations with movement, ? ETT tube positioning?\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with ETT\n REASON FOR THIS EXAMINATION:\n desaturations with movement, ? ETT tube positioning?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ET tube positioning.\n\n FINDINGS: In comparison with the earlier study of this date, the tip of the\n endotracheal tube lies just above the clavicles, approximately 6.8 cm above\n the carina. Otherwise, there is little change in the appearance of the heart\n and lungs.\n\n\n"},{"category":"Radiology","chartdate":"2130-02-06 00:00:00.000","description":"BY SAME PHYSICIAN","row_id":1225994,"text":" 6:11 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: s/p IJ line placement\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with s/p line\n REASON FOR THIS EXAMINATION:\n s/p IJ line placement\n ______________________________________________________________________________\n WET READ: OXZa MON 7:02 PM\n Right IJ tip at superior cavoatrial junction. otherwise, not significantly\n changed\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: IJ placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a right IJ catheter that extends to the cavoatrial junction or\n possibly into the upper portion of the right atrium. The remainder of the\n study is unchanged.\n\n\n"},{"category":"Radiology","chartdate":"2130-02-08 00:00:00.000","description":"CT ABD & PELVIS W/O CONTRAST","row_id":1226288,"text":" 5:55 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? e/o occult infection. Please include down to mid-thigh. T\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with fevers for past 24 hrs.\n REASON FOR THIS EXAMINATION:\n ? e/o occult infection. Please include down to mid-thigh. Thanks.\n CONTRAINDICATIONS for IV CONTRAST:\n Worsening renal failure\n ______________________________________________________________________________\n WET READ: OXZa WED 7:42 PM\n 1. increased, predominantly ground glass opacities throughout the right lung.\n given rapidity, infection and possible additional edema are likely\n 2. stable appearance of left hemithorax with post-surgical and radiation\n changes.\n 3. no pleural or pericardial effusion\n 4. intubated with material in distal trachea distal to balloon\n 5. small amount of perihepatic and pelvic ascites.\n 6. low density of the intravascular space consistent with anemia. known\n pulmonary emboli are not evaluated on this non-contrast study\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR THE EXAMINATION: This is a 69-year-old man with fever for the past\n 24 hours. The request is to rule out an occult infection.\n\n The patient is status post left upper lung lobectomy and neoadjuvant\n chemoradiation due due to squamous cell carcinoma.\n\n COMPARISON: Prior CT of the chest from .\n\n TECHNIQUE: CT of the chest, body and pelvis without IV contrast\n administration. Oral contrast was given.\n\n Coronal and sagittal reformations were made.\n\n TOTAL EXAM DLP: 1308.95 mGy-cm.\n\n FINDINGS:\n\n CHEST: A central line is seen with its tip in the inferior margin of the\n superior vena cava.\n\n Highly positioned endotracheal tube is seen\n Nasogastric tube is seen with its tip in the stomach.\n\n The heart is within normal limits regarding size and configuration. Unchanged\n small amount of pericardial effusion that is mainly concentrated on the left\n side.\n\n Status post left upper lobectomy. The surgical bed is filled with fluid with\n no gas bubbles within it.\n (Over)\n\n 5:55 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? e/o occult infection. Please include down to mid-thigh. T\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Few prominent mediastinal lymph nodes are identified, for example, a right\n paratracheal lymph node that measures 11 mm and a subcarinal lymph node with\n punctate calcifications that measures 12.4 mm on its short axis (2:30).\n Note is made to a calcified right hilar node and a calcified nodule in the\n right lower lobe, most consistent with old granulomatous disease.\n\n Reidentified are ground-glass opacities in the right upper, middle and lower\n lobes as well as in the superior segment of the left lower lobe.\n Consolidations are seen in the right lower lobe and in the superior segment of\n the left lower lobe.\n Both findings have increased in size in comparison to prior examinations\n\n Small amount of left pleural effusion is detected that was not seen on prior\n examination.\n\n ABDOMEN: The liver is with no gross pathology. The gallbladder is within\n normal limits. The spleen, the pancreas and both adrenals are with no gross\n pathology. Both kidneys are unremarkable. No peritoneal or retroperitoneal\n lymphadenopathy is detected.\n Diverticulosis is seen along the course of the colon without signs of\n diverticulitis. Otherwise, the large and small bowel is within normal limits.\n Small amount of ascites is seen.\n An IVC filter is identified.\n\n PELVIS: The urinary bladder is catheterized with a Foley catheter. Prostate\n gland is with no gross pathology. Free fluid is seen within the pelvis.\n There is no concerning lymphadenopathy in the pelvis.\n Vasectomy clips are seen.\n\n OSSEOUS STRUCTURES: Degenerative changes are seen along the course of the\n spine. No concerning lytic or osteoblastic lesions are identified.\n\n IMPRESSION:\n 1. Interval increase in the size of pulmonary ground-glass opacities and\n consolidations. These findings are consistent with multifocal pneumonia.\n 2. Unchanged small pericardial effusion.\n 3. Small left pleural effusion that was not seen on prior examination.\n 4. New ascites is seen.\n 5. Colon diverticulosis without signs of diverticulitis.\n\n Findings were discussed by Dr and the patient's referring\n physician Dr by phone at 11:00, .\n\n (Over)\n\n 5:55 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? e/o occult infection. Please include down to mid-thigh. T\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2130-02-06 00:00:00.000","description":"BY DIFFERENT PHYSICIAN","row_id":1225923,"text":" 12:04 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: intubation\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with intubation\n REASON FOR THIS EXAMINATION:\n intubation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: A single semi-upright portable chest view was reviewed in\n comparison with prior chest radiographs through with the most\n recent from , .\n\n FINDINGS:\n\n Endotracheal tube ends approximately 5.2 cm above the carina and is\n appropriate. An orogastric tube is seen to course below the diaphragm and\n ends into the stomach; however, the distal end is beyond the radiograph view.\n Bilateral lung opacities, right side more than left, which increased between\n and , concerning for an aspiration or pulmonary\n edema have improved over past five to six hours. Small pleural effusions\n bilaterally are unchanged. Left upper lung opacities which are due to\n combination of loculated fluid and collapsed adjacent lung and elevation of\n the left hemidiaphragm and left hilus are unchanged in appearance. The\n mediastinal silhouette is stable.\n\n IMPRESSION:\n 1. Bilateral lung opacities, right side more than left, which increased\n between and , concerning for an aspiration or\n pulmonary edema have improved.\n\n 2. Left upper lung opacities from loculated pleural fluid and collapse of the\n adjacent lung as suggested from the chest CT dated is\n unchanged.\n\n"},{"category":"Echo","chartdate":"2130-02-10 00:00:00.000","description":"Report","row_id":102166,"text":"PATIENT/TEST INFORMATION:\nIndication: Atrial flutter. Endocarditis\nHeight: (in) 71\nWeight (lb): 187\nBSA (m2): 2.05 m2\nBP (mm Hg): 102/64\nHR (bpm): 119\nStatus: Inpatient\nDate/Time: at 16:05\nTest: Portable TTE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Overall normal LVEF\n(>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. Abnormal diastolic septal\nmotion/position consistent with RV volume overload.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Moderate to severe [3+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Normal main\nPA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - ventilator. Suboptimal image quality -\npatient unable to cooperate. If clinically indicated, a transesophageal\nechocardiographic examination is recommended.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity is unusually small. Overall left ventricular systolic function is\nnormal (LVEF 60%). The right ventricular free wall is hypertrophied. The right\nventricular cavity is dilated There is abnormal diastolic septal\nmotion/position consistent with right ventricular volume overload. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. The tricuspid valve leaflets are mildly thickened. Moderate to\nsevere [3+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion. If clinically\nindicated, a transesophageal echocardiographic examination is recommended to\nrule out vegetations.\n\nIMPRESSION: No definite vegetations seen. Intercurrent development of moderate\npulmonary hypertension, moderate-to-severe tricuspid regurgitation and right\nheart chamber enlargement concerning for acute right heart strain. Consider\nacute pulmonary embolism.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n"},{"category":"Echo","chartdate":"2130-02-06 00:00:00.000","description":"Report","row_id":102167,"text":"PATIENT/TEST INFORMATION:\nIndication: Worsening hupoxia.\nHeight: (in) 71\nWeight (lb): 187\nBSA (m2): 2.05 m2\nBP (mm Hg): 108/59\nHR (bpm): 77\nStatus: Outpatient\nDate/Time: at 11:18\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Prolonged (>250ms)\ntransmitral E-wave decel time.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmildly dilated at the sinus level. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic stenosis or\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is moderate pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Normal biventricular systolic function.\nNo significant valvular disease. Mildly dilated aortic root. Moderate\npulmonary systolic hypertension.\n\nCompared with the findings of the prior study (images reviewed) of ,\nthe rhythm is now sinus (without ectopy) and the left ventricular ejection\nfraction appears normal.\n\n\n"},{"category":"ECG","chartdate":"2130-02-03 00:00:00.000","description":"Report","row_id":292783,"text":"Sinus rhythm with ventricular premature beats. Inferior ST segment elevation\nraises concern for myocardial ischemia. Lateral ST-T wave changes may be due to\nmyocardial ischemia. Clinical correlation is suggested. Compared to the\nprevious tracing of ST segment elevation in the inferior leads was seen\non the prior tracing suggesting that these findings may be chronic and may be\nassociated with an aneurysm. Lateral ST-T wave changes are also chronic.\nClinical correlation is suggested.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2130-02-10 00:00:00.000","description":"Report","row_id":296372,"text":"Typical atrial flutter is present again. S1-Q3-T3 is present as well as the\nanterolateral T wave changes noted previously, all compatible with acute\npulmonary embolism.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2130-02-09 00:00:00.000","description":"Report","row_id":296373,"text":"Atrial flutter with 2:1 response. S1-Q3-T3 pattern. Rule out pulmonary embolus.\nDiffuse T wave abnormalities. Compared to the previous tracing of \natrial flutter is new. Intra-atrial conduction defect cannot be interpreted\nsince rhythm is no longer sinus.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2130-02-07 00:00:00.000","description":"Report","row_id":296374,"text":"Sinus rhythm. Left atrial abnormality. Probable prior inferior myocardial\ninfarction of indeterminate age. ST segment depressions in leads I and aVL and\nT wave flattening in leads V2-V6 persist when compared to the previous tracing\nof .\n\n"},{"category":"ECG","chartdate":"2130-02-04 00:00:00.000","description":"Report","row_id":296375,"text":"Sinus rhythm. Left atrial abnormality. Possible prior myocardial infarction of\nindeterminate age with residual ST segment elevations suggesting possible\naneurysm. Compared to tracing #1 no diagnostic interim change.\nTRACING #2\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2130-02-04 00:00:00.000\",\n \"description\": \"DISTINCT PROCEDURAL SERVICE\",\n \"row_id\": 1225737,\n \"text\": \" 3:28 PM\\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \\n Reason: Please evaluate for worsening infiltrate, effusion, fluid ov\\n Admitting Diagnosis: PULMONARY EMBOLISM\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 69 year old man with PE/DVT, s/p LUL lobectomy with hypoxia\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for worsening infiltrate, effusion, fluid overload,\\n pneumothorax\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE FRONTAL VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Worsening hypoxia.\\n\\n Comparison is made with prior study performed 5 hours earlier.\\n\\n There appears to be increase in left pleural effusion that is loculated in the\\n left apex. Otherwise, there are no interval changes. No pneumothorax or\\n overt pulmonary edema. Extensive pneumonic consolidations in the right lung\\n are unchanged. Evidence of left upper lobe resection, elevation of the left\\n hilum and cardiomediastinal silhouette are unchanged.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2130-02-08 00:00:00.000\",\n \"description\": \"BY DIFFERENT PHYSICIAN\",\n \"row_id\": 1226250,\n \"text\": \" 12:28 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: desaturations with movement, ? ETT tube positioning?\\n Admitting Diagnosis: PULMONARY EMBOLISM\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 69 year old man with ETT\\n REASON FOR THIS EXAMINATION:\\n desaturations with movement, ? ETT tube positioning?\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: ET tube positioning.\\n\\n FINDINGS: In comparison with the earlier study of this date, the tip of the\\n endotracheal tube lies just above the clavicles, approximately 6.8 cm above\\n the carina. Otherwise, there is little change in the appearance of the heart\\n and lungs.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2130-02-06 00:00:00.000\",\n \"description\": \"BY SAME PHYSICIAN\",\n \"row_id\": 1225994,\n \"text\": \" 6:11 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: s/p IJ line placement\\n Admitting Diagnosis: PULMONARY EMBOLISM\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 69 year old man with s/p line\\n REASON FOR THIS EXAMINATION:\\n s/p IJ line placement\\n ______________________________________________________________________________\\n WET READ: OXZa MON 7:02 PM\\n Right IJ tip at superior cavoatrial junction. otherwise, not significantly\\n changed\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: IJ placement.\\n\\n FINDINGS: In comparison with the earlier study of this date, there has been\\n placement of a right IJ catheter that extends to the cavoatrial junction or\\n possibly into the upper portion of the right atrium. The remainder of the\\n study is unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2130-02-08 00:00:00.000\",\n \"description\": \"CT ABD & PELVIS W/O CONTRAST\",\n \"row_id\": 1226288,\n \"text\": \" 5:55 PM\\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \\n Reason: ? e/o occult infection. Please include down to mid-thigh. T\\n Admitting Diagnosis: PULMONARY EMBOLISM\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 69 year old man with fevers for past 24 hrs.\\n REASON FOR THIS EXAMINATION:\\n ? e/o occult infection. Please include down to mid-thigh. Thanks.\\n CONTRAINDICATIONS for IV CONTRAST:\\n Worsening renal failure\\n ______________________________________________________________________________\\n WET READ: OXZa WED 7:42 PM\\n 1. increased, predominantly ground glass opacities throughout the right lung.\\n given rapidity, infection and possible additional edema are likely\\n 2. stable appearance of left hemithorax with post-surgical and radiation\\n changes.\\n 3. no pleural or pericardial effusion\\n 4. intubated with material in distal trachea distal to balloon\\n 5. small amount of perihepatic and pelvic ascites.\\n 6. low density of the intravascular space consistent with anemia. known\\n pulmonary emboli are not evaluated on this non-contrast study\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR THE EXAMINATION: This is a 69-year-old man with fever for the past\\n 24 hours. The request is to rule out an occult infection.\\n\\n The patient is status post left upper lung lobectomy and neoadjuvant\\n chemoradiation due due to squamous cell carcinoma.\\n\\n COMPARISON: Prior CT of the chest from .\\n\\n TECHNIQUE: CT of the chest, body and pelvis without IV contrast\\n administration. Oral contrast was given.\\n\\n Coronal and sagittal reformations were made.\\n\\n TOTAL EXAM DLP: 1308.95 mGy-cm.\\n\\n FINDINGS:\\n\\n CHEST: A central line is seen with its tip in the inferior margin of the\\n superior vena cava.\\n\\n Highly positioned endotracheal tube is seen\\n Nasogastric tube is seen with its tip in the stomach.\\n\\n The heart is within normal limits regarding size and configuration. Unchanged\\n small amount of pericardial effusion that is mainly concentrated on the left\\n side.\\n\\n Status post left upper lobectomy. The surgical bed is filled with fluid with\\n no gas bubbles within it.\\n (Over)\\n\\n 5:55 PM\\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \\n Reason: ? e/o occult infection. Please include down to mid-thigh. T\\n Admitting Diagnosis: PULMONARY EMBOLISM\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n Few prominent mediastinal lymph nodes are identified, for example, a right\\n paratracheal lymph node that measures 11 mm and a subcarinal lymph node with\\n punctate calcifications that measures 12.4 mm on its short axis (2:30).\\n Note is made to a calcified right hilar node and a calcified nodule in the\\n right lower lobe, most consistent with old granulomatous disease.\\n\\n Reidentified are ground-glass opacities in the right upper, middle and lower\\n lobes as well as in the superior segment of the left lower lobe.\\n Consolidations are seen in the right lower lobe and in the superior segment of\\n the left lower lobe.\\n Both findings have increased in size in comparison to prior examinations\\n\\n Small amount of left pleural effusion is detected that was not seen on prior\\n examination.\\n\\n ABDOMEN: The liver is with no gross pathology. The gallbladder is within\\n normal limits. The spleen, the pancreas and both adrenals are with no gross\\n pathology. Both kidneys are unremarkable. No peritoneal or retroperitoneal\\n lymphadenopathy is detected.\\n Diverticulosis is seen along the course of the colon without signs of\\n diverticulitis. Otherwise, the large and small bowel is within normal limits.\\n Small amount of ascites is seen.\\n An IVC filter is identified.\\n\\n PELVIS: The urinary bladder is catheterized with a Foley catheter. Prostate\\n gland is with no gross pathology. Free fluid is seen within the pelvis.\\n There is no concerning lymphadenopathy in the pelvis.\\n Vasectomy clips are seen.\\n\\n OSSEOUS STRUCTURES: Degenerative changes are seen along the course of the\\n spine. No concerning lytic or osteoblastic lesions are identified.\\n\\n IMPRESSION:\\n 1. Interval increase in the size of pulmonary ground-glass opacities and\\n consolidations. These findings are consistent with multifocal pneumonia.\\n 2. Unchanged small pericardial effusion.\\n 3. Small left pleural effusion that was not seen on prior examination.\\n 4. New ascites is seen.\\n 5. Colon diverticulosis without signs of diverticulitis.\\n\\n Findings were discussed by Dr and the patient's referring\\n physician Dr by phone at 11:00, .\\n\\n (Over)\\n\\n 5:55 PM\\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \\n Reason: ? e/o occult infection. Please include down to mid-thigh. T\\n Admitting Diagnosis: PULMONARY EMBOLISM\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2130-02-06 00:00:00.000\",\n \"description\": \"BY DIFFERENT PHYSICIAN\",\n \"row_id\": 1225923,\n \"text\": \" 12:04 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: intubation\\n Admitting Diagnosis: PULMONARY EMBOLISM\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 69 year old man with intubation\\n REASON FOR THIS EXAMINATION:\\n intubation\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n TECHNIQUE: A single semi-upright portable chest view was reviewed in\\n comparison with prior chest radiographs through with the most\\n recent from , .\\n\\n FINDINGS:\\n\\n Endotracheal tube ends approximately 5.2 cm above the carina and is\\n appropriate. An orogastric tube is seen to course below the diaphragm and\\n ends into the stomach; however, the distal end is beyond the radiograph view.\\n Bilateral lung opacities, right side more than left, which increased between\\n and , concerning for an aspiration or pulmonary\\n edema have improved over past five to six hours. Small pleural effusions\\n bilaterally are unchanged. Left upper lung opacities which are due to\\n combination of loculated fluid and collapsed adjacent lung and elevation of\\n the left hemidiaphragm and left hilus are unchanged in appearance. The\\n mediastinal silhouette is stable.\\n\\n IMPRESSION:\\n 1. Bilateral lung opacities, right side more than left, which increased\\n between and , concerning for an aspiration or\\n pulmonary edema have improved.\\n\\n 2. Left upper lung opacities from loculated pleural fluid and collapse of the\\n adjacent lung as suggested from the chest CT dated is\\n unchanged.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2130-02-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 102166,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Atrial flutter. Endocarditis\\nHeight: (in) 71\\nWeight (lb): 187\\nBSA (m2): 2.05 m2\\nBP (mm Hg): 102/64\\nHR (bpm): 119\\nStatus: Inpatient\\nDate/Time: at 16:05\\nTest: Portable TTE (Complete)\\nDoppler: Limited Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Overall normal LVEF\\n(>55%). No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. Abnormal diastolic septal\\nmotion/position consistent with RV volume overload.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\\nof papillary muscles. No MS.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\\nvalve supporting structures. No TS. Moderate to severe [3+] TR. Moderate PA\\nsystolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Normal main\\nPA. No Doppler evidence for PDA\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\\nposition. Suboptimal image quality - ventilator. Suboptimal image quality -\\npatient unable to cooperate. If clinically indicated, a transesophageal\\nechocardiographic examination is recommended.\\n\\nConclusions:\\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\\ncavity is unusually small. Overall left ventricular systolic function is\\nnormal (LVEF 60%). The right ventricular free wall is hypertrophied. The right\\nventricular cavity is dilated There is abnormal diastolic septal\\nmotion/position consistent with right ventricular volume overload. The aortic\\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present.\\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\\nprolapse. The tricuspid valve leaflets are mildly thickened. Moderate to\\nsevere [3+] tricuspid regurgitation is seen. There is moderate pulmonary\\nartery systolic hypertension. There is no pericardial effusion. If clinically\\nindicated, a transesophageal echocardiographic examination is recommended to\\nrule out vegetations.\\n\\nIMPRESSION: No definite vegetations seen. Intercurrent development of moderate\\npulmonary hypertension, moderate-to-severe tricuspid regurgitation and right\\nheart chamber enlargement concerning for acute right heart strain. Consider\\nacute pulmonary embolism.\\n\\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\\ndoes not exclude endocarditis.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2130-02-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 102167,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Worsening hupoxia.\\nHeight: (in) 71\\nWeight (lb): 187\\nBSA (m2): 2.05 m2\\nBP (mm Hg): 108/59\\nHR (bpm): 77\\nStatus: Outpatient\\nDate/Time: at 11:18\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\\nsystolic function (LVEF >55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Prolonged (>250ms)\\ntransmitral E-wave decel time.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA\\nsystolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion.\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\\nsize and regional/global systolic function are normal (LVEF >55%). Right\\nventricular chamber size and free wall motion are normal. The aortic root is\\nmildly dilated at the sinus level. The aortic valve leaflets (3) appear\\nstructurally normal with good leaflet excursion and no aortic stenosis or\\naortic regurgitation. The mitral valve appears structurally normal with\\ntrivial mitral regurgitation. There is moderate pulmonary artery systolic\\nhypertension. There is a trivial/physiologic pericardial effusion.\\n\\nIMPRESSION: Suboptimal image quality. Normal biventricular systolic function.\\nNo significant valvular disease. Mildly dilated aortic root. Moderate\\npulmonary systolic hypertension.\\n\\nCompared with the findings of the prior study (images reviewed) of ,\\nthe rhythm is now sinus (without ectopy) and the left ventricular ejection\\nfraction appears normal.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2130-02-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 292783,\n \"text\": \"Sinus rhythm with ventricular premature beats. Inferior ST segment elevation\\nraises concern for myocardial ischemia. Lateral ST-T wave changes may be due to\\nmyocardial ischemia. Clinical correlation is suggested. Compared to the\\nprevious tracing of ST segment elevation in the inferior leads was seen\\non the prior tracing suggesting that these findings may be chronic and may be\\nassociated with an aneurysm. Lateral ST-T wave changes are also chronic.\\nClinical correlation is suggested.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2130-02-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 296372,\n \"text\": \"Typical atrial flutter is present again. S1-Q3-T3 is present as well as the\\nanterolateral T wave changes noted previously, all compatible with acute\\npulmonary embolism.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2130-02-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 296373,\n \"text\": \"Atrial flutter with 2:1 response. S1-Q3-T3 pattern. Rule out pulmonary embolus.\\nDiffuse T wave abnormalities. Compared to the previous tracing of \\natrial flutter is new. Intra-atrial conduction defect cannot be interpreted\\nsince rhythm is no longer sinus.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2130-02-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 296374,\n \"text\": \"Sinus rhythm. Left atrial abnormality. Probable prior inferior myocardial\\ninfarction of indeterminate age. ST segment depressions in leads I and aVL and\\nT wave flattening in leads V2-V6 persist when compared to the previous tracing\\nof .\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2130-02-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 296375,\n \"text\": \"Sinus rhythm. Left atrial abnormality. Possible prior myocardial infarction of\\nindeterminate age with residual ST segment elevations suggesting possible\\naneurysm. Compared to tracing #1 no diagnostic interim change.\\nTRACING #2\\n\\n\"\n }\n]"}}},{"rowIdx":95,"cells":{"subject_id":{"kind":"number","value":45847,"string":"45,847"},"hadm_id":{"kind":"number","value":184460,"string":"184,460"},"target_text":{"kind":"string","value":"The patient was brought to the operating room on where the patient underwent AVR, CABG x 2. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis, given the patient's preoperative stay of greater than 24 hours. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was hemodynamically stable, weaned from inotropic and vasopressor support. She did exhibit some immediate post-op confusion which resolved on discontinuation of narcotics. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. She did develop rapid atrial fibrillation and converted to sinus rhythm with IV amiodarone bolus and drip. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged in good condition with appropriate follow up instructions and all appointments advised."},"extractive_notes_summ":{"kind":"string","value":"Stable bibasilar atelectasis obscuring hemidiaphragms. Mild (1+) aortic regurgitation isseen.The mitral valve leaflets are mildly thickened. Mild (1+) MR.TRICUSPID VALVE: Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. FINDINGS: Right internal jugular venous catheter position is stable with tip in the lower SVC. Unchanged mildly enlarged cardiac silhouette. Mild pulmonary edema, moderate retrocardiac atelectasis. Normal position of the pleural and mediastinal drains. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderately thickened aortic valveleaflets. Improved mild vascular congestion. Improved mild vascular congestion. Improved mild vascular congestion. Mediastinal and hilar contours are normal. Porcine aortic valve replacement seen. Improved mild vascular congestion without pulmonary edema. Sternotomy sutures midline and intact. Aorta intact. Normal course of the right internal jugular vein central venous access line, the tip of the line projects over the inferior SVC. Mean residualgradient is 15 - 18 mmHg.No MR. .Very good biventricular systolic fxn. No TEE relatedcomplications.Conclusions:Pre-CPB:No spontaneous echo contrast is seen in the left atrial appendage.Overall left ventricular systolic function is normal (LVEF>55%).Right ventricular chamber size and free wall motion are normal.There are simple atheroma in the descending thoracic aorta.There are three aortic valve leaflets. ASStatus: InpatientDate/Time: at 12:28Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal descending aorta diameter. Normal sinus rhythm. No larger pleural effusions. TECHNIQUE: Chest PA and lateral radiograph obtained. Simple atheroma in descending aorta.AORTIC VALVE: Three aortic valve leaflets. IMPRESSION: Overall improved aeration of the lungs with stable bibasilar atelectasis. FINDINGS: Status post CABG, the sternal wires are in correct alignment. Mild (1+) mitral regurgitationis seen.There is no pericardial effusion.Post-CPB:The patient is on no inotropes.There is a prosthetic aortic valve with no AI and no leak. Right IJ catheter remains in place. Possible small bilateral pleural effusions. Possible small bilateral pleural effusions. Possible small bilateral pleural effusions. Possible small bilateral pleural effusions. New interstitial pulmonary edema and bibasilar left greater than right opacification, likely atelectasis though pneumonia is not excluded. Consider left ventricular hypertrophy. Left anteriorfascicular block. COMPARISON: Preoperative chest x-ray from . The patient was undergeneral anesthesia throughout the procedure. The endotracheal tube, nasogastric tube, and mediastinal drains have been removed. No pulmonary edema. No pulmonary edema. No pulmonary edema. FINDINGS: In comparison with the study of , the left chest tube has been removed and there is no evidence of pneumothorax. Compared to theprevious tracing of the ST-T wave changes in leads I and aVL are moreprominent. FINAL REPORT INDICATION: Status post CABG. , CSURG FA6A 10:01 AM CHEST (PA & LAT) Clip # Reason: eval effusion pod 5 from avr and cabg Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 71 year old woman with s/p avr and cabg REASON FOR THIS EXAMINATION: eval effusion pod 5 from avr and cabg PFI REPORT PFI: Overall improved aeration of the lungs with stable bibasilar atelectasis. COMPARISON: Comparison is made to portable chest film performed , and preop PA and lateral performed . I certifyI was present in compliance with HCFA regulations. 10:01 AM CHEST (PA & LAT) Clip # Reason: eval effusion pod 5 from avr and cabg Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 71 year old woman with s/p avr and cabg REASON FOR THIS EXAMINATION: eval effusion pod 5 from avr and cabg PROVISIONAL FINDINGS IMPRESSION (PFI): PBec MON 3:40 PM PFI: Overall improved aeration of the lungs with stable bibasilar atelectasis. ST-T wave changes in leads I and aVL. The aortic valve leaflets aremoderately thickened. The aortic valve has also been replaced. Continued enlargement of the cardiac silhouette with elevation of pulmonary venous pressure and bibasilar atelectatic change. Severe AS (area 0.8-1.0cm2). The TEE probe was passed withassistance from the anesthesioology staff using a laryngoscope. The tip of the endotracheal tube projects 3 cm above the carina. There is severe aortic valve stenosis (valve area 0.9 by2 observers; peak gradient 34, mean 22). No other diagnostic intervalchange. 4:43 PM CHEST PORT. PATIENT/TEST INFORMATION:Indication: CABG/AI/ ? Other parameters aspre-bypass. FINAL REPORT INDICATION: 71-year-old woman status post AVR and CABG, evaluate for effusion. No evidence of pneumothorax. No evidence of pneumothorax. Frontal plane axis at minus 55 degrees. LINE PLACEMENT Clip # Reason: PTX, EFFUSION - CARDIAC SURGERY, FAST TRACK EXTUBATION - ICU Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 71 year old woman with s/p AVR/CABG - - CARDIAC SURGERY, FAST TRACK EXTUBATION - ICU PROVIDER REASON FOR THIS EXAMINATION: PTX, EFFUSION - CARDIAC SURGERY, FAST TRACK EXTUBATION - ICU PROVIDER WET READ: DLrc WED 5:47 PM New support hardware in standard positions."},"n_notes":{"kind":"number","value":6,"string":"6"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2105-10-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1155076,"text":" 12:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PTX s/p chest tube removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with AVR/CABG\n REASON FOR THIS EXAMINATION:\n eval for PTX s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube removal, to assess for pneumothorax.\n\n FINDINGS: In comparison with the study of , the left chest tube has been\n removed and there is no evidence of pneumothorax. Continued enlargement of\n the cardiac silhouette with elevation of pulmonary venous pressure and\n bibasilar atelectatic change. The endotracheal tube, nasogastric tube, and\n mediastinal drains have been removed. Right IJ catheter remains in place.\n\n\n"},{"category":"Radiology","chartdate":"2105-10-26 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1155469,"text":" 10:01 AM\n CHEST (PA & LAT) Clip # \n Reason: eval effusion pod 5 from avr and cabg\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p avr and cabg\n REASON FOR THIS EXAMINATION:\n eval effusion pod 5 from avr and cabg\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PBec MON 3:40 PM\n PFI: Overall improved aeration of the lungs with stable bibasilar\n atelectasis. Improved mild vascular congestion. No pulmonary edema.\n Possible small bilateral pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman status post AVR and CABG, evaluate for\n effusion.\n\n TECHNIQUE: Chest PA and lateral radiograph obtained.\n\n COMPARISON: Comparison is made to portable chest film performed , and preop PA and lateral performed .\n\n FINDINGS: Right internal jugular venous catheter position is stable with tip\n in the lower SVC. Sternotomy sutures midline and intact. Porcine aortic\n valve replacement seen. Stable bibasilar atelectasis obscuring\n hemidiaphragms. Possible small bilateral pleural effusions. Improved mild\n vascular congestion without pulmonary edema. Unchanged mildly enlarged\n cardiac silhouette. Mediastinal and hilar contours are normal.\n\n IMPRESSION: Overall improved aeration of the lungs with stable bibasilar\n atelectasis. Improved mild vascular congestion. No pulmonary edema.\n Possible small bilateral pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2105-10-26 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1155470,"text":", CSURG FA6A 10:01 AM\n CHEST (PA & LAT) Clip # \n Reason: eval effusion pod 5 from avr and cabg\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p avr and cabg\n REASON FOR THIS EXAMINATION:\n eval effusion pod 5 from avr and cabg\n ______________________________________________________________________________\n PFI REPORT\n PFI: Overall improved aeration of the lungs with stable bibasilar\n atelectasis. Improved mild vascular congestion. No pulmonary edema.\n Possible small bilateral pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2105-10-21 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1154764,"text":" 4:43 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: PTX, EFFUSION - CARDIAC SURGERY, FAST TRACK EXTUBATION - ICU\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p AVR/CABG - - CARDIAC SURGERY, FAST TRACK EXTUBATION\n - ICU PROVIDER \n REASON FOR THIS EXAMINATION:\n PTX, EFFUSION - CARDIAC SURGERY, FAST TRACK EXTUBATION - ICU PROVIDER \n \n ______________________________________________________________________________\n WET READ: DLrc WED 5:47 PM\n New support hardware in standard positions. No evidence of pneumothorax. New\n interstitial pulmonary edema and bibasilar left greater than right\n opacification, likely atelectasis though pneumonia is not excluded.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG.\n\n COMPARISON: Preoperative chest x-ray from .\n\n FINDINGS: Status post CABG, the sternal wires are in correct alignment. The\n tip of the endotracheal tube projects 3 cm above the carina. Normal position\n of the pleural and mediastinal drains. Normal course of the right internal\n jugular vein central venous access line, the tip of the line projects over the\n inferior SVC.\n\n No evidence of pneumothorax. No larger pleural effusions. Mild pulmonary\n edema, moderate retrocardiac atelectasis.\n\n The aortic valve has also been replaced.\n\n\n"},{"category":"Echo","chartdate":"2105-10-21 00:00:00.000","description":"Report","row_id":64876,"text":"PATIENT/TEST INFORMATION:\nIndication: CABG/AI/ ? AS\nStatus: Inpatient\nDate/Time: at 12:28\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Severe AS (area 0.8-1.0cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications.\n\nConclusions:\nPre-CPB:\nNo spontaneous echo contrast is seen in the left atrial appendage.\nOverall left ventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal.\nThere are simple atheroma in the descending thoracic aorta.\nThere are three aortic valve leaflets. The aortic valve leaflets are\nmoderately thickened. There is severe aortic valve stenosis (valve area 0.9 by\n2 observers; peak gradient 34, mean 22). Mild (1+) aortic regurgitation is\nseen.\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\nis seen.\nThere is no pericardial effusion.\n\nPost-CPB:\nThe patient is on no inotropes.\nThere is a prosthetic aortic valve with no AI and no leak. Mean residual\ngradient is 15 - 18 mmHg.\nNo MR. .\nVery good biventricular systolic fxn. Aorta intact. Other parameters as\npre-bypass.\n\n\n"},{"category":"ECG","chartdate":"2105-10-21 00:00:00.000","description":"Report","row_id":129563,"text":"Normal sinus rhythm. Frontal plane axis at minus 55 degrees. Left anterior\nfascicular block. ST-T wave changes in leads I and aVL. Compared to the\nprevious tracing of the ST-T wave changes in leads I and aVL are more\nprominent. Consider left ventricular hypertrophy. No other diagnostic interval\nchange.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2105-10-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1155076,\n \"text\": \" 12:58 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for PTX s/p chest tube removal\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with AVR/CABG\\n REASON FOR THIS EXAMINATION:\\n eval for PTX s/p chest tube removal\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Chest tube removal, to assess for pneumothorax.\\n\\n FINDINGS: In comparison with the study of , the left chest tube has been\\n removed and there is no evidence of pneumothorax. Continued enlargement of\\n the cardiac silhouette with elevation of pulmonary venous pressure and\\n bibasilar atelectatic change. The endotracheal tube, nasogastric tube, and\\n mediastinal drains have been removed. Right IJ catheter remains in place.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2105-10-26 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1155469,\n \"text\": \" 10:01 AM\\n CHEST (PA & LAT) Clip # \\n Reason: eval effusion pod 5 from avr and cabg\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with s/p avr and cabg\\n REASON FOR THIS EXAMINATION:\\n eval effusion pod 5 from avr and cabg\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PBec MON 3:40 PM\\n PFI: Overall improved aeration of the lungs with stable bibasilar\\n atelectasis. Improved mild vascular congestion. No pulmonary edema.\\n Possible small bilateral pleural effusions.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old woman status post AVR and CABG, evaluate for\\n effusion.\\n\\n TECHNIQUE: Chest PA and lateral radiograph obtained.\\n\\n COMPARISON: Comparison is made to portable chest film performed , and preop PA and lateral performed .\\n\\n FINDINGS: Right internal jugular venous catheter position is stable with tip\\n in the lower SVC. Sternotomy sutures midline and intact. Porcine aortic\\n valve replacement seen. Stable bibasilar atelectasis obscuring\\n hemidiaphragms. Possible small bilateral pleural effusions. Improved mild\\n vascular congestion without pulmonary edema. Unchanged mildly enlarged\\n cardiac silhouette. Mediastinal and hilar contours are normal.\\n\\n IMPRESSION: Overall improved aeration of the lungs with stable bibasilar\\n atelectasis. Improved mild vascular congestion. No pulmonary edema.\\n Possible small bilateral pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2105-10-26 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1155470,\n \"text\": \", CSURG FA6A 10:01 AM\\n CHEST (PA & LAT) Clip # \\n Reason: eval effusion pod 5 from avr and cabg\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with s/p avr and cabg\\n REASON FOR THIS EXAMINATION:\\n eval effusion pod 5 from avr and cabg\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Overall improved aeration of the lungs with stable bibasilar\\n atelectasis. Improved mild vascular congestion. No pulmonary edema.\\n Possible small bilateral pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2105-10-21 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1154764,\n \"text\": \" 4:43 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: PTX, EFFUSION - CARDIAC SURGERY, FAST TRACK EXTUBATION - ICU\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with s/p AVR/CABG - - CARDIAC SURGERY, FAST TRACK EXTUBATION\\n - ICU PROVIDER \\n REASON FOR THIS EXAMINATION:\\n PTX, EFFUSION - CARDIAC SURGERY, FAST TRACK EXTUBATION - ICU PROVIDER \\n \\n ______________________________________________________________________________\\n WET READ: DLrc WED 5:47 PM\\n New support hardware in standard positions. No evidence of pneumothorax. New\\n interstitial pulmonary edema and bibasilar left greater than right\\n opacification, likely atelectasis though pneumonia is not excluded.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post CABG.\\n\\n COMPARISON: Preoperative chest x-ray from .\\n\\n FINDINGS: Status post CABG, the sternal wires are in correct alignment. The\\n tip of the endotracheal tube projects 3 cm above the carina. Normal position\\n of the pleural and mediastinal drains. Normal course of the right internal\\n jugular vein central venous access line, the tip of the line projects over the\\n inferior SVC.\\n\\n No evidence of pneumothorax. No larger pleural effusions. Mild pulmonary\\n edema, moderate retrocardiac atelectasis.\\n\\n The aortic valve has also been replaced.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2105-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 64876,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: CABG/AI/ ? AS\\nStatus: Inpatient\\nDate/Time: at 12:28\\nTest: TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\\n\\nLEFT VENTRICLE: Overall normal LVEF (>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal descending aorta diameter. Simple atheroma in descending aorta.\\n\\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\\nleaflets. Severe AS (area 0.8-1.0cm2). Mild (1+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Mild [1+] TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was under\\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\\ncomplications.\\n\\nConclusions:\\nPre-CPB:\\nNo spontaneous echo contrast is seen in the left atrial appendage.\\nOverall left ventricular systolic function is normal (LVEF>55%).\\nRight ventricular chamber size and free wall motion are normal.\\nThere are simple atheroma in the descending thoracic aorta.\\nThere are three aortic valve leaflets. The aortic valve leaflets are\\nmoderately thickened. There is severe aortic valve stenosis (valve area 0.9 by\\n2 observers; peak gradient 34, mean 22). Mild (1+) aortic regurgitation is\\nseen.\\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\\nis seen.\\nThere is no pericardial effusion.\\n\\nPost-CPB:\\nThe patient is on no inotropes.\\nThere is a prosthetic aortic valve with no AI and no leak. Mean residual\\ngradient is 15 - 18 mmHg.\\nNo MR. .\\nVery good biventricular systolic fxn. Aorta intact. Other parameters as\\npre-bypass.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2105-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 129563,\n \"text\": \"Normal sinus rhythm. Frontal plane axis at minus 55 degrees. Left anterior\\nfascicular block. ST-T wave changes in leads I and aVL. Compared to the\\nprevious tracing of the ST-T wave changes in leads I and aVL are more\\nprominent. Consider left ventricular hypertrophy. No other diagnostic interval\\nchange.\\n\\n\"\n }\n]"}}},{"rowIdx":96,"cells":{"subject_id":{"kind":"number","value":10774,"string":"10,774"},"hadm_id":{"kind":"number","value":179525,"string":"179,525"},"target_text":{"kind":"string","value":"Upper GI bleed: Pt. initially with borderline hypotension and tachycardia. Responded well to fluid resuscitation. Admitted initially to ICU, where an EGD was performed on AM of hospital day 2. EGD revealed duodenitis, no active bleed, no ulcer, Barrett's esophagus. In the ICU, was transfused 2 units pRBC, 1 unit FFP. Given initial low BP and GIB, all antihypertensives were initially held, as was coumadin.Throughout the rest of hospital stay, pt. had stable vital signs, no further GIB. Hct responded appropriately to transfusion, remained stable. Antihypertensives and coumadin were restarted on HD 3 and were tolerated well. Overall, continued ASA and warfarin, but stopped plavix after consultation with Cardiology. . Respiratory distress/asthma flare: On Hospital day 3, began to have increasing respiratory distress. Exam notable for marked wheezing. CXR with no definite infiltrates. While initially volume overloaded after MICU stay, no longer had evidence of CHF. Overall, he was treated with prednisone and nebs for asthma flare. Also empirically treated for PNA - although limited evidence for this on cxr - with rocephin/azithro. Will be d/c with levaquin to complete 7 day course. . Chest pressure: On the night of HD 3, patient had an episode of L-sided chest pain that was ssociated with diaphoresis and an increased 02 requirement (responded to 2L NC). Pain resolved quickly with 3 SL nitroglycerin, albuterol neb, and IV lasix. Cardiac enzymes were trended and over the following day climbed from 0.05 to a peak of 0.08. He had no further events, and had stress MIBI in hospital prior to discharge, which again demonstrated his severe ischemic dilated cardiomyopathy and also multiple predominantly fixed perfusion defects - previous stress in with progressively worse reversible perfusion defects. Will continue medicla management. . ARF on CKD: Pt. had briefly elevated Cr, which returned quickly to baseline with fluid resuscitation. In setting of GIB, seemed c/w prerenal picture. ACEI was initially held, but restarted without adverse effect once Cr returned to baseline. Remained at baseline thereafter with re-introduction of meds. . Abdominal pain/constipation: On HD 3, pt. developed bilateral lower quadrant abdominal pain, which he attributed to not having had a bowel movement since admission to hospital. Abdominal exam was benign, KUB unremarkable. Had relief after BM. ."},"extractive_notes_summ":{"kind":"string","value":"INR 2.6.Resp: 2L NC, o2sat 94-97, rr 17-22, LS clear upper diminished lower. Diet advanced to regular and tol well by pt with no N/V/D. Probable slow atrialtachycardia or possibly with 2;1 block. Next Hct due at 19:00.Resp) LS CTA with no resp distress noted. CE WERE DONE IN ER. HE BECAME LIGHTHEADED AND CALLED EMS. no c/o pain.Cardiac: Pacemaker and AICD, V-paced w/ occassional pvc's, HR 75-98, SBP 75-111, MAPs >55, given 1L NS bolus over 2H for decreased BP w/ some effect. PT DENIES CHEST PAIN. PT IS V PACED WITH PVC'S NOTED. Pt inc to DB&C W/A.GI) Abd dist/soft and non-tender to touch. voiding urine in adequate amts, approximately >75cc/hr, yellow/clear.ID: Temp 96.3-98.8, WBC 9.0. PT HAS AICD AND PACEMAKER. VSS as noted and found NOT to be orthostatic. Regular wide complex tachycardia, mechanism, uncertain. Pt is stable and VSS and WNL's. Since the previous tracing of Ventricular ectopyb and intermittent ventricular paced beats are not seen. Intraventricular conduction delay.Probable atypical right bundle-branch block with left anterior fascicularblock. Diffuse ST-T wave abnormalities. Abd soft distended/non-tender. NO FURTHER TREATMENT AT THIS TIME BUT PT HAS BEEN T/C FOR 6 UNITS OF PRBC'S TOTAL.RESP) PT LUNGS ARE CLEAR WITH OCCASIONAL EXP WHEEZING. PT DENIES PAIN. Pt denies any cardiac symptoms. Hct and VSS. MONITOR FOR HYPOTENSION PT HAS HISTORY OF ASTHMA.GI/GU) PT HAD EGD THIS AFTERNOON. PT HAD NG LAVAGE THAT WAS NEGATIVE. MAE.CV) PT IS STABLE. ON ARRIVAL TO ED HIS BP WAS IN THE 80'S, HR 105, HCT WAS 42, BUN AND CR ELEVATED. No bm this shift so far. Pt in for cardiology c/s re ? PT 3MG VERSED ADN 75 MCG OF FENT AND TOLERATED PROCEEDURE WELL. ACCORDING TO NOTES PT HCT IS BASELINE 31. PT WAS SUSPECT FOR VOLUME DEPLETION AND 3 L NS, 2 UNITS PRBC'S, AND 2 UNIT FFP (ONE IN ER AND ONE ON FLOOR) TRANSFERED TO MICU FOR FUTHER ASSESSMENT.NEURO) PT ALERT AND ORIETNED TIMES THREE. CLEAR YELLOW URINE.SKIN) NO BREAKDOWN NOTED.ID) AFEB NO ANTIBIOTICSSOCIAL) WIFE .PLAN) MONITOR HCT Q 6 HRS. pacer interigation. MD may be causing the pt to vagal, given 12.5mg Anzimet IV PRN. HR 80-100. PT CAN TX Q 3-4HRS. No signs of any bleeding at this time, and hct stable as noted (35.2->35.4). BP IS 90-110/60-70'S. hct stable @ 34.0 from 35.2, no blood products overnight, cont to monitor hct Q6H, next lab @ 0800. LAST HCT WAS AT 1415 WHICH RESULTED IN HCT 34. Had EGD yesterday and found nothing at the time. No edema noted. Pt is awaiting bed on floor.Neuro) Pt is awake and oriented x 3.CV) Pt is Ventricular paced with PVC's and is in and out of RBBB. HCT ARE Q 6 HRS. 7am to 7pm:Pt has had an uneventful day. PT BASELINE SBP IS IN THE 90'S. Cont med regimen and icu treatment. HL'd.GU) Good U/O via urinal.pain) Pt denies any discomfort.Soc) wife and son updated this am. PT CAN HAVE CLEAR LIQUIDS. Technically difficult studyProbable atrial fibrillation with rapid ventricular responseProbable ventricular coupletsMarked left axis deviationIntraventricular conduction defectLVH with secondary ST-T changesPossible RVH with secondary ST-T changesSince previous tracing, rhythm more irregular ventricular couplets new PT SATS ARE IN THE HIGH 90'S ON 2 LNC. Stool black and gritty, but guiac neg x2. PT IS ALSO ON ADVAIR. No signs of infection at this time. NPN: 0700-1900CODE STATUS: FULLALL: NKDAPMH: CAD, CABG, AICD, V PACED, EF 15-20%, A FIB, HYPOTYROID, HYPERLIPIDEMIA, DEPRESSION, ? PT HAS STRONG COUGH. PT IS VOIDING IN URINAL. Nursing Progress Note 1900-0700*Full Code*Access: Rant 18g PIV, Lhand 20g PIV*NKDA**Please see admit note/FHP for admit info and hxNeuro: pt A&O x3, follows commands, able to make needs known, assists w/ turns. 4pm:Pt to be transfered to 724. MAP > 60. Skin intact, iv sites wnl.Psychosocial: wife called yesterday but not heard from this shift.Dispo: cont to monitor BP and treat MD orders if needed (baseline systolic in 90's), monitor hct (next lab 0800). Pt to be transfered on telemetry. PT VERY PLEASANT AND COOPERATIVE. PT CONTINUES TO HAVE TARRY BLACK STOOLS IN SCANT AMOUNTS. c/o some increased dizziness when BP lower, but mentating well and easy to arouse from sleep. +BS, pt had 3 sm/med stools w/in 30 min (on and off bed pan). Pt OOB to chair. All belongings with pt on transfer. DEMENTIA, ANEMIA, VALVE REPLACEMENTREASON FOR ADMISSION: 70 Y/O M WHO HAD BLACK TARRY STOOLS TIMES TWO DAYS. Hx asthma, w/ some wheezing yesterday, albuterol neb prn, advair .GI/GU: clear liquid diet, had jello/apple juice/ice cream and tolerated well."},"n_notes":{"kind":"number","value":6,"string":"6"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2139-01-11 00:00:00.000","description":"Report","row_id":149562,"text":"Technically difficult study\nProbable atrial fibrillation with rapid ventricular response\nProbable ventricular couplets\nMarked left axis deviation\nIntraventricular conduction defect\nLVH with secondary ST-T changes\nPossible RVH with secondary ST-T changes\nSince previous tracing, rhythm more irregular ventricular couplets new\n\n"},{"category":"ECG","chartdate":"2139-01-06 00:00:00.000","description":"Report","row_id":149563,"text":"Regular wide complex tachycardia, mechanism, uncertain. Probable slow atrial\ntachycardia or possibly with 2;1 block. Intraventricular conduction delay.\nProbable atypical right bundle-branch block with left anterior fascicular\nblock. Diffuse ST-T wave abnormalities. Since the previous tracing of \nVentricular ectopyb and intermittent ventricular paced beats are not seen.\n\n"},{"category":"Nursing/other","chartdate":"2139-01-06 00:00:00.000","description":"Report","row_id":1404455,"text":"NPN: 0700-1900\nCODE STATUS: FULL\n\nALL: NKDA\n\nPMH: CAD, CABG, AICD, V PACED, EF 15-20%, A FIB, HYPOTYROID, HYPERLIPIDEMIA, DEPRESSION, ? DEMENTIA, ANEMIA, VALVE REPLACEMENT\n\nREASON FOR ADMISSION: 70 Y/O M WHO HAD BLACK TARRY STOOLS TIMES TWO DAYS. HE BECAME LIGHTHEADED AND CALLED EMS. ON ARRIVAL TO ED HIS BP WAS IN THE 80'S, HR 105, HCT WAS 42, BUN AND CR ELEVATED. PT HAD NG LAVAGE THAT WAS NEGATIVE. PT WAS SUSPECT FOR VOLUME DEPLETION AND 3 L NS, 2 UNITS PRBC'S, AND 2 UNIT FFP (ONE IN ER AND ONE ON FLOOR) TRANSFERED TO MICU FOR FUTHER ASSESSMENT.\n\nNEURO) PT ALERT AND ORIETNED TIMES THREE. PT ABLE TO MAKE NEEDS KNOWN, PT FOLLOWS ALL COMMANDS. PT VERY PLEASANT AND COOPERATIVE. PT DENIES PAIN. MAE.\n\nCV) PT IS STABLE. BP IS 90-110/60-70'S. PT BASELINE SBP IS IN THE 90'S. HR 80-100. PT HAS AICD AND PACEMAKER. PT IS V PACED WITH PVC'S NOTED. PT DENIES CHEST PAIN. CE WERE DONE IN ER. HCT ARE Q 6 HRS. LAST HCT WAS AT 1415 WHICH RESULTED IN HCT 34. ACCORDING TO NOTES PT HCT IS BASELINE 31. NO FURTHER TREATMENT AT THIS TIME BUT PT HAS BEEN T/C FOR 6 UNITS OF PRBC'S TOTAL.\n\nRESP) PT LUNGS ARE CLEAR WITH OCCASIONAL EXP WHEEZING. PT CAN TX Q 3-4HRS. PT IS ALSO ON ADVAIR. PT SATS ARE IN THE HIGH 90'S ON 2 LNC. PT HAS STRONG COUGH. PT HAS HISTORY OF ASTHMA.\n\nGI/GU) PT HAD EGD THIS AFTERNOON. PT 3MG VERSED ADN 75 MCG OF FENT AND TOLERATED PROCEEDURE WELL. PT CONTINUES TO HAVE TARRY BLACK STOOLS IN SCANT AMOUNTS. PT CAN HAVE CLEAR LIQUIDS. PT IS VOIDING IN URINAL. CLEAR YELLOW URINE.\n\nSKIN) NO BREAKDOWN NOTED.\n\nID) AFEB NO ANTIBIOTICS\n\nSOCIAL) WIFE .\n\nPLAN) MONITOR HCT Q 6 HRS.\n MONITOR FOR HYPOTENSION\n\n\n"},{"category":"Nursing/other","chartdate":"2139-01-07 00:00:00.000","description":"Report","row_id":1404456,"text":"Nursing Progress Note 1900-0700\n*Full Code\n\n*Access: Rant 18g PIV, Lhand 20g PIV\n\n*NKDA\n\n**Please see admit note/FHP for admit info and hx\n\nNeuro: pt A&O x3, follows commands, able to make needs known, assists w/ turns. c/o some increased dizziness when BP lower, but mentating well and easy to arouse from sleep. no c/o pain.\n\nCardiac: Pacemaker and AICD, V-paced w/ occassional pvc's, HR 75-98, SBP 75-111, MAPs >55, given 1L NS bolus over 2H for decreased BP w/ some effect. MD may be causing the pt to vagal, given 12.5mg Anzimet IV PRN. hct stable @ 34.0 from 35.2, no blood products overnight, cont to monitor hct Q6H, next lab @ 0800. INR 2.6.\n\nResp: 2L NC, o2sat 94-97, rr 17-22, LS clear upper diminished lower. Hx asthma, w/ some wheezing yesterday, albuterol neb prn, advair .\n\nGI/GU: clear liquid diet, had jello/apple juice/ice cream and tolerated well. +BS, pt had 3 sm/med stools w/in 30 min (on and off bed pan). Stool black and gritty, but guiac neg x2. Had EGD yesterday and found nothing at the time. Abd soft distended/non-tender. voiding urine in adequate amts, approximately >75cc/hr, yellow/clear.\n\nID: Temp 96.3-98.8, WBC 9.0. No signs of infection at this time. Skin intact, iv sites wnl.\n\nPsychosocial: wife called yesterday but not heard from this shift.\n\nDispo: cont to monitor BP and treat MD orders if needed (baseline systolic in 90's), monitor hct (next lab 0800). Cont med regimen and icu treatment.\n"},{"category":"Nursing/other","chartdate":"2139-01-07 00:00:00.000","description":"Report","row_id":1404457,"text":"7am to 7pm:\n\nPt has had an uneventful day. Hct and VSS. Pt is awaiting bed on floor.\n\nNeuro) Pt is awake and oriented x 3.\n\nCV) Pt is Ventricular paced with PVC's and is in and out of RBBB. Pt in for cardiology c/s re ? pacer interigation. Pt denies any cardiac symptoms. VSS as noted and found NOT to be orthostatic. MAP > 60. No edema noted. No signs of any bleeding at this time, and hct stable as noted (35.2->35.4). Next Hct due at 19:00.\n\nResp) LS CTA with no resp distress noted. Pt inc to DB&C W/A.\n\nGI) Abd dist/soft and non-tender to touch. Diet advanced to regular and tol well by pt with no N/V/D. No bm this shift so far. HL'd.\n\nGU) Good U/O via urinal.\n\npain) Pt denies any discomfort.\n\nSoc) wife and son updated this am. Pt OOB to chair.\n"},{"category":"Nursing/other","chartdate":"2139-01-07 00:00:00.000","description":"Report","row_id":1404458,"text":"4pm:\n\nPt to be transfered to 724. Pt is stable and VSS and WNL's. All belongings with pt on transfer. Pt to be transfered on telemetry.\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2139-01-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 149562,\n \"text\": \"Technically difficult study\\nProbable atrial fibrillation with rapid ventricular response\\nProbable ventricular couplets\\nMarked left axis deviation\\nIntraventricular conduction defect\\nLVH with secondary ST-T changes\\nPossible RVH with secondary ST-T changes\\nSince previous tracing, rhythm more irregular ventricular couplets new\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2139-01-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 149563,\n \"text\": \"Regular wide complex tachycardia, mechanism, uncertain. Probable slow atrial\\ntachycardia or possibly with 2;1 block. Intraventricular conduction delay.\\nProbable atypical right bundle-branch block with left anterior fascicular\\nblock. Diffuse ST-T wave abnormalities. Since the previous tracing of \\nVentricular ectopyb and intermittent ventricular paced beats are not seen.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-01-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1404455,\n \"text\": \"NPN: 0700-1900\\nCODE STATUS: FULL\\n\\nALL: NKDA\\n\\nPMH: CAD, CABG, AICD, V PACED, EF 15-20%, A FIB, HYPOTYROID, HYPERLIPIDEMIA, DEPRESSION, ? DEMENTIA, ANEMIA, VALVE REPLACEMENT\\n\\nREASON FOR ADMISSION: 70 Y/O M WHO HAD BLACK TARRY STOOLS TIMES TWO DAYS. HE BECAME LIGHTHEADED AND CALLED EMS. ON ARRIVAL TO ED HIS BP WAS IN THE 80'S, HR 105, HCT WAS 42, BUN AND CR ELEVATED. PT HAD NG LAVAGE THAT WAS NEGATIVE. PT WAS SUSPECT FOR VOLUME DEPLETION AND 3 L NS, 2 UNITS PRBC'S, AND 2 UNIT FFP (ONE IN ER AND ONE ON FLOOR) TRANSFERED TO MICU FOR FUTHER ASSESSMENT.\\n\\nNEURO) PT ALERT AND ORIETNED TIMES THREE. PT ABLE TO MAKE NEEDS KNOWN, PT FOLLOWS ALL COMMANDS. PT VERY PLEASANT AND COOPERATIVE. PT DENIES PAIN. MAE.\\n\\nCV) PT IS STABLE. BP IS 90-110/60-70'S. PT BASELINE SBP IS IN THE 90'S. HR 80-100. PT HAS AICD AND PACEMAKER. PT IS V PACED WITH PVC'S NOTED. PT DENIES CHEST PAIN. CE WERE DONE IN ER. HCT ARE Q 6 HRS. LAST HCT WAS AT 1415 WHICH RESULTED IN HCT 34. ACCORDING TO NOTES PT HCT IS BASELINE 31. NO FURTHER TREATMENT AT THIS TIME BUT PT HAS BEEN T/C FOR 6 UNITS OF PRBC'S TOTAL.\\n\\nRESP) PT LUNGS ARE CLEAR WITH OCCASIONAL EXP WHEEZING. PT CAN TX Q 3-4HRS. PT IS ALSO ON ADVAIR. PT SATS ARE IN THE HIGH 90'S ON 2 LNC. PT HAS STRONG COUGH. PT HAS HISTORY OF ASTHMA.\\n\\nGI/GU) PT HAD EGD THIS AFTERNOON. PT 3MG VERSED ADN 75 MCG OF FENT AND TOLERATED PROCEEDURE WELL. PT CONTINUES TO HAVE TARRY BLACK STOOLS IN SCANT AMOUNTS. PT CAN HAVE CLEAR LIQUIDS. PT IS VOIDING IN URINAL. CLEAR YELLOW URINE.\\n\\nSKIN) NO BREAKDOWN NOTED.\\n\\nID) AFEB NO ANTIBIOTICS\\n\\nSOCIAL) WIFE .\\n\\nPLAN) MONITOR HCT Q 6 HRS.\\n MONITOR FOR HYPOTENSION\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-01-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1404456,\n \"text\": \"Nursing Progress Note 1900-0700\\n*Full Code\\n\\n*Access: Rant 18g PIV, Lhand 20g PIV\\n\\n*NKDA\\n\\n**Please see admit note/FHP for admit info and hx\\n\\nNeuro: pt A&O x3, follows commands, able to make needs known, assists w/ turns. c/o some increased dizziness when BP lower, but mentating well and easy to arouse from sleep. no c/o pain.\\n\\nCardiac: Pacemaker and AICD, V-paced w/ occassional pvc's, HR 75-98, SBP 75-111, MAPs >55, given 1L NS bolus over 2H for decreased BP w/ some effect. MD may be causing the pt to vagal, given 12.5mg Anzimet IV PRN. hct stable @ 34.0 from 35.2, no blood products overnight, cont to monitor hct Q6H, next lab @ 0800. INR 2.6.\\n\\nResp: 2L NC, o2sat 94-97, rr 17-22, LS clear upper diminished lower. Hx asthma, w/ some wheezing yesterday, albuterol neb prn, advair .\\n\\nGI/GU: clear liquid diet, had jello/apple juice/ice cream and tolerated well. +BS, pt had 3 sm/med stools w/in 30 min (on and off bed pan). Stool black and gritty, but guiac neg x2. Had EGD yesterday and found nothing at the time. Abd soft distended/non-tender. voiding urine in adequate amts, approximately >75cc/hr, yellow/clear.\\n\\nID: Temp 96.3-98.8, WBC 9.0. No signs of infection at this time. Skin intact, iv sites wnl.\\n\\nPsychosocial: wife called yesterday but not heard from this shift.\\n\\nDispo: cont to monitor BP and treat MD orders if needed (baseline systolic in 90's), monitor hct (next lab 0800). Cont med regimen and icu treatment.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-01-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1404457,\n \"text\": \"7am to 7pm:\\n\\nPt has had an uneventful day. Hct and VSS. Pt is awaiting bed on floor.\\n\\nNeuro) Pt is awake and oriented x 3.\\n\\nCV) Pt is Ventricular paced with PVC's and is in and out of RBBB. Pt in for cardiology c/s re ? pacer interigation. Pt denies any cardiac symptoms. VSS as noted and found NOT to be orthostatic. MAP > 60. No edema noted. No signs of any bleeding at this time, and hct stable as noted (35.2->35.4). Next Hct due at 19:00.\\n\\nResp) LS CTA with no resp distress noted. Pt inc to DB&C W/A.\\n\\nGI) Abd dist/soft and non-tender to touch. Diet advanced to regular and tol well by pt with no N/V/D. No bm this shift so far. HL'd.\\n\\nGU) Good U/O via urinal.\\n\\npain) Pt denies any discomfort.\\n\\nSoc) wife and son updated this am. Pt OOB to chair.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2139-01-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1404458,\n \"text\": \"4pm:\\n\\nPt to be transfered to 724. Pt is stable and VSS and WNL's. All belongings with pt on transfer. Pt to be transfered on telemetry.\\n\"\n }\n]"}}},{"rowIdx":97,"cells":{"subject_id":{"kind":"number","value":13492,"string":"13,492"},"hadm_id":{"kind":"number","value":130812,"string":"130,812"},"target_text":{"kind":"string","value":"65y/o male transferred to from OSH s/p being kicked in the face by a horse. Pt. evaluated in the Emergency department by emergency medicine and trauma surgery staff. Pt. was imaged and found to have multiple facial fractures and mandibular fractures. The plastic surgery service was consulted and determined that the facial fractures were non-operative in nature. Pt. was admitted to the trauma service in anticipation of mandibular repair by OMFS. Pt. was taken to surgery by Dr. of OMFS and an ORIF of the mandible with wiring was performed. Pt. was followed postoperatively on the trauma service, pain was controlled, pured diet was started, nutrition was consulted and pt. was instructed regarding proper nutrition with a wired jaw. Pt. experienced a gouty attack of bilateral feet while recovering, R>L, rheumatology was consulted, and indomethacin and colchicine were begun. Pt. improved quickly and was able to walk with minimal pain prior to discharge. Pt. to be followed by OMFS for outpatient care."},"extractive_notes_summ":{"kind":"string","value":"Right mandibular body and left condyle fractures and maxillary sinus fractures. IMPRESSION: Segmental right mandible fracture. FINDINGS: With regard to the mandible, there is a complex fracture at the angle of the right ramus that extends to below the right condyle of the mandible resulting in complete displacement and mild angulation. Fracture of the mandible and maxillary sinuses are noted. On the left, there is a complete fracture through the ramus at the base of the mandibular condyle with minimal displacement and angulation. An additional fracture is noted in the region of the left mandibular condyle. There has been interval open reduction and internal fixation of a right mandibular fracture, which is maintained in satisfactory alignment with a plate and interlocking screws. Bilateral lateral wall fractures of the maxillary sinus with associated opacification, see details above. There is an associated lateral wall of fracture in the left maxillary sinus. Multiple mandibular fractures, see details above. There are bilateral fractures of the medial and lateral pterygoid plates. FINDINGS: Five views of the mandible redemonstrate a segmental fracture of the right portion of the mandible involving the body and ramus, which is displaced several millimeters superiorly. FINAL REPORT This is a skull study dated , with clinical indication of mandibular fracture status post open reduction and internal fixation. Right inferior orbital rim fracture, minimally displaced. Right and left lateral maxillary sinus wall fractures with associated opacification in both sinuses. Bilateral medial and lateral pterygoid plate fractures. Right inferior orbital rim fracture. Evaluate for fractures. Complete fracture through the right mandibular body. 2:42 PM SKULL (, LFT LAT, & BASE) Clip # Reason: evaluation of fracture. 2:09 PM MANDIBLE (PA, & BOTH OBLS) Clip # Reason: FX, MANDIBLE WIRING Admitting Diagnosis: MANDIBULAR FRACTURE FINAL REPORT TWO PORTABLE FILMS ON THE OR FOR FRACTURED MANDIBLE WITH WIRING Portable films of the mandible with somewhat limited diagnostic demonstrates of the mandible with wiring present. PA AND LATERAL CHEST RADIOGRAPHS: The aorta is tortuous and there is a left ventricular prominence to the cardiac silhouette. There is a minimally displaced right inferior orbital rim fracture. Pterygoid plate fractures. There is also a completely displaced fracture in the right body of the mandible. Again noted is right maxillary sinus opacification. Known fractures involving the right inferior orbital rim and maxillary sinuses are better demonstrated on the recent CT of the facial bones performed . TECHNIQUE: CT C-spine with sagittal and coronal reformatting. There is also a lateral wall fracture of the maxillary sinus on the right. There is complete opacification of the right maxillary sinus. (Over) 4:44 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: eval fir fx FINAL REPORT (Cont) AP and lateral radiograph centered at the level of the mandible were submitted for interpretation and compared to a previous study of . FINDINGS: The vertebral body heights and disc spaces are preserved. The multiple orbital and sinus fractures noted on the prior CT scan are not well demonstrated on these radiographs. Pt awake and cuff leak checked. COMPARISON: Facial bone CT, . A questionable infiltrate in the left upper lobe is present. On the left, there is an air fluid level seen in the left maxillary sinus. There has also been interval placement of hardware in the region of the oropharynx. Three cerclage wires overlie the mid portion of the mandible. 7:27 PM CHEST (PORTABLE AP) Clip # Reason: confirm nasotracheal tube placement Admitting Diagnosis: MANDIBULAR FRACTURE MEDICAL CONDITION: 64 year old man with NTT REASON FOR THIS EXAMINATION: confirm nasotracheal tube placement FINAL REPORT PORTABLE CHEST INDICATION: Intubation. 19/07 PT TO SICU S/P JAW FROM TRAMA ETT IN PLACE SEDATED VSS PROPOFOL IN PROGRESS NEURO SEDATED NO MOTION SL GAG ONLY TO BE DEEPLY SEDATED MD ETT VENT FULL CMV CONTROL SAT 100 SCANT SPUTUM BILAT B/S THRUOUT HEART S1S2 SPLIT S1 RBBB PULSES POS 3 2/6 M MITRIL AREA NSR GI POS B/S NOTED NPO PLAN SEDATED PLIERS AT BEDSIDE T/P ROM The patient has been intubated and the tube terminates at the level of the thoracic inlet, 5 cm above the carina. Admitting Diagnosis: MANDIBULAR FRACTURE MEDICAL CONDITION: 65 year old man s/p R ramus mandibular fracture, s/p ORIF R mandibular body fracture, evaluation of repair REASON FOR THIS EXAMINATION: evaluation of fracture."},"n_notes":{"kind":"number","value":12,"string":"12"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2122-09-12 00:00:00.000","description":"MANDIBLE (PA, TOWNES & BOTH OBLS)","row_id":883408,"text":" 2:09 PM\n MANDIBLE (PA, & BOTH OBLS) Clip # \n Reason: FX, MANDIBLE WIRING\n Admitting Diagnosis: MANDIBULAR FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n TWO PORTABLE FILMS ON THE OR FOR FRACTURED MANDIBLE WITH WIRING\n\n Portable films of the mandible with somewhat limited diagnostic demonstrates\n _____ of the mandible with wiring present.\n\n\n"},{"category":"Radiology","chartdate":"2122-09-13 00:00:00.000","description":"SKULL (CALDWELL, LFT LAT, TOWNES & BASE)","row_id":883492,"text":" 2:42 PM\n SKULL (, LFT LAT, & BASE) Clip # \n Reason: evaluation of fracture.\n Admitting Diagnosis: MANDIBULAR FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man s/p R ramus mandibular fracture, s/p ORIF R mandibular body\n fracture, evaluation of repair\n REASON FOR THIS EXAMINATION:\n evaluation of fracture.\n ______________________________________________________________________________\n FINAL REPORT\n This is a skull study dated , with clinical indication of\n mandibular fracture status post open reduction and internal fixation.\n\n AP and lateral radiograph centered at the level of the mandible were submitted\n for interpretation and compared to a previous study of .\n There has been interval open reduction and internal fixation of a right\n mandibular fracture, which is maintained in satisfactory alignment with a\n plate and interlocking screws. Three cerclage wires overlie the mid portion\n of the mandible. An additional fracture is noted in the region of the left\n mandibular condyle. There has also been interval placement of hardware in the\n region of the oropharynx. Known fractures involving the right inferior\n orbital rim and maxillary sinuses are better demonstrated on the recent CT of\n the facial bones performed .\n\n\n"},{"category":"Radiology","chartdate":"2122-09-11 00:00:00.000","description":"MANDIBLE (PA, TOWNES & BOTH OBLS)","row_id":883301,"text":" 11:55 AM\n MANDIBLE (PA, & BOTH OBLS) Clip # \n Reason: To delineate fracture lines and assess mandibular height\n Admitting Diagnosis: MANDIBULAR FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with multiple mandible fractures\n REASON FOR THIS EXAMINATION:\n To delineate fracture lines and assess mandibular height\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiple mandible fractures.\n\n COMPARISON: Facial bone CT, .\n\n FINDINGS: Five views of the mandible redemonstrate a segmental fracture of\n the right portion of the mandible involving the body and ramus, which is\n displaced several millimeters superiorly. Again noted is right maxillary\n sinus opacification. The multiple orbital and sinus fractures noted on the\n prior CT scan are not well demonstrated on these radiographs.\n\n IMPRESSION: Segmental right mandible fracture. Multiple other facial bone\n fractures are better demonstrated on recent CT examination.\n\n"},{"category":"Radiology","chartdate":"2122-09-11 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":883300,"text":" 11:55 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: PRE-OP FOR MANDIBLE \n Admitting Diagnosis: MANDIBULAR FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with pre-op for mandible fx surgery\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop for mandible surgery.\n\n COMPARISON: None.\n\n PA AND LATERAL CHEST RADIOGRAPHS: The aorta is tortuous and there is a left\n ventricular prominence to the cardiac silhouette. The lungs are clear. The\n osseous structures appear unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"},{"category":"Radiology","chartdate":"2122-09-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":883423,"text":" 7:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm nasotracheal tube placement\n Admitting Diagnosis: MANDIBULAR FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with NTT\n REASON FOR THIS EXAMINATION:\n confirm nasotracheal tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n INDICATION: Intubation.\n\n The patient has been intubated and the tube terminates at the level of the\n thoracic inlet, 5 cm above the carina. The heart is enlarged. There are low\n lung volumes. A questionable infiltrate in the left upper lobe is present.\n\n"},{"category":"ECG","chartdate":"2122-09-11 00:00:00.000","description":"Report","row_id":210148,"text":"Sinus rhythm\nConduction defect of RBBB type\nInferior ST-T changes\nLow QRS voltages in precordial leads\nProbable left ventricular hypertrophy by voltage in lead aVL\nSince previous tracing, no significant change\nClinical correlation is suggested\n\n"},{"category":"ECG","chartdate":"2122-09-09 00:00:00.000","description":"Report","row_id":210149,"text":"Sinus rhythm\nRight bundle branch block\nLow precordial lead QRS voltage - is nonspecific\nNo previous tracing available for comparison\n\n"},{"category":"Radiology","chartdate":"2122-09-09 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":883074,"text":" 5:58 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: eval for fracture/subluxation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man kicked in head by horse\n REASON FOR THIS EXAMINATION:\n eval for fracture/subluxation\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AZm WED 6:58 PM\n no injury to C- spine. right mandibular fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old man horse dentist kicked in the head by a horse.\n\n TECHNIQUE: CT C-spine with sagittal and coronal reformatting.\n\n FINDINGS: The vertebral body heights and disc spaces are preserved. No\n fractures or dislocations are visualized. The visualized thecal sac is\n normal.\n\n Fracture of the mandible and maxillary sinuses are noted.\n\n IMPRESSION: No evidence of traumatic injury to the cervical spine. Right\n mandibular body and left condyle fractures and maxillary sinus fractures.\n DFDgf\n\n"},{"category":"Radiology","chartdate":"2122-09-09 00:00:00.000","description":"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST","row_id":883068,"text":" 4:44 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: eval fir fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man kicked in head by horse c mult mandibular fxs, maxilla fx and\n orbital fx on OSH study\n REASON FOR THIS EXAMINATION:\n eval fir fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JVg WED 6:09 PM\n Complete fractures of the right and left mandibular rami. Complete fracture\n through the right mandibular body. Right and left lateral maxillary sinus wall\n fractures with associated opacification in both sinuses. Right inferior\n orbital rim fracture. No orbital floor fracture. Pterygoid plate fractures.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old man kicked in head by horse with multiple fractures\n including mandibular, maxilla, and orbital fractures seen on outside hospital\n study. Evaluate for fractures.\n\n TECHNIQUE: Axial and coronal non-contrast images of the paranasal sinuses and\n facial bones without contrast.\n\n FINDINGS: With regard to the mandible, there is a complex fracture at the\n angle of the right ramus that extends to below the right condyle of the\n mandible resulting in complete displacement and mild angulation. On the left,\n there is a complete fracture through the ramus at the base of the mandibular\n condyle with minimal displacement and angulation. There is also a completely\n displaced fracture in the right body of the mandible.\n\n There is complete opacification of the right maxillary sinus. There is a\n minimally displaced right inferior orbital rim fracture. There is also a\n lateral wall fracture of the maxillary sinus on the right. On the left, there\n is an air fluid level seen in the left maxillary sinus. There is an\n associated lateral wall of fracture in the left maxillary sinus.\n\n There are bilateral fractures of the medial and lateral pterygoid plates. A\n small amount of opacification in the right mastoid air cells is seen, however,\n no fractures are seen throughout the temporal bones.\n\n IMPRESSION:\n 1. Multiple mandibular fractures, see details above.\n 2. Right inferior orbital rim fracture, minimally displaced.\n 3. Bilateral lateral wall fractures of the maxillary sinus with associated\n opacification, see details above.\n 4. Bilateral medial and lateral pterygoid plate fractures.\n\n A wet read of these findings was sent to the emergency department at 6:00 p.m.\n on .\n (Over)\n\n 4:44 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: eval fir fx\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Nursing/other","chartdate":"2122-09-12 00:00:00.000","description":"Report","row_id":1437701,"text":" 19/07\n PT TO SICU S/P JAW FROM TRAMA ETT IN PLACE SEDATED VSS PROPOFOL IN PROGRESS\n NEURO SEDATED NO MOTION SL GAG ONLY TO BE DEEPLY SEDATED MD \n ETT VENT FULL CMV CONTROL SAT 100 SCANT SPUTUM BILAT B/S THRUOUT\n HEART S1S2 SPLIT S1 RBBB PULSES POS 3 2/6 M MITRIL AREA NSR\n GI POS B/S NOTED NPO\n PLAN SEDATED PLIERS AT BEDSIDE T/P ROM\n\n\n\n"},{"category":"Nursing/other","chartdate":"2122-09-13 00:00:00.000","description":"Report","row_id":1437702,"text":"Resp Care\nPt remains on vent, Nasaly intubated with #7 @ 27, patent and secure. Bs cta. Suctioned small amt of thick white to clear secretions. Rsbi 28. Placed on cpap/ps 5/5 40%. plan to extubate with team present.\n"},{"category":"Nursing/other","chartdate":"2122-09-13 00:00:00.000","description":"Report","row_id":1437703,"text":"Resp Care\nPt received on mech vent. Pt awake and cuff leak checked. Pt extubated over cook catheter with success. Currently on 4 L NC. Breath sounds are diminished bilat.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-09-12 00:00:00.000\",\n \"description\": \"MANDIBLE (PA, TOWNES & BOTH OBLS)\",\n \"row_id\": 883408,\n \"text\": \" 2:09 PM\\n MANDIBLE (PA, & BOTH OBLS) Clip # \\n Reason: FX, MANDIBLE WIRING\\n Admitting Diagnosis: MANDIBULAR FRACTURE\\n ______________________________________________________________________________\\n FINAL REPORT\\n TWO PORTABLE FILMS ON THE OR FOR FRACTURED MANDIBLE WITH WIRING\\n\\n Portable films of the mandible with somewhat limited diagnostic demonstrates\\n _____ of the mandible with wiring present.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-09-13 00:00:00.000\",\n \"description\": \"SKULL (CALDWELL, LFT LAT, TOWNES & BASE)\",\n \"row_id\": 883492,\n \"text\": \" 2:42 PM\\n SKULL (, LFT LAT, & BASE) Clip # \\n Reason: evaluation of fracture.\\n Admitting Diagnosis: MANDIBULAR FRACTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 65 year old man s/p R ramus mandibular fracture, s/p ORIF R mandibular body\\n fracture, evaluation of repair\\n REASON FOR THIS EXAMINATION:\\n evaluation of fracture.\\n ______________________________________________________________________________\\n FINAL REPORT\\n This is a skull study dated , with clinical indication of\\n mandibular fracture status post open reduction and internal fixation.\\n\\n AP and lateral radiograph centered at the level of the mandible were submitted\\n for interpretation and compared to a previous study of .\\n There has been interval open reduction and internal fixation of a right\\n mandibular fracture, which is maintained in satisfactory alignment with a\\n plate and interlocking screws. Three cerclage wires overlie the mid portion\\n of the mandible. An additional fracture is noted in the region of the left\\n mandibular condyle. There has also been interval placement of hardware in the\\n region of the oropharynx. Known fractures involving the right inferior\\n orbital rim and maxillary sinuses are better demonstrated on the recent CT of\\n the facial bones performed .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-09-11 00:00:00.000\",\n \"description\": \"MANDIBLE (PA, TOWNES & BOTH OBLS)\",\n \"row_id\": 883301,\n \"text\": \" 11:55 AM\\n MANDIBLE (PA, & BOTH OBLS) Clip # \\n Reason: To delineate fracture lines and assess mandibular height\\n Admitting Diagnosis: MANDIBULAR FRACTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 64 year old man with multiple mandible fractures\\n REASON FOR THIS EXAMINATION:\\n To delineate fracture lines and assess mandibular height\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Multiple mandible fractures.\\n\\n COMPARISON: Facial bone CT, .\\n\\n FINDINGS: Five views of the mandible redemonstrate a segmental fracture of\\n the right portion of the mandible involving the body and ramus, which is\\n displaced several millimeters superiorly. Again noted is right maxillary\\n sinus opacification. The multiple orbital and sinus fractures noted on the\\n prior CT scan are not well demonstrated on these radiographs.\\n\\n IMPRESSION: Segmental right mandible fracture. Multiple other facial bone\\n fractures are better demonstrated on recent CT examination.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-09-11 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 883300,\n \"text\": \" 11:55 AM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: PRE-OP FOR MANDIBLE \\n Admitting Diagnosis: MANDIBULAR FRACTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 64 year old man with pre-op for mandible fx surgery\\n REASON FOR THIS EXAMINATION:\\n pre-op\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Preop for mandible surgery.\\n\\n COMPARISON: None.\\n\\n PA AND LATERAL CHEST RADIOGRAPHS: The aorta is tortuous and there is a left\\n ventricular prominence to the cardiac silhouette. The lungs are clear. The\\n osseous structures appear unremarkable.\\n\\n IMPRESSION: No acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-09-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 883423,\n \"text\": \" 7:27 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: confirm nasotracheal tube placement\\n Admitting Diagnosis: MANDIBULAR FRACTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 64 year old man with NTT\\n REASON FOR THIS EXAMINATION:\\n confirm nasotracheal tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST\\n\\n INDICATION: Intubation.\\n\\n The patient has been intubated and the tube terminates at the level of the\\n thoracic inlet, 5 cm above the carina. The heart is enlarged. There are low\\n lung volumes. A questionable infiltrate in the left upper lobe is present.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2122-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 210148,\n \"text\": \"Sinus rhythm\\nConduction defect of RBBB type\\nInferior ST-T changes\\nLow QRS voltages in precordial leads\\nProbable left ventricular hypertrophy by voltage in lead aVL\\nSince previous tracing, no significant change\\nClinical correlation is suggested\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2122-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 210149,\n \"text\": \"Sinus rhythm\\nRight bundle branch block\\nLow precordial lead QRS voltage - is nonspecific\\nNo previous tracing available for comparison\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-09-09 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 883074,\n \"text\": \" 5:58 PM\\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: eval for fracture/subluxation\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 64 year old man kicked in head by horse\\n REASON FOR THIS EXAMINATION:\\n eval for fracture/subluxation\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: AZm WED 6:58 PM\\n no injury to C- spine. right mandibular fracture\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 64-year-old man horse dentist kicked in the head by a horse.\\n\\n TECHNIQUE: CT C-spine with sagittal and coronal reformatting.\\n\\n FINDINGS: The vertebral body heights and disc spaces are preserved. No\\n fractures or dislocations are visualized. The visualized thecal sac is\\n normal.\\n\\n Fracture of the mandible and maxillary sinuses are noted.\\n\\n IMPRESSION: No evidence of traumatic injury to the cervical spine. Right\\n mandibular body and left condyle fractures and maxillary sinus fractures.\\n DFDgf\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2122-09-09 00:00:00.000\",\n \"description\": \"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST\",\n \"row_id\": 883068,\n \"text\": \" 4:44 PM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: eval fir fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 64 year old man kicked in head by horse c mult mandibular fxs, maxilla fx and\\n orbital fx on OSH study\\n REASON FOR THIS EXAMINATION:\\n eval fir fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JVg WED 6:09 PM\\n Complete fractures of the right and left mandibular rami. Complete fracture\\n through the right mandibular body. Right and left lateral maxillary sinus wall\\n fractures with associated opacification in both sinuses. Right inferior\\n orbital rim fracture. No orbital floor fracture. Pterygoid plate fractures.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 64-year-old man kicked in head by horse with multiple fractures\\n including mandibular, maxilla, and orbital fractures seen on outside hospital\\n study. Evaluate for fractures.\\n\\n TECHNIQUE: Axial and coronal non-contrast images of the paranasal sinuses and\\n facial bones without contrast.\\n\\n FINDINGS: With regard to the mandible, there is a complex fracture at the\\n angle of the right ramus that extends to below the right condyle of the\\n mandible resulting in complete displacement and mild angulation. On the left,\\n there is a complete fracture through the ramus at the base of the mandibular\\n condyle with minimal displacement and angulation. There is also a completely\\n displaced fracture in the right body of the mandible.\\n\\n There is complete opacification of the right maxillary sinus. There is a\\n minimally displaced right inferior orbital rim fracture. There is also a\\n lateral wall fracture of the maxillary sinus on the right. On the left, there\\n is an air fluid level seen in the left maxillary sinus. There is an\\n associated lateral wall of fracture in the left maxillary sinus.\\n\\n There are bilateral fractures of the medial and lateral pterygoid plates. A\\n small amount of opacification in the right mastoid air cells is seen, however,\\n no fractures are seen throughout the temporal bones.\\n\\n IMPRESSION:\\n 1. Multiple mandibular fractures, see details above.\\n 2. Right inferior orbital rim fracture, minimally displaced.\\n 3. Bilateral lateral wall fractures of the maxillary sinus with associated\\n opacification, see details above.\\n 4. Bilateral medial and lateral pterygoid plate fractures.\\n\\n A wet read of these findings was sent to the emergency department at 6:00 p.m.\\n on .\\n (Over)\\n\\n 4:44 PM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: eval fir fx\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2122-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1437701,\n \"text\": \" 19/07\\n PT TO SICU S/P JAW FROM TRAMA ETT IN PLACE SEDATED VSS PROPOFOL IN PROGRESS\\n NEURO SEDATED NO MOTION SL GAG ONLY TO BE DEEPLY SEDATED MD \\n ETT VENT FULL CMV CONTROL SAT 100 SCANT SPUTUM BILAT B/S THRUOUT\\n HEART S1S2 SPLIT S1 RBBB PULSES POS 3 2/6 M MITRIL AREA NSR\\n GI POS B/S NOTED NPO\\n PLAN SEDATED PLIERS AT BEDSIDE T/P ROM\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2122-09-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1437702,\n \"text\": \"Resp Care\\nPt remains on vent, Nasaly intubated with #7 @ 27, patent and secure. Bs cta. Suctioned small amt of thick white to clear secretions. Rsbi 28. Placed on cpap/ps 5/5 40%. plan to extubate with team present.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2122-09-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1437703,\n \"text\": \"Resp Care\\nPt received on mech vent. Pt awake and cuff leak checked. Pt extubated over cook catheter with success. Currently on 4 L NC. Breath sounds are diminished bilat.\\n\"\n }\n]"}}},{"rowIdx":98,"cells":{"subject_id":{"kind":"number","value":19071,"string":"19,071"},"hadm_id":{"kind":"number","value":187636,"string":"187,636"},"target_text":{"kind":"string","value":"1) CVS-- Given h/o cardiac problems and new onset CP, pt was admitted for R/O MI. A CXR on admit noted no acute pulmonary process. Stable cardiac enlargement and aortic contour. EKG showed Atrial fibrillation with a moderate ventricular response and a suggestion of group beating. Borderline intraventricular conduction delay. Non-specific ST-T wave changes with relatively short interval consistent with digitalis effect, although ischemia, etc. is not excluded. Non-diagnostic Q waves in lead III. Prominent R wave in lead V3 without diagnostic criteria for left ventricular hypertrophy. Compared to the previous tracing of ST-T wave changes are more apparent. Mr. ruled out with 2 sets of negative enzymes. Tele bed was not d/c'ed, as he continued to have runs of NSVT up to 15 beats, during his hospitalization. He remained asymptomatic during these runs, only complaining of some dizziness. Mr.G was tried on a beta blocker, but he became bradycardic to the low 30s, so it was d/c'ed. His blood pressure was controlled with lisinopril 10mg qd and lasix 20mg qd, until his renal function worsened and these were discontinued and hydarlazine started. After epicardial pacemaker, pt was started on beta-blocker and hydralazine was deacresed. Pt was also started on Isordil. During Mr.G's hospitalization, an echo, stress test, and persantine mibi were obtained to evaluate further the etiology of the pt's cardiomyopathy. Echo showed an EF of 33%, as well as left ventricular cavity dilation with severe global hypokinesis c/w diffuse process (toxin, metabolic, multivessel CAD, etc.) Severe mitral regurgitation. Pulmonary artery systolic hypertension. Moderate tricuspid regurgitation. On stress test, Mr.G was found to have no anginal symptoms with an uninterpretable ECG. Finally, persantine mibi showed a predominantly fixed, moderate to severe perfusion defect in the distal inferior wall, extending into the inferior portion of the lateral wall. EP was consulted and determined that Mr.G was not a candidate for PM with EPS+ICD because his suprapubic catheter put him at risk for infection. Rather, it was decided that Mr.G should have an epicardial pacer, then rate controlled with beta-blockade +/- amiodarone. Mr.G was weaned off coumadin to an INR below 2.0 and he was started on heparin. On Mr. G had epicardial pacemaker placed. Pt was restart on warfarin once stable from pacemaker surgery. 2)Acute on chronic renal failure--On presentation, Mr.G's Cr was 4.1. His suprapubic catheter was flushed and found to be patent, ruling out a post-obstructive etiology. With gentle hydration, it down to 3.1, suggesting he was pre-renal. An echo to evaluate renal function found small kidneys + echogenicity. A renal consult found the echo to be highly suggestive of a chronic process (CKD (KDOQI)- stage IV) with HTN likely the cause. Biopsy not helpful with such small kidneys. No acute need for hemodialysis at this time and estimated GFR to be 17-20 cc/min. As well, Mr.G's PTH was elevated to 132, likely secondary to unresponsive failing kidneys, as he was not hypercalcemic. After a bout of diarrhea, Mr.G's renal function again deteriorated with Cr to 4.0. Lasix and ace inhibitor were held. It was decided not to give IV fluids in the face of Mr.G's poor cardiac function (EF 33%)...His electrolytes were monitored and repleted as necessary, and bicarb was given, as Mr. down to 16. Pt BUN/Cre stabalized with a Cre around 3.3-3.8. Pt will follow up with renal outpatient. 3) GU--It is unclear exactly why Mr.G has the supra-pubic catheter, presumably because of urinary incontinence. Of note, his PSA was elevated to 7.8. It was decided that Mr.G's urological problems and renal function could be further evaluated on an outpatient basis. A U/A gre out proteus mirabilis, but it was thought that this was due to contamination/catheterization. Abx were held in the abscence of fever or elevated WBC. Repeat Urine Cx showed mixed flora consistent with contamination with feces. Pt will follow up with outpatient. 3) ?Hypothyroidism-- TSH and T4 wnl -- unclear if needs chronic thyroxine given normal levels. f/u with outpatient PCP if staying in . 4) Diarrhea--On presentation, Mr.G had an episode of diarrhea, which resolved on its own. Stool was negative for C. diff. O+P showed several parasites, of debatable pathogenic significnace. However, in light of Mr.G's symptomatology, Flagyl was initiated and later decreased to renal dosing, as Mr.G's Cr bumped after the initiation of therapy. The diarrhea resolved. Pt finished course of flagyl while in hospital 5) Dizziness and weakness- During hospital course it was noticed that pt was dizzy and appeared to be weak. After speaking to family it was determined that this was the pt's baseline before hospitalization. A CT of head was done which showed encephalomalacia consistent with old infarcts. A MRA could not be performed since pt had a pacemaker."},"extractive_notes_summ":{"kind":"string","value":"Underlying rhythm again appearsto be atrial fibrillation with a slow to moderate ventricular response.Compared to the previous tracing of multiple abnormalities are aspreviously reported without diagnostic change, in the presence of the baselineartifact. Leftventricular hypertrophy with intraventricular conduction delay. There is mildglobal right ventricular free wall hypokinesis.AORTIC VALVE: The aortic valve leaflets are mildly thickened. Probable atrial fibrillationVentricular premature complexesNonspecific intraventricular conduction delayProbable left ventricular hypertrophy with ST-T wave abnormalitiesCannot exclude in part ischemia - clinical correlation is suggestedSince previous tracing of , ventricular ectopy seen Probable atrial fibrillationNonspecific intraventricular conduction delayProbable left ventricular hypertrophy with ST-T wave abnormalitiesCannot exclude in part ischemia - clinical correlation is suggestedSince previous tracing of , ventricular ectopy not seen There is mildpulmonary artery systolic hypertension. Intraventricular conduction delay related to leftventricular hypertrophy. ST-T wave abnormalities persist as recorded on thetracing of . Left ventricular wall thicknesses arenormal. Atrial fibrillation with a slow ventricular response. There is noaortic valve stenosis. The left ventricular cavity is mildly dilated with severe globalhypokinesis. Atrial fibrillation with a moderate ventricular response and a suggestion ofgroup beating. Moderate[2+] tricuspid regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Borderline intraventricular conduction delay. Moderate tricuspidregurgitation.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). There is blunting of the right and left lateral costophrenic recess consistent with small pleural effusions. 2) Global hypokinesis with decreased ejection fraction. Prominent R wave in lead V3 without diagnostic criteria for leftventricular hypertrophy. TECHNIQUE: Noncontrast head CT. Stress and resting perfusion images demonstrate a markedly enlarged left ventricle with moderate to severe perfusion defect in the distal inferior wall, extending into the inferolateral wall. IMPRESSION: 1) Predominantly fixed, moderate to severe perfusion defect in the distal inferior wall, extending into the inferior portion of the lateral wall. Non-specificST-T wave changes with relatively short interval consistent with digitaliseffect, although ischemia, etc. Left ventricular function.BP (mm Hg): 120/80Status: InpatientDate/Time: at 12:25Test: TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is markedly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. Atrial fibrillation with a controlled ventricular response. Leftventricular hypertrophy. Pulmonary artery systolic hypertension. The leftventricular cavity is mildly dilated. Severe (4+) mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Hypodensities in the periventricular white matter areas bilaterally are likely residua of chronic microvascular infarction. There is mild pulmonary artery systolichypertension.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,the echo findings indicate a moderate risk (prophylaxis recommended). Exclude digitalis excess if clinically indicated.Clinical correlation is suggested.TRACING #1 The ventricles and sulci are prominent, consistent with atrophy. There is severe global left ventricularhypokinesis. Mitral valve disease. Compared to the previoustracing of -4 the anterolateral ST-T wave abnormalities are somewhat moreprominent. Compared to the previoustracing of ventricular paced rhythm is no longer recorded. There is no pericardial effusion.IMPRESSION: Left ventricular cavity dilation with severe global hypokinesisc/w diffuse process (toxin, metabolic, multivessel CAD, etc.) Theaortic valve leaflets are mildly thickened but not stenotic. Rule out pulmonary congestion. TheST-T wave abnormalities persist without diagnostic interim change.TRACING #1 Stable cardiac enlargement and aortic contour. Non-diagnostic Q waves inlead III. IMPRESSION: Findings consistent with old infarctions. However, the accuracy of this percentage is in question due to the arrhythmia. No aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are moderately thickened. FINDINGS: There is marked cardiomegaly. FINAL REPORT INDICATION: Acute renal failure. Severe mitralregurgitation. The kidneys are atrophic and echogenic bilaterally. The tips of the papillary musclesare calcified. A ventricular pacemaker is now present. REASON FOR THIS EXAMINATION: Please evaluate for renal obstruction Additionally,pt w/questionable shifting dullness on exam and bulging flank. Atrial fibrillation with a rapid ventricular response. Atrial fibrillation with a rapid ventricular response. The mitral valve leaflets are moderately thickened.Severe (4+) mitral regurgitation is seen. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation/flutter. Clinicaldecisions regarding the need for prophylaxis should be based on clinical andechocardiographic data.Conclusions:The left atrium is markedly dilated. Atrial fibrillation and ventricular paced rhythm. Diffise ST-T waveabnormalities persist without diagnostic interim change compared to theprevious tracing of .TRACING #2 IMPRESSION: Small echogenic kidneys. Congestive heart failure. Non-specific ST-T wave abnormalities persist withoutdiagnostic interim change.TRACING #1 Baseline artifact precludes precise assessment. TECHNIQUE: Single AP view of the chest is provided. Resting perfusion images were obtained with thallium-201. Rightventricular chamber size is normal with mild global free wall hypokinesis. There is variation in theprecordial lead placement as compared to the previous tracing of . IMPRESSION: Marked cardiomegaly with CHF as described above. CHEST X-RAY: Single portable AP view was obtained and compared to prior study of . This is predominantly fixed on the rest perfusion images. Coronary artery disease. There is prominence of the descending aorta which is stable in the interval. There are several large areas of encephalomalacia, the largest within the right parietotemporal region, with smaller areas affecting the left frontal and left posterior parietal regions, likely residua of previous infarctions. Also with shifting dullness on exam. /nkg , M.D. IMPRESSION: No acute pulmonary process. There is bilateral prominent pulmonary arteries with increased haziness in the perihilar regions and possibly vascular redistribution. PLease mark for ascites if any. Compared to the previous tracing of ST-T wavechanges are more apparent. There is a small cyst at the midpole of the right kidney. The cardiac silhouette is enlarged. Approved: 11:42 AM West RADLINE ; A radiology consult service."},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2172-06-19 00:00:00.000","description":"RENAL U.S.","row_id":830712,"text":" 9:05 AM\n RENAL U.S. Clip # \n Reason: Please evaluate for obstruction.\n Admitting Diagnosis: R/O MYOCARDIAL INFARCTION-ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ARF--suprapubic catheter for ?prostate CA.\n REASON FOR THIS EXAMINATION:\n Please evaluate for renal obstruction Additionally,pt w/questionable shifting\n dullness on exam and bulging flank. PLease mark for ascites if any.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute renal failure. Suprapubic catheter for question of\n prostate cancer. Also with shifting dullness on exam.\n\n FINDINGS: There is no ascites. The kidneys are atrophic and echogenic\n bilaterally. The right and left kidney measure 7.6 cm and 8.7 cm respectively\n and demonstrate increased cortical echogenicity. There is a small cyst at the\n midpole of the right kidney. There is no hydronephrosis. Inflated balloon of\n the suprapubic catheter is identified below the anterior abdominal wall.\n\n IMPRESSION: Small echogenic kidneys. No ascites.\n\n\n"},{"category":"Echo","chartdate":"2172-06-24 00:00:00.000","description":"Report","row_id":62389,"text":"PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Congestive heart failure. Coronary artery disease. Mitral valve disease. Left ventricular function.\nBP (mm Hg): 120/80\nStatus: Inpatient\nDate/Time: at 12:25\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is markedly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is mildly dilated. There is severe global left ventricular\nhypokinesis. No masses or thrombi are seen in the left ventricle.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. There is mild\nglobal right ventricular free wall hypokinesis.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\naortic valve stenosis. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are moderately thickened. There is\nmild thickening of the mitral valve chordae. The tips of the papillary muscles\nare calcified. Severe (4+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Moderate\n[2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic\nhypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a moderate risk (prophylaxis recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is markedly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is mildly dilated with severe global\nhypokinesis. No masses or thrombi are seen in the left ventricle. Right\nventricular chamber size is normal with mild global free wall hypokinesis. The\naortic valve leaflets are mildly thickened but not stenotic. No aortic\nregurgitation is seen. The mitral valve leaflets are moderately thickened.\nSevere (4+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Left ventricular cavity dilation with severe global hypokinesis\nc/w diffuse process (toxin, metabolic, multivessel CAD, etc.) Severe mitral\nregurgitation. Pulmonary artery systolic hypertension. Moderate tricuspid\nregurgitation.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"},{"category":"Radiology","chartdate":"2172-06-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":830669,"text":" 4:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: any cardiac abnormaility\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with cp\n REASON FOR THIS EXAMINATION:\n any cardiac abnormaility\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain.\n\n CHEST X-RAY: Single portable AP view was obtained and compared to prior study\n of . The cardiac silhouette is enlarged. There is prominence\n of the descending aorta which is stable in the interval. Elevation of the left\n hemidiaphragm is present, which is also stable. There are no infiltrates or\n consolidations.\n\n IMPRESSION: No acute pulmonary process. Stable cardiac enlargement and aortic\n contour.\n\n"},{"category":"Radiology","chartdate":"2172-07-06 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":832416,"text":" 4:33 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: DIZZINESS ATAXIA R/O INFARCT\n Admitting Diagnosis: R/O MYOCARDIAL INFARCTION-ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p epicardial pacemaker, renal insuff, and a-fib,\n presenting with dizziness and ataxia\n REASON FOR THIS EXAMINATION:\n r/o infarct\n CONTRAINDICATIONS for IV CONTRAST:\n Renal insufficiency\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ataxia and dizziness after epicardial pacemaker placement.\n\n COMPARISON: None.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no sign of intracranial hemorrhage, mass effect, shift of\n the normally midline structures, or hydrocephalus. There are several large\n areas of encephalomalacia, the largest within the right parietotemporal\n region, with smaller areas affecting the left frontal and left posterior\n parietal regions, likely residua of previous infarctions. Hypodensities in\n the periventricular white matter areas bilaterally are likely residua of\n chronic microvascular infarction. There are focal calcifications in both\n frontal lobes. The ventricles and sulci are prominent, consistent with\n atrophy. There is no sign of fracture or bone destruction. The paranasal\n sinuses and orbits are unremarkable.\n\n IMPRESSION: Findings consistent with old infarctions. CT is not a sensitive\n examination for acute infarction, and to exclude this, MR \n weighting would be the test of choice.\n\n"},{"category":"Radiology","chartdate":"2172-06-23 00:00:00.000","description":"PERSANTINE MIBI","row_id":831016,"text":"PERSANTINE MIBI Clip # \n Reason: SOB, CHF.; observation for suspected coronary artery disease\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Seventy-three year old male with CHF, no documented coronary artery\n disease and frequent ectopy and shortness of breath.\n\n SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB:\n Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142\n mg/kg/min. Two minutes after the cessation of infusion, Tc-m sestamibi was\n administered IV.\n\n INTERPRETATION:\n\n Image Protocol: Gated SPECT.\n\n Resting perfusion images were obtained with thallium-201.\n Tracer was injected 15 minutes prior to obtaining the resting images.\n\n Stress and resting perfusion images demonstrate a markedly enlarged left\n ventricle with moderate to severe perfusion defect in the distal inferior wall,\n extending into the inferolateral wall. This is predominantly fixed on the rest\n perfusion images.\n\n Ejection fraction calculated from gated wall motion images obtained after\n Dipyridamole administration is 33%, with global hypokinesis. However, the\n accuracy of this percentage is in question due to the arrhythmia.\n\n IMPRESSION: 1) Predominantly fixed, moderate to severe perfusion defect in the\n distal inferior wall, extending into the inferior portion of the lateral wall.\n 2) Global hypokinesis with decreased ejection fraction.\n\n /nkg\n\n\n , M.D.\n , M.D. Approved: 11:42 AM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"},{"category":"Radiology","chartdate":"2172-07-05 00:00:00.000","description":"CHEST (SINGLE VIEW)","row_id":832296,"text":" 3:23 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: r/o pulmonary congestion\n Admitting Diagnosis: R/O MYOCARDIAL INFARCTION-ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p epicardial pacer\n REASON FOR THIS EXAMINATION:\n r/o pulmonary congestion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 73 y/o man with epicardial pacer. Rule out pulmonary\n congestion.\n\n TECHNIQUE: Single AP view of the chest is provided.\n\n FINDINGS: There is marked cardiomegaly. There is bilateral prominent\n pulmonary arteries with increased haziness in the perihilar regions and\n possibly vascular redistribution. These findings have increased compared to\n prior film from . The findings are consistent with CHF. There is no\n evidence for pneumothorax. There is blunting of the right and left lateral\n costophrenic recess consistent with small pleural effusions. An epicardial\n pacer is noted in the left hemithorax.\n\n IMPRESSION:\n\n Marked cardiomegaly with CHF as described above.\n\n\n"},{"category":"ECG","chartdate":"2172-07-08 00:00:00.000","description":"Report","row_id":123806,"text":"Probable atrial fibrillation\nNonspecific intraventricular conduction delay\nProbable left ventricular hypertrophy with ST-T wave abnormalities\nCannot exclude in part ischemia - clinical correlation is suggested\nSince previous tracing of , ventricular ectopy not seen\n\n"},{"category":"ECG","chartdate":"2172-07-07 00:00:00.000","description":"Report","row_id":123807,"text":"Probable atrial fibrillation\nVentricular premature complexes\nNonspecific intraventricular conduction delay\nProbable left ventricular hypertrophy with ST-T wave abnormalities\nCannot exclude in part ischemia - clinical correlation is suggested\nSince previous tracing of , ventricular ectopy seen\n\n\n"},{"category":"ECG","chartdate":"2172-07-04 00:00:00.000","description":"Report","row_id":123852,"text":"Atrial fibrillation with a rapid ventricular response. Compared to the previous\ntracing of -4 the anterolateral ST-T wave abnormalities are somewhat more\nprominent. Otherwise, no diagnostic interim change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2172-07-03 00:00:00.000","description":"Report","row_id":123853,"text":"Atrial fibrillation with a rapid ventricular response. Compared to the previous\ntracing of ventricular paced rhythm is no longer recorded. Left\nventricular hypertrophy with intraventricular conduction delay. The ventricular\nresponse has increased. Non-specific ST-T wave abnormalities persist without\ndiagnostic interim change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2172-07-01 00:00:00.000","description":"Report","row_id":123854,"text":"Atrial fibrillation and ventricular paced rhythm. Occasional fusion beats. Left\nventricular hypertrophy. Intraventricular conduction delay related to left\nventricular hypertrophy. ST-T wave abnormalities persist as recorded on the\ntracing of . A ventricular pacemaker is now present.\n\n"},{"category":"ECG","chartdate":"2172-06-20 00:00:00.000","description":"Report","row_id":123855,"text":"Atrial fibrillation with a controlled ventricular response. Diffise ST-T wave\nabnormalities persist without diagnostic interim change compared to the\nprevious tracing of .\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2172-06-20 00:00:00.000","description":"Report","row_id":123856,"text":"Atrial fibrillation with a slow ventricular response. There is variation in the\nprecordial lead placement as compared to the previous tracing of . The\nST-T wave abnormalities persist without diagnostic interim change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2172-06-18 00:00:00.000","description":"Report","row_id":123858,"text":"Atrial fibrillation with a moderate ventricular response and a suggestion of\ngroup beating. Borderline intraventricular conduction delay. Non-specific\nST-T wave changes with relatively short interval consistent with digitalis\neffect, although ischemia, etc. is not excluded. Non-diagnostic Q waves in\nlead III. Prominent R wave in lead V3 without diagnostic criteria for left\nventricular hypertrophy. Compared to the previous tracing of ST-T wave\nchanges are more apparent. Exclude digitalis excess if clinically indicated.\nClinical correlation is suggested.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2172-06-18 00:00:00.000","description":"Report","row_id":123857,"text":"Baseline artifact precludes precise assessment. Underlying rhythm again appears\nto be atrial fibrillation with a slow to moderate ventricular response.\nCompared to the previous tracing of multiple abnormalities are as\npreviously reported without diagnostic change, in the presence of the baseline\nartifact. Clinical correlation is suggested.\nTRACING #2\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-06-19 00:00:00.000\",\n \"description\": \"RENAL U.S.\",\n \"row_id\": 830712,\n \"text\": \" 9:05 AM\\n RENAL U.S. Clip # \\n Reason: Please evaluate for obstruction.\\n Admitting Diagnosis: R/O MYOCARDIAL INFARCTION-ACUTE RENAL FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with ARF--suprapubic catheter for ?prostate CA.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for renal obstruction Additionally,pt w/questionable shifting\\n dullness on exam and bulging flank. PLease mark for ascites if any.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Acute renal failure. Suprapubic catheter for question of\\n prostate cancer. Also with shifting dullness on exam.\\n\\n FINDINGS: There is no ascites. The kidneys are atrophic and echogenic\\n bilaterally. The right and left kidney measure 7.6 cm and 8.7 cm respectively\\n and demonstrate increased cortical echogenicity. There is a small cyst at the\\n midpole of the right kidney. There is no hydronephrosis. Inflated balloon of\\n the suprapubic catheter is identified below the anterior abdominal wall.\\n\\n IMPRESSION: Small echogenic kidneys. No ascites.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2172-06-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 62389,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Atrial fibrillation/flutter. Congestive heart failure. Coronary artery disease. Mitral valve disease. Left ventricular function.\\nBP (mm Hg): 120/80\\nStatus: Inpatient\\nDate/Time: at 12:25\\nTest: TTE (Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is markedly dilated.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\\n\\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\\nventricular cavity is mildly dilated. There is severe global left ventricular\\nhypokinesis. No masses or thrombi are seen in the left ventricle.\\n\\nRIGHT VENTRICLE: Right ventricular chamber size is normal. There is mild\\nglobal right ventricular free wall hypokinesis.\\n\\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\\naortic valve stenosis. No aortic regurgitation is seen.\\n\\nMITRAL VALVE: The mitral valve leaflets are moderately thickened. There is\\nmild thickening of the mitral valve chordae. The tips of the papillary muscles\\nare calcified. Severe (4+) mitral regurgitation is seen.\\n\\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Moderate\\n[2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic\\nhypertension.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\\nthe echo findings indicate a moderate risk (prophylaxis recommended). Clinical\\ndecisions regarding the need for prophylaxis should be based on clinical and\\nechocardiographic data.\\n\\nConclusions:\\nThe left atrium is markedly dilated. Left ventricular wall thicknesses are\\nnormal. The left ventricular cavity is mildly dilated with severe global\\nhypokinesis. No masses or thrombi are seen in the left ventricle. Right\\nventricular chamber size is normal with mild global free wall hypokinesis. The\\naortic valve leaflets are mildly thickened but not stenotic. No aortic\\nregurgitation is seen. The mitral valve leaflets are moderately thickened.\\nSevere (4+) mitral regurgitation is seen. The tricuspid valve leaflets are\\nmildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild\\npulmonary artery systolic hypertension. There is no pericardial effusion.\\n\\nIMPRESSION: Left ventricular cavity dilation with severe global hypokinesis\\nc/w diffuse process (toxin, metabolic, multivessel CAD, etc.) Severe mitral\\nregurgitation. Pulmonary artery systolic hypertension. Moderate tricuspid\\nregurgitation.\\n\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\\nregarding the need for prophylaxis should be based on clinical and\\nechocardiographic data.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-06-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 830669,\n \"text\": \" 4:54 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: any cardiac abnormaility\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with cp\\n REASON FOR THIS EXAMINATION:\\n any cardiac abnormaility\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Chest pain.\\n\\n CHEST X-RAY: Single portable AP view was obtained and compared to prior study\\n of . The cardiac silhouette is enlarged. There is prominence\\n of the descending aorta which is stable in the interval. Elevation of the left\\n hemidiaphragm is present, which is also stable. There are no infiltrates or\\n consolidations.\\n\\n IMPRESSION: No acute pulmonary process. Stable cardiac enlargement and aortic\\n contour.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-07-06 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 832416,\n \"text\": \" 4:33 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: DIZZINESS ATAXIA R/O INFARCT\\n Admitting Diagnosis: R/O MYOCARDIAL INFARCTION-ACUTE RENAL FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with s/p epicardial pacemaker, renal insuff, and a-fib,\\n presenting with dizziness and ataxia\\n REASON FOR THIS EXAMINATION:\\n r/o infarct\\n CONTRAINDICATIONS for IV CONTRAST:\\n Renal insufficiency\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Ataxia and dizziness after epicardial pacemaker placement.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Noncontrast head CT.\\n\\n FINDINGS: There is no sign of intracranial hemorrhage, mass effect, shift of\\n the normally midline structures, or hydrocephalus. There are several large\\n areas of encephalomalacia, the largest within the right parietotemporal\\n region, with smaller areas affecting the left frontal and left posterior\\n parietal regions, likely residua of previous infarctions. Hypodensities in\\n the periventricular white matter areas bilaterally are likely residua of\\n chronic microvascular infarction. There are focal calcifications in both\\n frontal lobes. The ventricles and sulci are prominent, consistent with\\n atrophy. There is no sign of fracture or bone destruction. The paranasal\\n sinuses and orbits are unremarkable.\\n\\n IMPRESSION: Findings consistent with old infarctions. CT is not a sensitive\\n examination for acute infarction, and to exclude this, MR \\n weighting would be the test of choice.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-06-23 00:00:00.000\",\n \"description\": \"PERSANTINE MIBI\",\n \"row_id\": 831016,\n \"text\": \"PERSANTINE MIBI Clip # \\n Reason: SOB, CHF.; observation for suspected coronary artery disease\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Seventy-three year old male with CHF, no documented coronary artery\\n disease and frequent ectopy and shortness of breath.\\n\\n SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB:\\n Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142\\n mg/kg/min. Two minutes after the cessation of infusion, Tc-m sestamibi was\\n administered IV.\\n\\n INTERPRETATION:\\n\\n Image Protocol: Gated SPECT.\\n\\n Resting perfusion images were obtained with thallium-201.\\n Tracer was injected 15 minutes prior to obtaining the resting images.\\n\\n Stress and resting perfusion images demonstrate a markedly enlarged left\\n ventricle with moderate to severe perfusion defect in the distal inferior wall,\\n extending into the inferolateral wall. This is predominantly fixed on the rest\\n perfusion images.\\n\\n Ejection fraction calculated from gated wall motion images obtained after\\n Dipyridamole administration is 33%, with global hypokinesis. However, the\\n accuracy of this percentage is in question due to the arrhythmia.\\n\\n IMPRESSION: 1) Predominantly fixed, moderate to severe perfusion defect in the\\n distal inferior wall, extending into the inferior portion of the lateral wall.\\n 2) Global hypokinesis with decreased ejection fraction.\\n\\n /nkg\\n\\n\\n , M.D.\\n , M.D. Approved: 11:42 AM\\n West \\n\\n\\n\\n RADLINE ; A radiology consult service.\\n To hear preliminary results, prior to transcription, call the\\n Radiology Listen Line .\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2172-07-05 00:00:00.000\",\n \"description\": \"CHEST (SINGLE VIEW)\",\n \"row_id\": 832296,\n \"text\": \" 3:23 PM\\n CHEST (SINGLE VIEW) Clip # \\n Reason: r/o pulmonary congestion\\n Admitting Diagnosis: R/O MYOCARDIAL INFARCTION-ACUTE RENAL FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with s/p epicardial pacer\\n REASON FOR THIS EXAMINATION:\\n r/o pulmonary congestion\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INDICATION: 73 y/o man with epicardial pacer. Rule out pulmonary\\n congestion.\\n\\n TECHNIQUE: Single AP view of the chest is provided.\\n\\n FINDINGS: There is marked cardiomegaly. There is bilateral prominent\\n pulmonary arteries with increased haziness in the perihilar regions and\\n possibly vascular redistribution. These findings have increased compared to\\n prior film from . The findings are consistent with CHF. There is no\\n evidence for pneumothorax. There is blunting of the right and left lateral\\n costophrenic recess consistent with small pleural effusions. An epicardial\\n pacer is noted in the left hemithorax.\\n\\n IMPRESSION:\\n\\n Marked cardiomegaly with CHF as described above.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2172-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 123806,\n \"text\": \"Probable atrial fibrillation\\nNonspecific intraventricular conduction delay\\nProbable left ventricular hypertrophy with ST-T wave abnormalities\\nCannot exclude in part ischemia - clinical correlation is suggested\\nSince previous tracing of , ventricular ectopy not seen\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2172-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 123807,\n \"text\": \"Probable atrial fibrillation\\nVentricular premature complexes\\nNonspecific intraventricular conduction delay\\nProbable left ventricular hypertrophy with ST-T wave abnormalities\\nCannot exclude in part ischemia - clinical correlation is suggested\\nSince previous tracing of , ventricular ectopy seen\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2172-07-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 123852,\n \"text\": \"Atrial fibrillation with a rapid ventricular response. Compared to the previous\\ntracing of -4 the anterolateral ST-T wave abnormalities are somewhat more\\nprominent. Otherwise, no diagnostic interim change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2172-07-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 123853,\n \"text\": \"Atrial fibrillation with a rapid ventricular response. Compared to the previous\\ntracing of ventricular paced rhythm is no longer recorded. Left\\nventricular hypertrophy with intraventricular conduction delay. The ventricular\\nresponse has increased. Non-specific ST-T wave abnormalities persist without\\ndiagnostic interim change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2172-07-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 123854,\n \"text\": \"Atrial fibrillation and ventricular paced rhythm. Occasional fusion beats. Left\\nventricular hypertrophy. Intraventricular conduction delay related to left\\nventricular hypertrophy. ST-T wave abnormalities persist as recorded on the\\ntracing of . A ventricular pacemaker is now present.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2172-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 123855,\n \"text\": \"Atrial fibrillation with a controlled ventricular response. Diffise ST-T wave\\nabnormalities persist without diagnostic interim change compared to the\\nprevious tracing of .\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2172-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 123856,\n \"text\": \"Atrial fibrillation with a slow ventricular response. There is variation in the\\nprecordial lead placement as compared to the previous tracing of . The\\nST-T wave abnormalities persist without diagnostic interim change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2172-06-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 123858,\n \"text\": \"Atrial fibrillation with a moderate ventricular response and a suggestion of\\ngroup beating. Borderline intraventricular conduction delay. Non-specific\\nST-T wave changes with relatively short interval consistent with digitalis\\neffect, although ischemia, etc. is not excluded. Non-diagnostic Q waves in\\nlead III. Prominent R wave in lead V3 without diagnostic criteria for left\\nventricular hypertrophy. Compared to the previous tracing of ST-T wave\\nchanges are more apparent. Exclude digitalis excess if clinically indicated.\\nClinical correlation is suggested.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2172-06-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 123857,\n \"text\": \"Baseline artifact precludes precise assessment. Underlying rhythm again appears\\nto be atrial fibrillation with a slow to moderate ventricular response.\\nCompared to the previous tracing of multiple abnormalities are as\\npreviously reported without diagnostic change, in the presence of the baseline\\nartifact. Clinical correlation is suggested.\\nTRACING #2\\n\\n\"\n }\n]"}}},{"rowIdx":99,"cells":{"subject_id":{"kind":"number","value":91520,"string":"91,520"},"hadm_id":{"kind":"number","value":149828,"string":"149,828"},"target_text":{"kind":"string","value":"The patient was admitted to the General Surgery Service for evaluation and treatment of the aforementioned complaint on . He was made NPO and started on IV fluid rescusitation. A foley was placed. He was given Dilaudid IV PRN for pain with good effect. In the ED, he was started on IV Vancomycin and Zosyn, which was changed to IV Flagyl and Cipro given the gallbladder findings once admitted. He was started on nebulizer treatments, chest PT, and aggressive respiratory toilet for tachypnea. Labwork and diagnostic studies were performed. He was hemodynamically stable. On , the patient was sent for an ERCP. At the time of the ERCP, he underwent an uncomplicated intubation. He was doing well during the procedures until pressures fell from baseline 170s/90s, to 80s/50s briefly while insufflating stomach. O2 sats fell at that time to unclear levels. He was noted to be gurgling. His pressures came back up and he never required pressors. ERCP with sphincterotomy and drainage of sludge was performed. At the end of case, his O2 saturation was 95% on 100% FiO2 with CO2 65. He remained intubated and was transferred to the for further care."},"extractive_notes_summ":{"kind":"string","value":"At the time of ERCP, he underwent anuncomplicated intubation. At the time of ERCP, he underwent anuncomplicated intubation. PPx - -pneumoboots -lansoprazole -bowel regimen . PPx - -pneumoboots -lansoprazole -bowel regimen . PPx - -pneumoboots -lansoprazole -bowel regimen . He was taken for ERCP. He was taken for ERCP. Wall motion, Pulm edema.Height: (in) 69Weight (lb): 218BSA (m2): 2.14 m2BP (mm Hg): 144/97HR (bpm): 93Status: InpatientDate/Time: at 15:30Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. - continue to hold lisinopril given recent hypotension . CXR with low lung volumes and plate like atelecatasis ( pre-intubation). There is a trivial/physiologic pericardial effusion. #) Hypertension: on lisinopril as an outpatient. #) Hypertension: on lisinopril as an outpatient. - stop heparin for now; pneumoboots for prophylaxis - continue to trend . - stop heparin for now; pneumoboots for prophylaxis - continue to trend . #) Hypertension: Holding lisinopril. Dispo - Pending extubation ICU Care Nutrition: NPO Glycemic Control: Lines: 18 Gauge - 09:27 PM 20 Gauge - 10:03 PM Prophylaxis: DVT: pneumoboots Stress ulcer: ppi VAP: Comments: Communication: Comments: Code status: Full code Disposition: icu Dispo - Pending extubation ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 09:27 PM 20 Gauge - 10:03 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: PPx - -pneumoboots -bowel regimen . PPx - -pneumoboots -lansoprazole -bowel regimen . PPx - -pneumoboots -lansoprazole -bowel regimen . PPx - -pneumoboots -lansoprazole -bowel regimen . PPx - -pneumoboots -lansoprazole -bowel regimen . PPx - -pneumoboots -lansoprazole -bowel regimen . - continue to hold lisinopril given recent hypotension . - continue to hold lisinopril given recent hypotension . Currently normotensive. Currently normotensive. Currently normotensive. - stop heparin for now; pneumoboots for prophylaxis - continue to trend . - stop heparin for now; pneumoboots for prophylaxis - continue to trend . - stop heparin for now; pneumoboots for prophylaxis - continue to trend . - repeat ABG . #) Hypertension: Holding lisinopril. #) Hypertension: Holding lisinopril. #) Hypertension: Holding lisinopril. Remians NPO. Remians NPO. - will need to restart lisinopril going forward given DM and chronic HTN . AST 241, ALT 344, Alk phos 198. Pt afebrile. #) Pancreatitis: Likely was secondary to a gallstone that has subsequently passed. #) Pancreatitis: Likely was secondary to a gallstone that has subsequently passed. #) Thrombocytopenia: Improving today Unclear etiology. #) Hypertension: on lisinopril as an outpatient. #) Hypertension: on lisinopril as an outpatient. #) Hypertension: on lisinopril as an outpatient. ABG 7.47/42/90. Afebrile. Afebrile. - increase PEEP to 10 - wean FiO2 as tolerated - transition to PSV if possible - stop IVF - consider further diuresis. - increase PEEP to 10 - wean FiO2 as tolerated - transition to PSV if possible - stop IVF - consider further diuresis. IMPRESSION: Right cephalic vein thrombus, without evidence of DVT. Small left greater than right fat-containing inguinal hernias are noted. IMPRESSION: Multifocal atelectasis without evidence for pneumonic consolidation or edema. no tenderness good pulses no cvl REASON FOR THIS EXAMINATION: R/O DVT WET READ: JXKc FRI 2:46 PM Thrombus in the right cephalic vein. IMPRESSION: AP chest reviewed in the absence of other chest radiographs or imaging of the torso. CT ABDOMEN: Small right and trace left pleural effusion are noted. The remainder of the vessels demonstrate normal compression, flow, and augmentation without evidence of DVT. Similarly, a bulge in the right lower paratracheal contour in the mediastinum could be a distended azygos vein, less likely adenopathy. Evaluation for focal lesion limited on this early arterial phase exam. SUPINE ABDOMEN: No prior comparisons. The gallbladder is within normal limits, without evidence of gallstones, gallbladder wall thickening, or pericholecystic fluid. Small amount of pericholecystic fluid, nonspecific, without additional findings to suggest cholecystitis. Periportal edema noted. Q waves in leads III, aVF.Consider inferior myocardial infarction. An endotracheal tube has been withdrawn. Small amount of pericholecystic and periportal fluid, of uncertain significance. The gallbladder appears otherwise unremarkable without evidence of stones or hydropic distention. There is expansion of the cephalic vein in the mid and distal portions, with internal echogenicity and non-compressibility, compatible with thrombus. Evaluation is limited by single arterial phase of contrast. The right costophrenic sulcus is now blunted. There is a small amount of fluid adjacent to the gallbladder. FINDINGS: Grayscale and color Doppler son of the right internal jugular, subclavian, axillary, brachials, basilic and cephalic veins were obtained. Mild-to- moderate enlargement of the heart is again noted. No definite mass is seen in the region of the ileocecal valve. IMPRESSION: Normal ERCP. Mild cardiomegaly is unchanged. Possible small right effusion. (Over) 4:24 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: r/o dissection, please r/o PE Contrast: OPTIRAY Amt: 80 FINAL REPORT (Cont) CT PELVIS: The cecum is moderately distended with a large amount of fecal material."},"n_notes":{"kind":"number","value":42,"string":"42"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2103-04-18 00:00:00.000","description":"Report","row_id":62450,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Wall motion, Pulm edema.\nHeight: (in) 69\nWeight (lb): 218\nBSA (m2): 2.14 m2\nBP (mm Hg): 144/97\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 15:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No MS.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and regional/global systolic function (LVEF>55%). There is\nno ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic regurgitation. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\nmitral valve prolapse. The pulmonary artery systolic pressure could not be\ndetermined. There is a trivial/physiologic pericardial effusion.\n\n\n"},{"category":"Nursing","chartdate":"2103-04-19 00:00:00.000","description":"Nursing Progress Note","row_id":461814,"text":"Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n Pt s/p ERCP as stated above. Abd soft and non-tender. Denies nausea\n and vomiting. Afebrile. Remians NPO. Positive BOS x 4.\n Action:\n Maintains NPO. Monitoring abd assessment.\n Response:\n Abdomen soft and non-tender. Pt comfortable.\n Plan:\n Continue to monitor for further s/s of infection. Monitor labs.\n Remain NPO. ? transfer to tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 40% face tent. LS clear. Non-productive cough. Pt\n denies SOB or resp distress. O2 sats 96-99%.\n Action:\n O2 weaned to 2 LNC.\n Response:\n Pt stable on 2LNC. Sats 96%. RR 20\ns-30\n Plan:\n Continue to monitor resp status.\n ------ Protected Section ------\n Pt originally called out to floor. Report given to 12 and Dr.\n decided to keep pt in ICU for another night as the pt was\n tachypneic. RR high 20\ns-low 30\ns on 2 LNC throughout shift. Denies\n discomfort.\n Pt has bed on 9 for the morning.\n ------ Protected Section Addendum Entered By: , RN\n on: 04:59 ------\n"},{"category":"Nursing","chartdate":"2103-04-18 00:00:00.000","description":"Nursing Progress Note","row_id":461564,"text":"Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2103-04-18 00:00:00.000","description":"Nursing Progress Note","row_id":461566,"text":"Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n S/P ERCP as mentioned above ,Abdomen firm distended with hypoactive\n bowel sounds\n Action:\n Labs on admission AST/ALT 241/340\n Response:\n Continued\n Plan:\n Monitor labs\n Continue NPO\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted intubated from procedure room,wheezy on admission\n Action:\n ABG on admission 7.39/48/151\n Multiple vent changes\n Nebs given,Lasix 10 mg IV\n Response:\n Able to wean vent\n Plan:\n Possible extubation at AM,PRN nebs\n"},{"category":"Respiratory ","chartdate":"2103-04-18 00:00:00.000","description":"Respiratory Care Shift Note","row_id":461575,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt received from IR S/P ERCP intub with OETT and placed on\n mech vent as per Metavision. Lung sounds coarse suct sm th white sput.\n ABGs stable on current vent settings. Cont wean PSV and hopefully extub\n today.\n"},{"category":"Physician ","chartdate":"2103-04-18 00:00:00.000","description":"Physician Resident Admission Note","row_id":461561,"text":"TITLE:\n Chief Complaint:\n HPI:\n Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP.\n .\n At the time of ERCP, he underwent anuncomplicated intubation. He was\n doing well during the procedures until pressures fell from baseline\n 170s/90s, to 80s/50s briefly while insufflating stomach. O2 sats fell\n at that time to unclear levels. He was noted to be gurgling. His\n pressures came back up and he never required pressors. ERCP with\n sphincterotomy and drainage of sludge was performed. At the end of case\n he was satting 95% on 100% FiO2 with CO2 65. He remained intubated and\n was transferred to the for further care.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Metronidazole - 12:36 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Home medications\n lisinopril 5 mg daily\n omeprazole 20 mg \n simvastatin 40 mg daily\n ASA 81 mg daily:\n Past medical history:\n Family history:\n Social History:\n - traumatic brain injury ( in )\n - insomnia\n - hyperlipidemia\n - umbilical hernia\n - H. pylori\n - chronic polyps\n - diabetes mellitus type II\n not obtained\n per OMR: Has a son who is quite involved in his care. He does not\n smoke or drink EtOH.\n Review of systems:\n Flowsheet Data as of 01:57 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.5\nC (97.7\n HR: 94 (88 - 115) bpm\n BP: 127/91(98) {117/83(90) - 189/101(98)} mmHg\n RR: 24 (19 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 81 mL\n 330 mL\n PO:\n TF:\n IVF:\n 81 mL\n 330 mL\n Blood products:\n Total out:\n 760 mL\n 560 mL\n Urine:\n 160 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -679 mL\n -230 mL\n Respiratory\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 600) mL\n Vt (Spontaneous): 397 (397 - 397) mL\n PS : 15 cmH2O\n RR (Set): 19\n RR (Spontaneous): 26\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n SpO2: 97%\n ABG: 7.39/48/151/22/3\n Ve: 9.8 L/min\n PaO2 / FiO2: 377\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 63 K/uL\n 12.4 g/dL\n 118 mg/dL\n 0.9 mg/dL\n 18 mg/dL\n 22 mEq/L\n 107 mEq/L\n 4.6 mEq/L\n 138 mEq/L\n 36.8 %\n 12.4 K/uL\n [image002.jpg]\n \n 2:33 A5/26/ 09:58 PM\n \n 10:20 P5/26/ 10:57 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 12.4\n Hct\n 36.8\n Plt\n 63\n Cr\n 0.9\n TC02\n 30\n Glucose\n 118\n Other labs: ALT / AST:340/241, Alk Phos / T Bili:163/1.5,\n Differential-Neuts:83.1 %, Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %,\n Albumin:2.6 g/dL, LDH:546 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\n pancreatitis, aspiration peri-proceudre, restriction from large\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\n pain, immobility, and volume overload. He has received a significant\n amount of volume and been net in several liters daily for 2 days.\n Also, CXR notable for low lung volumes and atelectasis.\n - increase PEEP to 10\n - wean FiO2 as tolerated\n - transition to PSV if possible\n - stop IVF\n - consider diuresis in AM\n .\n #) Pancreatitis: Patient presented with exam and labs consistent with\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\n Furthermore, elevated TBili and pancreatic enzymes that quickly\n improved are consistent with the theory of a stone that was passed.\n - stop IV fluid hydration\n - trend LFTs\n - continue cipro/flagyl for now; re-address this with surgery\n - continue NPO for now; may consider advance in AM\n .\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\n currently. The time course would be too fast for HIT (no known\n exposure to heparin within the past 30 days), and no evidence of\n thrombosis, but the magnitude is approximately right for that. No\n obvious medications that would cause this.\n - stop heparin for now; pneumoboots for prophylaxis\n - continue to trend\n .\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\n admission (possibly due to mild acute renal failure) and BPs per\n nursing records mostly 150s-160s. Hypotensive briefly during\n procedure, possibly a vagal reaction to stomach insufflation and/or\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\n - continue to monitor\n - hydralazine PRN\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo - Pending extubation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2103-04-18 00:00:00.000","description":"Physician Resident Admission Note","row_id":461562,"text":"TITLE:\n Chief Complaint:\n HPI:\n Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP.\n .\n At the time of ERCP, he underwent anuncomplicated intubation. He was\n doing well during the procedures until pressures fell from baseline\n 170s/90s, to 80s/50s briefly while insufflating stomach. O2 sats fell\n at that time to unclear levels. He was noted to be gurgling. His\n pressures came back up and he never required pressors. ERCP with\n sphincterotomy and drainage of sludge was performed. At the end of case\n he was satting 95% on 100% FiO2 with CO2 65. He remained intubated and\n was transferred to the for further care.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Metronidazole - 12:36 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Home medications\n lisinopril 5 mg daily\n omeprazole 20 mg \n simvastatin 40 mg daily\n ASA 81 mg daily:\n Past medical history:\n Family history:\n Social History:\n - traumatic brain injury ( in )\n - insomnia\n - hyperlipidemia\n - umbilical hernia\n - H. pylori\n - chronic polyps\n - diabetes mellitus type II\n not obtained\n per OMR: Has a son who is quite involved in his care. He does not\n smoke or drink EtOH.\n Review of systems:\n Flowsheet Data as of 01:57 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.5\nC (97.7\n HR: 94 (88 - 115) bpm\n BP: 127/91(98) {117/83(90) - 189/101(98)} mmHg\n RR: 24 (19 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 81 mL\n 330 mL\n PO:\n TF:\n IVF:\n 81 mL\n 330 mL\n Blood products:\n Total out:\n 760 mL\n 560 mL\n Urine:\n 160 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -679 mL\n -230 mL\n Respiratory\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 600) mL\n Vt (Spontaneous): 397 (397 - 397) mL\n PS : 15 cmH2O\n RR (Set): 19\n RR (Spontaneous): 26\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n SpO2: 97%\n ABG: 7.39/48/151/22/3\n Ve: 9.8 L/min\n PaO2 / FiO2: 377\n Physical Examination\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\n Gen: intubated, sedated, appears comfortable\n Heart: regular, tachycardic, no murmurs\n Lungs: diffuse wheezes, otherwise clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: not responsive to verbal or physical stimuli\n Labs / Radiology\n 63 K/uL\n 12.4 g/dL\n 118 mg/dL\n 0.9 mg/dL\n 18 mg/dL\n 22 mEq/L\n 107 mEq/L\n 4.6 mEq/L\n 138 mEq/L\n 36.8 %\n 12.4 K/uL\n [image002.jpg]\n \n 2:33 A5/26/ 09:58 PM\n \n 10:20 P5/26/ 10:57 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 12.4\n Hct\n 36.8\n Plt\n 63\n Cr\n 0.9\n TC02\n 30\n Glucose\n 118\n Other labs: ALT / AST:340/241, Alk Phos / T Bili:163/1.5,\n Differential-Neuts:83.1 %, Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %,\n Albumin:2.6 g/dL, LDH:546 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\n pancreatitis, aspiration peri-proceudre, restriction from large\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\n pain, immobility, and volume overload. He has received a significant\n amount of volume and been net in several liters daily for 2 days.\n Also, CXR notable for low lung volumes and atelectasis.\n - increase PEEP to 10\n - wean FiO2 as tolerated\n - transition to PSV if possible\n - stop IVF\n - consider diuresis in AM\n .\n #) Pancreatitis: Patient presented with exam and labs consistent with\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\n Furthermore, elevated TBili and pancreatic enzymes that quickly\n improved are consistent with the theory of a stone that was passed.\n - stop IV fluid hydration\n - trend LFTs\n - continue cipro/flagyl for now; re-address this with surgery\n - continue NPO for now; may consider advance in AM\n .\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\n currently. The time course would be too fast for HIT (no known\n exposure to heparin within the past 30 days), and no evidence of\n thrombosis, but the magnitude is approximately right for that. No\n obvious medications that would cause this.\n - stop heparin for now; pneumoboots for prophylaxis\n - continue to trend\n .\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\n admission (possibly due to mild acute renal failure) and BPs per\n nursing records mostly 150s-160s. Hypotensive briefly during\n procedure, possibly a vagal reaction to stomach insufflation and/or\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\n - continue to monitor\n - hydralazine PRN\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo - Pending extubation\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n"},{"category":"Nursing","chartdate":"2103-04-18 00:00:00.000","description":"Nursing Progress Note","row_id":461563,"text":"Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP\n .H/O pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2103-04-18 00:00:00.000","description":"Nursing Progress Note","row_id":461615,"text":"Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n S/P ERCP as mentioned above ,Abdomen firm distended with hypoactive\n bowel sounds\n Small Bm X1 @0600\n Denies any pain or discomfort\n Action:\n Labs on admission AST/ALT 241/340\n AM labs repeated at 0600\n Response:\n Continued\n Plan:\n Follow up on AM labs\n Continue NPO\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted intubated from procedure room deeply sedated on\n admission,sedations weaned appropriately\npt more awake and able to\n communicate and follow commands,wheezy on admission,low grade temp. ST\n 115 and NBP systolic 180\ns on admission which did not require any\n intervention\n WBC 10.5\n Action:\n ABG on admission 7.39/48/151\n Multiple vent changes and ABG :please see metavision for\n details,currently on CPAP + PS 40/10/15.\n Propofol 10 mg/kg/min\n Nebs given,Lasix 10 mg IV\n Blood cultures x 1\n Response:\n Able to wean vent\n Haemodinamically stable\n Responded well to lasix 10 mg\n Plan:\n Possible extubation at AM,PRN nebs\n"},{"category":"Nursing","chartdate":"2103-04-18 00:00:00.000","description":"Nursing Progress Note","row_id":461571,"text":"Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n S/P ERCP as mentioned above ,Abdomen firm distended with hypoactive\n bowel sounds\n Action:\n Labs on admission AST/ALT 241/340\n Response:\n Continued\n Plan:\n Monitor labs\n Continue NPO\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted intubated from procedure room,wheezy on admission\n Action:\n ABG on admission 7.39/48/151\n Multiple vent changes and ABG :please see metavision for details.\n Nebs given,Lasix 10 mg IV\n Response:\n Able to wean vent\n Plan:\n Possible extubation at AM,PRN nebs\n"},{"category":"General","chartdate":"2103-04-17 00:00:00.000","description":"Generic Note","row_id":461556,"text":"MICU ATTENDING ADMISSION NOTE\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with Dr\n \ns note above, including the assessment and plan. I would\n emphasize and add the following points:\n Mr presents after ERCP procedure this evening, done for\n management of acute gallstone pancreatitis. He was admitted to Dr\n \ns service 2 days ago with severe abdominal pain, lipase of\n 12,400 and creatinine of 2.0. His USG did shows features of\n peri-cholecystic fluid collection but no dilation of intra or\n extra-hepatic ducts. He has responded well to LR fluid resuscitation on\n the floor with improving LFT\ns and creatinine. His Calcium is down to\n 7.2 and his Hct is down to 34 with fluids. His ERCP/sphincterotomy was\n fairly unrevealing ( no stones, normal pancreatic ducts). He needed\n FiO2 of 100% during procedure with transient hypotension too. He has\n received Cipro/ Flagyl so far.\n Exam notable for edematous BM Tm 100.4 BP 144/70 HR of 88 RR of 16\n with sats of 99% on PEEP 10 . He has 2 IV\ns in RUE, good breath sounds\n in all lung fields and distended belly with scant bowel sounds.\n Labs notable for WBC 14.5 K, HCT of 34.9 , Cr 1.2 , Ca of 7.2.\n CXR with low lung volumes and plate like atelecatasis (\n pre-intubation).\n Agree with plan to support on ventilator with higher PEEP to offset\n abdominal distension and chest wall anasarca. We will use IVF\ns in\n bolus form only if hemodynamically unstable. He will benefit from\n gentle diuresis if BP allows in am and attempts at PSV/ CPAP\n support provided we can wean FiO2 tonight. He appears to have responded\n to vigorous fluid rescucitation but remains at high risk for other\n complications from pancreatitis.\n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n _________\n , MD\n Division of Pulmonary, Critical Care and Sleep Medicine\n \n , KS-B23\n , \n"},{"category":"Nursing","chartdate":"2103-04-18 00:00:00.000","description":"Nursing Progress Note","row_id":461712,"text":"Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n Pt s/p ERCP as above. Abd soft, non-tender. AST 241, ALT 344, Alk phos\n 198. Pt afebrile.\n Action:\n Monitoring abdominal assessment and labs as ordered. Pt NPO for now.\n Response:\n Abdomen remains soft, non-tender. BS present.\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on vent settings CPAP/PS 15/10 FiO2 40%. BBS CTA\n to diminished at bases. Atelectasis to LLL improved on CXR per team.\n ABG 7.47/42/90. Pt awake, though comfortable on propofol at\n 10mcg/kg/min. Pt denies SOB, free of s/s distress\n Action:\n Monitoring respiratory status closely. Vent settings weaned gradually\n to CPA/PS 5/5 FiO2 40%. Echo done at bedside given concern for previous\n pulmonary edema.\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2103-04-18 00:00:00.000","description":"Physician Resident Progress Note","row_id":461689,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:00 PM\n BLOOD CULTURED - At 05:40 AM\n EKG - At 06:28 AM\n .\n - admitted to from ERCP, intubated\n - weaned FiO2 from 100% to 40%, increased PEEP from 5 to 10\n - changed to pressure support\n - ET tube was too deep and was pulled back\n - received 10 mg IV lasix x 1 with excellent UOP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Metronidazole - 12:36 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 104 (88 - 115) bpm\n BP: 134/93(99) {117/76(88) - 189/101(100)} mmHg\n RR: 27 (19 - 27) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 81 mL\n 377 mL\n PO:\n TF:\n IVF:\n 81 mL\n 377 mL\n Blood products:\n Total out:\n 760 mL\n 1,560 mL\n Urine:\n 160 mL\n 1,560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -679 mL\n -1,183 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 600) mL\n Vt (Spontaneous): 435 (397 - 435) mL\n PS : 15 cmH2O\n RR (Set): 19\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n SpO2: 94%\n ABG: 7.47/42/90./30/6\n Ve: 9.2 L/min\n PaO2 / FiO2: 225\n Physical Examination\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\n Gen: intubated but awake\n Heart: regular, tachycardic, no murmurs\n Lungs: clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: awake and following commands\n Labs / Radiology\n 69 K/uL\n 13.0 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 104 mEq/L\n 142 mEq/L\n 36.2 %\n 10.5 K/uL\n [image002.jpg]\n 09:58 PM\n 10:57 PM\n 02:49 AM\n 04:23 AM\n WBC\n 12.4\n 10.5\n Hct\n 36.8\n 36.2\n Plt\n 63\n 69\n Cr\n 0.9\n 1.0\n TCO2\n 30\n 31\n Glucose\n 118\n 111\n Other labs: PT / PTT / INR:15.2/25.1/1.3, ALT / AST:344/241, Alk Phos /\n T Bili:198/3.0, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:546 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:1.0 mg/dL\n LFTs:\n AST 241\n ALT 340\n AP 163\n Tbili: 1.8\n Assessment and Plan\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Hypoxia: Likely contributions from volume overload and atelectasis\n with V/Q mismatch. Also there would be concern for procedure-related\n complication, but there was no stone extraction, so an inflammatory\n response to that seems less likely. Also, he was apparently having\n some respiratory issues prior to ERCP given the choice for elective\n intubation. Regardless, he has diuresed well to a single 10 mg IV\n lasix dose, now on PSV, and A-a gradient has improved.\n - decrease PEEP to 5\n - repeat ABG\n - SBT\n - extubate\n - no further IV fluids or diuresis for now\n .\n #) Pancreatitis: Likely was secondary to a gallstone that has\n subsequently passed. Improving by most accounts (clinical exam per\n notes, fever curve, labs). Bump in tbili today may be procedure\n related. Co-managing with surgery.\n - advance diet as tolerated after extubation\n - continue cipro/flagyl as per the preference of surgery\n - trend LFTs\n - no need for further IV fluid hydration\n .\n #) Thrombocytopenia: Unclear etiology. Platelets stable today after\n having fallen from 173 on admit to 63 currently. The time course would\n be too fast for HIT, but there was a suggestion of portal vein\n thrombosis on admission CT (but this was prior to heparin). After\n discussion with surgery, they would like to send PF4 antibody. PPI\n could also cause thrombocytopenia\n - no heparin for now\n - f/u PF4 antibody\n - stop PPI\n - continue to trend platelets\n .\n #) Hypertension: Holding lisinopril. Currently normotensive.\n - continue to hold lisinopril given recent hypotension\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo\n likely to return to surgical service today pending\n extubation\n ICU Care\n Nutrition: advance diet today as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: call out to floor\n"},{"category":"Nursing","chartdate":"2103-04-18 00:00:00.000","description":"Nursing Progress Note","row_id":461783,"text":"Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n Pt s/p ERCP as stated above. Abd soft and non-tender. Denies nausea\n and vomiting. Afebrile. Remians NPO. Positive BOS x 4.\n Action:\n Maintains NPO. Monitoring abd assessment.\n Response:\n Abdomen soft and non-tender. Pt comfortable.\n Plan:\n Continue to monitor for further s/s of infection. Monitor labs.\n Remain NPO. ? transfer to tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 40% face tent. LS clear. Non-productive cough. Pt\n denies SOB or resp distress. O2 sats 96-99%.\n Action:\n O2 weaned to 2 LNC.\n Response:\n Pt stable on 2LNC. Sats 96%. RR 20\ns-30\n Plan:\n Continue to monitor resp status.\n"},{"category":"Nursing","chartdate":"2103-04-18 00:00:00.000","description":"Nursing Transfer Note","row_id":461784,"text":"Demographics\n Attending MD:\n M.\n Admit diagnosis:\n PANCREATITIS\n Code status:\n Full code\n Height:\n Admission weight:\n 99 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:152\n D:89\n Temperature:\n 99.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,068 mL\n 24h total out:\n 3,150 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:40 PM\n Potassium:\n 3.7 mEq/L\n 02:40 PM\n Chloride:\n 103 mEq/L\n 02:40 PM\n CO2:\n 27 mEq/L\n 02:40 PM\n BUN:\n 14 mg/dL\n 02:40 PM\n Creatinine:\n 0.8 mg/dL\n 02:40 PM\n Glucose:\n 113 mg/dL\n 02:40 PM\n Hematocrit:\n 37.7 %\n 02:40 PM\n Finger Stick Glucose:\n 130\n 06:00 PM\n Valuables / Signature\n Patient valuables: sent with pt\n valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4\n Transferred to: 12 \n Date & time of Transfer: 2330\n Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n Pt s/p ERCP as stated above. Abd soft and non-tender. Denies nausea\n and vomiting. Afebrile. Remians NPO. Positive BOS x 4.\n Action:\n Maintains NPO. Monitoring abd assessment.\n Response:\n Abdomen soft and non-tender. Pt comfortable.\n Plan:\n Continue to monitor for further s/s of infection. Monitor labs.\n Remain NPO. ? transfer to tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 40% face tent. LS clear. Non-productive cough. Pt\n denies SOB or resp distress. O2 sats 96-99%.\n Action:\n O2 weaned to 2 LNC.\n Response:\n Pt stable on 2LNC. Sats 96%. RR 20\ns-30\n Plan:\n Continue to monitor resp status.\n"},{"category":"Physician ","chartdate":"2103-04-19 00:00:00.000","description":"Physician Resident Progress Note","row_id":461849,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:33 PM\n - Extubated afternoon\n - Attempted to call out to 9, surgery would like him monitored\n overnight for high respiratory rate.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 11:40 PM\n Metronidazole - 12:56 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 82 (80 - 98) bpm\n BP: 129/81(93) {126/81(93) - 159/102(116)} mmHg\n RR: 23 (20 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,308 mL\n 168 mL\n PO:\n TF:\n IVF:\n 1,308 mL\n 168 mL\n Blood products:\n Total out:\n 3,150 mL\n 1,020 mL\n Urine:\n 3,150 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,842 mL\n -852 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 23 (23 - 406) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 91\n SpO2: 93%\n ABG: ///27/\n Ve: 9.2 L/min\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\n Gen: intubated but awake\n Heart: regular, tachycardic, no murmurs\n Lungs: clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: awake and following commands\n Labs / Radiology\n 84 K/uL\n 12.9 g/dL\n 92 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 106 mEq/L\n 142 mEq/L\n 38.5 %\n 8.0 K/uL\n [image002.jpg]\n 09:58 PM\n 10:57 PM\n 02:49 AM\n 04:23 AM\n 02:40 PM\n 04:10 AM\n WBC\n 12.4\n 10.5\n 10.6\n 8.0\n Hct\n 36.8\n 36.2\n 37.7\n 38.5\n Plt\n 63\n 69\n 76\n 84\n Cr\n 0.9\n 1.0\n 0.8\n 0.8\n TCO2\n 30\n 31\n Glucose\n 118\n 111\n 113\n 92\n Other labs: PT / PTT / INR:16.2/24.7/1.4, ALT / AST:249/129, Alk Phos /\n T Bili:204/1.2, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.8 g/dL, LDH:444 IU/L,\n Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n PANCREATITIS, ACUTE\n THROMBOCYTOPENIA, ACUTE\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Hypoxia: Likely contributions from volume overload and atelectasis\n with V/Q mismatch. Also there would be concern for procedure-related\n complication, but there was no stone extraction, so an inflammatory\n response to that seems less likely. Also, he was apparently having\n some respiratory issues prior to ERCP given the choice for elective\n intubation. Regardless, he has diuresed well to a single 10 mg IV\n lasix dose, now on PSV, and A-a gradient has improved.\n - decrease PEEP to 5\n - repeat ABG\n - SBT\n - extubate\n - no further IV fluids or diuresis for now\n .\n #) Pancreatitis: Likely was secondary to a gallstone that has\n subsequently passed. Improving by most accounts (clinical exam per\n notes, fever curve, labs). Bump in tbili today may be procedure\n related. Co-managing with surgery.\n - advance diet as tolerated after extubation\n - continue cipro/flagyl as per the preference of surgery\n - trend LFTs\n - no need for further IV fluid hydration\n .\n #) Thrombocytopenia: Unclear etiology. Platelets stable today after\n having fallen from 173 on admit to 63 currently. The time course would\n be too fast for HIT, but there was a suggestion of portal vein\n thrombosis on admission CT (but this was prior to heparin). After\n discussion with surgery, they would like to send PF4 antibody. PPI\n could also cause thrombocytopenia\n - no heparin for now\n - f/u PF4 antibody\n - stop PPI\n - continue to trend platelets\n .\n #) Hypertension: Holding lisinopril. Currently normotensive.\n - continue to hold lisinopril given recent hypotension\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo\n likely to return to surgical service today pending\n extubation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2103-04-19 00:00:00.000","description":"Physician Resident Progress Note","row_id":461851,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:33 PM\n - Extubated afternoon\n - Attempted to call out to 9, surgery would like him monitored\n overnight for high respiratory rate.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 11:40 PM\n Metronidazole - 12:56 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 82 (80 - 98) bpm\n BP: 129/81(93) {126/81(93) - 159/102(116)} mmHg\n RR: 23 (20 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,308 mL\n 168 mL\n PO:\n TF:\n IVF:\n 1,308 mL\n 168 mL\n Blood products:\n Total out:\n 3,150 mL\n 1,020 mL\n Urine:\n 3,150 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,842 mL\n -852 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, 2L\n Gen: awake\n Heart: regular, tachycardic, no murmurs\n Lungs: clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: awake and following commands\n Labs / Radiology\n 84 K/uL\n 12.9 g/dL\n 92 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 106 mEq/L\n 142 mEq/L\n 38.5 %\n 8.0 K/uL\n [image002.jpg]\n 09:58 PM\n 10:57 PM\n 02:49 AM\n 04:23 AM\n 02:40 PM\n 04:10 AM\n WBC\n 12.4\n 10.5\n 10.6\n 8.0\n Hct\n 36.8\n 36.2\n 37.7\n 38.5\n Plt\n 63\n 69\n 76\n 84\n Cr\n 0.9\n 1.0\n 0.8\n 0.8\n TCO2\n 30\n 31\n Glucose\n 118\n 111\n 113\n 92\n Other labs: PT / PTT / INR:16.2/24.7/1.4, ALT / AST:249/129, Alk Phos /\n T Bili:204/1.2, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.8 g/dL, LDH:444 IU/L,\n Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.0 mg/dL\n HIT antibody negative\n Blood cx , NGTD\n Assessment and Plan\n PANCREATITIS, ACUTE\n THROMBOCYTOPENIA, ACUTE\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Increased respiratory rate: likely\n Likely contributions from volume overload and atelectasis with V/Q\n mismatch. Also there would be concern for procedure-related\n complication, but there was no stone extraction, so an inflammatory\n response to that seems less likely. Also, he was apparently having\n some respiratory issues prior to ERCP given the choice for elective\n intubation. Regardless, he has diuresed well to a single 10 mg IV\n lasix dose, now on PSV, and A-a gradient has improved.\n - decrease PEEP to 5\n - repeat ABG\n - SBT\n - extubate\n - no further IV fluids or diuresis for now\n .\n #) Pancreatitis: Likely was secondary to a gallstone that has\n subsequently passed. Improving by most accounts (clinical exam per\n notes, fever curve, labs). Bump in tbili today may be procedure\n related. Co-managing with surgery.\n - advance diet as tolerated after extubation\n - continue cipro/flagyl as per the preference of surgery\n - trend LFTs\n - no need for further IV fluid hydration\n .\n #) Thrombocytopenia: Improving today\n Unclear etiology. Platelets stable today after having fallen from 173\n on admit to 63 currently. The time course would be too fast for HIT,\n but there was a suggestion of portal vein thrombosis on admission CT\n (but this was prior to heparin). After discussion with surgery, they\n would like to send PF4 antibody. PPI could also cause\n thrombocytopenia\n - no heparin for now\n - f/u PF4 antibody\n - stop PPI\n - continue to trend platelets\n .\n #) Hypertension: Holding lisinopril. Currently normotensive.\n - continue to hold lisinopril given recent hypotension\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo\n likely to return to surgical service today pending\n extubation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2103-04-19 00:00:00.000","description":"Physician Resident Progress Note","row_id":461979,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:33 PM\n - Extubated yesterday afternoon\n - Attempted to call out to 9, surgery would like him monitored\n overnight for high respiratory rate.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 11:40 PM\n Metronidazole - 12:56 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 82 (80 - 98) bpm\n BP: 129/81(93) {126/81(93) - 159/102(116)} mmHg\n RR: 23 (20 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,308 mL\n 168 mL\n PO:\n TF:\n IVF:\n 1,308 mL\n 168 mL\n Blood products:\n Total out:\n 3,150 mL\n 1,020 mL\n Urine:\n 3,150 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,842 mL\n -852 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, 2L\n Gen: awake and interactive\n Heart: regular, tachycardic, no murmurs\n Lungs: clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: awake and following commands\n Labs / Radiology\n 84 K/uL\n 12.9 g/dL\n 92 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 106 mEq/L\n 142 mEq/L\n 38.5 %\n 8.0 K/uL\n [image002.jpg]\n 09:58 PM\n 10:57 PM\n 02:49 AM\n 04:23 AM\n 02:40 PM\n 04:10 AM\n WBC\n 12.4\n 10.5\n 10.6\n 8.0\n Hct\n 36.8\n 36.2\n 37.7\n 38.5\n Plt\n 63\n 69\n 76\n 84\n Cr\n 0.9\n 1.0\n 0.8\n 0.8\n TCO2\n 30\n 31\n Glucose\n 118\n 111\n 113\n 92\n Other labs: PT / PTT / INR:16.2/24.7/1.4, ALT / AST:249/129, Alk Phos /\n T Bili:204/1.2, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.8 g/dL, LDH:444 IU/L,\n Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.0 mg/dL\n HIT antibody negative\n Blood cx , NGTD\n Assessment and Plan\n PANCREATITIS, ACUTE\n THROMBOCYTOPENIA, ACUTE\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, transferred to ICU with\n difficulty extubating, now extubated but mildly tachypneic.\n .\n #) Increased respiratory rate: likely secondary to discomfort in\n abdomen, may still have some extra volume on board. Echo yesterday\n showed normal EF, so it is unclear exactly why he went into pulmonary\n edema. Regardless, he was successfully extubated and RR is improving.\n - repeat ABG\n .\n #) Pancreatitis: All labs, fever curve improving. Likely was secondary\n to a gallstone that has subsequently passed. Improving by most\n accounts (clinical exam per notes, fever curve, labs). Co-managing\n with surgery. He will go back to their service today.\n - advance diet as tolerated\n - continue cipro/flagyl as per the preference of surgery\n - trend LFTs\n - no need for further IV fluid hydration\n .\n #) Thrombocytopenia: Improving today. HIT antibody negative.\n Heparin and PPI stopped yesterday.\n - continue to trend platelets\n .\n #) Hypertension: Holding lisinopril. Currently normotensive.\n - will need to restart lisinopril going forward given DM and chronic\n HTN\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo\n likely to return to surgical service today pending\n extubation\n ICU Care\n Nutrition: advance diet\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: return to surgery today\n"},{"category":"Nursing","chartdate":"2103-04-18 00:00:00.000","description":"Nursing Progress Note","row_id":461600,"text":"Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n S/P ERCP as mentioned above ,Abdomen firm distended with hypoactive\n bowel sounds\n Denies any pain or discomfort\n Action:\n Labs on admission AST/ALT 241/340\n AM labs repeated at 0600\n Response:\n Continued\n Plan:\n Follow up on AM labs\n Continue NPO\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted intubated from procedure room deeply sedated on\n admission,sedations weaned appropriately\npt more awake and able to\n communicate and follow commands,wheezy on admission,low grade temp.\n Action:\n ABG on admission 7.39/48/151\n Multiple vent changes and ABG :please see metavision for\n details,currently on CPAP + PS 40/10/15.\n Propofol 10 mg/kg/min\n Nebs given,Lasix 10 mg IV\n Blood cultures x 1\n Response:\n Able to wean vent\n Responded well to lasix 10 mg\n Plan:\n Possible extubation at AM,PRN nebs\n"},{"category":"General","chartdate":"2103-04-18 00:00:00.000","description":"Generic Note","row_id":461681,"text":"TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined. He has diuresed 2L\n overnight. Abd exam relatively unremarkable\n no tenderness mild\n distention. We are switching to PSV, reducing PEEP to 5 and will do a\n long SBT prior to extubation.\n Time spent 40 min\n Critically ill\n"},{"category":"Nursing","chartdate":"2103-04-18 00:00:00.000","description":"Nursing Progress Note","row_id":461764,"text":"Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n Pt s/p ERCP as above. Abd soft, non-tender. AST 241, ALT 344, Alk phos\n 198. Pt afebrile.\n Action:\n Monitoring abdominal assessment and labs as ordered. Pt NPO for now.\n Response:\n Abdomen remains soft, non-tender. BS present.\n Plan:\n Continue monitor abdominal assessment. Monitor labs. Pt to remain NPO\n for now.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on vent settings CPAP/PS 15/10 FiO2 40%. BBS CTA\n to diminished at bases. Atelectasis to LLL improved on CXR per team.\n ABG 7.47/42/90. Pt awake, though comfortable on propofol at\n 10mcg/kg/min. Pt denies SOB, free of s/s distress\n Action:\n Monitoring respiratory status closely. Vent settings weaned gradually\n to CPA/PS 5/5 FiO2 40%. Echo done at bedside given concern for previous\n pulmonary edema.\n Response:\n Pt tolerated vent weaning well and was extubated ~1600. Pt presently\n resting quietly in bed. BBS CTA to diminished at bilat bases. SpO2\n >97%. Pt denies SOB, reports comfortable remains free of distress.\n Plan:\n Continue to monitor respiratory status. Anticipate C/O to floor (\n 9) tomorrow if pt remains stable.\n"},{"category":"Physician ","chartdate":"2103-04-18 00:00:00.000","description":"Physician Resident Progress Note","row_id":461632,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:00 PM\n BLOOD CULTURED - At 05:40 AM\n EKG - At 06:28 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Metronidazole - 12:36 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 104 (88 - 115) bpm\n BP: 134/93(99) {117/76(88) - 189/101(100)} mmHg\n RR: 27 (19 - 27) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 81 mL\n 377 mL\n PO:\n TF:\n IVF:\n 81 mL\n 377 mL\n Blood products:\n Total out:\n 760 mL\n 1,560 mL\n Urine:\n 160 mL\n 1,560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -679 mL\n -1,183 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 600) mL\n Vt (Spontaneous): 435 (397 - 435) mL\n PS : 15 cmH2O\n RR (Set): 19\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n SpO2: 94%\n ABG: 7.47/42/90./30/6\n Ve: 9.2 L/min\n PaO2 / FiO2: 225\n Physical Examination\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\n Gen: intubated, sedated, appears comfortable\n Heart: regular, tachycardic, no murmurs\n Lungs: diffuse wheezes, otherwise clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: not responsive to verbal or physical stimuli\n Labs / Radiology\n 69 K/uL\n 13.0 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 104 mEq/L\n 142 mEq/L\n 36.2 %\n 10.5 K/uL\n [image002.jpg]\n 09:58 PM\n 10:57 PM\n 02:49 AM\n 04:23 AM\n WBC\n 12.4\n 10.5\n Hct\n 36.8\n 36.2\n Plt\n 63\n 69\n Cr\n 0.9\n 1.0\n TCO2\n 30\n 31\n Glucose\n 118\n 111\n Other labs: PT / PTT / INR:15.2/25.1/1.3, ALT / AST:344/241, Alk Phos /\n T Bili:198/3.0, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:546 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:1.0 mg/dL\n LFTs:\n AST 241\n ALT 340\n AP 163\n Tbili: 1.8\n CXR:\n Assessment and Plan\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\n pancreatitis, aspiration peri-proceudre, restriction from large\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\n pain, immobility, and volume overload. He has received a significant\n amount of volume and been net in several liters daily for 2 days.\n Also, CXR notable for low lung volumes and atelectasis.\n - increase PEEP to 10\n - wean FiO2 as tolerated\n - transition to PSV if possible\n - stop IVF\n - consider further diuresis.\n .\n #) Pancreatitis: Patient presented with exam and labs consistent with\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\n Furthermore, elevated TBili and pancreatic enzymes that quickly\n improved are consistent with the theory of a stone that was passed.\n Now Tibili increasing again\n - stop IV fluid hydration\n - trend LFTs\n - continue cipro/flagyl for now; re-address this with surgery\n - continue NPO for now; may consider advance in AM\n .\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\n currently. The time course would be too fast for HIT (no known\n exposure to heparin within the past 30 days), and no evidence of\n thrombosis, but the magnitude is approximately right for that. No\n obvious medications that would cause this.\n - stop heparin for now; pneumoboots for prophylaxis\n - continue to trend\n .\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\n admission (possibly due to mild acute renal failure) and BPs per\n nursing records mostly 150s-160s. Hypotensive briefly during\n procedure, possibly a vagal reaction to stomach insufflation and/or\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\n - continue to monitor\n - hydralazine PRN\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo - Pending extubation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2103-04-18 00:00:00.000","description":"Physician Resident Progress Note","row_id":461633,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:00 PM\n BLOOD CULTURED - At 05:40 AM\n EKG - At 06:28 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Metronidazole - 12:36 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 104 (88 - 115) bpm\n BP: 134/93(99) {117/76(88) - 189/101(100)} mmHg\n RR: 27 (19 - 27) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 81 mL\n 377 mL\n PO:\n TF:\n IVF:\n 81 mL\n 377 mL\n Blood products:\n Total out:\n 760 mL\n 1,560 mL\n Urine:\n 160 mL\n 1,560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -679 mL\n -1,183 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 600) mL\n Vt (Spontaneous): 435 (397 - 435) mL\n PS : 15 cmH2O\n RR (Set): 19\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n SpO2: 94%\n ABG: 7.47/42/90./30/6\n Ve: 9.2 L/min\n PaO2 / FiO2: 225\n Physical Examination\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\n Gen: intubated, sedated, appears comfortable\n Heart: regular, tachycardic, no murmurs\n Lungs: diffuse wheezes, otherwise clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: not responsive to verbal or physical stimuli\n Labs / Radiology\n 69 K/uL\n 13.0 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 104 mEq/L\n 142 mEq/L\n 36.2 %\n 10.5 K/uL\n [image002.jpg]\n 09:58 PM\n 10:57 PM\n 02:49 AM\n 04:23 AM\n WBC\n 12.4\n 10.5\n Hct\n 36.8\n 36.2\n Plt\n 63\n 69\n Cr\n 0.9\n 1.0\n TCO2\n 30\n 31\n Glucose\n 118\n 111\n Other labs: PT / PTT / INR:15.2/25.1/1.3, ALT / AST:344/241, Alk Phos /\n T Bili:198/3.0, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:546 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:1.0 mg/dL\n LFTs:\n AST 241\n ALT 340\n AP 163\n Tbili: 1.8\n CXR:\n Assessment and Plan\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\n pancreatitis, aspiration peri-proceudre, restriction from large\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\n pain, immobility, and volume overload. He has received a significant\n amount of volume and been net in several liters daily for 2 days.\n Also, CXR notable for low lung volumes and atelectasis.\n - increase PEEP to 10\n - wean FiO2 as tolerated\n - transition to PSV if possible\n - stop IVF\n - consider further diuresis.\n .\n #) Pancreatitis: Patient presented with exam and labs consistent with\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\n Furthermore, elevated TBili and pancreatic enzymes that quickly\n improved are consistent with the theory of a stone that was passed.\n Now Tibili increasing again\n - stop IV fluid hydration\n - trend LFTs\n - continue cipro/flagyl for now; re-address this with surgery\n - continue NPO for now; may consider advance in AM\n .\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\n currently. The time course would be too fast for HIT (no known\n exposure to heparin within the past 30 days), and no evidence of\n thrombosis, but the magnitude is approximately right for that. No\n obvious medications that would cause this.\n - stop heparin for now; pneumoboots for prophylaxis\n - continue to trend\n .\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\n admission (possibly due to mild acute renal failure) and BPs per\n nursing records mostly 150s-160s. Hypotensive briefly during\n procedure, possibly a vagal reaction to stomach insufflation and/or\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\n - continue to monitor\n - hydralazine PRN\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo - Pending extubation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2103-04-18 00:00:00.000","description":"Physician Resident Progress Note","row_id":461636,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:00 PM\n BLOOD CULTURED - At 05:40 AM\n EKG - At 06:28 AM\n .\n - admitted to from ERCP, intubated\n - weaned FiO2 from 100% to 40%, increased PEEP from 5 to 10\n - changed to pressure support\n - pulled back ET tube\n - received 10 mg IV lasix x 1 with excellent UOP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Metronidazole - 12:36 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 104 (88 - 115) bpm\n BP: 134/93(99) {117/76(88) - 189/101(100)} mmHg\n RR: 27 (19 - 27) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 81 mL\n 377 mL\n PO:\n TF:\n IVF:\n 81 mL\n 377 mL\n Blood products:\n Total out:\n 760 mL\n 1,560 mL\n Urine:\n 160 mL\n 1,560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -679 mL\n -1,183 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 600) mL\n Vt (Spontaneous): 435 (397 - 435) mL\n PS : 15 cmH2O\n RR (Set): 19\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n SpO2: 94%\n ABG: 7.47/42/90./30/6\n Ve: 9.2 L/min\n PaO2 / FiO2: 225\n Physical Examination\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\n Gen: intubated, sedated, appears comfortable\n Heart: regular, tachycardic, no murmurs\n Lungs: diffuse wheezes, otherwise clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: not responsive to verbal or physical stimuli\n Labs / Radiology\n 69 K/uL\n 13.0 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 104 mEq/L\n 142 mEq/L\n 36.2 %\n 10.5 K/uL\n [image002.jpg]\n 09:58 PM\n 10:57 PM\n 02:49 AM\n 04:23 AM\n WBC\n 12.4\n 10.5\n Hct\n 36.8\n 36.2\n Plt\n 63\n 69\n Cr\n 0.9\n 1.0\n TCO2\n 30\n 31\n Glucose\n 118\n 111\n Other labs: PT / PTT / INR:15.2/25.1/1.3, ALT / AST:344/241, Alk Phos /\n T Bili:198/3.0, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:546 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:1.0 mg/dL\n LFTs:\n AST 241\n ALT 340\n AP 163\n Tbili: 1.8\n CXR:\n Assessment and Plan\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\n pancreatitis, aspiration peri-proceudre, restriction from large\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\n pain, immobility, and volume overload. He has received a significant\n amount of volume and been net in several liters daily for 2 days.\n Also, CXR notable for low lung volumes and atelectasis.\n - increase PEEP to 10\n - wean FiO2 as tolerated\n - transition to PSV if possible\n - stop IVF\n - consider further diuresis.\n .\n #) Pancreatitis: Patient presented with exam and labs consistent with\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\n Furthermore, elevated TBili and pancreatic enzymes that quickly\n improved are consistent with the theory of a stone that was passed.\n Now Tibili increasing again\n - stop IV fluid hydration\n - trend LFTs\n - continue cipro/flagyl for now; re-address this with surgery\n - continue NPO for now; may consider advance in AM\n .\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\n currently. The time course would be too fast for HIT (no known\n exposure to heparin within the past 30 days), and no evidence of\n thrombosis, but the magnitude is approximately right for that. No\n obvious medications that would cause this.\n - stop heparin for now; pneumoboots for prophylaxis\n - continue to trend\n .\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\n admission (possibly due to mild acute renal failure) and BPs per\n nursing records mostly 150s-160s. Hypotensive briefly during\n procedure, possibly a vagal reaction to stomach insufflation and/or\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\n - continue to monitor\n - hydralazine PRN\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo - Pending extubation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2103-04-19 00:00:00.000","description":"Nursing Transfer Note","row_id":461892,"text":"Demographics\n Attending MD:\n M.\n Admit diagnosis:\n PANCREATITIS\n Code status:\n Full code\n Height:\n Admission weight:\n 99 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:152\n D:89\n Temperature:\n 99.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,068 mL\n 24h total out:\n 3,150 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:40 PM\n Potassium:\n 3.7 mEq/L\n 02:40 PM\n Chloride:\n 103 mEq/L\n 02:40 PM\n CO2:\n 27 mEq/L\n 02:40 PM\n BUN:\n 14 mg/dL\n 02:40 PM\n Creatinine:\n 0.8 mg/dL\n 02:40 PM\n Glucose:\n 113 mg/dL\n 02:40 PM\n Hematocrit:\n 37.7 %\n 02:40 PM\n Finger Stick Glucose:\n 130\n 06:00 PM\n Valuables / Signature\n Patient valuables: sent with pt\n valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4\n Transferred to: 12 \n Date & time of Transfer: 2330\n Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n Pt s/p ERCP as stated above. Abd soft and non-tender. Denies nausea\n and vomiting. Afebrile. Remians NPO. Positive BOS x 4.\n Action:\n Maintains NPO. Monitoring abd assessment.\n Response:\n Abdomen soft and non-tender. Pt comfortable.\n Plan:\n Continue to monitor for further s/s of infection. Monitor labs.\n Remain NPO. ? transfer to tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 40% face tent. LS clear. Non-productive cough. Pt\n denies SOB or resp distress. O2 sats 96-99%.\n Action:\n O2 weaned to 2 LNC.\n Response:\n Pt stable on 2LNC. Sats 96%. RR 20\ns-30\n Plan:\n Continue to monitor resp status.\n ------ Protected Section ------\n Agree with above note.\n ------ Protected Section Addendum Entered By: , RN\n on: 09:14 ------\n"},{"category":"ECG","chartdate":"2103-04-18 00:00:00.000","description":"Report","row_id":121673,"text":"Sinus tachycardia with increase in rate as compared with previous tracing\nof . There is non-specific ST-T wave flattening and delayed precordial\nR wave transition as previously recorded without diagnostic interim change.\n\n"},{"category":"ECG","chartdate":"2103-04-15 00:00:00.000","description":"Report","row_id":121674,"text":"Sinus rhythm. Within normal limits.\n\n"},{"category":"ECG","chartdate":"2103-04-24 00:00:00.000","description":"Report","row_id":121631,"text":"Sinus rhythm. Probable anterior myocardial infarction. Non-specific\ninferior ST-T wave changes. Compared to the previous tracing of \nthe inferior Q waves are less prominent. Otherwise, no diagnostic interim\nchange.\n\n"},{"category":"ECG","chartdate":"2103-04-23 00:00:00.000","description":"Report","row_id":121632,"text":"Sinus rhythm. Somewhat late R wave progression. Q waves in leads III, aVF.\nConsider inferior myocardial infarction. Since the previous tracing of \nthe limb lead QRS voltage is more prominent.\n\n"},{"category":"Radiology","chartdate":"2103-04-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1080514,"text":" 4:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement, interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man intubated after ERCP.\n REASON FOR THIS EXAMINATION:\n ET tube placement, interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n\n REASON FOR EXAM: 57-year-old male intubated after ERCP.\n\n ET tube tip is 3 cm above the carina. Moderate cardiomegaly is stable.\n Multiple opacities, greater on the lower lobes that have minimally improved in\n the left base, are consistent with atelectasis. The lungs are better\n aerated.\n\n"},{"category":"Radiology","chartdate":"2103-04-23 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":1081435,"text":" 3:56 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ELEVATED LFTS\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with RUQ pain, recurrent elevation of amylase and lipase\n REASON FOR THIS EXAMINATION:\n eval for signs of cholecystitis\n ______________________________________________________________________________\n WET READ: JXKc MON 4:39 PM\n Fatty liver. No gallstones or evidence of cholecystitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old male with right upper quadrant pain, recurrent elevation\n of amylase and lipase. Evaluate for signs of cholecystitis.\n\n COMPARISON: .\n\n FINDINGS: The liver is diffusely echogenic, compatible with fatty\n infiltration. No focal hepatic lesion is identified. The portal vein is\n patent with hepatopetal flow. The gallbladder is within normal limits,\n without evidence of gallstones, gallbladder wall thickening, or\n pericholecystic fluid. No son sign was evident. There is no\n intra- or extra-hepatic biliary ductal dilatation with the CBD measuring 5 mm.\n Visualized pancreatic head is grossly unremarkable, with the remainder of the\n pancreas not well visualized due to overlying bowel gas.\n\n IMPRESSION:\n 1. Diffusely echogenic liver, compatible with fatty infiltration. Other\n forms of liver disease, and more advanced liver disease cannot be entirely\n excluded on this study.\n 2. No evidence of gallstones or cholecystitis.\n\n"},{"category":"Radiology","chartdate":"2103-04-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1080172,"text":" 8:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess pulm status\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57M with rigid abdomen, with exam and laboratory data consistent with acute\n pancreatitis. now with increased work of breathing,SOB\n REASON FOR THIS EXAMINATION:\n assess pulm status\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Shortness of breath. Patient with pancreatitis.\n\n Comparison is made with prior study, .\n\n Mild cardiomegaly is unchanged. Bilateral multifocal subsegmental atelectases\n have increased. There is no pneumothorax or enlarging pleural effusions.\n There are low lung volumes.\n\n"},{"category":"Radiology","chartdate":"2103-04-18 00:00:00.000","description":"ERCP BILIARY&PANCREAS BY GI UNIT","row_id":1080799,"text":" 2:30 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images done \n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 yr old male. Admitted with acute pancreatitis - suspected gallstone\n pancreatitis. Elevated transaminases with normal bilirubin.\n REASON FOR THIS EXAMINATION:\n Please review ERCP images done \n ______________________________________________________________________________\n FINAL REPORT\n ERCP\n\n COMPARISON: None.\n\n HISTORY: 57-year-old male with acute pancreatitis, elevated transaminases and\n normal bilirubin.\n\n FINDINGS: Fifteen fluoroscopic images were obtained without a radiologist\n present and submitted for review. This demonstrates normal contrast\n opacification of the hepatobiliary tree. There is no evidence of compression,\n filling defects, or ductal abnormalities.\n\n IMPRESSION: Normal ERCP. Please refer to ERCP note for further details.\n\n\n"},{"category":"Radiology","chartdate":"2103-04-23 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":1081439,"text":" 4:23 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: PANCREATITIS\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man pre-op for cholecystectomy\n REASON FOR THIS EXAMINATION:\n please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old male, for preoperative evaluation for cholecystitis.\n\n COMPARISON: CXR .\n\n PA AND LATERAL CHEST: Elevation of the right hemidiaphragm is associated with\n right basilar atelectasis. Band-like atelectasis along the medial aspect of\n the left lung is not significantly changed in the short interval. Mild-to-\n moderate enlargement of the heart is again noted. The pulmonary vascularity\n is stable. There is no pleural effusion or pneumothorax.\n\n IMPRESSION: Multifocal atelectasis without evidence for pneumonic\n consolidation or edema.\n\n"},{"category":"Radiology","chartdate":"2103-04-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1081057,"text":" 5:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with fever\n REASON FOR THIS EXAMINATION:\n please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Fever.\n\n One portable view. Comparison with . There is some motion artifact.\n There is streaky density bilaterally consistent with subsegmental atelectasis.\n The right costophrenic sulcus is now blunted. The heart and mediastinal\n structures are unchanged. An endotracheal tube has been withdrawn.\n\n IMPRESSION: Limited study demonstrating interval improvement in subsegmental\n atelectasis. Possible small right effusion.\n\n\n"},{"category":"Radiology","chartdate":"2103-04-15 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1080107,"text":" 4:24 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: r/o dissection, please r/o PE\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with acute onset chest and abdominal pain, radiating to the\n back with distention and firmness on abdominal exam\n REASON FOR THIS EXAMINATION:\n r/o dissection, please r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CTA of the chest and abdomen, .\n\n INDICATION: Acute onset chest and abdominal pain, rigid abdomen. ?\n dissection.\n\n COMPARISON: Abdominal radiographs from same day.\n\n TECHNIQUE: Volumetric CT acquisition of the chest and abdomen was performed\n following administration of intravenous contrast per CTA dissection protocol.\n Multiplanar reformatted images were obtained and reviewed.\n\n CTA CHEST: Thoracic aorta is normal in caliber and contour throughout. There\n is no dissection. Heart is mildly enlarged, with evidence of left ventricular\n hypertrophy. There is no pleural or pericardial effusion. Central airways\n are patent to the subsegmental level. There is no pathologic intrathoracic\n lymphadenopathy.\n\n Evaluation of the lung parenchyma is markedly limited due to respiratory\n motion artifact, and expiratory phase of scan acquisition.\n\n CTA ABDOMEN: Abdominal aorta is normal in caliber and contour throughout.\n There is no dissection.\n\n Liver contour is normal. There is no biliary ductal dilatation or ascites.\n Evaluation is limited by single arterial phase of contrast. There is somewhat\n ill-defined heterogeneous appearance to the parenchyma in the right lobe of\n the liver. Periportal edema noted. Main portal vein is just beginning to\n opacify, limiting evaluation for portal vein thrombus. Small amount of fluid\n is also seen in the porta hepatis, tracking along the region of the third\n portion of the duodenum. The duodenum itself is somewhat difficult to evaluate\n as it is largely collapsed. The stomach is mildly distended, with fluid and\n ingested material. There is a small amount of pericholecystic fluid though\n the GB is not fully distended.\n\n Pancreas, spleen, adrenal glands, and kidneys are normal. There is no free\n air or free intraperitoneal fluid.\n\n There is appearance to the abdominal mesentery in the left upper\n quadrant, with multiple small lymph nodes.\n (Over)\n\n 4:24 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: r/o dissection, please r/o PE\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT PELVIS: The cecum is moderately distended with a large amount of fecal\n material. Fecal material is also seen in the terminal ileum, which is\n borderline distended, measuring just greater than 3 cm. Fecal material is\n seen within the small bowel as far proximal as the mid ileum in the right\n upper quadrant. Proximal loops of small bowel are collapsed, however, and\n there is no sign of obstruction. No definite mass is seen in the region of\n the ileocecal valve. The appendix is normal.\n\n There is no free fluid, or abnormal intra-abdominal lymphadenopathy.\n\n There is no osseous lesion suspicious for malignancy.\n\n IMPRESSION:\n 1. No aortic dissection.\n 2. Heterogeneous appearance of the liver. Evaluation for focal lesion limited\n on this early arterial phase exam. If there is concern for portal vein\n thrombosis, recommend correlation with ultrasound.\n 3. Small amount of pericholecystic and periportal fluid, of uncertain\n significance. No other definite evidence of pancreatitis or cholecystitis.\n 4. appearance of the abdominal mesentery, with multiple small nodes\n could be seen in the setting of mesenteric adenitis/panniculitis.\n 5. Marked fecal impaction in the cecum, with small bowel fecalization seen as\n well, but no definite evidence of obstruction.\n\n Findings discussed with Dr. at time of study interpretation on\n .\n SESHa\n\n"},{"category":"Radiology","chartdate":"2103-04-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1080104,"text":" 4:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o acute intrapulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with acute onset abdomin pain, tachypnic\n REASON FOR THIS EXAMINATION:\n r/o acute intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:23 P.M. ON \n\n HISTORY: Acute onset of abdominal pain and tachypnea.\n\n IMPRESSION: AP chest reviewed in the absence of other chest radiographs or\n imaging of the torso.\n\n Heart is mildly-to-moderately enlarged. A 28-mm wide elliptical nodular\n opacity projecting over the left heart border could be fluid trapped in the\n major fissure though there is no evidence of pleural effusion collecting\n elsewhere. Similarly, a bulge in the right lower paratracheal contour in the\n mediastinum could be a distended azygos vein, less likely adenopathy. Lungs\n are low in volume but otherwise clear. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2103-04-20 00:00:00.000","description":"R UNILAT UP EXT VEINS US RIGHT","row_id":1080959,"text":" 1:24 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: SWELLING IN RT ARM; R/O DVT\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with pancreatitis. Developed swollen right arm over 24 hrs.\n no tenderness good pulses no cvl\n REASON FOR THIS EXAMINATION:\n R/O DVT\n ______________________________________________________________________________\n WET READ: JXKc FRI 2:46 PM\n Thrombus in the right cephalic vein.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old male with pancreatitis, with swollen right arm over the\n last 24 hours. Rule out DVT.\n\n No prior studies are available for comparison.\n\n FINDINGS: Grayscale and color Doppler son of the right internal jugular,\n subclavian, axillary, brachials, basilic and cephalic veins were obtained.\n There is expansion of the cephalic vein in the mid and distal portions, with\n internal echogenicity and non-compressibility, compatible with thrombus. The\n remainder of the vessels demonstrate normal compression, flow, and\n augmentation without evidence of DVT.\n\n IMPRESSION: Right cephalic vein thrombus, without evidence of DVT.\n\n"},{"category":"Radiology","chartdate":"2103-04-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1080482,"text":" 9:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: aspiration or other acute process?\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hypoxia after ERCP.\n REASON FOR THIS EXAMINATION:\n aspiration or other acute process?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Hypoxia after ERCP, intubated.\n\n Comparison is made to prior study performed a day earlier.\n\n ET tube tip is 2.2 cm above the carina. It can be withdrawn a couple of\n centimeters for standard positioning. There are lower lung volumes. Increased\n opacity in the left lower lobe is new and consistent with almost complete\n collapse of the left lower lobe. Right lower lobe atelectasis has worsened.\n Atelectases in the upper lobes medially are stable. There is no pneumothorax\n or pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2103-04-15 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1080103,"text":" 4:11 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with acute onset abdomin pain and fullness, distended on exam\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute onset abdominal pain.\n\n SUPINE ABDOMEN: No prior comparisons. There is no sign of free\n intraperitoneal air on this single supine radiograph. Several stool-filled\n loops of colon are noted, but bowel gas pattern is otherwise unremarkable.\n Visualized skeletal structures are normal.\n\n Please refer to CT abdomen performed same day.\n SESHa\n\n"},{"category":"Radiology","chartdate":"2103-04-15 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":1080114,"text":" 6:15 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOP ABD/PEL LIMITEDClip # \n Reason: EVAL FOR PV THROMBOSIS AND LIVER MASS SEEN IN CT SCAN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with ? portal vein thrombosis and liver mass on CT abdomen\n REASON FOR THIS EXAMINATION:\n evaluate portal vein and liver texture\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND OF THE RIGHT UPPER QUADRANT.\n\n Comparison is made with a CT abdomen performed on the same day.\n\n CLINICAL HISTORY: 57-year-old man with heterogeneous appearance of the liver\n on CT and periduodenal stranding, question portal venous thrombosis.\n\n FINDINGS: The liver has a heterogeneous echotexture, which may be related to\n fatty replacement though more serious forms of liver disease cannot be\n excluded. No focal liver lesions are detected. There is a small amount of\n fluid adjacent to the gallbladder. The gallbladder appears otherwise\n unremarkable without evidence of stones or hydropic distention. No\n son sign is elicited. The main portal vein, left portal\n vein, right anterior and posterior portal veins are patent with correct\n direction of flow. The right, left, and middle hepatic veins demonstrate\n patency.\n\n IMPRESSION:\n 1. Heterogeneous hepatic echotexture may be related to fatty replacement\n though more advanced forms of liver disease cannot be excluded.\n 2. Small amount of pericholecystic fluid, nonspecific, without additional\n findings to suggest cholecystitis.\n 3. Patent portal vein with no evidence of central thrombosis.\n SESHa\n\n"},{"category":"Radiology","chartdate":"2103-04-25 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":1081747,"text":" 9:56 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: IV contrast, eval for hepatic abscess\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p lap chole who was found to have ?hepatic abscess intraop\n REASON FOR THIS EXAMINATION:\n IV contrast, eval for hepatic abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 57 year old man post laparoscopic cholecystectomy was found to\n have a possible hepatic abscess intraoperatively.\n\n COMPARISON: Multiple prior exams, the most recent ultrasound performed\n and the most recent CTA chest performed .\n\n CT ABDOMEN: Small right and trace left pleural effusion are noted. Mild\n cardiomegaly is stable.\n\n Segmental peripheral subcentimeter cystic lesions in the right liver periphery\n predominantly involve the subcapsular portion of segment VIII, with some\n extending to segment V peripherally. They are slightly more prominent since\n . Fluid tracking along the falciform ligament is within the spectrum\n of postsurgical change and there is no evidence of rim enhancement or\n drainable fluid collection. A right abdominal appraoch drainage catheter\n enters medial to the 9th costochondral junction and courses through the\n gallbladder fossa to terminate near the falciform ligament. A second right\n abdominal catheter enters below the right 10th rib anteriorly courses\n posterior to the liver and loops around the liver to terminate anterior to the\n left lobe adjacent to the falciform ligament. Stranding adjacent to the\n splenic flexure is within the spectrum of post- surgical change. Scattered\n subcentimeter renal hypodensities likely represent cysts but are too small to\n characterize. The abdominal loops of large and small bowel are unremarkable.\n There is no pneumatosis, free air, or evidence of obstruction.\n\n CT PELVIS: The rectum, sigmoid, prostate and seminal vesicles are\n unremarkable. Air within the bladder is likely related to Foley\n catheterization. Small left greater than right fat-containing inguinal hernias\n are noted.\n\n Bone windows demonstrate no lesion concerning for metastasis or infection.\n\n IMPRESSION:\n\n 1. Focal heterogeneous peripheral subcentimeter cystic lesions most\n prominent along segment VIII have increased in conspicuity since and\n likely represent focal cholangitis or microabscess. This should be followed\n to ensure it does not progress to frank abscess.\n\n 2. No evidence of drainable fluid collection. Fluid tracking along the\n (Over)\n\n 9:56 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: IV contrast, eval for hepatic abscess\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n falciform ligament demonstrates no rim enhancement to suggest abscess and is\n likely within the spectrum of post-surgical change. There is no abdominal\n fluid collection.\n\n 3. Subcentimeter renal hypodensities likely represent cysts but are too small\n to be characterized.\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 62450,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Wall motion, Pulm edema.\\nHeight: (in) 69\\nWeight (lb): 218\\nBSA (m2): 2.14 m2\\nBP (mm Hg): 144/97\\nHR (bpm): 93\\nStatus: Inpatient\\nDate/Time: at 15:30\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\\nNo ASD by 2D or color Doppler.\\n\\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\\nsystolic function (LVEF>55%). No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No MS.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\nIndeterminate PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion.\\n\\nConclusions:\\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\\ncolor Doppler. There is mild symmetric left ventricular hypertrophy with\\nnormal cavity size and regional/global systolic function (LVEF>55%). There is\\nno ventricular septal defect. Right ventricular chamber size and free wall\\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\\nwith good leaflet excursion and no aortic regurgitation. The mitral valve\\nappears structurally normal with trivial mitral regurgitation. There is no\\nmitral valve prolapse. The pulmonary artery systolic pressure could not be\\ndetermined. There is a trivial/physiologic pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2103-04-19 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 461814,\n \"text\": \"Mr. is a 57-year-old man who presented with epigastric and\\n back pain and reportedly a witnessed syncopal episode. Labs on\\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\\n and a total bili of 1.8. CT showed a small amount of pericholecystic\\n and periportal fluid, and US was without stones or evidence of\\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \\n ERCP with sphincterotomy and drainage of sludge was performed. At the\\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\\n intubated and was transferred to the for further care.\\n .H/O pancreatitis, acute\\n Assessment:\\n Pt s/p ERCP as stated above. Abd soft and non-tender. Denies nausea\\n and vomiting. Afebrile. Remians NPO. Positive BOS x 4.\\n Action:\\n Maintains NPO. Monitoring abd assessment.\\n Response:\\n Abdomen soft and non-tender. Pt comfortable.\\n Plan:\\n Continue to monitor for further s/s of infection. Monitor labs.\\n Remain NPO. ? transfer to tomorrow.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on 40% face tent. LS clear. Non-productive cough. Pt\\n denies SOB or resp distress. O2 sats 96-99%.\\n Action:\\n O2 weaned to 2 LNC.\\n Response:\\n Pt stable on 2LNC. Sats 96%. RR 20\\ns-30\\n Plan:\\n Continue to monitor resp status.\\n ------ Protected Section ------\\n Pt originally called out to floor. Report given to 12 and Dr.\\n decided to keep pt in ICU for another night as the pt was\\n tachypneic. RR high 20\\ns-low 30\\ns on 2 LNC throughout shift. Denies\\n discomfort.\\n Pt has bed on 9 for the morning.\\n ------ Protected Section Addendum Entered By: , RN\\n on: 04:59 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 461564,\n \"text\": \"Mr. is a 57-year-old man who presented with epigastric and\\n back pain and reportedly a witnessed syncopal episode. Labs on\\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\\n and a total bili of 1.8. CT showed a small amount of pericholecystic\\n and periportal fluid, and US was without stones or evidence of\\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \\n ERCP with sphincterotomy and drainage of sludge was performed. At the\\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\\n intubated and was transferred to the for further care.\\n .H/O pancreatitis, acute\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 461566,\n \"text\": \"Mr. is a 57-year-old man who presented with epigastric and\\n back pain and reportedly a witnessed syncopal episode. Labs on\\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\\n and a total bili of 1.8. CT showed a small amount of pericholecystic\\n and periportal fluid, and US was without stones or evidence of\\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \\n ERCP with sphincterotomy and drainage of sludge was performed. At the\\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\\n intubated and was transferred to the for further care.\\n .H/O pancreatitis, acute\\n Assessment:\\n S/P ERCP as mentioned above ,Abdomen firm distended with hypoactive\\n bowel sounds\\n Action:\\n Labs on admission AST/ALT 241/340\\n Response:\\n Continued\\n Plan:\\n Monitor labs\\n Continue NPO\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt admitted intubated from procedure room,wheezy on admission\\n Action:\\n ABG on admission 7.39/48/151\\n Multiple vent changes\\n Nebs given,Lasix 10 mg IV\\n Response:\\n Able to wean vent\\n Plan:\\n Possible extubation at AM,PRN nebs\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 461575,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 2\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Exp Wheeze\\n RUL Lung Sounds: Exp Wheeze\\n LUL Lung Sounds: Exp Wheeze\\n LLL Lung Sounds: Exp Wheeze\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments: Pt received from IR S/P ERCP intub with OETT and placed on\\n mech vent as per Metavision. Lung sounds coarse suct sm th white sput.\\n ABGs stable on current vent settings. Cont wean PSV and hopefully extub\\n today.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 461561,\n \"text\": \"TITLE:\\n Chief Complaint:\\n HPI:\\n Mr. is a 57-year-old man who presented with epigastric and\\n back pain and reportedly a witnessed syncopal episode. Labs on\\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\\n and a total bili of 1.8. CT showed a small amount of pericholecystic\\n and periportal fluid, and US was without stones or evidence of\\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\\n resusucitated with LR at 150 cc/h. He was taken for ERCP.\\n .\\n At the time of ERCP, he underwent anuncomplicated intubation. He was\\n doing well during the procedures until pressures fell from baseline\\n 170s/90s, to 80s/50s briefly while insufflating stomach. O2 sats fell\\n at that time to unclear levels. He was noted to be gurgling. His\\n pressures came back up and he never required pressors. ERCP with\\n sphincterotomy and drainage of sludge was performed. At the end of case\\n he was satting 95% on 100% FiO2 with CO2 65. He remained intubated and\\n was transferred to the for further care.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 12:00 AM\\n Metronidazole - 12:36 AM\\n Infusions:\\n Propofol - 20 mcg/Kg/min\\n Other ICU medications:\\n Home medications\\n lisinopril 5 mg daily\\n omeprazole 20 mg \\n simvastatin 40 mg daily\\n ASA 81 mg daily:\\n Past medical history:\\n Family history:\\n Social History:\\n - traumatic brain injury ( in )\\n - insomnia\\n - hyperlipidemia\\n - umbilical hernia\\n - H. pylori\\n - chronic polyps\\n - diabetes mellitus type II\\n not obtained\\n per OMR: Has a son who is quite involved in his care. He does not\\n smoke or drink EtOH.\\n Review of systems:\\n Flowsheet Data as of 01:57 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 36.5\\nC (97.7\\n HR: 94 (88 - 115) bpm\\n BP: 127/91(98) {117/83(90) - 189/101(98)} mmHg\\n RR: 24 (19 - 24) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 81 mL\\n 330 mL\\n PO:\\n TF:\\n IVF:\\n 81 mL\\n 330 mL\\n Blood products:\\n Total out:\\n 760 mL\\n 560 mL\\n Urine:\\n 160 mL\\n 560 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -679 mL\\n -230 mL\\n Respiratory\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 450 (450 - 600) mL\\n Vt (Spontaneous): 397 (397 - 397) mL\\n PS : 15 cmH2O\\n RR (Set): 19\\n RR (Spontaneous): 26\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n PIP: 33 cmH2O\\n Plateau: 28 cmH2O\\n SpO2: 97%\\n ABG: 7.39/48/151/22/3\\n Ve: 9.8 L/min\\n PaO2 / FiO2: 377\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 63 K/uL\\n 12.4 g/dL\\n 118 mg/dL\\n 0.9 mg/dL\\n 18 mg/dL\\n 22 mEq/L\\n 107 mEq/L\\n 4.6 mEq/L\\n 138 mEq/L\\n 36.8 %\\n 12.4 K/uL\\n [image002.jpg]\\n \\n 2:33 A5/26/ 09:58 PM\\n \\n 10:20 P5/26/ 10:57 PM\\n \\n 1:20 P\\n \\n 11:50 P\\n \\n 1:20 A\\n \\n 7:20 P\\n 1//11/006\\n 1:23 P\\n \\n 1:20 P\\n \\n 11:20 P\\n \\n 4:20 P\\n WBC\\n 12.4\\n Hct\\n 36.8\\n Plt\\n 63\\n Cr\\n 0.9\\n TC02\\n 30\\n Glucose\\n 118\\n Other labs: ALT / AST:340/241, Alk Phos / T Bili:163/1.5,\\n Differential-Neuts:83.1 %, Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %,\\n Albumin:2.6 g/dL, LDH:546 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:2.1\\n mg/dL\\n Assessment and Plan\\n .H/O PANCREATITIS, ACUTE\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n .\\n 57 year-old man presented with epigastric discomfort and laboratory\\n data consistent with gallstone pancreatitis, now with difficulty\\n extubating.\\n .\\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\\n pancreatitis, aspiration peri-proceudre, restriction from large\\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\\n pain, immobility, and volume overload. He has received a significant\\n amount of volume and been net in several liters daily for 2 days.\\n Also, CXR notable for low lung volumes and atelectasis.\\n - increase PEEP to 10\\n - wean FiO2 as tolerated\\n - transition to PSV if possible\\n - stop IVF\\n - consider diuresis in AM\\n .\\n #) Pancreatitis: Patient presented with exam and labs consistent with\\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\\n Furthermore, elevated TBili and pancreatic enzymes that quickly\\n improved are consistent with the theory of a stone that was passed.\\n - stop IV fluid hydration\\n - trend LFTs\\n - continue cipro/flagyl for now; re-address this with surgery\\n - continue NPO for now; may consider advance in AM\\n .\\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\\n currently. The time course would be too fast for HIT (no known\\n exposure to heparin within the past 30 days), and no evidence of\\n thrombosis, but the magnitude is approximately right for that. No\\n obvious medications that would cause this.\\n - stop heparin for now; pneumoboots for prophylaxis\\n - continue to trend\\n .\\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\\n admission (possibly due to mild acute renal failure) and BPs per\\n nursing records mostly 150s-160s. Hypotensive briefly during\\n procedure, possibly a vagal reaction to stomach insufflation and/or\\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\\n - continue to monitor\\n - hydralazine PRN\\n .\\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\\n - insulin SS\\n .\\n #. FEN - NPO\\n .\\n #. Access - PIV\\n .\\n #. PPx -\\n -pneumoboots\\n -lansoprazole\\n -bowel regimen\\n .\\n #. Code - full code, confirmed with son \\n .\\n #. Communication - son \\n .\\n #. Dispo - Pending extubation\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 09:27 PM\\n 20 Gauge - 10:03 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 461562,\n \"text\": \"TITLE:\\n Chief Complaint:\\n HPI:\\n Mr. is a 57-year-old man who presented with epigastric and\\n back pain and reportedly a witnessed syncopal episode. Labs on\\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\\n and a total bili of 1.8. CT showed a small amount of pericholecystic\\n and periportal fluid, and US was without stones or evidence of\\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\\n resusucitated with LR at 150 cc/h. He was taken for ERCP.\\n .\\n At the time of ERCP, he underwent anuncomplicated intubation. He was\\n doing well during the procedures until pressures fell from baseline\\n 170s/90s, to 80s/50s briefly while insufflating stomach. O2 sats fell\\n at that time to unclear levels. He was noted to be gurgling. His\\n pressures came back up and he never required pressors. ERCP with\\n sphincterotomy and drainage of sludge was performed. At the end of case\\n he was satting 95% on 100% FiO2 with CO2 65. He remained intubated and\\n was transferred to the for further care.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 12:00 AM\\n Metronidazole - 12:36 AM\\n Infusions:\\n Propofol - 20 mcg/Kg/min\\n Other ICU medications:\\n Home medications\\n lisinopril 5 mg daily\\n omeprazole 20 mg \\n simvastatin 40 mg daily\\n ASA 81 mg daily:\\n Past medical history:\\n Family history:\\n Social History:\\n - traumatic brain injury ( in )\\n - insomnia\\n - hyperlipidemia\\n - umbilical hernia\\n - H. pylori\\n - chronic polyps\\n - diabetes mellitus type II\\n not obtained\\n per OMR: Has a son who is quite involved in his care. He does not\\n smoke or drink EtOH.\\n Review of systems:\\n Flowsheet Data as of 01:57 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 36.5\\nC (97.7\\n HR: 94 (88 - 115) bpm\\n BP: 127/91(98) {117/83(90) - 189/101(98)} mmHg\\n RR: 24 (19 - 24) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 81 mL\\n 330 mL\\n PO:\\n TF:\\n IVF:\\n 81 mL\\n 330 mL\\n Blood products:\\n Total out:\\n 760 mL\\n 560 mL\\n Urine:\\n 160 mL\\n 560 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -679 mL\\n -230 mL\\n Respiratory\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 450 (450 - 600) mL\\n Vt (Spontaneous): 397 (397 - 397) mL\\n PS : 15 cmH2O\\n RR (Set): 19\\n RR (Spontaneous): 26\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n PIP: 33 cmH2O\\n Plateau: 28 cmH2O\\n SpO2: 97%\\n ABG: 7.39/48/151/22/3\\n Ve: 9.8 L/min\\n PaO2 / FiO2: 377\\n Physical Examination\\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\\n Gen: intubated, sedated, appears comfortable\\n Heart: regular, tachycardic, no murmurs\\n Lungs: diffuse wheezes, otherwise clear anteriorly\\n Abdomen: distended, somewhat tense, bowel sounds present, no\\n tenderness elicited\\n Ext: 1+ pitting edema\\n Neuro: not responsive to verbal or physical stimuli\\n Labs / Radiology\\n 63 K/uL\\n 12.4 g/dL\\n 118 mg/dL\\n 0.9 mg/dL\\n 18 mg/dL\\n 22 mEq/L\\n 107 mEq/L\\n 4.6 mEq/L\\n 138 mEq/L\\n 36.8 %\\n 12.4 K/uL\\n [image002.jpg]\\n \\n 2:33 A5/26/ 09:58 PM\\n \\n 10:20 P5/26/ 10:57 PM\\n \\n 1:20 P\\n \\n 11:50 P\\n \\n 1:20 A\\n \\n 7:20 P\\n 1//11/006\\n 1:23 P\\n \\n 1:20 P\\n \\n 11:20 P\\n \\n 4:20 P\\n WBC\\n 12.4\\n Hct\\n 36.8\\n Plt\\n 63\\n Cr\\n 0.9\\n TC02\\n 30\\n Glucose\\n 118\\n Other labs: ALT / AST:340/241, Alk Phos / T Bili:163/1.5,\\n Differential-Neuts:83.1 %, Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %,\\n Albumin:2.6 g/dL, LDH:546 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:2.1\\n mg/dL\\n Assessment and Plan\\n .H/O PANCREATITIS, ACUTE\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n .\\n 57 year-old man presented with epigastric discomfort and laboratory\\n data consistent with gallstone pancreatitis, now with difficulty\\n extubating.\\n .\\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\\n pancreatitis, aspiration peri-proceudre, restriction from large\\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\\n pain, immobility, and volume overload. He has received a significant\\n amount of volume and been net in several liters daily for 2 days.\\n Also, CXR notable for low lung volumes and atelectasis.\\n - increase PEEP to 10\\n - wean FiO2 as tolerated\\n - transition to PSV if possible\\n - stop IVF\\n - consider diuresis in AM\\n .\\n #) Pancreatitis: Patient presented with exam and labs consistent with\\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\\n Furthermore, elevated TBili and pancreatic enzymes that quickly\\n improved are consistent with the theory of a stone that was passed.\\n - stop IV fluid hydration\\n - trend LFTs\\n - continue cipro/flagyl for now; re-address this with surgery\\n - continue NPO for now; may consider advance in AM\\n .\\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\\n currently. The time course would be too fast for HIT (no known\\n exposure to heparin within the past 30 days), and no evidence of\\n thrombosis, but the magnitude is approximately right for that. No\\n obvious medications that would cause this.\\n - stop heparin for now; pneumoboots for prophylaxis\\n - continue to trend\\n .\\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\\n admission (possibly due to mild acute renal failure) and BPs per\\n nursing records mostly 150s-160s. Hypotensive briefly during\\n procedure, possibly a vagal reaction to stomach insufflation and/or\\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\\n - continue to monitor\\n - hydralazine PRN\\n .\\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\\n - insulin SS\\n .\\n #. FEN - NPO\\n .\\n #. Access - PIV\\n .\\n #. PPx -\\n -pneumoboots\\n -lansoprazole\\n -bowel regimen\\n .\\n #. Code - full code, confirmed with son \\n .\\n #. Communication - son \\n .\\n #. Dispo - Pending extubation\\n ICU Care\\n Nutrition: NPO\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 09:27 PM\\n 20 Gauge - 10:03 PM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer: ppi\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: icu\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 461563,\n \"text\": \"Mr. is a 57-year-old man who presented with epigastric and\\n back pain and reportedly a witnessed syncopal episode. Labs on\\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\\n and a total bili of 1.8. CT showed a small amount of pericholecystic\\n and periportal fluid, and US was without stones or evidence of\\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\\n resusucitated with LR at 150 cc/h. He was taken for ERCP\\n .H/O pancreatitis, acute\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 461615,\n \"text\": \"Mr. is a 57-year-old man who presented with epigastric and\\n back pain and reportedly a witnessed syncopal episode. Labs on\\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\\n and a total bili of 1.8. CT showed a small amount of pericholecystic\\n and periportal fluid, and US was without stones or evidence of\\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \\n ERCP with sphincterotomy and drainage of sludge was performed. At the\\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\\n intubated and was transferred to the for further care.\\n .H/O pancreatitis, acute\\n Assessment:\\n S/P ERCP as mentioned above ,Abdomen firm distended with hypoactive\\n bowel sounds\\n Small Bm X1 @0600\\n Denies any pain or discomfort\\n Action:\\n Labs on admission AST/ALT 241/340\\n AM labs repeated at 0600\\n Response:\\n Continued\\n Plan:\\n Follow up on AM labs\\n Continue NPO\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt admitted intubated from procedure room deeply sedated on\\n admission,sedations weaned appropriately\\npt more awake and able to\\n communicate and follow commands,wheezy on admission,low grade temp. ST\\n 115 and NBP systolic 180\\ns on admission which did not require any\\n intervention\\n WBC 10.5\\n Action:\\n ABG on admission 7.39/48/151\\n Multiple vent changes and ABG :please see metavision for\\n details,currently on CPAP + PS 40/10/15.\\n Propofol 10 mg/kg/min\\n Nebs given,Lasix 10 mg IV\\n Blood cultures x 1\\n Response:\\n Able to wean vent\\n Haemodinamically stable\\n Responded well to lasix 10 mg\\n Plan:\\n Possible extubation at AM,PRN nebs\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 461571,\n \"text\": \"Mr. is a 57-year-old man who presented with epigastric and\\n back pain and reportedly a witnessed syncopal episode. Labs on\\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\\n and a total bili of 1.8. CT showed a small amount of pericholecystic\\n and periportal fluid, and US was without stones or evidence of\\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \\n ERCP with sphincterotomy and drainage of sludge was performed. At the\\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\\n intubated and was transferred to the for further care.\\n .H/O pancreatitis, acute\\n Assessment:\\n S/P ERCP as mentioned above ,Abdomen firm distended with hypoactive\\n bowel sounds\\n Action:\\n Labs on admission AST/ALT 241/340\\n Response:\\n Continued\\n Plan:\\n Monitor labs\\n Continue NPO\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt admitted intubated from procedure room,wheezy on admission\\n Action:\\n ABG on admission 7.39/48/151\\n Multiple vent changes and ABG :please see metavision for details.\\n Nebs given,Lasix 10 mg IV\\n Response:\\n Able to wean vent\\n Plan:\\n Possible extubation at AM,PRN nebs\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2103-04-17 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 461556,\n \"text\": \"MICU ATTENDING ADMISSION NOTE\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with Dr\\n \\ns note above, including the assessment and plan. I would\\n emphasize and add the following points:\\n Mr presents after ERCP procedure this evening, done for\\n management of acute gallstone pancreatitis. He was admitted to Dr\\n \\ns service 2 days ago with severe abdominal pain, lipase of\\n 12,400 and creatinine of 2.0. His USG did shows features of\\n peri-cholecystic fluid collection but no dilation of intra or\\n extra-hepatic ducts. He has responded well to LR fluid resuscitation on\\n the floor with improving LFT\\ns and creatinine. His Calcium is down to\\n 7.2 and his Hct is down to 34 with fluids. His ERCP/sphincterotomy was\\n fairly unrevealing ( no stones, normal pancreatic ducts). He needed\\n FiO2 of 100% during procedure with transient hypotension too. He has\\n received Cipro/ Flagyl so far.\\n Exam notable for edematous BM Tm 100.4 BP 144/70 HR of 88 RR of 16\\n with sats of 99% on PEEP 10 . He has 2 IV\\ns in RUE, good breath sounds\\n in all lung fields and distended belly with scant bowel sounds.\\n Labs notable for WBC 14.5 K, HCT of 34.9 , Cr 1.2 , Ca of 7.2.\\n CXR with low lung volumes and plate like atelecatasis (\\n pre-intubation).\\n Agree with plan to support on ventilator with higher PEEP to offset\\n abdominal distension and chest wall anasarca. We will use IVF\\ns in\\n bolus form only if hemodynamically unstable. He will benefit from\\n gentle diuresis if BP allows in am and attempts at PSV/ CPAP\\n support provided we can wean FiO2 tonight. He appears to have responded\\n to vigorous fluid rescucitation but remains at high risk for other\\n complications from pancreatitis.\\n Remainder of plan as outlined above.\\n Patient is critically ill\\n Total time: 50 min\\n _________\\n , MD\\n Division of Pulmonary, Critical Care and Sleep Medicine\\n \\n , KS-B23\\n , \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 461712,\n \"text\": \"Mr. is a 57-year-old man who presented with epigastric and\\n back pain and reportedly a witnessed syncopal episode. Labs on\\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\\n and a total bili of 1.8. CT showed a small amount of pericholecystic\\n and periportal fluid, and US was without stones or evidence of\\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \\n ERCP with sphincterotomy and drainage of sludge was performed. At the\\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\\n intubated and was transferred to the for further care.\\n .H/O pancreatitis, acute\\n Assessment:\\n Pt s/p ERCP as above. Abd soft, non-tender. AST 241, ALT 344, Alk phos\\n 198. Pt afebrile.\\n Action:\\n Monitoring abdominal assessment and labs as ordered. Pt NPO for now.\\n Response:\\n Abdomen remains soft, non-tender. BS present.\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt intubated on vent settings CPAP/PS 15/10 FiO2 40%. BBS CTA\\n to diminished at bases. Atelectasis to LLL improved on CXR per team.\\n ABG 7.47/42/90. Pt awake, though comfortable on propofol at\\n 10mcg/kg/min. Pt denies SOB, free of s/s distress\\n Action:\\n Monitoring respiratory status closely. Vent settings weaned gradually\\n to CPA/PS 5/5 FiO2 40%. Echo done at bedside given concern for previous\\n pulmonary edema.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 461689,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n INVASIVE VENTILATION - START 10:00 PM\\n BLOOD CULTURED - At 05:40 AM\\n EKG - At 06:28 AM\\n .\\n - admitted to from ERCP, intubated\\n - weaned FiO2 from 100% to 40%, increased PEEP from 5 to 10\\n - changed to pressure support\\n - ET tube was too deep and was pulled back\\n - received 10 mg IV lasix x 1 with excellent UOP\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 12:00 AM\\n Metronidazole - 12:36 AM\\n Infusions:\\n Propofol - 10 mcg/Kg/min\\n Other ICU medications:\\n Furosemide (Lasix) - 12:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.8\\nC (100.1\\n Tcurrent: 37.8\\nC (100.1\\n HR: 104 (88 - 115) bpm\\n BP: 134/93(99) {117/76(88) - 189/101(100)} mmHg\\n RR: 27 (19 - 27) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 81 mL\\n 377 mL\\n PO:\\n TF:\\n IVF:\\n 81 mL\\n 377 mL\\n Blood products:\\n Total out:\\n 760 mL\\n 1,560 mL\\n Urine:\\n 160 mL\\n 1,560 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -679 mL\\n -1,183 mL\\n Respiratory support\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 450 (450 - 600) mL\\n Vt (Spontaneous): 435 (397 - 435) mL\\n PS : 15 cmH2O\\n RR (Set): 19\\n RR (Spontaneous): 24\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 33 cmH2O\\n Plateau: 28 cmH2O\\n SpO2: 94%\\n ABG: 7.47/42/90./30/6\\n Ve: 9.2 L/min\\n PaO2 / FiO2: 225\\n Physical Examination\\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\\n Gen: intubated but awake\\n Heart: regular, tachycardic, no murmurs\\n Lungs: clear anteriorly\\n Abdomen: distended, somewhat tense, bowel sounds present, no\\n tenderness elicited\\n Ext: 1+ pitting edema\\n Neuro: awake and following commands\\n Labs / Radiology\\n 69 K/uL\\n 13.0 g/dL\\n 111 mg/dL\\n 1.0 mg/dL\\n 30 mEq/L\\n 3.7 mEq/L\\n 16 mg/dL\\n 104 mEq/L\\n 142 mEq/L\\n 36.2 %\\n 10.5 K/uL\\n [image002.jpg]\\n 09:58 PM\\n 10:57 PM\\n 02:49 AM\\n 04:23 AM\\n WBC\\n 12.4\\n 10.5\\n Hct\\n 36.8\\n 36.2\\n Plt\\n 63\\n 69\\n Cr\\n 0.9\\n 1.0\\n TCO2\\n 30\\n 31\\n Glucose\\n 118\\n 111\\n Other labs: PT / PTT / INR:15.2/25.1/1.3, ALT / AST:344/241, Alk Phos /\\n T Bili:198/3.0, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:546 IU/L,\\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:1.0 mg/dL\\n LFTs:\\n AST 241\\n ALT 340\\n AP 163\\n Tbili: 1.8\\n Assessment and Plan\\n .H/O PANCREATITIS, ACUTE\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n .\\n 57 year-old man presented with epigastric discomfort and laboratory\\n data consistent with gallstone pancreatitis, now with difficulty\\n extubating.\\n .\\n #) Hypoxia: Likely contributions from volume overload and atelectasis\\n with V/Q mismatch. Also there would be concern for procedure-related\\n complication, but there was no stone extraction, so an inflammatory\\n response to that seems less likely. Also, he was apparently having\\n some respiratory issues prior to ERCP given the choice for elective\\n intubation. Regardless, he has diuresed well to a single 10 mg IV\\n lasix dose, now on PSV, and A-a gradient has improved.\\n - decrease PEEP to 5\\n - repeat ABG\\n - SBT\\n - extubate\\n - no further IV fluids or diuresis for now\\n .\\n #) Pancreatitis: Likely was secondary to a gallstone that has\\n subsequently passed. Improving by most accounts (clinical exam per\\n notes, fever curve, labs). Bump in tbili today may be procedure\\n related. Co-managing with surgery.\\n - advance diet as tolerated after extubation\\n - continue cipro/flagyl as per the preference of surgery\\n - trend LFTs\\n - no need for further IV fluid hydration\\n .\\n #) Thrombocytopenia: Unclear etiology. Platelets stable today after\\n having fallen from 173 on admit to 63 currently. The time course would\\n be too fast for HIT, but there was a suggestion of portal vein\\n thrombosis on admission CT (but this was prior to heparin). After\\n discussion with surgery, they would like to send PF4 antibody. PPI\\n could also cause thrombocytopenia\\n - no heparin for now\\n - f/u PF4 antibody\\n - stop PPI\\n - continue to trend platelets\\n .\\n #) Hypertension: Holding lisinopril. Currently normotensive.\\n - continue to hold lisinopril given recent hypotension\\n .\\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\\n - insulin SS\\n .\\n #. FEN - NPO\\n .\\n #. Access - PIV\\n .\\n #. PPx -\\n -pneumoboots\\n -lansoprazole\\n -bowel regimen\\n .\\n #. Code - full code, confirmed with son \\n .\\n #. Communication - son \\n .\\n #. Dispo\\n likely to return to surgical service today pending\\n extubation\\n ICU Care\\n Nutrition: advance diet today as tolerated\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 09:27 PM\\n 20 Gauge - 10:03 PM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: call out to floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 461783,\n \"text\": \"Mr. is a 57-year-old man who presented with epigastric and\\n back pain and reportedly a witnessed syncopal episode. Labs on\\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\\n and a total bili of 1.8. CT showed a small amount of pericholecystic\\n and periportal fluid, and US was without stones or evidence of\\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \\n ERCP with sphincterotomy and drainage of sludge was performed. At the\\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\\n intubated and was transferred to the for further care.\\n .H/O pancreatitis, acute\\n Assessment:\\n Pt s/p ERCP as stated above. Abd soft and non-tender. Denies nausea\\n and vomiting. Afebrile. Remians NPO. Positive BOS x 4.\\n Action:\\n Maintains NPO. Monitoring abd assessment.\\n Response:\\n Abdomen soft and non-tender. Pt comfortable.\\n Plan:\\n Continue to monitor for further s/s of infection. Monitor labs.\\n Remain NPO. ? transfer to tomorrow.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on 40% face tent. LS clear. Non-productive cough. Pt\\n denies SOB or resp distress. O2 sats 96-99%.\\n Action:\\n O2 weaned to 2 LNC.\\n Response:\\n Pt stable on 2LNC. Sats 96%. RR 20\\ns-30\\n Plan:\\n Continue to monitor resp status.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 461784,\n \"text\": \"Demographics\\n Attending MD:\\n M.\\n Admit diagnosis:\\n PANCREATITIS\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 99 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions: No Additional Precautions\\n PMH: Diabetes - Insulin\\n CV-PMH: Hypertension\\n Additional history:\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:152\\n D:89\\n Temperature:\\n 99.6\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 25 insp/min\\n Heart Rate:\\n 85 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 98% %\\n O2 flow:\\n 2 L/min\\n FiO2 set:\\n 40% %\\n 24h total in:\\n 1,068 mL\\n 24h total out:\\n 3,150 mL\\n Pertinent Lab Results:\\n Sodium:\\n 138 mEq/L\\n 02:40 PM\\n Potassium:\\n 3.7 mEq/L\\n 02:40 PM\\n Chloride:\\n 103 mEq/L\\n 02:40 PM\\n CO2:\\n 27 mEq/L\\n 02:40 PM\\n BUN:\\n 14 mg/dL\\n 02:40 PM\\n Creatinine:\\n 0.8 mg/dL\\n 02:40 PM\\n Glucose:\\n 113 mg/dL\\n 02:40 PM\\n Hematocrit:\\n 37.7 %\\n 02:40 PM\\n Finger Stick Glucose:\\n 130\\n 06:00 PM\\n Valuables / Signature\\n Patient valuables: sent with pt\\n valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: 4\\n Transferred to: 12 \\n Date & time of Transfer: 2330\\n Mr. is a 57-year-old man who presented with epigastric and\\n back pain and reportedly a witnessed syncopal episode. Labs on\\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\\n and a total bili of 1.8. CT showed a small amount of pericholecystic\\n and periportal fluid, and US was without stones or evidence of\\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \\n ERCP with sphincterotomy and drainage of sludge was performed. At the\\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\\n intubated and was transferred to the for further care.\\n .H/O pancreatitis, acute\\n Assessment:\\n Pt s/p ERCP as stated above. Abd soft and non-tender. Denies nausea\\n and vomiting. Afebrile. Remians NPO. Positive BOS x 4.\\n Action:\\n Maintains NPO. Monitoring abd assessment.\\n Response:\\n Abdomen soft and non-tender. Pt comfortable.\\n Plan:\\n Continue to monitor for further s/s of infection. Monitor labs.\\n Remain NPO. ? transfer to tomorrow.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on 40% face tent. LS clear. Non-productive cough. Pt\\n denies SOB or resp distress. O2 sats 96-99%.\\n Action:\\n O2 weaned to 2 LNC.\\n Response:\\n Pt stable on 2LNC. Sats 96%. RR 20\\ns-30\\n Plan:\\n Continue to monitor resp status.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2103-04-19 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 461849,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n INVASIVE VENTILATION - STOP 03:33 PM\\n - Extubated afternoon\\n - Attempted to call out to 9, surgery would like him monitored\\n overnight for high respiratory rate.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 11:40 PM\\n Metronidazole - 12:56 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 08:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:46 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.4\\nC (99.3\\n HR: 82 (80 - 98) bpm\\n BP: 129/81(93) {126/81(93) - 159/102(116)} mmHg\\n RR: 23 (20 - 30) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,308 mL\\n 168 mL\\n PO:\\n TF:\\n IVF:\\n 1,308 mL\\n 168 mL\\n Blood products:\\n Total out:\\n 3,150 mL\\n 1,020 mL\\n Urine:\\n 3,150 mL\\n 1,020 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,842 mL\\n -852 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: Standby\\n Vt (Spontaneous): 23 (23 - 406) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 24\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 91\\n SpO2: 93%\\n ABG: ///27/\\n Ve: 9.2 L/min\\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\\n Gen: intubated but awake\\n Heart: regular, tachycardic, no murmurs\\n Lungs: clear anteriorly\\n Abdomen: distended, somewhat tense, bowel sounds present, no\\n tenderness elicited\\n Ext: 1+ pitting edema\\n Neuro: awake and following commands\\n Labs / Radiology\\n 84 K/uL\\n 12.9 g/dL\\n 92 mg/dL\\n 0.8 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 13 mg/dL\\n 106 mEq/L\\n 142 mEq/L\\n 38.5 %\\n 8.0 K/uL\\n [image002.jpg]\\n 09:58 PM\\n 10:57 PM\\n 02:49 AM\\n 04:23 AM\\n 02:40 PM\\n 04:10 AM\\n WBC\\n 12.4\\n 10.5\\n 10.6\\n 8.0\\n Hct\\n 36.8\\n 36.2\\n 37.7\\n 38.5\\n Plt\\n 63\\n 69\\n 76\\n 84\\n Cr\\n 0.9\\n 1.0\\n 0.8\\n 0.8\\n TCO2\\n 30\\n 31\\n Glucose\\n 118\\n 111\\n 113\\n 92\\n Other labs: PT / PTT / INR:16.2/24.7/1.4, ALT / AST:249/129, Alk Phos /\\n T Bili:204/1.2, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.8 g/dL, LDH:444 IU/L,\\n Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.0 mg/dL\\n Assessment and Plan\\n PANCREATITIS, ACUTE\\n THROMBOCYTOPENIA, ACUTE\\n .H/O PANCREATITIS, ACUTE\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n .H/O PANCREATITIS, ACUTE\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n .\\n 57 year-old man presented with epigastric discomfort and laboratory\\n data consistent with gallstone pancreatitis, now with difficulty\\n extubating.\\n .\\n #) Hypoxia: Likely contributions from volume overload and atelectasis\\n with V/Q mismatch. Also there would be concern for procedure-related\\n complication, but there was no stone extraction, so an inflammatory\\n response to that seems less likely. Also, he was apparently having\\n some respiratory issues prior to ERCP given the choice for elective\\n intubation. Regardless, he has diuresed well to a single 10 mg IV\\n lasix dose, now on PSV, and A-a gradient has improved.\\n - decrease PEEP to 5\\n - repeat ABG\\n - SBT\\n - extubate\\n - no further IV fluids or diuresis for now\\n .\\n #) Pancreatitis: Likely was secondary to a gallstone that has\\n subsequently passed. Improving by most accounts (clinical exam per\\n notes, fever curve, labs). Bump in tbili today may be procedure\\n related. Co-managing with surgery.\\n - advance diet as tolerated after extubation\\n - continue cipro/flagyl as per the preference of surgery\\n - trend LFTs\\n - no need for further IV fluid hydration\\n .\\n #) Thrombocytopenia: Unclear etiology. Platelets stable today after\\n having fallen from 173 on admit to 63 currently. The time course would\\n be too fast for HIT, but there was a suggestion of portal vein\\n thrombosis on admission CT (but this was prior to heparin). After\\n discussion with surgery, they would like to send PF4 antibody. PPI\\n could also cause thrombocytopenia\\n - no heparin for now\\n - f/u PF4 antibody\\n - stop PPI\\n - continue to trend platelets\\n .\\n #) Hypertension: Holding lisinopril. Currently normotensive.\\n - continue to hold lisinopril given recent hypotension\\n .\\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\\n - insulin SS\\n .\\n #. FEN - NPO\\n .\\n #. Access - PIV\\n .\\n #. PPx -\\n -pneumoboots\\n -lansoprazole\\n -bowel regimen\\n .\\n #. Code - full code, confirmed with son \\n .\\n #. Communication - son \\n .\\n #. Dispo\\n likely to return to surgical service today pending\\n extubation\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 09:27 PM\\n 20 Gauge - 10:03 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2103-04-19 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 461851,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n INVASIVE VENTILATION - STOP 03:33 PM\\n - Extubated afternoon\\n - Attempted to call out to 9, surgery would like him monitored\\n overnight for high respiratory rate.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 11:40 PM\\n Metronidazole - 12:56 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 08:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:46 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.4\\nC (99.3\\n HR: 82 (80 - 98) bpm\\n BP: 129/81(93) {126/81(93) - 159/102(116)} mmHg\\n RR: 23 (20 - 30) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,308 mL\\n 168 mL\\n PO:\\n TF:\\n IVF:\\n 1,308 mL\\n 168 mL\\n Blood products:\\n Total out:\\n 3,150 mL\\n 1,020 mL\\n Urine:\\n 3,150 mL\\n 1,020 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,842 mL\\n -852 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula, 2L\\n Gen: awake\\n Heart: regular, tachycardic, no murmurs\\n Lungs: clear anteriorly\\n Abdomen: distended, somewhat tense, bowel sounds present, no\\n tenderness elicited\\n Ext: 1+ pitting edema\\n Neuro: awake and following commands\\n Labs / Radiology\\n 84 K/uL\\n 12.9 g/dL\\n 92 mg/dL\\n 0.8 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 13 mg/dL\\n 106 mEq/L\\n 142 mEq/L\\n 38.5 %\\n 8.0 K/uL\\n [image002.jpg]\\n 09:58 PM\\n 10:57 PM\\n 02:49 AM\\n 04:23 AM\\n 02:40 PM\\n 04:10 AM\\n WBC\\n 12.4\\n 10.5\\n 10.6\\n 8.0\\n Hct\\n 36.8\\n 36.2\\n 37.7\\n 38.5\\n Plt\\n 63\\n 69\\n 76\\n 84\\n Cr\\n 0.9\\n 1.0\\n 0.8\\n 0.8\\n TCO2\\n 30\\n 31\\n Glucose\\n 118\\n 111\\n 113\\n 92\\n Other labs: PT / PTT / INR:16.2/24.7/1.4, ALT / AST:249/129, Alk Phos /\\n T Bili:204/1.2, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.8 g/dL, LDH:444 IU/L,\\n Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.0 mg/dL\\n HIT antibody negative\\n Blood cx , NGTD\\n Assessment and Plan\\n PANCREATITIS, ACUTE\\n THROMBOCYTOPENIA, ACUTE\\n .H/O PANCREATITIS, ACUTE\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n .H/O PANCREATITIS, ACUTE\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n .\\n 57 year-old man presented with epigastric discomfort and laboratory\\n data consistent with gallstone pancreatitis, now with difficulty\\n extubating.\\n .\\n #) Increased respiratory rate: likely\\n Likely contributions from volume overload and atelectasis with V/Q\\n mismatch. Also there would be concern for procedure-related\\n complication, but there was no stone extraction, so an inflammatory\\n response to that seems less likely. Also, he was apparently having\\n some respiratory issues prior to ERCP given the choice for elective\\n intubation. Regardless, he has diuresed well to a single 10 mg IV\\n lasix dose, now on PSV, and A-a gradient has improved.\\n - decrease PEEP to 5\\n - repeat ABG\\n - SBT\\n - extubate\\n - no further IV fluids or diuresis for now\\n .\\n #) Pancreatitis: Likely was secondary to a gallstone that has\\n subsequently passed. Improving by most accounts (clinical exam per\\n notes, fever curve, labs). Bump in tbili today may be procedure\\n related. Co-managing with surgery.\\n - advance diet as tolerated after extubation\\n - continue cipro/flagyl as per the preference of surgery\\n - trend LFTs\\n - no need for further IV fluid hydration\\n .\\n #) Thrombocytopenia: Improving today\\n Unclear etiology. Platelets stable today after having fallen from 173\\n on admit to 63 currently. The time course would be too fast for HIT,\\n but there was a suggestion of portal vein thrombosis on admission CT\\n (but this was prior to heparin). After discussion with surgery, they\\n would like to send PF4 antibody. PPI could also cause\\n thrombocytopenia\\n - no heparin for now\\n - f/u PF4 antibody\\n - stop PPI\\n - continue to trend platelets\\n .\\n #) Hypertension: Holding lisinopril. Currently normotensive.\\n - continue to hold lisinopril given recent hypotension\\n .\\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\\n - insulin SS\\n .\\n #. FEN - NPO\\n .\\n #. Access - PIV\\n .\\n #. PPx -\\n -pneumoboots\\n -lansoprazole\\n -bowel regimen\\n .\\n #. Code - full code, confirmed with son \\n .\\n #. Communication - son \\n .\\n #. Dispo\\n likely to return to surgical service today pending\\n extubation\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 09:27 PM\\n 20 Gauge - 10:03 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2103-04-19 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 461979,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n INVASIVE VENTILATION - STOP 03:33 PM\\n - Extubated yesterday afternoon\\n - Attempted to call out to 9, surgery would like him monitored\\n overnight for high respiratory rate.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 11:40 PM\\n Metronidazole - 12:56 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 08:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:46 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.4\\nC (99.3\\n HR: 82 (80 - 98) bpm\\n BP: 129/81(93) {126/81(93) - 159/102(116)} mmHg\\n RR: 23 (20 - 30) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 1,308 mL\\n 168 mL\\n PO:\\n TF:\\n IVF:\\n 1,308 mL\\n 168 mL\\n Blood products:\\n Total out:\\n 3,150 mL\\n 1,020 mL\\n Urine:\\n 3,150 mL\\n 1,020 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,842 mL\\n -852 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula, 2L\\n Gen: awake and interactive\\n Heart: regular, tachycardic, no murmurs\\n Lungs: clear anteriorly\\n Abdomen: distended, somewhat tense, bowel sounds present, no\\n tenderness elicited\\n Ext: 1+ pitting edema\\n Neuro: awake and following commands\\n Labs / Radiology\\n 84 K/uL\\n 12.9 g/dL\\n 92 mg/dL\\n 0.8 mg/dL\\n 27 mEq/L\\n 3.8 mEq/L\\n 13 mg/dL\\n 106 mEq/L\\n 142 mEq/L\\n 38.5 %\\n 8.0 K/uL\\n [image002.jpg]\\n 09:58 PM\\n 10:57 PM\\n 02:49 AM\\n 04:23 AM\\n 02:40 PM\\n 04:10 AM\\n WBC\\n 12.4\\n 10.5\\n 10.6\\n 8.0\\n Hct\\n 36.8\\n 36.2\\n 37.7\\n 38.5\\n Plt\\n 63\\n 69\\n 76\\n 84\\n Cr\\n 0.9\\n 1.0\\n 0.8\\n 0.8\\n TCO2\\n 30\\n 31\\n Glucose\\n 118\\n 111\\n 113\\n 92\\n Other labs: PT / PTT / INR:16.2/24.7/1.4, ALT / AST:249/129, Alk Phos /\\n T Bili:204/1.2, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.8 g/dL, LDH:444 IU/L,\\n Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.0 mg/dL\\n HIT antibody negative\\n Blood cx , NGTD\\n Assessment and Plan\\n PANCREATITIS, ACUTE\\n THROMBOCYTOPENIA, ACUTE\\n .H/O PANCREATITIS, ACUTE\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n .H/O PANCREATITIS, ACUTE\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n .\\n 57 year-old man presented with epigastric discomfort and laboratory\\n data consistent with gallstone pancreatitis, transferred to ICU with\\n difficulty extubating, now extubated but mildly tachypneic.\\n .\\n #) Increased respiratory rate: likely secondary to discomfort in\\n abdomen, may still have some extra volume on board. Echo yesterday\\n showed normal EF, so it is unclear exactly why he went into pulmonary\\n edema. Regardless, he was successfully extubated and RR is improving.\\n - repeat ABG\\n .\\n #) Pancreatitis: All labs, fever curve improving. Likely was secondary\\n to a gallstone that has subsequently passed. Improving by most\\n accounts (clinical exam per notes, fever curve, labs). Co-managing\\n with surgery. He will go back to their service today.\\n - advance diet as tolerated\\n - continue cipro/flagyl as per the preference of surgery\\n - trend LFTs\\n - no need for further IV fluid hydration\\n .\\n #) Thrombocytopenia: Improving today. HIT antibody negative.\\n Heparin and PPI stopped yesterday.\\n - continue to trend platelets\\n .\\n #) Hypertension: Holding lisinopril. Currently normotensive.\\n - will need to restart lisinopril going forward given DM and chronic\\n HTN\\n .\\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\\n - insulin SS\\n .\\n #. FEN - NPO\\n .\\n #. Access - PIV\\n .\\n #. PPx -\\n -pneumoboots\\n -bowel regimen\\n .\\n #. Code - full code, confirmed with son \\n .\\n #. Communication - son \\n .\\n #. Dispo\\n likely to return to surgical service today pending\\n extubation\\n ICU Care\\n Nutrition: advance diet\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 09:27 PM\\n 20 Gauge - 10:03 PM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: return to surgery today\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 461600,\n \"text\": \"Mr. is a 57-year-old man who presented with epigastric and\\n back pain and reportedly a witnessed syncopal episode. Labs on\\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\\n and a total bili of 1.8. CT showed a small amount of pericholecystic\\n and periportal fluid, and US was without stones or evidence of\\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \\n ERCP with sphincterotomy and drainage of sludge was performed. At the\\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\\n intubated and was transferred to the for further care.\\n .H/O pancreatitis, acute\\n Assessment:\\n S/P ERCP as mentioned above ,Abdomen firm distended with hypoactive\\n bowel sounds\\n Denies any pain or discomfort\\n Action:\\n Labs on admission AST/ALT 241/340\\n AM labs repeated at 0600\\n Response:\\n Continued\\n Plan:\\n Follow up on AM labs\\n Continue NPO\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt admitted intubated from procedure room deeply sedated on\\n admission,sedations weaned appropriately\\npt more awake and able to\\n communicate and follow commands,wheezy on admission,low grade temp.\\n Action:\\n ABG on admission 7.39/48/151\\n Multiple vent changes and ABG :please see metavision for\\n details,currently on CPAP + PS 40/10/15.\\n Propofol 10 mg/kg/min\\n Nebs given,Lasix 10 mg IV\\n Blood cultures x 1\\n Response:\\n Able to wean vent\\n Responded well to lasix 10 mg\\n Plan:\\n Possible extubation at AM,PRN nebs\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 461681,\n \"text\": \"TITLE: Critical Care\\n Present for the key portions of the resident\\ns history and exam. Agree\\n substantially with assessment and plan as outlined. He has diuresed 2L\\n overnight. Abd exam relatively unremarkable\\n no tenderness mild\\n distention. We are switching to PSV, reducing PEEP to 5 and will do a\\n long SBT prior to extubation.\\n Time spent 40 min\\n Critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 461764,\n \"text\": \"Mr. is a 57-year-old man who presented with epigastric and\\n back pain and reportedly a witnessed syncopal episode. Labs on\\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\\n and a total bili of 1.8. CT showed a small amount of pericholecystic\\n and periportal fluid, and US was without stones or evidence of\\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \\n ERCP with sphincterotomy and drainage of sludge was performed. At the\\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\\n intubated and was transferred to the for further care.\\n .H/O pancreatitis, acute\\n Assessment:\\n Pt s/p ERCP as above. Abd soft, non-tender. AST 241, ALT 344, Alk phos\\n 198. Pt afebrile.\\n Action:\\n Monitoring abdominal assessment and labs as ordered. Pt NPO for now.\\n Response:\\n Abdomen remains soft, non-tender. BS present.\\n Plan:\\n Continue monitor abdominal assessment. Monitor labs. Pt to remain NPO\\n for now.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt intubated on vent settings CPAP/PS 15/10 FiO2 40%. BBS CTA\\n to diminished at bases. Atelectasis to LLL improved on CXR per team.\\n ABG 7.47/42/90. Pt awake, though comfortable on propofol at\\n 10mcg/kg/min. Pt denies SOB, free of s/s distress\\n Action:\\n Monitoring respiratory status closely. Vent settings weaned gradually\\n to CPA/PS 5/5 FiO2 40%. Echo done at bedside given concern for previous\\n pulmonary edema.\\n Response:\\n Pt tolerated vent weaning well and was extubated ~1600. Pt presently\\n resting quietly in bed. BBS CTA to diminished at bilat bases. SpO2\\n >97%. Pt denies SOB, reports comfortable remains free of distress.\\n Plan:\\n Continue to monitor respiratory status. Anticipate C/O to floor (\\n 9) tomorrow if pt remains stable.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 461632,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n INVASIVE VENTILATION - START 10:00 PM\\n BLOOD CULTURED - At 05:40 AM\\n EKG - At 06:28 AM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 12:00 AM\\n Metronidazole - 12:36 AM\\n Infusions:\\n Propofol - 10 mcg/Kg/min\\n Other ICU medications:\\n Furosemide (Lasix) - 12:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.8\\nC (100.1\\n Tcurrent: 37.8\\nC (100.1\\n HR: 104 (88 - 115) bpm\\n BP: 134/93(99) {117/76(88) - 189/101(100)} mmHg\\n RR: 27 (19 - 27) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 81 mL\\n 377 mL\\n PO:\\n TF:\\n IVF:\\n 81 mL\\n 377 mL\\n Blood products:\\n Total out:\\n 760 mL\\n 1,560 mL\\n Urine:\\n 160 mL\\n 1,560 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -679 mL\\n -1,183 mL\\n Respiratory support\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 450 (450 - 600) mL\\n Vt (Spontaneous): 435 (397 - 435) mL\\n PS : 15 cmH2O\\n RR (Set): 19\\n RR (Spontaneous): 24\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 33 cmH2O\\n Plateau: 28 cmH2O\\n SpO2: 94%\\n ABG: 7.47/42/90./30/6\\n Ve: 9.2 L/min\\n PaO2 / FiO2: 225\\n Physical Examination\\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\\n Gen: intubated, sedated, appears comfortable\\n Heart: regular, tachycardic, no murmurs\\n Lungs: diffuse wheezes, otherwise clear anteriorly\\n Abdomen: distended, somewhat tense, bowel sounds present, no\\n tenderness elicited\\n Ext: 1+ pitting edema\\n Neuro: not responsive to verbal or physical stimuli\\n Labs / Radiology\\n 69 K/uL\\n 13.0 g/dL\\n 111 mg/dL\\n 1.0 mg/dL\\n 30 mEq/L\\n 3.7 mEq/L\\n 16 mg/dL\\n 104 mEq/L\\n 142 mEq/L\\n 36.2 %\\n 10.5 K/uL\\n [image002.jpg]\\n 09:58 PM\\n 10:57 PM\\n 02:49 AM\\n 04:23 AM\\n WBC\\n 12.4\\n 10.5\\n Hct\\n 36.8\\n 36.2\\n Plt\\n 63\\n 69\\n Cr\\n 0.9\\n 1.0\\n TCO2\\n 30\\n 31\\n Glucose\\n 118\\n 111\\n Other labs: PT / PTT / INR:15.2/25.1/1.3, ALT / AST:344/241, Alk Phos /\\n T Bili:198/3.0, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:546 IU/L,\\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:1.0 mg/dL\\n LFTs:\\n AST 241\\n ALT 340\\n AP 163\\n Tbili: 1.8\\n CXR:\\n Assessment and Plan\\n .H/O PANCREATITIS, ACUTE\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n .\\n 57 year-old man presented with epigastric discomfort and laboratory\\n data consistent with gallstone pancreatitis, now with difficulty\\n extubating.\\n .\\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\\n pancreatitis, aspiration peri-proceudre, restriction from large\\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\\n pain, immobility, and volume overload. He has received a significant\\n amount of volume and been net in several liters daily for 2 days.\\n Also, CXR notable for low lung volumes and atelectasis.\\n - increase PEEP to 10\\n - wean FiO2 as tolerated\\n - transition to PSV if possible\\n - stop IVF\\n - consider further diuresis.\\n .\\n #) Pancreatitis: Patient presented with exam and labs consistent with\\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\\n Furthermore, elevated TBili and pancreatic enzymes that quickly\\n improved are consistent with the theory of a stone that was passed.\\n Now Tibili increasing again\\n - stop IV fluid hydration\\n - trend LFTs\\n - continue cipro/flagyl for now; re-address this with surgery\\n - continue NPO for now; may consider advance in AM\\n .\\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\\n currently. The time course would be too fast for HIT (no known\\n exposure to heparin within the past 30 days), and no evidence of\\n thrombosis, but the magnitude is approximately right for that. No\\n obvious medications that would cause this.\\n - stop heparin for now; pneumoboots for prophylaxis\\n - continue to trend\\n .\\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\\n admission (possibly due to mild acute renal failure) and BPs per\\n nursing records mostly 150s-160s. Hypotensive briefly during\\n procedure, possibly a vagal reaction to stomach insufflation and/or\\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\\n - continue to monitor\\n - hydralazine PRN\\n .\\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\\n - insulin SS\\n .\\n #. FEN - NPO\\n .\\n #. Access - PIV\\n .\\n #. PPx -\\n -pneumoboots\\n -lansoprazole\\n -bowel regimen\\n .\\n #. Code - full code, confirmed with son \\n .\\n #. Communication - son \\n .\\n #. Dispo - Pending extubation\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 09:27 PM\\n 20 Gauge - 10:03 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 461633,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n INVASIVE VENTILATION - START 10:00 PM\\n BLOOD CULTURED - At 05:40 AM\\n EKG - At 06:28 AM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 12:00 AM\\n Metronidazole - 12:36 AM\\n Infusions:\\n Propofol - 10 mcg/Kg/min\\n Other ICU medications:\\n Furosemide (Lasix) - 12:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.8\\nC (100.1\\n Tcurrent: 37.8\\nC (100.1\\n HR: 104 (88 - 115) bpm\\n BP: 134/93(99) {117/76(88) - 189/101(100)} mmHg\\n RR: 27 (19 - 27) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 81 mL\\n 377 mL\\n PO:\\n TF:\\n IVF:\\n 81 mL\\n 377 mL\\n Blood products:\\n Total out:\\n 760 mL\\n 1,560 mL\\n Urine:\\n 160 mL\\n 1,560 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -679 mL\\n -1,183 mL\\n Respiratory support\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 450 (450 - 600) mL\\n Vt (Spontaneous): 435 (397 - 435) mL\\n PS : 15 cmH2O\\n RR (Set): 19\\n RR (Spontaneous): 24\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 33 cmH2O\\n Plateau: 28 cmH2O\\n SpO2: 94%\\n ABG: 7.47/42/90./30/6\\n Ve: 9.2 L/min\\n PaO2 / FiO2: 225\\n Physical Examination\\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\\n Gen: intubated, sedated, appears comfortable\\n Heart: regular, tachycardic, no murmurs\\n Lungs: diffuse wheezes, otherwise clear anteriorly\\n Abdomen: distended, somewhat tense, bowel sounds present, no\\n tenderness elicited\\n Ext: 1+ pitting edema\\n Neuro: not responsive to verbal or physical stimuli\\n Labs / Radiology\\n 69 K/uL\\n 13.0 g/dL\\n 111 mg/dL\\n 1.0 mg/dL\\n 30 mEq/L\\n 3.7 mEq/L\\n 16 mg/dL\\n 104 mEq/L\\n 142 mEq/L\\n 36.2 %\\n 10.5 K/uL\\n [image002.jpg]\\n 09:58 PM\\n 10:57 PM\\n 02:49 AM\\n 04:23 AM\\n WBC\\n 12.4\\n 10.5\\n Hct\\n 36.8\\n 36.2\\n Plt\\n 63\\n 69\\n Cr\\n 0.9\\n 1.0\\n TCO2\\n 30\\n 31\\n Glucose\\n 118\\n 111\\n Other labs: PT / PTT / INR:15.2/25.1/1.3, ALT / AST:344/241, Alk Phos /\\n T Bili:198/3.0, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:546 IU/L,\\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:1.0 mg/dL\\n LFTs:\\n AST 241\\n ALT 340\\n AP 163\\n Tbili: 1.8\\n CXR:\\n Assessment and Plan\\n .H/O PANCREATITIS, ACUTE\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n .\\n 57 year-old man presented with epigastric discomfort and laboratory\\n data consistent with gallstone pancreatitis, now with difficulty\\n extubating.\\n .\\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\\n pancreatitis, aspiration peri-proceudre, restriction from large\\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\\n pain, immobility, and volume overload. He has received a significant\\n amount of volume and been net in several liters daily for 2 days.\\n Also, CXR notable for low lung volumes and atelectasis.\\n - increase PEEP to 10\\n - wean FiO2 as tolerated\\n - transition to PSV if possible\\n - stop IVF\\n - consider further diuresis.\\n .\\n #) Pancreatitis: Patient presented with exam and labs consistent with\\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\\n Furthermore, elevated TBili and pancreatic enzymes that quickly\\n improved are consistent with the theory of a stone that was passed.\\n Now Tibili increasing again\\n - stop IV fluid hydration\\n - trend LFTs\\n - continue cipro/flagyl for now; re-address this with surgery\\n - continue NPO for now; may consider advance in AM\\n .\\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\\n currently. The time course would be too fast for HIT (no known\\n exposure to heparin within the past 30 days), and no evidence of\\n thrombosis, but the magnitude is approximately right for that. No\\n obvious medications that would cause this.\\n - stop heparin for now; pneumoboots for prophylaxis\\n - continue to trend\\n .\\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\\n admission (possibly due to mild acute renal failure) and BPs per\\n nursing records mostly 150s-160s. Hypotensive briefly during\\n procedure, possibly a vagal reaction to stomach insufflation and/or\\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\\n - continue to monitor\\n - hydralazine PRN\\n .\\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\\n - insulin SS\\n .\\n #. FEN - NPO\\n .\\n #. Access - PIV\\n .\\n #. PPx -\\n -pneumoboots\\n -lansoprazole\\n -bowel regimen\\n .\\n #. Code - full code, confirmed with son \\n .\\n #. Communication - son \\n .\\n #. Dispo - Pending extubation\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 09:27 PM\\n 20 Gauge - 10:03 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 461636,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n INVASIVE VENTILATION - START 10:00 PM\\n BLOOD CULTURED - At 05:40 AM\\n EKG - At 06:28 AM\\n .\\n - admitted to from ERCP, intubated\\n - weaned FiO2 from 100% to 40%, increased PEEP from 5 to 10\\n - changed to pressure support\\n - pulled back ET tube\\n - received 10 mg IV lasix x 1 with excellent UOP\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 12:00 AM\\n Metronidazole - 12:36 AM\\n Infusions:\\n Propofol - 10 mcg/Kg/min\\n Other ICU medications:\\n Furosemide (Lasix) - 12:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.8\\nC (100.1\\n Tcurrent: 37.8\\nC (100.1\\n HR: 104 (88 - 115) bpm\\n BP: 134/93(99) {117/76(88) - 189/101(100)} mmHg\\n RR: 27 (19 - 27) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 81 mL\\n 377 mL\\n PO:\\n TF:\\n IVF:\\n 81 mL\\n 377 mL\\n Blood products:\\n Total out:\\n 760 mL\\n 1,560 mL\\n Urine:\\n 160 mL\\n 1,560 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -679 mL\\n -1,183 mL\\n Respiratory support\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 450 (450 - 600) mL\\n Vt (Spontaneous): 435 (397 - 435) mL\\n PS : 15 cmH2O\\n RR (Set): 19\\n RR (Spontaneous): 24\\n PEEP: 10 cmH2O\\n FiO2: 40%\\n RSBI Deferred: PEEP > 10\\n PIP: 33 cmH2O\\n Plateau: 28 cmH2O\\n SpO2: 94%\\n ABG: 7.47/42/90./30/6\\n Ve: 9.2 L/min\\n PaO2 / FiO2: 225\\n Physical Examination\\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\\n Gen: intubated, sedated, appears comfortable\\n Heart: regular, tachycardic, no murmurs\\n Lungs: diffuse wheezes, otherwise clear anteriorly\\n Abdomen: distended, somewhat tense, bowel sounds present, no\\n tenderness elicited\\n Ext: 1+ pitting edema\\n Neuro: not responsive to verbal or physical stimuli\\n Labs / Radiology\\n 69 K/uL\\n 13.0 g/dL\\n 111 mg/dL\\n 1.0 mg/dL\\n 30 mEq/L\\n 3.7 mEq/L\\n 16 mg/dL\\n 104 mEq/L\\n 142 mEq/L\\n 36.2 %\\n 10.5 K/uL\\n [image002.jpg]\\n 09:58 PM\\n 10:57 PM\\n 02:49 AM\\n 04:23 AM\\n WBC\\n 12.4\\n 10.5\\n Hct\\n 36.8\\n 36.2\\n Plt\\n 63\\n 69\\n Cr\\n 0.9\\n 1.0\\n TCO2\\n 30\\n 31\\n Glucose\\n 118\\n 111\\n Other labs: PT / PTT / INR:15.2/25.1/1.3, ALT / AST:344/241, Alk Phos /\\n T Bili:198/3.0, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:546 IU/L,\\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:1.0 mg/dL\\n LFTs:\\n AST 241\\n ALT 340\\n AP 163\\n Tbili: 1.8\\n CXR:\\n Assessment and Plan\\n .H/O PANCREATITIS, ACUTE\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n .\\n 57 year-old man presented with epigastric discomfort and laboratory\\n data consistent with gallstone pancreatitis, now with difficulty\\n extubating.\\n .\\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\\n pancreatitis, aspiration peri-proceudre, restriction from large\\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\\n pain, immobility, and volume overload. He has received a significant\\n amount of volume and been net in several liters daily for 2 days.\\n Also, CXR notable for low lung volumes and atelectasis.\\n - increase PEEP to 10\\n - wean FiO2 as tolerated\\n - transition to PSV if possible\\n - stop IVF\\n - consider further diuresis.\\n .\\n #) Pancreatitis: Patient presented with exam and labs consistent with\\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\\n Furthermore, elevated TBili and pancreatic enzymes that quickly\\n improved are consistent with the theory of a stone that was passed.\\n Now Tibili increasing again\\n - stop IV fluid hydration\\n - trend LFTs\\n - continue cipro/flagyl for now; re-address this with surgery\\n - continue NPO for now; may consider advance in AM\\n .\\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\\n currently. The time course would be too fast for HIT (no known\\n exposure to heparin within the past 30 days), and no evidence of\\n thrombosis, but the magnitude is approximately right for that. No\\n obvious medications that would cause this.\\n - stop heparin for now; pneumoboots for prophylaxis\\n - continue to trend\\n .\\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\\n admission (possibly due to mild acute renal failure) and BPs per\\n nursing records mostly 150s-160s. Hypotensive briefly during\\n procedure, possibly a vagal reaction to stomach insufflation and/or\\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\\n - continue to monitor\\n - hydralazine PRN\\n .\\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\\n - insulin SS\\n .\\n #. FEN - NPO\\n .\\n #. Access - PIV\\n .\\n #. PPx -\\n -pneumoboots\\n -lansoprazole\\n -bowel regimen\\n .\\n #. Code - full code, confirmed with son \\n .\\n #. Communication - son \\n .\\n #. Dispo - Pending extubation\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 09:27 PM\\n 20 Gauge - 10:03 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2103-04-19 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 461892,\n \"text\": \"Demographics\\n Attending MD:\\n M.\\n Admit diagnosis:\\n PANCREATITIS\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 99 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions: No Additional Precautions\\n PMH: Diabetes - Insulin\\n CV-PMH: Hypertension\\n Additional history:\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:152\\n D:89\\n Temperature:\\n 99.6\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 25 insp/min\\n Heart Rate:\\n 85 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 98% %\\n O2 flow:\\n 2 L/min\\n FiO2 set:\\n 40% %\\n 24h total in:\\n 1,068 mL\\n 24h total out:\\n 3,150 mL\\n Pertinent Lab Results:\\n Sodium:\\n 138 mEq/L\\n 02:40 PM\\n Potassium:\\n 3.7 mEq/L\\n 02:40 PM\\n Chloride:\\n 103 mEq/L\\n 02:40 PM\\n CO2:\\n 27 mEq/L\\n 02:40 PM\\n BUN:\\n 14 mg/dL\\n 02:40 PM\\n Creatinine:\\n 0.8 mg/dL\\n 02:40 PM\\n Glucose:\\n 113 mg/dL\\n 02:40 PM\\n Hematocrit:\\n 37.7 %\\n 02:40 PM\\n Finger Stick Glucose:\\n 130\\n 06:00 PM\\n Valuables / Signature\\n Patient valuables: sent with pt\\n valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: 4\\n Transferred to: 12 \\n Date & time of Transfer: 2330\\n Mr. is a 57-year-old man who presented with epigastric and\\n back pain and reportedly a witnessed syncopal episode. Labs on\\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\\n and a total bili of 1.8. CT showed a small amount of pericholecystic\\n and periportal fluid, and US was without stones or evidence of\\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \\n ERCP with sphincterotomy and drainage of sludge was performed. At the\\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\\n intubated and was transferred to the for further care.\\n .H/O pancreatitis, acute\\n Assessment:\\n Pt s/p ERCP as stated above. Abd soft and non-tender. Denies nausea\\n and vomiting. Afebrile. Remians NPO. Positive BOS x 4.\\n Action:\\n Maintains NPO. Monitoring abd assessment.\\n Response:\\n Abdomen soft and non-tender. Pt comfortable.\\n Plan:\\n Continue to monitor for further s/s of infection. Monitor labs.\\n Remain NPO. ? transfer to tomorrow.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on 40% face tent. LS clear. Non-productive cough. Pt\\n denies SOB or resp distress. O2 sats 96-99%.\\n Action:\\n O2 weaned to 2 LNC.\\n Response:\\n Pt stable on 2LNC. Sats 96%. RR 20\\ns-30\\n Plan:\\n Continue to monitor resp status.\\n ------ Protected Section ------\\n Agree with above note.\\n ------ Protected Section Addendum Entered By: , RN\\n on: 09:14 ------\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 121673,\n \"text\": \"Sinus tachycardia with increase in rate as compared with previous tracing\\nof . There is non-specific ST-T wave flattening and delayed precordial\\nR wave transition as previously recorded without diagnostic interim change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2103-04-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 121674,\n \"text\": \"Sinus rhythm. Within normal limits.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2103-04-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 121631,\n \"text\": \"Sinus rhythm. Probable anterior myocardial infarction. Non-specific\\ninferior ST-T wave changes. Compared to the previous tracing of \\nthe inferior Q waves are less prominent. Otherwise, no diagnostic interim\\nchange.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2103-04-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 121632,\n \"text\": \"Sinus rhythm. Somewhat late R wave progression. Q waves in leads III, aVF.\\nConsider inferior myocardial infarction. Since the previous tracing of \\nthe limb lead QRS voltage is more prominent.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1080514,\n \"text\": \" 4:49 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ET tube placement, interval change\\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man intubated after ERCP.\\n REASON FOR THIS EXAMINATION:\\n ET tube placement, interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST:\\n\\n REASON FOR EXAM: 57-year-old male intubated after ERCP.\\n\\n ET tube tip is 3 cm above the carina. Moderate cardiomegaly is stable.\\n Multiple opacities, greater on the lower lobes that have minimally improved in\\n the left base, are consistent with atelectasis. The lungs are better\\n aerated.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-04-23 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 1081435,\n \"text\": \" 3:56 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \\n Reason: ELEVATED LFTS\\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with RUQ pain, recurrent elevation of amylase and lipase\\n REASON FOR THIS EXAMINATION:\\n eval for signs of cholecystitis\\n ______________________________________________________________________________\\n WET READ: JXKc MON 4:39 PM\\n Fatty liver. No gallstones or evidence of cholecystitis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 57-year-old male with right upper quadrant pain, recurrent elevation\\n of amylase and lipase. Evaluate for signs of cholecystitis.\\n\\n COMPARISON: .\\n\\n FINDINGS: The liver is diffusely echogenic, compatible with fatty\\n infiltration. No focal hepatic lesion is identified. The portal vein is\\n patent with hepatopetal flow. The gallbladder is within normal limits,\\n without evidence of gallstones, gallbladder wall thickening, or\\n pericholecystic fluid. No son sign was evident. There is no\\n intra- or extra-hepatic biliary ductal dilatation with the CBD measuring 5 mm.\\n Visualized pancreatic head is grossly unremarkable, with the remainder of the\\n pancreas not well visualized due to overlying bowel gas.\\n\\n IMPRESSION:\\n 1. Diffusely echogenic liver, compatible with fatty infiltration. Other\\n forms of liver disease, and more advanced liver disease cannot be entirely\\n excluded on this study.\\n 2. No evidence of gallstones or cholecystitis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-04-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1080172,\n \"text\": \" 8:12 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess pulm status\\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57M with rigid abdomen, with exam and laboratory data consistent with acute\\n pancreatitis. now with increased work of breathing,SOB\\n REASON FOR THIS EXAMINATION:\\n assess pulm status\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Shortness of breath. Patient with pancreatitis.\\n\\n Comparison is made with prior study, .\\n\\n Mild cardiomegaly is unchanged. Bilateral multifocal subsegmental atelectases\\n have increased. There is no pneumothorax or enlarging pleural effusions.\\n There are low lung volumes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-04-18 00:00:00.000\",\n \"description\": \"ERCP BILIARY&PANCREAS BY GI UNIT\",\n \"row_id\": 1080799,\n \"text\": \" 2:30 PM\\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \\n Reason: Please review ERCP images done \\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 yr old male. Admitted with acute pancreatitis - suspected gallstone\\n pancreatitis. Elevated transaminases with normal bilirubin.\\n REASON FOR THIS EXAMINATION:\\n Please review ERCP images done \\n ______________________________________________________________________________\\n FINAL REPORT\\n ERCP\\n\\n COMPARISON: None.\\n\\n HISTORY: 57-year-old male with acute pancreatitis, elevated transaminases and\\n normal bilirubin.\\n\\n FINDINGS: Fifteen fluoroscopic images were obtained without a radiologist\\n present and submitted for review. This demonstrates normal contrast\\n opacification of the hepatobiliary tree. There is no evidence of compression,\\n filling defects, or ductal abnormalities.\\n\\n IMPRESSION: Normal ERCP. Please refer to ERCP note for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-04-23 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 1081439,\n \"text\": \" 4:23 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: PANCREATITIS\\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man pre-op for cholecystectomy\\n REASON FOR THIS EXAMINATION:\\n please evaluate\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 57-year-old male, for preoperative evaluation for cholecystitis.\\n\\n COMPARISON: CXR .\\n\\n PA AND LATERAL CHEST: Elevation of the right hemidiaphragm is associated with\\n right basilar atelectasis. Band-like atelectasis along the medial aspect of\\n the left lung is not significantly changed in the short interval. Mild-to-\\n moderate enlargement of the heart is again noted. The pulmonary vascularity\\n is stable. There is no pleural effusion or pneumothorax.\\n\\n IMPRESSION: Multifocal atelectasis without evidence for pneumonic\\n consolidation or edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-04-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1081057,\n \"text\": \" 5:36 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate\\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with fever\\n REASON FOR THIS EXAMINATION:\\n please evaluate\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST\\n\\n HISTORY: Fever.\\n\\n One portable view. Comparison with . There is some motion artifact.\\n There is streaky density bilaterally consistent with subsegmental atelectasis.\\n The right costophrenic sulcus is now blunted. The heart and mediastinal\\n structures are unchanged. An endotracheal tube has been withdrawn.\\n\\n IMPRESSION: Limited study demonstrating interval improvement in subsegmental\\n atelectasis. Possible small right effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-04-15 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1080107,\n \"text\": \" 4:24 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \\n CTA PELVIS W&W/O C & RECONS\\n Reason: r/o dissection, please r/o PE\\n Contrast: OPTIRAY Amt: 80\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with acute onset chest and abdominal pain, radiating to the\\n back with distention and firmness on abdominal exam\\n REASON FOR THIS EXAMINATION:\\n r/o dissection, please r/o PE\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: CTA of the chest and abdomen, .\\n\\n INDICATION: Acute onset chest and abdominal pain, rigid abdomen. ?\\n dissection.\\n\\n COMPARISON: Abdominal radiographs from same day.\\n\\n TECHNIQUE: Volumetric CT acquisition of the chest and abdomen was performed\\n following administration of intravenous contrast per CTA dissection protocol.\\n Multiplanar reformatted images were obtained and reviewed.\\n\\n CTA CHEST: Thoracic aorta is normal in caliber and contour throughout. There\\n is no dissection. Heart is mildly enlarged, with evidence of left ventricular\\n hypertrophy. There is no pleural or pericardial effusion. Central airways\\n are patent to the subsegmental level. There is no pathologic intrathoracic\\n lymphadenopathy.\\n\\n Evaluation of the lung parenchyma is markedly limited due to respiratory\\n motion artifact, and expiratory phase of scan acquisition.\\n\\n CTA ABDOMEN: Abdominal aorta is normal in caliber and contour throughout.\\n There is no dissection.\\n\\n Liver contour is normal. There is no biliary ductal dilatation or ascites.\\n Evaluation is limited by single arterial phase of contrast. There is somewhat\\n ill-defined heterogeneous appearance to the parenchyma in the right lobe of\\n the liver. Periportal edema noted. Main portal vein is just beginning to\\n opacify, limiting evaluation for portal vein thrombus. Small amount of fluid\\n is also seen in the porta hepatis, tracking along the region of the third\\n portion of the duodenum. The duodenum itself is somewhat difficult to evaluate\\n as it is largely collapsed. The stomach is mildly distended, with fluid and\\n ingested material. There is a small amount of pericholecystic fluid though\\n the GB is not fully distended.\\n\\n Pancreas, spleen, adrenal glands, and kidneys are normal. There is no free\\n air or free intraperitoneal fluid.\\n\\n There is appearance to the abdominal mesentery in the left upper\\n quadrant, with multiple small lymph nodes.\\n (Over)\\n\\n 4:24 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \\n CTA PELVIS W&W/O C & RECONS\\n Reason: r/o dissection, please r/o PE\\n Contrast: OPTIRAY Amt: 80\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n CT PELVIS: The cecum is moderately distended with a large amount of fecal\\n material. Fecal material is also seen in the terminal ileum, which is\\n borderline distended, measuring just greater than 3 cm. Fecal material is\\n seen within the small bowel as far proximal as the mid ileum in the right\\n upper quadrant. Proximal loops of small bowel are collapsed, however, and\\n there is no sign of obstruction. No definite mass is seen in the region of\\n the ileocecal valve. The appendix is normal.\\n\\n There is no free fluid, or abnormal intra-abdominal lymphadenopathy.\\n\\n There is no osseous lesion suspicious for malignancy.\\n\\n IMPRESSION:\\n 1. No aortic dissection.\\n 2. Heterogeneous appearance of the liver. Evaluation for focal lesion limited\\n on this early arterial phase exam. If there is concern for portal vein\\n thrombosis, recommend correlation with ultrasound.\\n 3. Small amount of pericholecystic and periportal fluid, of uncertain\\n significance. No other definite evidence of pancreatitis or cholecystitis.\\n 4. appearance of the abdominal mesentery, with multiple small nodes\\n could be seen in the setting of mesenteric adenitis/panniculitis.\\n 5. Marked fecal impaction in the cecum, with small bowel fecalization seen as\\n well, but no definite evidence of obstruction.\\n\\n Findings discussed with Dr. at time of study interpretation on\\n .\\n SESHa\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-04-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1080104,\n \"text\": \" 4:12 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o acute intrapulmonary process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with acute onset abdomin pain, tachypnic\\n REASON FOR THIS EXAMINATION:\\n r/o acute intrapulmonary process\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 4:23 P.M. ON \\n\\n HISTORY: Acute onset of abdominal pain and tachypnea.\\n\\n IMPRESSION: AP chest reviewed in the absence of other chest radiographs or\\n imaging of the torso.\\n\\n Heart is mildly-to-moderately enlarged. A 28-mm wide elliptical nodular\\n opacity projecting over the left heart border could be fluid trapped in the\\n major fissure though there is no evidence of pleural effusion collecting\\n elsewhere. Similarly, a bulge in the right lower paratracheal contour in the\\n mediastinum could be a distended azygos vein, less likely adenopathy. Lungs\\n are low in volume but otherwise clear. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-04-20 00:00:00.000\",\n \"description\": \"R UNILAT UP EXT VEINS US RIGHT\",\n \"row_id\": 1080959,\n \"text\": \" 1:24 PM\\n UNILAT UP EXT VEINS US RIGHT Clip # \\n Reason: SWELLING IN RT ARM; R/O DVT\\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with pancreatitis. Developed swollen right arm over 24 hrs.\\n no tenderness good pulses no cvl\\n REASON FOR THIS EXAMINATION:\\n R/O DVT\\n ______________________________________________________________________________\\n WET READ: JXKc FRI 2:46 PM\\n Thrombus in the right cephalic vein.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 57-year-old male with pancreatitis, with swollen right arm over the\\n last 24 hours. Rule out DVT.\\n\\n No prior studies are available for comparison.\\n\\n FINDINGS: Grayscale and color Doppler son of the right internal jugular,\\n subclavian, axillary, brachials, basilic and cephalic veins were obtained.\\n There is expansion of the cephalic vein in the mid and distal portions, with\\n internal echogenicity and non-compressibility, compatible with thrombus. The\\n remainder of the vessels demonstrate normal compression, flow, and\\n augmentation without evidence of DVT.\\n\\n IMPRESSION: Right cephalic vein thrombus, without evidence of DVT.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-04-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1080482,\n \"text\": \" 9:38 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: aspiration or other acute process?\\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with hypoxia after ERCP.\\n REASON FOR THIS EXAMINATION:\\n aspiration or other acute process?\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Hypoxia after ERCP, intubated.\\n\\n Comparison is made to prior study performed a day earlier.\\n\\n ET tube tip is 2.2 cm above the carina. It can be withdrawn a couple of\\n centimeters for standard positioning. There are lower lung volumes. Increased\\n opacity in the left lower lobe is new and consistent with almost complete\\n collapse of the left lower lobe. Right lower lobe atelectasis has worsened.\\n Atelectases in the upper lobes medially are stable. There is no pneumothorax\\n or pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-04-15 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1080103,\n \"text\": \" 4:11 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: r/o obstruction\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with acute onset abdomin pain and fullness, distended on exam\\n REASON FOR THIS EXAMINATION:\\n r/o obstruction\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Acute onset abdominal pain.\\n\\n SUPINE ABDOMEN: No prior comparisons. There is no sign of free\\n intraperitoneal air on this single supine radiograph. Several stool-filled\\n loops of colon are noted, but bowel gas pattern is otherwise unremarkable.\\n Visualized skeletal structures are normal.\\n\\n Please refer to CT abdomen performed same day.\\n SESHa\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-04-15 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 1080114,\n \"text\": \" 6:15 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOP ABD/PEL LIMITEDClip # \\n Reason: EVAL FOR PV THROMBOSIS AND LIVER MASS SEEN IN CT SCAN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with ? portal vein thrombosis and liver mass on CT abdomen\\n REASON FOR THIS EXAMINATION:\\n evaluate portal vein and liver texture\\n ______________________________________________________________________________\\n FINAL REPORT\\n ULTRASOUND OF THE RIGHT UPPER QUADRANT.\\n\\n Comparison is made with a CT abdomen performed on the same day.\\n\\n CLINICAL HISTORY: 57-year-old man with heterogeneous appearance of the liver\\n on CT and periduodenal stranding, question portal venous thrombosis.\\n\\n FINDINGS: The liver has a heterogeneous echotexture, which may be related to\\n fatty replacement though more serious forms of liver disease cannot be\\n excluded. No focal liver lesions are detected. There is a small amount of\\n fluid adjacent to the gallbladder. The gallbladder appears otherwise\\n unremarkable without evidence of stones or hydropic distention. No\\n son sign is elicited. The main portal vein, left portal\\n vein, right anterior and posterior portal veins are patent with correct\\n direction of flow. The right, left, and middle hepatic veins demonstrate\\n patency.\\n\\n IMPRESSION:\\n 1. Heterogeneous hepatic echotexture may be related to fatty replacement\\n though more advanced forms of liver disease cannot be excluded.\\n 2. Small amount of pericholecystic fluid, nonspecific, without additional\\n findings to suggest cholecystitis.\\n 3. Patent portal vein with no evidence of central thrombosis.\\n SESHa\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-04-25 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 1081747,\n \"text\": \" 9:56 AM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: IV contrast, eval for hepatic abscess\\n Admitting Diagnosis: PANCREATITIS\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man s/p lap chole who was found to have ?hepatic abscess intraop\\n REASON FOR THIS EXAMINATION:\\n IV contrast, eval for hepatic abscess\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 57 year old man post laparoscopic cholecystectomy was found to\\n have a possible hepatic abscess intraoperatively.\\n\\n COMPARISON: Multiple prior exams, the most recent ultrasound performed\\n and the most recent CTA chest performed .\\n\\n CT ABDOMEN: Small right and trace left pleural effusion are noted. Mild\\n cardiomegaly is stable.\\n\\n Segmental peripheral subcentimeter cystic lesions in the right liver periphery\\n predominantly involve the subcapsular portion of segment VIII, with some\\n extending to segment V peripherally. They are slightly more prominent since\\n . Fluid tracking along the falciform ligament is within the spectrum\\n of postsurgical change and there is no evidence of rim enhancement or\\n drainable fluid collection. A right abdominal appraoch drainage catheter\\n enters medial to the 9th costochondral junction and courses through the\\n gallbladder fossa to terminate near the falciform ligament. A second right\\n abdominal catheter enters below the right 10th rib anteriorly courses\\n posterior to the liver and loops around the liver to terminate anterior to the\\n left lobe adjacent to the falciform ligament. Stranding adjacent to the\\n splenic flexure is within the spectrum of post- surgical change. Scattered\\n subcentimeter renal hypodensities likely represent cysts but are too small to\\n characterize. The abdominal loops of large and small bowel are unremarkable.\\n There is no pneumatosis, free air, or evidence of obstruction.\\n\\n CT PELVIS: The rectum, sigmoid, prostate and seminal vesicles are\\n unremarkable. Air within the bladder is likely related to Foley\\n catheterization. Small left greater than right fat-containing inguinal hernias\\n are noted.\\n\\n Bone windows demonstrate no lesion concerning for metastasis or infection.\\n\\n IMPRESSION:\\n\\n 1. Focal heterogeneous peripheral subcentimeter cystic lesions most\\n prominent along segment VIII have increased in conspicuity since and\\n likely represent focal cholangitis or microabscess. This should be followed\\n to ensure it does not progress to frank abscess.\\n\\n 2. No evidence of drainable fluid collection. Fluid tracking along the\\n (Over)\\n\\n 9:56 AM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: IV contrast, eval for hepatic abscess\\n Admitting Diagnosis: PANCREATITIS\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n falciform ligament demonstrates no rim enhancement to suggest abscess and is\\n likely within the spectrum of post-surgical change. There is no abdominal\\n fluid collection.\\n\\n 3. Subcentimeter renal hypodensities likely represent cysts but are too small\\n to be characterized.\\n\\n\"\n }\n]"}}}],"truncated":false,"partial":false},"paginationData":{"pageIndex":0,"numItemsPerPage":100,"numTotalItems":24993,"offset":0,"length":100}},"jwt":"eyJhbGciOiJFZERTQSJ9.eyJyZWFkIjp0cnVlLCJwZXJtaXNzaW9ucyI6eyJyZXBvLmNvbnRlbnQucmVhZCI6dHJ1ZX0sImlhdCI6MTcyMDI2MTQ0Mywic3ViIjoiL2RhdGFzZXRzL2RtYWNyZXMvbWltaWNpaWktaG9zcGl0YWxjb3Vyc2UtbWV0YSIsImV4cCI6MTcyMDI2NTA0MywiaXNzIjoiaHR0cHM6Ly9odWdnaW5nZmFjZS5jbyJ9.VgE1fJNtLyju3zJshg4AXyqWJT332ioTlqZOO3rDMMidm5h6P6iR7yd1hV2eLCYd7tkijKdkxzORgDi5dSOCCg","displayUrls":true},"discussionsStats":{"closed":0,"open":1,"total":1},"fullWidth":true,"hasGatedAccess":true,"hasFullAccess":true}">
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19,278 | 159,960 | Patient was admitted to the neurosurgery service and underwent an emergent R craniotomy with drainage of his subdural hemorrhage. Postoperatively he was transferred to the intensive care unit extubated and stable. He was maintained on dilantin for seizure prophylaxis, his blood pressure was controlled and he was monitored with close neuro checks. He was also maintained on prn ativan for prevention of alcohol withdrawal considering patient's significant drinking history. A postoperative CT scan demonstrated postoperative changes and an improvement in his subdural. He remained stable, his diet was advanced and he was awake and appropriate. He was found to have a simple urinary tract infection and was treated with ciprofloxacin. He was evaluated by both occupational and physical therapy and cleared for home. He was discharged to home on POD2 in good condition and will follow up in Dr. clinic for wound in approximately 10 days. | There remains some low attenuation right subdural fluid. There remains subfalcine herniation. nsr w/ rare pac noted.resp: lungs clear. subtherapeutic dilantin level this am. The leftward shift of the septum pellucidum, measured at the same location, has decreased from 1.3 cm to 0.8 cm. Superficial to that, underlying and extending inferior to the craniotomy, there is a blood air level in what appears to be the epidural space. Visualized portions of the mastoid air cells and right maxillary sinus are unremarkable. dim rt base. There is much less mass effect following subdural hematoma evacuation. u op qs though c/o foley discomfort.pain: mso4 2mg iv prn for h/a w/ effect. ciwa scale as noted, prn ativan w/ effect thus far.assess: stable day, off neuro intact. TECHNIQUE: Non-contrast head CT. ativan w/ effect.plan: bp < 140, hob flat. neuro checks,clears liquids. hob flat. abd softly distended. prn iv hydralazine and po bid lopressor to maintain sbp< 140 efffect. There is compression of the right lateral ventricle. Just inferior and anterior at that level, there was 1.7 cm leftward shift of the septum pellucidum at the level of the frontal horns, now reduced to 8 mm. diet advance to clears but only taking some h20 at present. ct head repeated.cv: refer to flowsheet for vs. nipride wean to off. 100mg tid began. Overall, there is much less mass effect. IMPRESSION: 1. bsp, no BM, glucose w/ SS coverage. IMPRESSION: Large right subdural hematoma with iso and hyperdense components producing focal effacement and mass effect with subfalcine herniation. The subdural collection seen previously is much smaller and lower in attenuation. There is significant mass effect and effacement of adjacent sulci with 13 mm leftward shift of normally midline structures. sats 99-100%.gi/gu: uop qs. Neuro-pt impulsive, attemting to get OOB, confused at times, reoients to place and time, immediately forgetful and restless, CIWA scale and ativan for agitation, PERL, MAEW, sitter at bedside to maintain safetydilantin TIDCV-Lopressor , VSS MP SB, CSM WNLResp-100% Fio2 per Dr. , Sao2 RA 98, and 100% with O2 on, LS coarse upper lobes, congested cough, encourage IS pt unable to participate due to agitationGI-clear liqueds, +BSGU-foley to cd urine output adequatePlan-sitter for safety, CIWA scale, monitor neuro exam, attempt to remain flat in bed, clear liqs Advance as tolerates, SBP <140 The ambient cisterns are symmetric. FINDINGS: Since the study of the preceding day, the patient has undergone a right frontal/parietal craniotomy. Basal cisterns not effaced. rt eye more swollen this afternoon. The basal cistern is not effaced. o2 100% ofm for neuro reasons. Pt to SICU-R sided SDH, one week history of ataxia, states he may have hit his head on the "bulk head", c/o of H/A and took asa, to OSH where CT showed right subdural hematoma was then transfered to , PMH HTN, NIDDM, hypercholesteromia, drinks per dayOn arrival to SICU: pt 3, MAEW R and L side full stregth, denies H/A, PERLLA, smile/tongue midline, denies h/a, denies dizzynessCV-VSS MP SB, CSM WNL HS S1 S2 RRRResp-LS clear A/P Sao2 97 RAGI-NPO, abs round soft distended +BSGU-voidsSkin-intactPlan-pt to OR for Burr holes Deep to the craniotomy, there is epidural high attenuation material, likely hemorrhage, with a large amount of extradural air and an air-fluid level. sicu updates/p subdural burr hole evacuationneuro: pt sleepier this afternoon, though cont to arouse easily. loaded w/ total of 750mg po dilantin in 2 doses. A large ovoid soft tissue density in the left maxillary sinus may reflect large mucus retention cyst. Neurosurgical consult needed! FINDINGS: There is a large right subdural hematoma measuring 3 cm with iso and hyperdense components producing focal effacement and mass effect with right to left shift of the septum pellucidum approximately 13 mm. FINAL REPORT INDICATION: 82-year-old male with known subdural. 3:53 PM CT HEAD W/O CONTRAST Clip # Reason: please reacess; thanks MEDICAL CONDITION: 62 year old man with known subdural REASON FOR THIS EXAMINATION: please reacess; thanks No contraindications for IV contrast WET READ: BTCa SAT 4:58 PM Large right subdural hematoma measuring up to 2.9 cm across with areas of low and high density consitent with acute on chronic bleed. 3. oriented x3, approp in conversation.perl. TECHNIQUE: Contiguous scans were obtained from the skull base to the vertex. 2. Postop: Arrived from OR extubated restless, attempting to sit up in Bed, reoriented, MAEW, s/p burr hole evacuation of subdural hematoma, intraop bradycardia responsive to levophed, levophed off on arrival to SICU MP SR 63, VSS, PRN nipride to maintain SBP <140, pt to remain flat in bed per Dr. , pt started to CIWA scale and PRN ativan due to ETOH historyPlan-CIWA scale, neuro cks, SBP<,140 11:41 AM CT HEAD W/O CONTRAST Clip # Reason: please check post op Admitting Diagnosis: SUBDURAL HEMATOMA MEDICAL CONDITION: 62 year old man with s/p crani w/ evacuation SDH REASON FOR THIS EXAMINATION: please check post op No contraindications for IV contrast FINAL REPORT CT OF THE HEAD CLINICAL HISTORY: Evacuation of subdural hematoma. | 6 | [
{
"category": "Nursing/other",
"chartdate": "2170-06-17 00:00:00.000",
"description": "Report",
"row_id": 1516710,
"text": "Pt to SICU-R sided SDH, one week history of ataxia, states he may have hit his head on the \"bulk head\", c/o of H/A and took asa, to OSH where CT showed right subdural hematoma was then transfered to , PMH HTN, NIDDM, hypercholesteromia, drinks per day\n\nOn arrival to SICU: pt 3, MAEW R and L side full stregth, denies H/A, PERLLA, smile/tongue midline, denies h/a, denies dizzyness\nCV-VSS MP SB, CSM WNL HS S1 S2 RRR\nResp-LS clear A/P Sao2 97 RA\nGI-NPO, abs round soft distended +BS\nGU-voids\nSkin-intact\n\nPlan-pt to OR for Burr holes\n"
},
{
"category": "Nursing/other",
"chartdate": "2170-06-17 00:00:00.000",
"description": "Report",
"row_id": 1516711,
"text": "Postop: Arrived from OR extubated restless, attempting to sit up in Bed, reoriented, MAEW, s/p burr hole evacuation of subdural hematoma, intraop bradycardia responsive to levophed, levophed off on arrival to SICU MP SR 63, VSS, PRN nipride to maintain SBP <140, pt to remain flat in bed per Dr. , pt started to CIWA scale and PRN ativan due to ETOH history\n\nPlan-CIWA scale, neuro cks, SBP<,140\n"
},
{
"category": "Nursing/other",
"chartdate": "2170-06-17 00:00:00.000",
"description": "Report",
"row_id": 1516712,
"text": "sicu update\ns/p subdural burr hole evacuation\n\nneuro: pt sleepier this afternoon, though cont to arouse easily. oriented x3, approp in conversation.perl. strong equal strength of all extrems. rt eye more swollen this afternoon. subtherapeutic dilantin level this am. loaded w/ total of 750mg po dilantin in 2 doses. 100mg tid began. hob flat. ct head repeated.\n\ncv: refer to flowsheet for vs. nipride wean to off. prn iv hydralazine and po bid lopressor to maintain sbp< 140 efffect. nsr w/ rare pac noted.\n\nresp: lungs clear. dim rt base. o2 100% ofm for neuro reasons. sats 99-100%.\n\ngi/gu: uop qs. diet advance to clears but only taking some h20 at present. abd softly distended. bsp, no BM, glucose w/ SS coverage. u op qs though c/o foley discomfort.\n\npain: mso4 2mg iv prn for h/a w/ effect. ciwa scale as noted, prn ativan w/ effect thus far.\n\nassess: stable day, off neuro intact. ativan w/ effect.\n\nplan: bp < 140, hob flat. neuro checks,clears liquids.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2170-06-18 00:00:00.000",
"description": "Report",
"row_id": 1516713,
"text": "Neuro-pt impulsive, attemting to get OOB, confused at times, reoients to place and time, immediately forgetful and restless, CIWA scale and ativan for agitation, PERL, MAEW, sitter at bedside to maintain safety\ndilantin TID\nCV-Lopressor , VSS MP SB, CSM WNL\nResp-100% Fio2 per Dr. , Sao2 RA 98, and 100% with O2 on, LS coarse upper lobes, congested cough, encourage IS pt unable to participate due to agitation\nGI-clear liqueds, +BS\nGU-foley to cd urine output adequate\n\nPlan-sitter for safety, CIWA scale, monitor neuro exam, attempt to remain flat in bed, clear liqs Advance as tolerates, SBP <140\n"
},
{
"category": "Radiology",
"chartdate": "2170-06-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 916342,
"text": " 3:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please reacess; thanks \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with known subdural\n REASON FOR THIS EXAMINATION:\n please reacess; thanks \n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: BTCa SAT 4:58 PM\n Large right subdural hematoma measuring up to 2.9 cm across with areas of low\n and high density consitent with acute on chronic bleed. There is significant\n mass effect and effacement of adjacent sulci with 13 mm leftward shift of\n normally midline structures. Basal cisterns not effaced. Neurosurgical\n consult needed!\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old male with known subdural.\n\n COMPARISONS: No prior studies are available at this institution for\n comparison.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is a large right subdural hematoma measuring 3 cm with iso\n and hyperdense components producing focal effacement and mass effect with\n right to left shift of the septum pellucidum approximately 13 mm. There is\n compression of the right lateral ventricle. The basal cistern is not effaced.\n No major vascular territorial infarct is identified. Visualized portions of\n the mastoid air cells and right maxillary sinus are unremarkable. A large\n ovoid soft tissue density in the left maxillary sinus may reflect large mucus\n retention cyst. No fractures are identified.\n\n IMPRESSION: Large right subdural hematoma with iso and hyperdense components\n producing focal effacement and mass effect with subfalcine herniation.\n\n The above relayed to the ED dashboard at 4:50 p.m. and flagged for urgent\n attention.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-06-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 916409,
"text": " 11:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please check post op\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with s/p crani w/ evacuation SDH\n REASON FOR THIS EXAMINATION:\n please check post op\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD\n\n CLINICAL HISTORY: Evacuation of subdural hematoma.\n\n TECHNIQUE: Contiguous scans were obtained from the skull base to the vertex.\n\n FINDINGS:\n\n Since the study of the preceding day, the patient has undergone a right\n frontal/parietal craniotomy. Deep to the craniotomy, there is epidural high\n attenuation material, likely hemorrhage, with a large amount of extradural air\n and an air-fluid level. The subdural collection seen previously is much\n smaller and lower in attenuation. Overall, there is much less mass effect.\n The leftward shift of the septum pellucidum, measured at the same location,\n has decreased from 1.3 cm to 0.8 cm. Just inferior and anterior at that\n level, there was 1.7 cm leftward shift of the septum pellucidum at the level\n of the frontal horns, now reduced to 8 mm. There remains subfalcine\n herniation. The ambient cisterns are symmetric.\n\n IMPRESSION:\n 1. There is much less mass effect following subdural hematoma evacuation.\n 2. There remains some low attenuation right subdural fluid.\n 3. Superficial to that, underlying and extending inferior to the craniotomy,\n there is a blood air level in what appears to be the epidural space.\n\n\n"
}
] |
82,177 | 176,262 | 38 y/o female with history of autoimmune diseases (Crohn's vasculitis, psoriasis) with autoimmune hemolytic anemia following fever. . 1. Autoimmune Hemolytic Anemia: Etiology includes acquired post infectious autoimmune process, reactive autoimmune process after tappering steroids. Presented febrile. WBC was elevated in the setting of hemolysis and elevated bone marow turnover. Fevers could have been due to vasculitis, infection (unclear source). She received 6 units of PRBC's. She was treated initially with IV solumedrol, to which she had some psychosis. She was later changed to Prednisone 80 mg PO QD. Her hemolysis labs slowly improved. Her HCT was stable in the mid 20's. She was treated with B12 and folate. Hematology will follow her as an outpatient. Would recommend watching for fevers once off steroids. . 2. Non Gap Metabolic Acidosis: Likely lactic acidosis from cell lysis, as LDH was elevated. She was treated with IV fluids- Lactated Ringers. . 3. Elevated Blood Sugars: Likely due to steroids. She was covered with insulin based on a sliding scale. . 4. Vasculitis: Much improved per patient with prednisone. Unclear . Diagnosed and followed at B&W Hospital. . 5. Crohn's: Stable. . 6. Psoriasis: Stable. . FULL CODE | Sinus arrhythmiaSince previous tracing of , the heart rate has decreased | 2 | [
{
"category": "ECG",
"chartdate": "2151-03-22 00:00:00.000",
"description": "Report",
"row_id": 268032,
"text": "Sinus arrhythmia\nSince previous tracing of , the heart rate has decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2151-03-21 00:00:00.000",
"description": "Report",
"row_id": 268033,
"text": "Sinus tachycardia\nShort PR interval\nClinical correlation is suggested\n\n"
}
] |
22,500 | 127,625 | The patient was admitted to the Trauma Team for observation. Secondary to patient's age and multiple rib fractures with associated morbidity, the Anesthesia Department was consulted to perform epidural anesthesia on the patient to aid in the aggressive pulmonary toilet. The patient declined this. The patient was treated with morphine until the morning. Secondary to patient's persistent flank and back pain, the Department of Orthopedics was consulted, L1-L2 transverse processes fractures with stable injuries that required symptomatic treatment and recommended patient being fitted with thoracolumbar corset for comfort. The patient also received CT imaging of the cervical spine. Findings were notable for multiple areas of anterolisthesis of a mild degree at C3-C4, C4-C5, and C6-C7, C7-T1. No fractures were identified. Spinous process of C3 was displaced slightly forward. DENS intact. Lateral masses of C1 were well lined on C2 without any soft tissue swelling. The patient also received Flex X plain radiograph and plain film trauma series of the cervical spine, which were negative. The patient continued to improve during the remainder of the hospital stay under good pain management with morphine and dilaudid. The patient worked with PT and continued to make an improvement. Now, the patient is stable with improved pain control. The patient will be discharged to rehabilitation to progress with independence in mobility. The patient should followup with the Trauma Clinic in two weeks' time. | NEEDS ENCOURAGEMENT FOR FLD INTAKE.GU: VOIDING CLEAR YELLOW ON BEDPAN QS.ID: AFEBRILEA/ HD STABLE. GIVEN FENT 50MCG X2 AND VIOXX WITH EFFECT. )Renal- adequate u/o per foley..clear/yellowResp- 4L nc with rr mid teens to 21 in nonlabored breathing pattern breath sounds are clear with diminished coarse sounds at LLL. afebrile.bp 120-130's when asleep 100 to 120. hr 50's 60's nsr no ectopy. USING IS TO 1200CC WITH EASE.GI: ABD SOFT WITH +BS. Nursing Progress Notes/o- pt systolic pressure down to 100/20, hr in the 50's sinus no ectopi noted. Hr 50-60's Sb w/o ectopy magnesium repleted serial enzymes ongoing(negative so far. PT SUSTAINED LT RIB FX'S AND L1-2 TRANSVERSE PROCESS FXS.PMH: CAD, PVD, CEREBELLAR CVA, HTN, ULCERATIVE COLITIS, MI ', S/P RIH REPAIR, ^CHOLALLERGIES: SULFA, PCN, AND ASA.MEDS: ZESTRIL, PLAVIX, NORVASC, SPIRONOLACTONE, DETROL, PRILOSEC, QUININE, COLACE.N: A/OX3 PLEASANT AND COOP. UNSTEADY GAIT--ASSIST X2.CV: NSR 60-70 NO ECTOPY. T/Sicu Nsg Progress Note0700>>190015:40Events- transfused with PC's 1u for drifting hct(33>>27) and below baseline bp: bp ranging 90-110/ with recommended range of 140-160 per Dr /Aoresty. sats >96 on nasal prongs. routine diuretic and anti-HTN meds on hold today d/t bpNeuro- A&O x3...no issuesPain- c/o left chest pain(at site of injury..lower rib cage) at pre medication and post medication with 12.5mg ivp fentanyl q3/hr. pt u/o 30-40cc clear yellow urinegi- pt taking po fluid, c/o dry mouth, sipping H2O whenever awake.resp- pt Sats down to 90-92, while asleep, nasal canula at 2l increaed to 4l, pt mouth breathing at times, pt rr 16-24, coughs and deep breaths well, with weak cough.Used IS when awake. CXR today reported as no change from -weak NPID- afebrile, wbc wnlHeme- 1 u PRBC'sGI- regular diet with lactose restrictions..well tolerated soft abd; hypoactive bowel sounds...no stoolskin- left lower falnk ecchymosis warm pale skin compression boots in use.Activity- mobilize once hemodynamics are stable son/daughter visiting the day.assess- yo woman s/p fall with left sided rib fx ICU for management of resp status and pain issues. pt moving all extremes prrposefully and to command.Pt wears a soft collar, c/o of increased neck pain.Pt easily aroused when sleepinggu- pt had not voided over last 8h, pt had foley cath inserted #16, u/o 175cc. decreased breath sounds in the bases.skin- intact. reap rate teens low 20's. pt repositioned for comfort.Only c/o of pain with movement. pt given 500cc bolus of NS without effect, pt cont to receive volume, and systolic pressure dropped to 85/20, total of 3 liters NS given overnight, hr remains in a sinus bradycardia,pt hct down to 27. no transfusion at this time. Sinus bradycardiaRight bundle branch blockLateral ST-T changes are nonspecific may be due to myocardial ischemia -clinical correlation is suggestedSince previous tracing, : lateral T wave changes present Cont with C&DB, and use of IS. SBP 110'S-20'S. lytes WNL. Qd vioxx given at 1500.CVS- bp 110-133/40-50 with blood infusing. C/O ONLY MINIMAL PAIN AND MEDICATED WITH EFFECT. PT IS A Y/O FEMALE ADM TODAY AFTER FALL AT HOME IN BR. (BASELINE PER PT.) ivf at kvo. uo initally good dwindled to 20ccs per hr from 3 to 6 then down to 11 ccs at 7am. RESP STABLEP/ TRANSFER TO FLR IF REMAINS STABLE pt alert and oriented X3. potential for resp depression/ resp distress d/t narcotic/injuries.plan- per care plan/ sicu/trauma trauma teams WARM PALP PP.R: LUNGS CLEAR WITH SCATTERED FINE CRACKLES AT BASES. pt alert and coop oriented times three. STRONG PROD COUGH WHEN SPLINTING ABDOMEN. medicated times three with 12.5 of fentanyl for rib pain. good appetite for dinner taking flds but none over night as pt slept well.a stable with low utine out putp start her aldactone this am and watch her urine output. O2 VIA NC 2L. TOL HOUSE DIET. using is. Pt may need swan to determine volume status, with her cardiac history,will discuss transfusion on rounds. son left at 8pm and her daughter is driving to from PA.A/P - pt has had large volume requirement and drop in hct with min u/o. Cont to monitor and support. getting up to 900ccs. ecchymotic L sidePain pt has not received any pain med and she has slept most noc. pt is hard of hearing. | 5 | [
{
"category": "Nursing/other",
"chartdate": "2200-11-14 00:00:00.000",
"description": "Report",
"row_id": 1556642,
"text": "PT IS A Y/O FEMALE ADM TODAY AFTER FALL AT HOME IN BR. PT SUSTAINED LT RIB FX'S AND L1-2 TRANSVERSE PROCESS FXS.\nPMH: CAD, PVD, CEREBELLAR CVA, HTN, ULCERATIVE COLITIS, MI ', S/P RIH REPAIR, ^CHOL\nALLERGIES: SULFA, PCN, AND ASA.\nMEDS: ZESTRIL, PLAVIX, NORVASC, SPIRONOLACTONE, DETROL, PRILOSEC, QUININE, COLACE.\n\nN: A/OX3 PLEASANT AND COOP. GIVEN FENT 50MCG X2 AND VIOXX WITH EFFECT. C/O ONLY MINIMAL PAIN AND MEDICATED WITH EFFECT. UNSTEADY GAIT--ASSIST X2.\nCV: NSR 60-70 NO ECTOPY. SBP 110'S-20'S. WARM PALP PP.\nR: LUNGS CLEAR WITH SCATTERED FINE CRACKLES AT BASES. (BASELINE PER PT.) O2 VIA NC 2L. STRONG PROD COUGH WHEN SPLINTING ABDOMEN. USING IS TO 1200CC WITH EASE.\nGI: ABD SOFT WITH +BS. TOL HOUSE DIET. NEEDS ENCOURAGEMENT FOR FLD INTAKE.\nGU: VOIDING CLEAR YELLOW ON BEDPAN QS.\nID: AFEBRILE\nA/ HD STABLE. RESP STABLE\nP/ TRANSFER TO FLR IF REMAINS STABLE\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-11-16 00:00:00.000",
"description": "Report",
"row_id": 1556645,
"text": "pt alert and coop oriented times three. sats >96 on nasal prongs. reap rate teens low 20's. crackles in bases. using is. getting up to 900ccs. afebrile.\nbp 120-130's when asleep 100 to 120. hr 50's 60's nsr no ectopy. uo initally good dwindled to 20ccs per hr from 3 to 6 then down to 11 ccs at 7am. ivf at kvo. medicated times three with 12.5 of fentanyl for rib pain. good appetite for dinner taking flds but none over night as pt slept well.\na stable with low utine out put\np start her aldactone this am and watch her urine output.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-11-15 00:00:00.000",
"description": "Report",
"row_id": 1556643,
"text": "Nursing Progress Note\ns/o- pt systolic pressure down to 100/20, hr in the 50's sinus no ectopi noted. pt given 500cc bolus of NS without effect, pt cont to receive volume, and systolic pressure dropped to 85/20, total of 3 liters NS given overnight, hr remains in a sinus bradycardia,pt hct down to 27. no transfusion at this time. lytes WNL.\n pt alert and oriented X3. pt is hard of hearing. pt moving all extremes prrposefully and to command.Pt wears a soft collar, c/o of increased neck pain.Pt easily aroused when sleeping\ngu- pt had not voided over last 8h, pt had foley cath inserted #16, u/o 175cc. pt u/o 30-40cc clear yellow urine\ngi- pt taking po fluid, c/o dry mouth, sipping H2O whenever awake.\nresp- pt Sats down to 90-92, while asleep, nasal canula at 2l increaed to 4l, pt mouth breathing at times, pt rr 16-24, coughs and deep breaths well, with weak cough.Used IS when awake. decreased breath sounds in the bases.\nskin- intact. ecchymotic L side\nPain pt has not received any pain med and she has slept most noc. pt repositioned for comfort.Only c/o of pain with movement.\n son left at 8pm and her daughter is driving to from PA.\nA/P - pt has had large volume requirement and drop in hct with min u/o. Pt may need swan to determine volume status, with her cardiac history,will discuss transfusion on rounds. Cont with C&DB, and use of IS. Cont to monitor and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-11-15 00:00:00.000",
"description": "Report",
"row_id": 1556644,
"text": "T/Sicu Nsg Progress Note\n0700>>1900\n\n15:40\nEvents- transfused with PC's 1u for drifting hct(33>>27) and below baseline bp: bp ranging 90-110/ with recommended range of 140-160 per Dr /Aoresty.\n routine diuretic and anti-HTN meds on hold today d/t bp\n\nNeuro- A&O x3...no issues\nPain- c/o left chest pain(at site of injury..lower rib cage) at pre medication and post medication with 12.5mg ivp fentanyl q3/hr. Qd vioxx given at 1500.\n\nCVS- bp 110-133/40-50 with blood infusing. Hr 50-60's Sb w/o ectopy\n magnesium repleted\n serial enzymes ongoing(negative so far.)\n\nRenal- adequate u/o per foley..clear/yellow\n\nResp- 4L nc with rr mid teens to 21 in nonlabored breathing pattern\n breath sounds are clear with diminished coarse sounds at LLL.\n CXR today reported as no change from \n -weak NP\nID- afebrile, wbc wnl\n\nHeme- 1 u PRBC's\n\nGI- regular diet with lactose restrictions..well tolerated\n soft abd; hypoactive bowel sounds...no stool\n\nskin- left lower falnk ecchymosis\n warm pale skin\n compression boots in use.\n\nActivity- mobilize once hemodynamics are stable\n\n son/daughter visiting the day.\n\nassess- yo woman s/p fall with left sided rib fx\n ICU for management of resp status and pain issues.\n potential for resp depression/ resp distress d/t narcotic/injuries.\n\nplan- per care plan/ sicu/trauma trauma teams\n\n"
},
{
"category": "ECG",
"chartdate": "2200-11-15 00:00:00.000",
"description": "Report",
"row_id": 274785,
"text": "Sinus bradycardia\nRight bundle branch block\nLateral ST-T changes are nonspecific may be due to myocardial ischemia -\nclinical correlation is suggested\nSince previous tracing, : lateral T wave changes present\n\n"
}
] |
66,532 | 127,137 | 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic low back pain, anemia, GERD, asthma recently admitted with subarachnoid hemorrhage readmitted with acute change in mental status acute on chronic hypercarbic respiratory failure . # Acute on chronic hypercarbic respiratory failure: Patient was felt to have a multifactorial etiologies for her respirtory failure including central and obstructive apnea, a chronic paralyzed R hemidiaphragm, and obesity hypoventilation which all contibuted to her difficulty with respiration. She underwent tracheostomy and had significant improvement in oxygenation and acid base status. She remained mostly on AC vent settings with daily pressure support trials which were sometimes limited by hypercarbia. In addition, during pressure support trials she occasionally desat in setting of decreasing TV to 280's. In addition, she would benefit from diamox PRN to aid with alkalosis while on vent. She was also noted to be volume overloaded with a length of stay net +7L. Her CXR was suggestive of pulmonary edema, and lasix gtt was started on with goal for 1-2L fluid removal. After discharge, her lasix gtt should be adjusted to pulmonary exam. . # Tracheal tear: On , pt underwent a CTA to rule out PE given tachycardia and hypoxia. CT revealed and abnl trachea. The next day, patient was taken to OR for fiberoptic intubation and rigid bronch which showed a 5cm tracheal tear. IP was involved and recommended prolonged intubation to allow tear to heal as well as ppx abx with Unasyn and fluconazole (both started on ) for total 10 day course (last day ). After further discussion with family and IP, it was felt that the most cautious management for be for tracheostomy to bypass the area of the tear given that she is at very high risk for repeated intubation and the risk of causing perforation of the tear would be greater in setting of re-intubation. She tolerated the tracheostomy. She will need follow-up with Dr. in weeks. Trach can NOT be changed until after . Sutures can be removed after . . # ? Mass in L hilum: Pt reportedly has a mass on OSH chest CT in L hilum at location of bleed which was noticed by IP during bronchoscopy. This will need to be assessed with contrast CT as an outpatient. Please arrange with her PCP to have this follow-up. . # Recent Left temporal hemorrhage: Unclear etiology, less likely due to trauma, more likely HTN and anticoagulation. No evidence of rebleeding or new bleed on head CT. She will need follow-up with neurosurgery (Dr. , ) within one month post-discharge. At that time, he will re-evaluate restarting coumadin and aspirin. She was maintained on keppra for seizure ppx in setting of bleed. . # Paroxysmal Atrial fibrillation: HR remained mostly well controlled int he 60's. Coumadin and aspirin were held given recent hemorrhage. She will need to discuss restarting anticoagulation with neurosurgeon. . # HTN: Her BP was variable. Her regimen was adjusted to include enalapril 30 mg daily and hydralazine 25 mg PO QID. Her metoprolol was intermittently held given bradycardia, but it was felt that she does need nodal blockade for her paroxsysmal afib. . # Altered mental status: Improved steadily over hospital course, but pt still frequently confused. Per her husband, this is near her baseline following anoxic brain injury and hypoglycemia in the past. Head CT unchanged, Chest CTA w/o PE, no evidence of MI, TTE w/ nl EF, UA unremarkable. . # Hypernatremia: She was found to be intermittently hypernatremia and her free water flushes were adjusted accordingly. | Q2-3 hrs;no desating,gets resp distress that easily clears with suction ,cxr more pul edema picture Action: Weaned to cpap/psv,started on Lasix drip,suctioned as needed Response: Currently satting 93-97% on this setting,sats improoved post suctioning,fluid balance is even,Lasix drip titrated,abg shows ph 7.48 pco2 54 Plan: Cont to wean as tolerated,goal fluid balance 1-2L neg,pt has bed available at rehab for tomarrow @10am Others:recevd 40 meq K this am for k 3.3Rpt k levl 3.9,lext lab due at 2100 hrs Tolerating the tube feed @goal. #Paroxysmal Atrial fibrillation: in sinus rhythm on admission, does have limited bursts of afib - coumadin being held given recent hemorrhage - metoprolol IV prn for tachycardia/htn - not on asa left temporal hemorrhage . #Paroxysmal Atrial fibrillation: in sinus rhythm on admission, does have limited bursts of afib - coumadin being held given recent hemorrhage - metoprolol IV prn for tachycardia/htn - not on asa left temporal hemorrhage . #Paroxysmal Atrial fibrillation: in sinus rhythm on admission, does have limited bursts of afib - coumadin being held given recent hemorrhage - metoprolol IV prn for tachycardia/htn - not on asa left temporal hemorrhage . Post procedure, pt was intubated using fiberoptics ,Trach in place,recevd the pt on capap 15/5 Action: Suctioned as needed,contd prophylactic abx,weaned down to 12/5 Response: Pt now with #8 adjustable neck flange portex trach (at 12.5 marked),pt deos have period of apnea with low minute volume.,now pt is resting on AC. Post procedure, pt was intubated using fiberoptics ,Trach in place,recevd the pt on capap 15/5 Action: Suctioned as needed,contd prophylactic abx,weaned down to 12/5 Response: Pt now with #8 adjustable neck flange portex trach (at 12.5 marked),pt deos have period of apnea with low minute volume.,now pt is resting on AC. Post procedure, pt was intubated using fiberoptics ,Trach in place,recevd the pt on capap 15/5 Action: Suctioned as needed,contd prophylactic abx,weaned down to 12/5 Response: Pt now with #8 adjustable neck flange portex trach (at 12.5 marked),pt deos have period of apnea with low minute volume. 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic low back pain, anemia, GERD, asthma recently admitted with subarachnoid hemorrhage readmitted with acute change in mental status acute on chronic hypercarbic respiratory failure Hypertension, benign Assessment: Action: Response: Plan: Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: # HTN continues to be quite hypertensive -lasix as tolerated -holding acebutolol, enalapril while npo -consider hydralazine if hypertensives ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:34 PM 20 Gauge - 08:20 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Hypertension, benign Assessment: Pt received on nitro gtt @ 1mcg/kg/min with SBPs via cuff ranging 180s-190s. Response: Plan: Respiratory failure, acute (not ARDS/) Assessment: Vented via trach. - q 8 HCT - guaic stools - obtain hemolysis labs - repeat CXR, if truly worsening effusion will consider CT and thoracentesis . 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic low back pain, anemia, GERD, asthma recently admitted with subarachnoid hemorrhage readmitted with acute change in mental status acute on chronic hypercarbic respiratory failure.- Pt had CTA chest to r/o PE and CT head for mal-appearance/HTN/diaphoresis AM of . 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic low back pain, anemia, GERD, asthma recently admitted with subarachnoid hemorrhage readmitted with acute change in mental status acute on chronic hypercarbic respiratory failure.- Pt had CTA chest to r/o PE and CT head for mal-appearance/HTN/diaphoresis AM of . Also later c/o abd discomfort and nausea; stopped TF and gave zofran IV. Pt had CTA chest to r/o PE and CT head for mal-appearance/HTN/diaphoresis AM of . Pt had CTA chest to r/o PE and CT head for mal-appearance/HTN/diaphoresis AM of . Pt had CTA chest to r/o PE and CT head for mal-appearance/HTN/diaphoresis AM of . Pt had CTA chest to r/o PE and CT head for mal-appearance/HTN/diaphoresis AM of . ABG now with hypoxia in the setting of turning pt and right mainstem intubation (now s/p pulling back ET tube) and with metabolic alkalosis overventilation. Post procedure, pt was intubated using fiberoptics ,Trach in place,recevd the pt on capap 15/5 Action: Suctioned as needed,contd prophylactic abx,weaned down to 12/5 Response: Pt now with #8 adjustable neck flange portex trach (at 12.5 marked),pt deos have period of apnea with low minute volume. Response: Able to wean nitro down as low as Plan: Cont nitro gtt until BPs maintained 160-180 systolic Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: Pt had CTA chest to r/o PE and CT head for mal-appearance/HTN/diaphoresis AM of . extubation; recheck ABG NSR with occasional ectopy, history of afib not on coumadin in setting of recent intracranial bleed; BP stable 130-150s; weakly palpable pedal pulses. extubation; recheck ABG NSR with occasional ectopy, history of afib not on coumadin in setting of recent intracranial bleed; BP stable 130-150s; weakly palpable pedal pulses. extubation; recheck ABG NSR with occasional ectopy, history of afib not on coumadin in setting of recent intracranial bleed; BP stable 130-150s; weakly palpable pedal pulses. Lung sounds RLL Lung Sounds: Diminished RUL Lung Sounds: Rhonchi LUL Lung Sounds: Rhonchi LLL Lung Sounds: Diminished Secretions Sputum color / consistency: Yellow / Thick Sputum source/amount: Nasotrachial Suction / Small Plan: Next 24-48 hours: NIV as tolerated. | 180 | [
{
"category": "Nursing",
"chartdate": "2103-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 669760,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\n .\n She was just discharged yesterday from MICU course for altered\n mental status and hypercarbia. Her altered mental status was likely\n multifactorial to include medications (diazepam, percocet) and\n hypercarbia OSA and sleep hypoventilation. She returned to baseline\n on discharge. Her hypercarbia was thought related to her COPD and\n likely newly diagnosed sleep disordered breathing. She underwent a\n sleep study and was discharged on BiPAP to follow up in sleep clinic\n for a complete sleep study.\n .\n She was found somnolent this morning, was not placed on BiPaP last\n night. Sent to for CO2 115. At placed on BiPap with\n excellent response and transferred to . On the EMS she was taken off\n BIPAP and placed on high flow oxygen. By arrival she was altered with\n saturations in 70s. She was trialed on CPAP with no success and bagged\n to try and take off CO2 with no success and subsequently intubated and\n admitted to MICU. CTH negative.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 669761,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\n .\n She was just discharged yesterday from MICU course for altered\n mental status and hypercarbia. Her altered mental status was likely\n multifactorial to include medications (diazepam, percocet) and\n hypercarbia OSA and sleep hypoventilation. She returned to baseline\n on discharge. Her hypercarbia was thought related to her COPD and\n likely newly diagnosed sleep disordered breathing. She underwent a\n sleep study and was discharged on BiPAP to follow up in sleep clinic\n for a complete sleep study.\n .\n She was found somnolent this morning, was not placed on BiPaP last\n night. Sent to for CO2 115. At placed on BiPap with\n excellent response and transferred to . On the EMS she was taken off\n BIPAP and placed on high flow oxygen. By arrival she was altered with\n saturations in 70s. She was trialed on CPAP with no success and bagged\n to try and take off CO2 with no success and subsequently intubated and\n admitted to MICU. CTH negative.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Hypercarbic CO2 of 139, lethargic upon arrival at ED. Sedated with\n propofol but became hypotensive to the 80\ns switched to versed 6 mgs\n /hr. stable vital signs upon arrival at MICU\n sats > 95% denies pain.\n Awake and following commands, bilateral wrist immobilizer in place.\n Patient intermittently restless and anxious, wanted to take tube out\n and have drink of juice/water, initial ABG upon arrival at MICU\n 7.54/55/48\n Action:\n Vent settings adjusted with ABG results, placed on AC 30% FiO2 300\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 669762,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\n .\n She was just discharged yesterday from MICU course for altered\n mental status and hypercarbia. Her altered mental status was likely\n multifactorial to include medications (diazepam, percocet) and\n hypercarbia OSA and sleep hypoventilation. She returned to baseline\n on discharge. Her hypercarbia was thought related to her COPD and\n likely newly diagnosed sleep disordered breathing. She underwent a\n sleep study and was discharged on BiPAP to follow up in sleep clinic\n for a complete sleep study.\n .\n She was found somnolent this morning, was not placed on BiPaP last\n night. Sent to for CO2 115. At placed on BiPap with\n excellent response and transferred to . On the EMS she was taken off\n BIPAP and placed on high flow oxygen. By arrival she was altered with\n saturations in 70s. She was trialed on CPAP with no success and bagged\n to try and take off CO2 with no success and subsequently intubated and\n admitted to MICU. CTH negative.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Hypercarbic CO2 of 139, lethargic upon arrival at ED. Sedated with\n propofol but became hypotensive to the 80\ns switched to versed 6 mgs\n /hr. stable vital signs upon arrival at MICU\n sats > 95% denies pain.\n Awake and following commands, bilateral wrist immobilizer in place.\n Patient intermittently restless and anxious, wanted to take tube out\n and have drink of juice/water, initial ABG upon arrival at MICU\n 7.54/55/48; lung sounds clear, dim at bases, suctioned small amount of\n whitish yellow secretions; slightly febrile 100.9\n Action:\n Vent settings changed from 30% 400x24 peep 5 to 350 x 10 since patient\n was very alkalotic\n Response:\n Recent ABG 7.38/85/59 FiO2 increased to 40% insetting of desaturation\n low 80\n responded well > 90; slept intermittently\n Plan:\n Try PS in am, ? extubation\n NSR with occasional ectopy, history of afib\n not on coumadin in\n setting of recent intracranial bleed; BP stable 130-150\ns; weakly\n palpable pedal pulses. + edema of lower extremities\n Bowel sounds present, no bowel movement. OGT in place, patent but will\n need to confirm with early am CXR\n On glipizide and RISS, coverage given for FS 180 at MN\n Foley in place, yellow urine with sediments\n Coccyx reddened but intact, barrier cream applied. Turn q2hrs\n Patient\ns husband came with her, updates given. Left past MN, will call\n in am for updates\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-04 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 669756,
"text": "Chief Complaint: Acute on chronic hypercarbic respiratory failure\n HPI:\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\n .\n She was just discharged yesterday from MICU course for altered\n mental status and hypercarbia. Her altered mental status was likely\n multifactorial to include medications (diazepam, percocet) and\n hypercarbia OSA and sleep hypoventilation. She returned to baseline\n on discharge. Her hypercarbia was thought related to her COPD and\n likely newly diagnosed sleep disordered breathing. She underwent a\n sleep study and was discharged on BiPAP to follow up in sleep clinic\n for a complete sleep study.\n .\n She was found somnolent this morning, was not placed on BiPaP last\n night. Sent to for CO2 115. At placed on BiPap with\n excellent response and transferred to . On the EMS she was taken off\n BIPAP and placed on high flow oxygen. By arrival she was altered with\n saturations in 70s. She was trialed on CPAP with no success and bagged\n to try and take off CO2 with no success and subsequently intubated and\n admitted to MICU. CTH negative.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n CURRENT MEDICATIONS: Discharge meds from DC summ\n 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:\n 2-4 Puffs Inhalation Q4H (every 4 hours) as needed.\n 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff\n Inhalation (2 times a day).\n 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)\n injection Injection TID (3 times a day).\n 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID\n (4 times a day) as needed.\n 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)\n Capsule, Delayed Release(E.C.) PO DAILY (Daily).\n 6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY\n (Daily).\n 7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2\n times a day).\n 8. Acebutolol 200 mg Capsule Sig: One (1) Capsule PO BID (2\n times a day).\n 9. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY\n (Daily).\n 10. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a\n day).\n 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6\n hours) as needed.\n 12. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,\n Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for\n agitation.\n 13. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H\n (every 8 hours): both eyes.\n 14. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS\n (at bedtime): both eyes.\n 15. Humalog/Regular insulin sliding scale\n per protocol qACHS\n 16. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.\n Past medical history:\n Family history:\n Social History:\n OSA/Sleep hypoventilation- b/l CO2 70-80s\n Left Temporal Intraparenchymal hemorrhage\n COPD- no prior h/o tobacco use, + secondhand exposure\n afib- was on coumadin for last few years\n TIA- had prior episodes of flashes of light going across her\n visual field, was placed on plavix.\n Dementia- secondary to diabetic coma\n Chronic Low Back Pain\n Anemia\n GERD\n nc\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives with husband until recent admission, used to\n work as the press secretary to a state senator in the state\n house. no tob/etoh or illicits.\n Review of systems:\n Flowsheet Data as of 12:40 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 77 (62 - 77) bpm\n BP: 143/105(114) {139/41(64) - 145/105(114)} mmHg\n RR: 17 (16 - 21) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134 kg\n Total In:\n 3,035 mL\n 6 mL\n PO:\n TF:\n IVF:\n 35 mL\n 6 mL\n Blood products:\n Total out:\n 200 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,835 mL\n 6 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 350 (350 - 400) mL\n RR (Set): 10\n RR (Spontaneous): 3\n PEEP: 5 cmH2O\n FiO2: 30%\n PIP: 42 cmH2O\n Plateau: 30 cmH2O\n Compliance: 14 cmH2O/mL\n SpO2: 94%\n ABG: 7.37/85./59//18\n Ve: 5.4 L/min\n PaO2 / FiO2: 197\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, NG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), distant heart sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: b/l)\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A4/18/ 09:01 PM\n \n 10:20 P4/18/ 11:48 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 49\n 51\n Imaging: CXR- line in place, no acute change\n Microbiology: blood cx pending\n ECG: no ischemic changes\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n .\n # Acute on chronic hypercarbic respiratory failure- patient has\n baseline elevated PCO2 of 70-80s which is well compensated based on pH\n of 7.35 and bicarbonate of 43. Patient meets criteria for OSA bases on\n pulse oximetry sleep study.\n - plan to keep on AC overnight, decrease TV and RR to allow hypercarbia\n to trend towards baseline given alkalosis then switch to pressure\n support and once pulling good tidal volume and gas at\n baseline>>>extubate\n - check TTE\n - consider diuresis with acetazolamide/furosemide\n - consider theophylline to stimulate respiratory drive\n - wean up on Fi02 to if hypoxemia as needed\n - continue flovent, albuterol, atrovent\n - if patient continues to fail on BIPAP will likely need tracheostomy\n .\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix\n - Per neurology -> cont keppra for now\n .\n #Paroxysmal Atrial fibrillation: in sinus rhythm on admission\n -coumadin being held given recent hemorrhage\n -not on rate control as outpt\n .\n #Type II DM - has had recent up titration of her diabetes regimen.\n Blood sugars poorly controlled here despite adding back her glipizide,\n avandia. Januvia not on formulary.\n - glargine at 10units to attempt to improve glycemic control\n - hiss\n .\n # HTN\n - continue acebutolol\n - Hold enalapril given hyperkalemia\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion\n Lines:\n 18 Gauge - 08:34 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 669813,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n :\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Prolonged exhalation\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: RSBI = 101, plan is to extubate this morning as soon\n as able.\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 669914,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent non-invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment: Tolerated well\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Increase ventilatory support at night\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Pt was weaned and extubated, placed on full face bipap, 20IPAP/8EPAP as\n per previous admission . Pt has become more somulent\n requiring lpm for sats 88%\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670079,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\n .\n She was just discharged yesterday from MICU course for altered\n mental status and hypercarbia. Her altered mental status was likely\n multifactorial to include medications (diazepam, percocet) and\n hypercarbia OSA and sleep hypoventilation. She returned to baseline\n on discharge. Her hypercarbia was thought related to her COPD and\n likely newly diagnosed sleep disordered breathing. She underwent a\n sleep study and was discharged on BiPAP to follow up in sleep clinic\n for a complete sleep study.\n .\n She was found somnolent this morning, was not placed on BiPaP last\n night. Sent to for CO2 115. At placed on BiPap with\n excellent response and transferred to . On the EMS she was taken off\n BIPAP and placed on high flow oxygen. By arrival she was altered with\n saturations in 70s. She was trialed on CPAP with no success and bagged\n to try and take off CO2 with no success and subsequently intubated and\n admitted to MICU. CTH negative.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Extubated yesterday. On and off bipap yesterday and last night. Sats\n 88-98%. NT sxned for mod. amounts of tan, thick secretions. Noted to\n have shallow respirations while off bipap. Also, very sleepy, only\n arousing to stimuli. Abg off bipap for ~4 hours 7.16/141/114. Thus\n placed back on bipap, monitoring abg\ns, ? need for intubation. CXR\n today with entire right lung white out.\n Action:\n Back and forth between face tent and bipap. Chest PT. Encouraged\n coughing and deep breathing. NT sxned prn. Abg\ns prn.\n Response:\n CXR with some improvement after chest PT and sxning. Rising CO2 off\n bipap. Continued coughing and need for sxning. ? Need for intubation.\n Plan:\n Cont. to monitor abg\ns NT sxning prn. Chest PT and coughing deep\n breathing as appropriate.. Plan for ECHO Tue.\n Dr. . aware of abg\ns, shallow breathing, and cxr. No immediate\n plans to intubate at this time.\n Plan for speech and swallow on Tue. If appropriate, as ? aspiration of\n thin liquids yesterday.\n Two loose, brown stools.\n Coccyx reddened but intact, barrier cream applied. Mepilex in place to\n small, pink stage two on buttocks. Yeast looking rash in perineal\n area, antifungal criticaid applied. Miconazole powder ordered. Left\n lower extreme. Cellulitis looking erethema, appears to be improving.\n Had LENI\ns of bilat. Lower extrem. Negative.\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671494,
"text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n ULTRASOUND - At 11:29 AM\n LENI to r/o dvt\n ULTRASOUND - At 03:19 PM\n chest usg to assess the diaphragm\n \n - has paralyzed right hemidiaphragm per dynamic U/S, per pt has been\n present for 10 years\n - LENIs without DVTs\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin/Sulbactam (Unasyn) - 09:52 AM\n Ampicillin - 04:10 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Furosemide (Lasix) - 09:00 PM\n Hydralazine - 06:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.8\n HR: 68 (55 - 79) bpm\n BP: 164/53(81) {101/35(50) - 175/74(87)} mmHg\n RR: 19 (15 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 3,612 mL\n 672 mL\n PO:\n TF:\n 1,652 mL\n 501 mL\n IVF:\n 1,200 mL\n 171 mL\n Blood products:\n Total out:\n 2,675 mL\n 1,040 mL\n Urine:\n 2,675 mL\n 790 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n 937 mL\n -368 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 633 (633 - 633) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/65/126/32/14\n Ve: 7.3 L/min\n PaO2 / FiO2: 315\n Physical Examination\n GEN: pleasant, awake, slightly confused but conversational\n HEENT: PERRL, MMM\n Neck: JVP at\n PULM: clear ant and laterally\n Heart: RRR, no murmurs\n ABD: soft, obese, normal BS\n EXT: 3+ pitting edema\n Labs / Radiology\n 194 K/uL\n 6.3 g/dL\n 152 mg/dL\n 0.4 mg/dL\n 32 mEq/L\n 3.3 mEq/L\n 7 mg/dL\n 109 mEq/L\n 150 mEq/L\n 20.0 %\n 3.4 K/uL\n [image002.jpg]\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n 01:04 PM\n 06:05 PM\n 04:49 AM\n WBC\n 3.8\n 4.3\n 6.1\n 3.4\n Hct\n 24.1\n 24.5\n 23\n 24.9\n 20.0\n Plt\n 161\n 181\n 235\n 194\n Cr\n 0.4\n 0.3\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 37\n 38\n 37\n 44\n Glucose\n 144\n 122\n 152\n 169\n 172\n 152\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL, PO4:1.3 mg/dL\n Fluid analysis / Other labs: BNP 1800\n Imaging: LENI: no DVT\n Diaphragm Fluoro: paralyzed R hemi diaphragm\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Respiratory failure: . Patient remains on vent and has failed SBT.\n Currently appears to be component of hypercarbic resp failure likely\n from cental apnea as well as mild pulm edema. Furthermore, she has\n mechanical deficits with chronic R hemidiaphragm. In addition, pt has\n had hypoxia as well. Hypoxia may be atelecatsis or vol overload; PE\n in differential but hypoxia does improve with PEEP which would not be\n consistent with PE. LENI on neg for DVT. Her resp issues are\n likely a combination of OSA, CO2 retention andf her hospital course has\n also been complicated by right lung collapse, R mainstem intubation.\n - goal I/O 1L neg today with lasix drip\n - continue flovent, albuterol, atrovent\n - obtain LENI\n # Hct drop: Hct from 24 to 20 this morning; however, all other cell\n lines are slightly down as well. She has been hemodynamically stable\n and no reports of bleeding. I suspect dilutional\n - repeat CBC\n - if persistant, guaiac all stools, transfuse for HCT<21\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - continue to try PS trials, although continues to become hypercarbic\n likely central apnea\n - if does well try Passey-Muir valve\n - continue Unasyn () and Fluconazole () for ppx for tracheal\n tear for goal 10 day course\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns, but had an\n episode of afib with RVR last night.\n - BB restarted\n - coumadin being held given recent hemorrhage\n - not on asa left temporal hemorrhage\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - continue enalapril, and hydralazine\n # Altered mental status\n Has been improved, but still frequently\n confused. h/o SAH/IPH, but now unclear etiology as no clear\n complaints. Likely hemorrage, prior hypoglycemic coma from which\n she did not recover and ICU delirium. Head CT unchanged, Chest CTA w/o\n PE, no evidence of MI, TTE w/ nl EF, UA unremarkable.\n - haldol\n - if more confused will decrease fentanyl\n # Hypernatremia: sodium cont to be elevated\n - continue free water flushes 250 cc Q4H\n # Fevers: no further fevers, cultures have been negative, c.diff neg on\n unasyn and fluconazole ppx for traceal tear\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:47 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671496,
"text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n ULTRASOUND - At 11:29 AM\n LENI to r/o dvt\n ULTRASOUND - At 03:19 PM\n chest usg to assess the diaphragm\n \n - has paralyzed right hemidiaphragm per dynamic U/S, per pt has been\n present for 10 years\n - LENIs without DVTs\n - no further hypoxic episodes and Fi02 decreased to 40%\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin/Sulbactam (Unasyn) - 09:52 AM\n Ampicillin - 04:10 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Furosemide (Lasix) - 09:00 PM\n Hydralazine - 06:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.8\n HR: 68 (55 - 79) bpm\n BP: 164/53(81) {101/35(50) - 175/74(87)} mmHg\n RR: 19 (15 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 3,612 mL\n 672 mL\n PO:\n TF:\n 1,652 mL\n 501 mL\n IVF:\n 1,200 mL\n 171 mL\n Blood products:\n Total out:\n 2,675 mL\n 1,040 mL\n Urine:\n 2,675 mL\n 790 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n 937 mL\n -368 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 633 (633 - 633) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/65/126/32/14\n Ve: 7.3 L/min\n PaO2 / FiO2: 315\n Physical Examination\n GEN: pleasant, awake, slightly confused but conversational\n HEENT: PERRL, EOM intact, MMM\n Neck: JVP at earlobe\n PULM: clear ant and laterally\n Heart: RRR, no murmurs\n ABD: soft, obese, normal BS\n EXT: 3+ pitting edema\n Labs / Radiology\n 194 K/uL\n 6.3 g/dL\n 152 mg/dL\n 0.4 mg/dL\n 32 mEq/L\n 3.3 mEq/L\n 7 mg/dL\n 109 mEq/L\n 150 mEq/L\n 20.0 %\n 3.4 K/uL\n [image002.jpg]\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n 01:04 PM\n 06:05 PM\n 04:49 AM\n WBC\n 3.8\n 4.3\n 6.1\n 3.4\n Hct\n 24.1\n 24.5\n 23\n 24.9\n 20.0\n Plt\n 161\n 181\n 235\n 194\n Cr\n 0.4\n 0.3\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 37\n 38\n 37\n 44\n Glucose\n 144\n 122\n 152\n 169\n 172\n 152\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL, PO4:1.3 mg/dL\n Fluid analysis / Other labs: BNP 1800\n Imaging: LENI: no DVT\n Diaphragm Fluoro: paralyzed R hemi diaphragm\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Respiratory failure: . Patient remains on vent and has failed SBT.\n Currently appears to be component of hypercarbic resp failure likely\n from cental apnea as well as mild pulm edema. Furthermore, she has\n mechanical deficits with chronic R hemidiaphragm. In addition, pt has\n had hypoxia as well. Hypoxia may be atelecatsis or vol overload; PE\n in differential but hypoxia does improve with PEEP which would not be\n consistent with PE. LENI on neg for DVT. Her resp issues are\n likely a combination of OSA, CO2 retention andf her hospital course has\n also been complicated by right lung collapse, R mainstem intubation.\n - try another pressure support trial today\n - goal I/O 1L neg today with lasix drip\n - continue flovent, albuterol, atrovent\n - LENI\ns neg for DVT\n # Hct drop: Hct from 24 to 20 this morning; however, all other cell\n lines are slightly down as well. She has been hemodynamically stable\n and no reports of bleeding. I suspect dilutional\n - repeat CBC\n - if persistant, guaiac all stools, transfuse for HCT<21\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - continue to try PS trials, although continues to become hypercarbic\n likely central apnea\n - if does well try Passey-Muir valve\n - continue Unasyn () and Fluconazole () for ppx for tracheal\n tear for goal 10 day course\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns, but had an\n episode of afib with RVR last night.\n - BB restarted\n - coumadin being held given recent hemorrhage\n - not on asa left temporal hemorrhage\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - continue enalapril, and hydralazine\n # Altered mental status\n Has been improved, but still frequently\n confused. h/o SAH/IPH, but now unclear etiology as no clear\n complaints. Likely hemorrage, prior hypoglycemic coma from which\n she did not recover and ICU delirium. Head CT unchanged, Chest CTA w/o\n PE, no evidence of MI, TTE w/ nl EF, UA unremarkable.\n - haldol\n - if more confused will decrease fentanyl\n # Hypernatremia: sodium cont to be elevated\n - continue free water flushes 250 cc Q4H\n # Fevers: no further fevers, cultures have been negative, c.diff neg on\n unasyn and fluconazole ppx for traceal tear\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:47 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671599,
"text": "Hypertension, benign\n Assessment:\n Known hypertensive,max sbp up to 180\ns ,hr 60-70\ns sinus.\n Action:\n Increased hydralazine,enalapril,contd lopressor started on Lasix drip.\n Response:\n Sbp started trending down post Lasix drip/increased dose of meds,pt\n gets anxious and tearful at times,no pain,pt seems more oriented and\n appropriate.\n Plan:\n Monitor BP, cont the current management,goal fluid balance 1-2 l neg\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +10peep. Lung sounds\n ronchorous .Sxn for thick white/yellow secretions. Q2-3 hrs;no\n desating,gets resp distress that easily clears with suction ,cxr more\n pul edema picture\n Action:\n Weaned to cpap/psv,started on Lasix drip,suctioned as needed\n Response:\n Currently satting 93-97% on this setting,sats improoved post\n suctioning,fluid balance is even,Lasix drip titrated,abg shows ph 7.48\n pco2 54\n Plan:\n Cont to wean as tolerated,goal fluid balance 1-2L neg,pt has bed\n available at rehab for tomarrow @10am\n Others:recevd 40 meq K this am for k 3.3Rpt k levl 3.9,lext lab due at\n 2100 hrs\n Tolerating the tube feed @goal.\n Na stable at 144,on 250cc free water q6h.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671601,
"text": "Hypertension, benign\n Assessment:\n Known hypertensive,max sbp up to 180\ns ,hr 60-70\ns sinus.\n Action:\n Increased hydralazine,enalapril,contd lopressor started on Lasix drip.\n Response:\n Sbp started trending down post Lasix drip/increased dose of meds,pt\n gets anxious and tearful at times,no pain,pt seems more oriented and\n appropriate.\n Plan:\n Monitor BP, cont the current management,goal fluid balance 1-2 l neg\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +10peep. Lung sounds\n ronchorous .Sxn for thick white/yellow secretions. Q2-3 hrs;no\n desating,gets resp distress that easily clears with suction ,cxr more\n pul edema picture,chest ultrasound shows rt diaphragmatic paralysis\n Action:\n Weaned to cpap/psv,started on Lasix drip,suctioned as needed\n Response:\n Currently satting 93-97% on this setting,sats improoved post\n suctioning,fluid balance is even,Lasix drip titrated,abg shows ph 7.48\n pco2 54\n Plan:\n Cont to wean as tolerated,goal fluid balance 1-2L neg,pt has bed\n available at rehab for tomarrow @10am\n Others:\n recevd 40 meq K this am for k 3.3Rpt k levl 3.9,lext lab due at 2100\n hrs\n Tolerating the tube feed @goal.\n Na stable at 144,on 250cc free water q6h.\n Huband was at bedside afternoon,updated by MD and this RN\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 671661,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: \n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 671460,
"text": "Demographics\n Day of mechanical ventilation: 8\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tracheostomy tube:\n Type: Cuffed, Adjustable Neck Flange\n Manufacturer: \n Size: 8.0mm\n Management:\n Vol/Press:\n pressure: 28 cmH2O\n volume: 8 mL /\n Airway problems: leak with volume loss-very\n positional\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments: mdi as ordered\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Trigger work assessment: Triggering synchronously\n Comments: occ failed trigger efforts\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Remained on a/c all night. Trach with persistent leak-pt able to\n speak around the trach.Flange marked at 12.5. Will cont to follow with\n psv trials as tolerated.:\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671780,
"text": "Patient discharged to Rehab @ approx 11am today. Her\n assessment is per her page 2. She was discharged with ACLS certified\n EMTs.\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671783,
"text": "Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan.\n 24 Hour Events: increased hydralazine and enalapril yesterday\n PS 15/10 trial 7.48/55/78 desated to 80\ns after 4 hours intial TV\n were in 350-400 and she dropped her volumes to less that 300.\n Lasix drip started and negative this morning.\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin - 04:10 AM\n Ampicillin/Sulbactam (Unasyn) - 04:17 AM\n Infusions:\n Furosemide (Lasix) - 8 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 AM\n Lansoprazole (Prevacid) - 07:50 AM\n Other medications:\n Levetiracetam 500 po bid\n Metoprolol 25 po bid\n Pyridium finished\n Enalapril 30mg po qday\n Hydralazine 25mg po qid\n Senna\n Docusate\n Insulin\n Lantoprost\n Brimonidine\n Simvistatin\n Hep SQ tid\n Changes to medical and family history:\n No changes see H+P\n Review of systems is unchanged from admission except as noted below\n Review of systems:No complaints\n Flowsheet Data as of 08:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.2\nC (98.9\n HR: 76 (60 - 80) bpm\n BP: 157/47(74) {108/39(56) - 170/76(87)} mmHg\n RR: 20 (12 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 3,504 mL\n 986 mL\n PO:\n TF:\n 1,684 mL\n 575 mL\n IVF:\n 860 mL\n 351 mL\n Blood products:\n Total out:\n 3,700 mL\n 2,045 mL\n Urine:\n 3,450 mL\n 2,045 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -196 mL\n -1,059 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 404 (355 - 404) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: 7.48/54/78./39/14\n Ve: 7.7 L/min\n PaO2 / FiO2: 197\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trach\n Neck: JVP earlobe\n Cardiovascular: RRR s1s2 no m/r/g\n Respiratory / Chest: Course BS ant/post no bronchial BS noted\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: no rash or erythema\n Ext: + edema\n Neurologic: Attentive, A+O x 3 no gross motor sensory deficits.\n Lines: Clean dry intact.\n Skin: Not assessed\n Labs / Radiology: Chest decreased effusions.\n 8.1 g/dL\n 286 K/uL\n 181 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 4.1 mEq/L\n 9 mg/dL\n 99 mEq/L\n 142 mEq/L\n 25.3 %\n 5.4 K/uL\n [image002.jpg]\n 09:05 PM\n 03:45 AM\n 01:04 PM\n 06:05 PM\n 04:49 AM\n 07:19 AM\n 02:44 PM\n 05:07 PM\n 12:01 AM\n 05:38 AM\n WBC\n 6.1\n 3.4\n 4.4\n 5.4\n Hct\n 23\n 24.9\n 20.0\n 25.4\n 25.3\n Plt\n 235\n 194\n 255\n 286\n Cr\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.5\n TCO2\n 37\n 44\n 41\n Glucose\n 169\n 172\n 152\n 168\n 177\n 170\n 181\n Other labs: PT / PTT / INR:12.1/22.1/1.0, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, Albumin:2.7\n g/dL, LDH:203 IU/L, Ca++:8.5 mg/dL, Mg++:1.7 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status readmitted with\n acute hypercarbic respiratory failure secondary. Found to have a\n tracheal tear and paralyzed right HD. She is status post trach this\n admission.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC Central and paralyzed right HD\n -Acute on chronic hypercarbic respiratory failure - likely OSA, ?OHS,\n ?element central\n -wean vent as tolerated failing SBT would try to optimize her volume\n status and trial of PS sitting up.\n -Continue diuresis until BUN/Cr bump\n -Would consider giving diamox to help with contraction and to spill\n retained bicarb to help her breath.\nTracheal tear\n -presumably occurred during intubation at start of prior admission\n -IP following\n -trach in place to bypass injured area will need 6-8 weeks to heal\n -empiric abx coverage inc anti-fungal coverage 10 days of coverage\n hypoxemia\n -suspect atelectasis/failure/hypoventilation given she is back to her\n baseline.\n -Will diuresis\n ? Hilar fullness on CT-Repeat CT when stable withing next months.\n -Placed in discharge summary\n HYPERTENSION\n -cont enalapril to 30mg qday\n -Continue Beta blocker\n -Cont hydralazine to 25mg qid\n -Will start lasix with goal negative fluid balance 500cc-1L negative.\n Will also help with BP.\n DIABETES MELLITUS (DM), TYPE II:\n -SSRI\nFever-Pan culture-Resolved\n -new\n -is post trach placement which could be explanation\n -already on fluc and unasyn for trach/upper trachea tear proph\nMental status\n -very alert & interactive this morning intermittently confused\n -Consider Haldol will follow closely.\n -review medications consider hold fentanyl although no change since she\n did not receive a dose\n -wean sedation as tolerated\n Remainder of plan per resident note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ hep\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Transfer to rehab center.\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671580,
"text": "Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan.\n 24 Hour Events:\n Negative US for DVT\n Back to baseline fi02\n Hx of chronic right hemi diaphragm paralysisper patient unable to\n locate records\n started on lasix drip\n ULTRASOUND - At 11:29 AM\n LENI to r/o dvt\n ULTRASOUND - At 03:19 PM\n chest usg to assess the diaphragm\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n # 6 Fluconazole - 08:27 PM\n # 6 Ampicillin/Sulbactam (Unasyn) - 09:52 AM\n Ampicillin - 04:10 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Hydralazine - 06:30 AM\n Lansoprazole (Prevacid) - 08:23 AM\n Heparin Sodium (Prophylaxis) - 08:23 AM\n Other medications:\n Levetiracetam 500 po bid\n Metoprolol 25 po bid\n Vit K x 3 doses\n Enalapril 30mg po qday\n Hydralazine 25mg po qid\n Senna\n Docusate\n Insulin\n Lantoprost\n Brimonidine\n Simvistatin\n Hep SQ tid\n Changes to medical and family history:\n Hx of paralyzed right HD.\n Review of systems is unchanged from admission except as noted below\n Review of systems:see resident note no acute issues.\n Flowsheet Data as of 09:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.3\nC (99.2\n HR: 76 (55 - 79) bpm\n BP: 186/52(84) {115/42(61) - 186/74(87)} mmHg\n RR: 21 (15 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 3,612 mL\n 976 mL\n PO:\n TF:\n 1,652 mL\n 662 mL\n IVF:\n 1,200 mL\n 194 mL\n Blood products:\n Total out:\n 2,675 mL\n 1,200 mL\n Urine:\n 2,675 mL\n 950 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n 937 mL\n -224 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 633 (633 - 633) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/65/126/37/14\n Ve: 7.2 L/min\n PaO2 / FiO2: 315\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trach\n Neck: JVP earlobe\n Cardiovascular: RRR s1s2 no m/r/g\n Respiratory / Chest: Course BS ant/post no bronchial BS noted\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: no rash or erythema\n Ext: + edema\n Neurologic: Attentive, A+O x 3 no gross motor sensory deficits.\n Lines: Clean dry intact.\n Skin: Not assessed\n Labs / Radiology: trach in place and NG in place Low lung volumes small\n effusions and plum vasculature\n 8.0 g/dL\n 255 K/uL\n 168 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 102 mEq/L\n 144 mEq/L\n 25.4 %\n 4.4 K/uL\n [image002.jpg]\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n 01:04 PM\n 06:05 PM\n 04:49 AM\n 07:19 AM\n WBC\n 4.3\n 6.1\n 3.4\n 4.4\n Hct\n 24.5\n 23\n 24.9\n 20.0\n 25.4\n Plt\n 181\n 235\n 194\n 255\n Cr\n 0.3\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 37\n 38\n 37\n 44\n Glucose\n 122\n 152\n 169\n 172\n 152\n 168\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, Albumin:2.7\n g/dL, LDH:203 IU/L, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL, PO4:1.3 mg/dL BNP\n 1874\n Micro-no new micro\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status readmitted with\n acute hypercarbic respiratory failure secondary. Found to have a\n tracheal tear and paralyzed right HD. She is status post trach this\n admission.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC Central and paralyzed right HD\n -Acute on chronic hypercarbic respiratory failure - likely OSA, ?OHS,\n ?element central\n -wean vent as tolerated change to PS today\nTracheal tear\n -presumably occurred during intubation at start of prior admission\n -IP following\n -trach in place to bypass injured area will need 6-8 weeks to heal\n -empiric abx coverage inc anti-fungal coverage 10 days of coverage\n hypoxemia\n -suspect atelectasis/failure given she is back to her baseline.\n -Will diuresis\n HYPERTENSION\n -Will increase enalapril to 30mg qday\n -Continue Beta blocker\n -hydralazine increase to 25mg qid\n -Will start lasix with goal negative fluid balance 500cc-1L negative.\n Will also help with BP.\n DIABETES MELLITUS (DM), TYPE II:\n -SSRI\nFever-Pan culture-Resolved\n -new\n -is post trach placement which could be explanation\n -already on fluc and unasyn for trach/upper trachea tear proph\nMental status\n -very alert & interactive this morning intermittently confused\n -Consider Haldol will follow closely.\n -review medications consider hold fentanyl although no change since she\n did not receive a dose\n -wean sedation as tolerated\n Remainder of plan per resident note\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:47 AM 70 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: Boots Hep SQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Screen for pulm rehab.\n Total time spent:\n ------ Protected Section ------\n Attending Note: Attending Note:\n I was physically present with the resident team and independently\n examined the patient on this date. I agree with the findings as\n described above including history, exam, ROS, Fam Hx and assessment and\n plan. I would add/emphasize the following:\n Stable overnight. LENIs were negative. LOS 8 L positive and mild\n increase in pulmonary edema on today\ns CXR.\n Started on Lasix drip. Currently 300 ml positive today.\n Plan is to retry PSV. She will likely be transferred to rehab\n in AM.\n Time 35 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:05 ------\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671560,
"text": "Hypertension, benign\n Assessment:\n Pt has been hypertensive to 180\ns last few days,HR 50-70 sinus now,h/o\n a fib ,pt has been agitated intermittently\n Action:\n Contd hydralazine,metoprolol and enalapril,also recvd lasix 40 mg iv x1\n Response:\n Most of the day sbp 110-150,1 of sbp 175 which was right\n recorded during the time of suctioning,pt was very somnolent in the\n beginning of the shift (post haldol) and started getting agitated aroud\n 0930am,a wrist restraint has been applied to protect the tubes and\n lines which infact worsen her agitation,pt is alert and oriented x3,but\n gets confused intermittently,doing well off restraints\n Plan:\n Monitor BP, cont standing IV hydral, goal diuresis 1L neg,will hold off\n fentanyl.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 100% +10peep. Lung sounds\n ronchorous .Sxn for thick white/yellow secretions. Q2-3 hrs;no\n desating,gets resp distress that easily clears with suction ,BNP 1820.\n Action:\n Fi02 weaned to 40%,chest USG to assess the diaphragm,recvd Lasix 40mg\n iv,A leni has been done to r/o DVT\n Response:\n sats 94-100%,no episode of acute desating,chest usg s/o rt\n diaphragmatic paralysis,Tv 100-600cc.\n Plan:\n Cont to wean as tolerated,goal fluid balance 1L neg,vent rehab screen\n ongoing..\n Others:recevd 40 meq K this am for k 3.5.Rpt level pending\n Tolerating the tube feed @goal.\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671725,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin - 04:10 AM\n Ampicillin/Sulbactam (Unasyn) - 04:17 AM\n Infusions:\n Furosemide (Lasix) - 8 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 AM\n Lansoprazole (Prevacid) - 07:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.2\nC (98.9\n HR: 76 (60 - 80) bpm\n BP: 157/47(74) {108/39(56) - 170/76(87)} mmHg\n RR: 20 (12 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 3,504 mL\n 986 mL\n PO:\n TF:\n 1,684 mL\n 575 mL\n IVF:\n 860 mL\n 351 mL\n Blood products:\n Total out:\n 3,700 mL\n 2,045 mL\n Urine:\n 3,450 mL\n 2,045 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -196 mL\n -1,059 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 404 (355 - 404) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: 7.48/54/78./39/14\n Ve: 7.7 L/min\n PaO2 / FiO2: 197\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.1 g/dL\n 286 K/uL\n 181 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 4.1 mEq/L\n 9 mg/dL\n 99 mEq/L\n 142 mEq/L\n 25.3 %\n 5.4 K/uL\n [image002.jpg]\n 09:05 PM\n 03:45 AM\n 01:04 PM\n 06:05 PM\n 04:49 AM\n 07:19 AM\n 02:44 PM\n 05:07 PM\n 12:01 AM\n 05:38 AM\n WBC\n 6.1\n 3.4\n 4.4\n 5.4\n Hct\n 23\n 24.9\n 20.0\n 25.4\n 25.3\n Plt\n 235\n 194\n 255\n 286\n Cr\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.5\n TCO2\n 37\n 44\n 41\n Glucose\n 169\n 172\n 152\n 168\n 177\n 170\n 181\n Other labs: PT / PTT / INR:12.1/22.1/1.0, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, Albumin:2.7\n g/dL, LDH:203 IU/L, Ca++:8.5 mg/dL, Mg++:1.7 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671726,
"text": "Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan.\n 24 Hour Events:\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin - 04:10 AM\n Ampicillin/Sulbactam (Unasyn) - 04:17 AM\n Infusions:\n Furosemide (Lasix) - 8 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 AM\n Lansoprazole (Prevacid) - 07:50 AM\n Other medications:\n Levetiracetam 500 po bid\n Metoprolol 25 po bid\n Vit K x 3 doses\n Enalapril 30mg po qday\n Hydralazine 25mg po qid\n Senna\n Docusate\n Insulin\n Lantoprost\n Brimonidine\n Simvistatin\n Hep SQ tid\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.2\nC (98.9\n HR: 76 (60 - 80) bpm\n BP: 157/47(74) {108/39(56) - 170/76(87)} mmHg\n RR: 20 (12 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 3,504 mL\n 986 mL\n PO:\n TF:\n 1,684 mL\n 575 mL\n IVF:\n 860 mL\n 351 mL\n Blood products:\n Total out:\n 3,700 mL\n 2,045 mL\n Urine:\n 3,450 mL\n 2,045 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -196 mL\n -1,059 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 404 (355 - 404) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: 7.48/54/78./39/14\n Ve: 7.7 L/min\n PaO2 / FiO2: 197\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trach\n Neck: JVP earlobe\n Cardiovascular: RRR s1s2 no m/r/g\n Respiratory / Chest: Course BS ant/post no bronchial BS noted\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: no rash or erythema\n Ext: + edema\n Neurologic: Attentive, A+O x 3 no gross motor sensory deficits.\n Lines: Clean dry intact.\n Skin: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 286 K/uL\n 181 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 4.1 mEq/L\n 9 mg/dL\n 99 mEq/L\n 142 mEq/L\n 25.3 %\n 5.4 K/uL\n [image002.jpg]\n 09:05 PM\n 03:45 AM\n 01:04 PM\n 06:05 PM\n 04:49 AM\n 07:19 AM\n 02:44 PM\n 05:07 PM\n 12:01 AM\n 05:38 AM\n WBC\n 6.1\n 3.4\n 4.4\n 5.4\n Hct\n 23\n 24.9\n 20.0\n 25.4\n 25.3\n Plt\n 235\n 194\n 255\n 286\n Cr\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.5\n TCO2\n 37\n 44\n 41\n Glucose\n 169\n 172\n 152\n 168\n 177\n 170\n 181\n Other labs: PT / PTT / INR:12.1/22.1/1.0, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, Albumin:2.7\n g/dL, LDH:203 IU/L, Ca++:8.5 mg/dL, Mg++:1.7 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status readmitted with\n acute hypercarbic respiratory failure secondary. Found to have a\n tracheal tear and paralyzed right HD. She is status post trach this\n admission.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC Central and paralyzed right HD\n -Acute on chronic hypercarbic respiratory failure - likely OSA, ?OHS,\n ?element central\n -wean vent as tolerated change to PS today\nTracheal tear\n -presumably occurred during intubation at start of prior admission\n -IP following\n -trach in place to bypass injured area will need 6-8 weeks to heal\n -empiric abx coverage inc anti-fungal coverage 10 days of coverage\n hypoxemia\n -suspect atelectasis/failure given she is back to her baseline.\n -Will diuresis\n HYPERTENSION\n -Will increase enalapril to 30mg qday\n -Continue Beta blocker\n -hydralazine increase to 25mg qid\n -Will start lasix with goal negative fluid balance 500cc-1L negative.\n Will also help with BP.\n DIABETES MELLITUS (DM), TYPE II:\n -SSRI\nFever-Pan culture-Resolved\n -new\n -is post trach placement which could be explanation\n -already on fluc and unasyn for trach/upper trachea tear proph\nMental status\n -very alert & interactive this morning intermittently confused\n -Consider Haldol will follow closely.\n -review medications consider hold fentanyl although no change since she\n did not receive a dose\n -wean sedation as tolerated\n Remainder of plan per resident note\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671734,
"text": "Chief Complaint:\n 24 Hour Events:\n - increased hydral and enalapril for good BP control\n - failed another PS trial after 3-4hrs with ABG at end 7.48/55/78.\n After 4 hrs, she was noted to have desat to 80's with reduced tidal\n volumes despite increasing PEEP to 15. CXR -> unchanged and pt put back\n on AC\n - lasix gtt started\n - plan for d/c to at 10 AM\n - ? pt's left hilar mass needs f/u CT\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin - 04:10 AM\n Ampicillin/Sulbactam (Unasyn) - 04:17 AM\n Infusions:\n Furosemide (Lasix) - 8 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:23 AM\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 36.9\nC (98.5\n HR: 79 (60 - 80) bpm\n BP: 142/45(68) {108/39(56) - 186/76(87)} mmHg\n RR: 21 (12 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 3,504 mL\n 873 mL\n PO:\n TF:\n 1,684 mL\n 533 mL\n IVF:\n 860 mL\n 340 mL\n Blood products:\n Total out:\n 3,700 mL\n 2,045 mL\n Urine:\n 3,450 mL\n 2,045 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -196 mL\n -1,172 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 404 (355 - 404) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.48/54/78./39/14\n Ve: 5.1 L/min\n PaO2 / FiO2: 197\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 286 K/uL\n 8.1 g/dL\n 181 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 4.1 mEq/L\n 9 mg/dL\n 99 mEq/L\n 142 mEq/L\n 25.3 %\n 5.4 K/uL\n [image002.jpg]\n 09:05 PM\n 03:45 AM\n 01:04 PM\n 06:05 PM\n 04:49 AM\n 07:19 AM\n 02:44 PM\n 05:07 PM\n 12:01 AM\n 05:38 AM\n WBC\n 6.1\n 3.4\n 4.4\n 5.4\n Hct\n 23\n 24.9\n 20.0\n 25.4\n 25.3\n Plt\n 235\n 194\n 255\n 286\n Cr\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.5\n TCO2\n 37\n 44\n 41\n Glucose\n 169\n 172\n 152\n 168\n 177\n 170\n 181\n Other labs: PT / PTT / INR:12.1/22.1/1.0, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, Albumin:2.7\n g/dL, LDH:203 IU/L, Ca++:8.5 mg/dL, Mg++:1.7 mg/dL, PO4:1.7 mg/dL\n Imaging: CXR:\n Interval improvement in aeration of the lung bases bilaterally, with\n mild\n residual bibasilar opacities, may reflect atelectasis. There is\n persistent\n elevation of the right hemidiaphragm. Vague opacity is seen in the\n right mid\n lung, may reflect atelectasis; though, developing consolidation can't\n be\n excluded. NG tube partially coiled in stomch, unchanged. -jkang.\n Microbiology: BCX: NGTD\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Respiratory failure: . Patient remains on vent and has failed SBT.\n Currently appears to be component of hypercarbic resp failure likely\n from cental apnea as well as mild pulm edema. Furthermore, she has\n mechanical deficits with chronic R hemidiaphragm. In addition, pt has\n had hypoxia as well. Hypoxia may be atelecatsis or vol overload; PE\n in differential but hypoxia does improve with PEEP which would not be\n consistent with PE. LENI on neg for DVT. Her resp issues are\n likely a combination of OSA, CO2 retention and her hospital course has\n also been complicated by right lung collapse, R mainstem intubation.\n - try another pressure support trial today\n - goal I/O 1-2L neg today with lasix drip\n - continue flovent, albuterol, atrovent\n - LENI\ns neg for DVT\n # Hct drop: Hct from 24 to 20 this morning; however, all other cell\n lines are slightly down as well. She has been hemodynamically stable\n and no reports of bleeding. I suspect dilutional\n - repeat CBC\n - if persistant, guaiac all stools, transfuse for HCT<21\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - continue to try PS trials, although continues to become hypercarbic\n likely central apnea\n - if does well try Passey-Muir valve\n - continue Unasyn () and Fluconazole () for ppx for tracheal\n tear for goal 10 day course\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns, but had an\n episode of afib with RVR last night.\n - BB restarted\n - coumadin being held given recent hemorrhage\n - not on asa left temporal hemorrhage\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - increase enalapril and hydralazine\n # Altered mental status\n Has been improved, but still frequently\n confused. h/o SAH/IPH, but now unclear etiology as no clear\n complaints. Likely hemorrage, prior hypoglycemic coma from which\n she did not recover and ICU delirium. Head CT unchanged, Chest CTA w/o\n PE, no evidence of MI, TTE w/ nl EF, UA unremarkable.\n - haldol\n - if more confused will decrease fentanyl\n # Hypernatremia: sodium cont to be elevated\n - continue free water flushes 250 cc Q4H\n # Fevers: no further fevers, cultures have been negative, c.diff neg on\n unasyn and fluconazole ppx for traceal tear\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:56 PM 70 mL/hour\n Glycemic Control: Insulin\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQH, boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: D/C to rehab today\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671735,
"text": "Chief Complaint:\n 24 Hour Events:\n - increased hydral and enalapril for good BP control\n - failed another PS trial after 3-4hrs with ABG at end 7.48/55/78.\n After 4 hrs, she was noted to have desat to 80's with reduced tidal\n volumes despite increasing PEEP to 15. CXR -> unchanged and pt put back\n on AC\n - lasix gtt started\n - plan for d/c to at 10 AM\n - ? pt's left hilar mass needs f/u CT\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin - 04:10 AM\n Ampicillin/Sulbactam (Unasyn) - 04:17 AM\n Infusions:\n Furosemide (Lasix) - 8 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:23 AM\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 36.9\nC (98.5\n HR: 79 (60 - 80) bpm\n BP: 142/45(68) {108/39(56) - 186/76(87)} mmHg\n RR: 21 (12 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 3,504 mL\n 873 mL\n PO:\n TF:\n 1,684 mL\n 533 mL\n IVF:\n 860 mL\n 340 mL\n Blood products:\n Total out:\n 3,700 mL\n 2,045 mL\n Urine:\n 3,450 mL\n 2,045 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -196 mL\n -1,172 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 404 (355 - 404) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.48/54/78./39/14\n Ve: 5.1 L/min\n PaO2 / FiO2: 197\n Physical Examination\n GEN: pleasant, awake, slightly confused but conversational\n HEENT: PERRL, EOM intact, MMM\n Neck: JVP at earlobe, tach in place w/o erythema or swelling\n PULM: clear ant and laterally\n Heart: RRR, no murmurs\n ABD: soft, obese, normal BS\n EXT: 3+ pitting edema\n Labs / Radiology\n 286 K/uL\n 8.1 g/dL\n 181 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 4.1 mEq/L\n 9 mg/dL\n 99 mEq/L\n 142 mEq/L\n 25.3 %\n 5.4 K/uL\n [image002.jpg]\n 09:05 PM\n 03:45 AM\n 01:04 PM\n 06:05 PM\n 04:49 AM\n 07:19 AM\n 02:44 PM\n 05:07 PM\n 12:01 AM\n 05:38 AM\n WBC\n 6.1\n 3.4\n 4.4\n 5.4\n Hct\n 23\n 24.9\n 20.0\n 25.4\n 25.3\n Plt\n 235\n 194\n 255\n 286\n Cr\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.5\n TCO2\n 37\n 44\n 41\n Glucose\n 169\n 172\n 152\n 168\n 177\n 170\n 181\n Other labs: PT / PTT / INR:12.1/22.1/1.0, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, Albumin:2.7\n g/dL, LDH:203 IU/L, Ca++:8.5 mg/dL, Mg++:1.7 mg/dL, PO4:1.7 mg/dL\n Imaging: CXR:\n Interval improvement in aeration of the lung bases bilaterally, with\n mild\n residual bibasilar opacities, may reflect atelectasis. There is\n persistent\n elevation of the right hemidiaphragm. Vague opacity is seen in the\n right mid\n lung, may reflect atelectasis; though, developing consolidation can't\n be\n excluded. NG tube partially coiled in stomch, unchanged. -jkang.\n Microbiology: BCX: NGTD\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Respiratory failure: . Patient remains on vent and has failed SBT.\n Currently appears to be component of hypercarbic resp failure likely\n from cental apnea as well as mild pulm edema. Furthermore, she has\n mechanical deficits with chronic R hemidiaphragm. In addition, pt has\n had hypoxia as well. Hypoxia may be atelecatsis or vol overload; PE\n in differential but hypoxia does improve with PEEP which would not be\n consistent with PE. LENI on neg for DVT. Her resp issues are\n likely a combination of OSA, CO2 retention and her hospital course has\n also been complicated by right lung collapse, R mainstem intubation.\n - try another pressure support trial today\n - goal I/O 1-2L neg today with lasix drip\n - continue flovent, albuterol, atrovent\n # Hct drop: Hct from 24 to 20 this morning; however, all other cell\n lines are slightly down as well. She has been hemodynamically stable\n and no reports of bleeding. I suspect dilutional\n - repeat CBC\n - if persstant, guaiac all stools, transfuse for HCT<21\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - continue to try PS trials, although continues to become hypercarbic\n likely central apnea\n - if does well try Passey-Muir valve\n - continue Unasyn () and Fluconazole () for ppx for tracheal\n tear for goal 10 day course to end on \n #Paroxysmal Atrial fibrillation: HR currently in 60\ns, but had an\n episode of afib with RVR last night.\n - BB restarted\n - coumadin being held given recent hemorrhage\n - not on asa left temporal hemorrhage\n # HTN\n BP variable , Previously needed nitro drip fro SBP 220\ns but\n has improved with enalapril and hydralazine once NGT was placed\n - cont enalapril and hydralazine\n # Altered mental status\n Has been improved, but still frequently\n confused. h/o SAH/IPH, but now unclear etiology as no clear\n complaints. Likely hemorrage, prior hypoglycemic coma from which\n she did not recover and ICU delirium. Head CT unchanged, Chest CTA w/o\n PE, no evidence of MI, TTE w/ nl EF, UA unremarkable.\n - haldol\n - if more confused will decrease fentanyl\n # Hypernatremia: sodium cont to be elevated\n - continue free water flushes 250 cc Q4\n # Fevers: no further fevers, cultures have been negative, c.diff neg on\n unasyn and fluconazole ppx for traceal tear\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:56 PM 70 mL/hour\n Glycemic Control: Insulin\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQH, boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: D/C to rehab today\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671737,
"text": "Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan.\n 24 Hour Events: increased hydralazine and enalapril yesterday\n PS 15/10 trial 7.48/55/78 desated to 80\ns after 4 hours intial TV\n were in 350-400 and she dropped her volumes to less that 300.\n Lasix drip started and negative this morning.\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin - 04:10 AM\n Ampicillin/Sulbactam (Unasyn) - 04:17 AM\n Infusions:\n Furosemide (Lasix) - 8 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 AM\n Lansoprazole (Prevacid) - 07:50 AM\n Other medications:\n Levetiracetam 500 po bid\n Metoprolol 25 po bid\n Pyridium finished\n Enalapril 30mg po qday\n Hydralazine 25mg po qid\n Senna\n Docusate\n Insulin\n Lantoprost\n Brimonidine\n Simvistatin\n Hep SQ tid\n Changes to medical and family history:\n No changes see H+P\n Review of systems is unchanged from admission except as noted below\n Review of systems:No complaints\n Flowsheet Data as of 08:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.2\nC (98.9\n HR: 76 (60 - 80) bpm\n BP: 157/47(74) {108/39(56) - 170/76(87)} mmHg\n RR: 20 (12 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 3,504 mL\n 986 mL\n PO:\n TF:\n 1,684 mL\n 575 mL\n IVF:\n 860 mL\n 351 mL\n Blood products:\n Total out:\n 3,700 mL\n 2,045 mL\n Urine:\n 3,450 mL\n 2,045 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -196 mL\n -1,059 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 404 (355 - 404) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: 7.48/54/78./39/14\n Ve: 7.7 L/min\n PaO2 / FiO2: 197\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trach\n Neck: JVP earlobe\n Cardiovascular: RRR s1s2 no m/r/g\n Respiratory / Chest: Course BS ant/post no bronchial BS noted\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: no rash or erythema\n Ext: + edema\n Neurologic: Attentive, A+O x 3 no gross motor sensory deficits.\n Lines: Clean dry intact.\n Skin: Not assessed\n Labs / Radiology: Chest decreased effusions.\n 8.1 g/dL\n 286 K/uL\n 181 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 4.1 mEq/L\n 9 mg/dL\n 99 mEq/L\n 142 mEq/L\n 25.3 %\n 5.4 K/uL\n [image002.jpg]\n 09:05 PM\n 03:45 AM\n 01:04 PM\n 06:05 PM\n 04:49 AM\n 07:19 AM\n 02:44 PM\n 05:07 PM\n 12:01 AM\n 05:38 AM\n WBC\n 6.1\n 3.4\n 4.4\n 5.4\n Hct\n 23\n 24.9\n 20.0\n 25.4\n 25.3\n Plt\n 235\n 194\n 255\n 286\n Cr\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.5\n TCO2\n 37\n 44\n 41\n Glucose\n 169\n 172\n 152\n 168\n 177\n 170\n 181\n Other labs: PT / PTT / INR:12.1/22.1/1.0, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, Albumin:2.7\n g/dL, LDH:203 IU/L, Ca++:8.5 mg/dL, Mg++:1.7 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status readmitted with\n acute hypercarbic respiratory failure secondary. Found to have a\n tracheal tear and paralyzed right HD. She is status post trach this\n admission.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC Central and paralyzed right HD\n -Acute on chronic hypercarbic respiratory failure - likely OSA, ?OHS,\n ?element central\n -wean vent as tolerated failing SBT would try to optimize her volume\n status and trial of PS sitting up.\n -Continue diuresis until BUN/Cr bump\n -Would consider giving diamox to help with contraction and to spill\n retained bicarb to help her breath.\nTracheal tear\n -presumably occurred during intubation at start of prior admission\n -IP following\n -trach in place to bypass injured area will need 6-8 weeks to heal\n -empiric abx coverage inc anti-fungal coverage 10 days of coverage\n hypoxemia\n -suspect atelectasis/failure/hypoventilation given she is back to her\n baseline.\n -Will diuresis\n ? Hilar fullness on CT-Repeat CT when stable withing next months.\n -Placed in discharge summary\n HYPERTENSION\n -cont enalapril to 30mg qday\n -Continue Beta blocker\n -Cont hydralazine to 25mg qid\n -Will start lasix with goal negative fluid balance 500cc-1L negative.\n Will also help with BP.\n DIABETES MELLITUS (DM), TYPE II:\n -SSRI\nFever-Pan culture-Resolved\n -new\n -is post trach placement which could be explanation\n -already on fluc and unasyn for trach/upper trachea tear proph\nMental status\n -very alert & interactive this morning intermittently confused\n -Consider Haldol will follow closely.\n -review medications consider hold fentanyl although no change since she\n did not receive a dose\n -wean sedation as tolerated\n Remainder of plan per resident note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ hep\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Transfer to rehab center.\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 671555,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Patient on & off Non-Invasive ventilation. Last ABG\n 7.26-61-105-0-91% ON 40% Cool mist. . Nasally suctioned 3 times during\n day shift for moderate amount of secretion .Will be using NIV\n intermittently as needed.\n"
},
{
"category": "Case Management ",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Case Management Discharge Plan",
"row_id": 671563,
"text": "TITLE: Discharge Plan\n Case Management\n has offered a bed for Wednesday, . They\n would like the patient to leave no later than 10 AM. A discharge\n summary as well as Pages 1, 2 and 3 of the patient care referral form\n should accompany the patient. In addition, the discharging nurse\n should call the nursing unit at -Kapln to give a\n nurse-to-nurse report. The number on that unit is . NCM\n has notified the patient's husband of the likely transfer on .\n Please page at # for any questions or concerns.\n , RN, BSN\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671623,
"text": "Hypertension, benign\n Assessment:\n Known hypertensive,max sbp up to 180\ns ,hr 60-70\ns sinus.\n Action:\n Increased hydralazine,enalapril,contd lopressor started on Lasix drip.\n Response:\n Sbp started trending down post Lasix drip/increased dose of meds,pt\n gets anxious and tearful at times,no pain,pt seems more oriented and\n appropriate.\n Plan:\n Monitor BP, cont the current management,goal fluid balance 1-2 l neg\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +10peep. Lung sounds\n ronchorous .Sxn for thick white/yellow secretions. Q2-3 hrs;no\n desating,gets resp distress that easily clears with suction ,cxr more\n pul edema picture,chest ultrasound shows rt diaphragmatic paralysis\n Action:\n Weaned to cpap/psv,started on Lasix drip,suctioned as needed\n Response:\n Currently satting 93-97% on this setting,sats improoved post\n suctioning,fluid balance is even,Lasix drip titrated,abg shows ph 7.48\n pco2 54\n Plan:\n Cont to wean as tolerated,goal fluid balance 1-2L neg,pt has bed\n available at rehab for tomarrow @10am\n Others:\n recevd 40 meq K this am for k 3.3Rpt k levl 3.9,lext lab due at 2100\n hrs\n Tolerating the tube feed @goal.\n Na stable at 144,on 250cc free water q6h.\n Huband was at bedside afternoon,updated by MD and this RN\n ------ Protected Section ------\n Pt desatted to 80\ns(lowest noted 86%,suctioned few times didn\nt improve\n the oxygenation,currently in 89-91% on the same settings,need stat\n CXR,radiology called and informed.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:01 ------\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671715,
"text": "Chief Complaint:\n 24 Hour Events:\n - increased hydral and enalapril for good BP control\n - tolerated another PS trial, 3hrs with ABG at end 7.48/55/78. After 4\n hrs, she was noted to have desat to 80's despite increaing PEEP to 15.\n CXR -> unchanged and pt put back on AC\n - lasix gtt started\n - plan for d/c to at 10 AM\n - ? pt's left hilar mass needs f/u CT\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin - 04:10 AM\n Ampicillin/Sulbactam (Unasyn) - 04:17 AM\n Infusions:\n Furosemide (Lasix) - 8 mg/hour\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:23 AM\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 36.9\nC (98.5\n HR: 79 (60 - 80) bpm\n BP: 142/45(68) {108/39(56) - 186/76(87)} mmHg\n RR: 21 (12 - 28) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 3,504 mL\n 873 mL\n PO:\n TF:\n 1,684 mL\n 533 mL\n IVF:\n 860 mL\n 340 mL\n Blood products:\n Total out:\n 3,700 mL\n 2,045 mL\n Urine:\n 3,450 mL\n 2,045 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n -196 mL\n -1,172 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 404 (355 - 404) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 22 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.48/54/78./39/14\n Ve: 5.1 L/min\n PaO2 / FiO2: 197\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 286 K/uL\n 8.1 g/dL\n 181 mg/dL\n 0.5 mg/dL\n 39 mEq/L\n 4.1 mEq/L\n 9 mg/dL\n 99 mEq/L\n 142 mEq/L\n 25.3 %\n 5.4 K/uL\n [image002.jpg]\n 09:05 PM\n 03:45 AM\n 01:04 PM\n 06:05 PM\n 04:49 AM\n 07:19 AM\n 02:44 PM\n 05:07 PM\n 12:01 AM\n 05:38 AM\n WBC\n 6.1\n 3.4\n 4.4\n 5.4\n Hct\n 23\n 24.9\n 20.0\n 25.4\n 25.3\n Plt\n 235\n 194\n 255\n 286\n Cr\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n 0.5\n TCO2\n 37\n 44\n 41\n Glucose\n 169\n 172\n 152\n 168\n 177\n 170\n 181\n Other labs: PT / PTT / INR:12.1/22.1/1.0, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, Albumin:2.7\n g/dL, LDH:203 IU/L, Ca++:8.5 mg/dL, Mg++:1.7 mg/dL, PO4:1.7 mg/dL\n Imaging: CXR:\n Interval improvement in aeration of the lung bases bilaterally, with\n mild\n residual bibasilar opacities, may reflect atelectasis. There is\n persistent\n elevation of the right hemidiaphragm. Vague opacity is seen in the\n right mid\n lung, may reflect atelectasis; though, developing consolidation can't\n be\n excluded. NG tube partially coiled in stomch, unchanged. -jkang.\n Microbiology: BCX: NGTD\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Respiratory failure: . Patient remains on vent and has failed SBT.\n Currently appears to be component of hypercarbic resp failure likely\n from cental apnea as well as mild pulm edema. Furthermore, she has\n mechanical deficits with chronic R hemidiaphragm. In addition, pt has\n had hypoxia as well. Hypoxia may be atelecatsis or vol overload; PE\n in differential but hypoxia does improve with PEEP which would not be\n consistent with PE. LENI on neg for DVT. Her resp issues are\n likely a combination of OSA, CO2 retention and her hospital course has\n also been complicated by right lung collapse, R mainstem intubation.\n - try another pressure support trial today\n - goal I/O 1-2L neg today with lasix drip\n - continue flovent, albuterol, atrovent\n - LENI\ns neg for DVT\n # Hct drop: Hct from 24 to 20 this morning; however, all other cell\n lines are slightly down as well. She has been hemodynamically stable\n and no reports of bleeding. I suspect dilutional\n - repeat CBC\n - if persistant, guaiac all stools, transfuse for HCT<21\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - continue to try PS trials, although continues to become hypercarbic\n likely central apnea\n - if does well try Passey-Muir valve\n - continue Unasyn () and Fluconazole () for ppx for tracheal\n tear for goal 10 day course\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns, but had an\n episode of afib with RVR last night.\n - BB restarted\n - coumadin being held given recent hemorrhage\n - not on asa left temporal hemorrhage\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - increase enalapril and hydralazine\n # Altered mental status\n Has been improved, but still frequently\n confused. h/o SAH/IPH, but now unclear etiology as no clear\n complaints. Likely hemorrage, prior hypoglycemic coma from which\n she did not recover and ICU delirium. Head CT unchanged, Chest CTA w/o\n PE, no evidence of MI, TTE w/ nl EF, UA unremarkable.\n - haldol\n - if more confused will decrease fentanyl\n # Hypernatremia: sodium cont to be elevated\n - continue free water flushes 250 cc Q4H\n # Fevers: no further fevers, cultures have been negative, c.diff neg on\n unasyn and fluconazole ppx for traceal tear\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:56 PM 70 mL/hour\n Glycemic Control: Insulin\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQH, boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: D/C to rehab today\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 671622,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason: Elective\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: \n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Patient was on A/C this AM , but changed to PSV this evening\n with good result. Patient became very passive ABG drawn to assess\n hypercapnea. Result ok but patient begins to desaturate about 18.30 CXR\n is ordered. Suctioned for moderate amount of thick clear secretion .\n If CXR not acceptable will switch patient to A/C over night.\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671548,
"text": "Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan.\n 24 Hour Events:\n Negative US for DVT\n Back to baseline fi02\n Hx of chronic right hemi diaphragm paralysisper patient unable to\n locate records\n started on lasix drip\n ULTRASOUND - At 11:29 AM\n LENI to r/o dvt\n ULTRASOUND - At 03:19 PM\n chest usg to assess the diaphragm\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n # 6 Fluconazole - 08:27 PM\n # 6 Ampicillin/Sulbactam (Unasyn) - 09:52 AM\n Ampicillin - 04:10 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Hydralazine - 06:30 AM\n Lansoprazole (Prevacid) - 08:23 AM\n Heparin Sodium (Prophylaxis) - 08:23 AM\n Other medications:\n Levetiracetam 500 po bid\n Metoprolol 25 po bid\n Vit K x 3 doses\n Enalapril 30mg po qday\n Hydralazine 25mg po qid\n Senna\n Docusate\n Insulin\n Lantoprost\n Brimonidine\n Simvistatin\n Hep SQ tid\n Changes to medical and family history:\n Hx of paralyzed right HD.\n Review of systems is unchanged from admission except as noted below\n Review of systems:see resident note no acute issues.\n Flowsheet Data as of 09:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.3\nC (99.2\n HR: 76 (55 - 79) bpm\n BP: 186/52(84) {115/42(61) - 186/74(87)} mmHg\n RR: 21 (15 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 3,612 mL\n 976 mL\n PO:\n TF:\n 1,652 mL\n 662 mL\n IVF:\n 1,200 mL\n 194 mL\n Blood products:\n Total out:\n 2,675 mL\n 1,200 mL\n Urine:\n 2,675 mL\n 950 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n 937 mL\n -224 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 633 (633 - 633) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/65/126/37/14\n Ve: 7.2 L/min\n PaO2 / FiO2: 315\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trach\n Neck: JVP earlobe\n Cardiovascular: RRR s1s2 no m/r/g\n Respiratory / Chest: Course BS ant/post no bronchial BS noted\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: no rash or erythema\n Ext: + edema\n Neurologic: Attentive, A+O x 3 no gross motor sensory deficits.\n Lines: Clean dry intact.\n Skin: Not assessed\n Labs / Radiology: trach in place and NG in place Low lung volumes small\n effusions and plum vasculature\n 8.0 g/dL\n 255 K/uL\n 168 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 102 mEq/L\n 144 mEq/L\n 25.4 %\n 4.4 K/uL\n [image002.jpg]\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n 01:04 PM\n 06:05 PM\n 04:49 AM\n 07:19 AM\n WBC\n 4.3\n 6.1\n 3.4\n 4.4\n Hct\n 24.5\n 23\n 24.9\n 20.0\n 25.4\n Plt\n 181\n 235\n 194\n 255\n Cr\n 0.3\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 37\n 38\n 37\n 44\n Glucose\n 122\n 152\n 169\n 172\n 152\n 168\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, Albumin:2.7\n g/dL, LDH:203 IU/L, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL, PO4:1.3 mg/dL BNP\n 1874\n Micro-no new micro\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status readmitted with\n acute hypercarbic respiratory failure secondary. Found to have a\n tracheal tear and paralyzed right HD. She is status post trach this\n admission.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC Central and paralyzed right HD\n -Acute on chronic hypercarbic respiratory failure - likely OSA, ?OHS,\n ?element central\n -wean vent as tolerated change to PS today\nTracheal tear\n -presumably occurred during intubation at start of prior admission\n -IP following\n -trach in place to bypass injured area will need 6-8 weeks to heal\n -empiric abx coverage inc anti-fungal coverage 10 days of coverage\n hypoxemia\n -suspect atelectasis/failure given she is back to her baseline.\n -Will diuresis\n HYPERTENSION\n -Will increase enalapril to 30mg qday\n -Continue Beta blocker\n -hydralazine increase to 25mg qid\n -Will start lasix with goal negative fluid balance 500cc-1L negative.\n Will also help with BP.\n DIABETES MELLITUS (DM), TYPE II:\n -SSRI\nFever-Pan culture-Resolved\n -new\n -is post trach placement which could be explanation\n -already on fluc and unasyn for trach/upper trachea tear proph\nMental status\n -very alert & interactive this morning intermittently confused\n -Consider Haldol will follow closely.\n -review medications consider hold fentanyl although no change since she\n did not receive a dose\n -wean sedation as tolerated\n Remainder of plan per resident note\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:47 AM 70 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: Boots Hep SQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Screen for pulm rehab.\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671523,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 11:29 AM\n LENI to r/o dvt\n ULTRASOUND - At 03:19 PM\n chest usg to assess the diaphragm\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin/Sulbactam (Unasyn) - 09:52 AM\n Ampicillin - 04:10 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Hydralazine - 06:30 AM\n Lansoprazole (Prevacid) - 08:23 AM\n Heparin Sodium (Prophylaxis) - 08:23 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.3\nC (99.2\n HR: 76 (55 - 79) bpm\n BP: 186/52(84) {115/42(61) - 186/74(87)} mmHg\n RR: 21 (15 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 3,612 mL\n 976 mL\n PO:\n TF:\n 1,652 mL\n 662 mL\n IVF:\n 1,200 mL\n 194 mL\n Blood products:\n Total out:\n 2,675 mL\n 1,200 mL\n Urine:\n 2,675 mL\n 950 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n 937 mL\n -224 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 633 (633 - 633) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/65/126/37/14\n Ve: 7.2 L/min\n PaO2 / FiO2: 315\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.0 g/dL\n 255 K/uL\n 168 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 102 mEq/L\n 144 mEq/L\n 25.4 %\n 4.4 K/uL\n [image002.jpg]\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n 01:04 PM\n 06:05 PM\n 04:49 AM\n 07:19 AM\n WBC\n 4.3\n 6.1\n 3.4\n 4.4\n Hct\n 24.5\n 23\n 24.9\n 20.0\n 25.4\n Plt\n 181\n 235\n 194\n 255\n Cr\n 0.3\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 37\n 38\n 37\n 44\n Glucose\n 122\n 152\n 169\n 172\n 152\n 168\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, Albumin:2.7\n g/dL, LDH:203 IU/L, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:47 AM 70 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671529,
"text": "Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan.\n 24 Hour Events:\n neg DVT\n Back to baseline fi02\n Hx of chronic right hemi diaphragm paralysis\n started on lasix drip\n ULTRASOUND - At 11:29 AM\n LENI to r/o dvt\n ULTRASOUND - At 03:19 PM\n chest usg to assess the diaphragm\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n # 6 Fluconazole - 08:27 PM\n # 6 Ampicillin/Sulbactam (Unasyn) - 09:52 AM\n Ampicillin - 04:10 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Hydralazine - 06:30 AM\n Lansoprazole (Prevacid) - 08:23 AM\n Heparin Sodium (Prophylaxis) - 08:23 AM\n Other medications:\n Changes to medical and family history:\n Hx of paralyzed right HD.\n Review of systems is unchanged from admission except as noted below\n Review of systems:see resident note no acute issues.\n Flowsheet Data as of 09:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.3\nC (99.2\n HR: 76 (55 - 79) bpm\n BP: 186/52(84) {115/42(61) - 186/74(87)} mmHg\n RR: 21 (15 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 3,612 mL\n 976 mL\n PO:\n TF:\n 1,652 mL\n 662 mL\n IVF:\n 1,200 mL\n 194 mL\n Blood products:\n Total out:\n 2,675 mL\n 1,200 mL\n Urine:\n 2,675 mL\n 950 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n 937 mL\n -224 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 633 (633 - 633) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/65/126/37/14\n Ve: 7.2 L/min\n PaO2 / FiO2: 315\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trach\n Neck: JVP earlobe\n Cardiovascular: RRR s1s2 no m/r/g\n Respiratory / Chest: Course BS ant/post no bronchial BS noted\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: no rash or erythema\n Ext: + edema\n Neurologic: Attentive, A+O x 3 no gross motor sensory deficits.\n Lines: Clean dry intact.\n Skin: Not assessed\n Labs / Radiology: trach in place and NG in place Low lung volumes small\n effusions and plum vasculature\n 8.0 g/dL\n 255 K/uL\n 168 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 102 mEq/L\n 144 mEq/L\n 25.4 %\n 4.4 K/uL\n [image002.jpg]\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n 01:04 PM\n 06:05 PM\n 04:49 AM\n 07:19 AM\n WBC\n 4.3\n 6.1\n 3.4\n 4.4\n Hct\n 24.5\n 23\n 24.9\n 20.0\n 25.4\n Plt\n 181\n 235\n 194\n 255\n Cr\n 0.3\n 0.4\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 37\n 38\n 37\n 44\n Glucose\n 122\n 152\n 169\n 172\n 152\n 168\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, Albumin:2.7\n g/dL, LDH:203 IU/L, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL, PO4:1.3 mg/dL BNP\n 1874\n Micro-no new micro\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure secondary to tracheal tear,\n S/P trach.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC Central and paralyzed right HD\n -Acute on chronic hypercarbic respiratory failure - likely OSA, ?OHS,\n ?element central\n -wean vent as tolerated change to PS today\nTracheal tear\n -presumably occurred during intubation at start of prior admission\n -IP following\n -trach in place to bypass injured area will need 6-8 weeks to heal\n -empiric abx coverage inc anti-fungal coverage 10 days of coverage\n hypoxemia\n -suspect atelectasis/failure given she is back to her baseline.\n -Will diuresis\n HYPERTENSION\n -Will increase enalapril to 30mg qday\n -Continue Beta blocker\n -hydralazine increase to 15mg qid\n -Will start lasix with goal negative fluid balance 500cc-1L negative\n Will also help with BP.\n DIABETES MELLITUS (DM), TYPE II:\n -SSRI\nFever-Pan culture-Resolved\n -new\n -is post trach placement which could be explanation\n -already on fluc and unasyn for trach/upper trachea tear proph\nMental status\n -very alert & interactive this morning intermittently confused\n -Consider Haldol will follow closely.\n -review medications consider hold fentanyl although no change since she\n did not receive a dose\n -wean sedation as tolerated\n Remainder of plan per resident note\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:47 AM 70 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: Boots Hep SQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Screen for pulm rehab.\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671530,
"text": "Chief Complaint: respiratory failure\n 24 Hour Events:\n ULTRASOUND - At 11:29 AM\n LENI to r/o dvt\n ULTRASOUND - At 03:19 PM\n chest usg to assess the diaphragm\n \n - has paralyzed right hemidiaphragm per dynamic U/S, per pt has been\n present for 10 years\n - LENIs without DVTs\n - no further hypoxic episodes and Fi02 decreased to 40%\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin/Sulbactam (Unasyn) - 09:52 AM\n Ampicillin - 04:10 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Furosemide (Lasix) - 09:00 PM\n Hydralazine - 06:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.1\nC (98.8\n HR: 68 (55 - 79) bpm\n BP: 164/53(81) {101/35(50) - 175/74(87)} mmHg\n RR: 19 (15 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 3,612 mL\n 672 mL\n PO:\n TF:\n 1,652 mL\n 501 mL\n IVF:\n 1,200 mL\n 171 mL\n Blood products:\n Total out:\n 2,675 mL\n 1,040 mL\n Urine:\n 2,675 mL\n 790 mL\n NG:\n Stool:\n 250 mL\n Drains:\n Balance:\n 937 mL\n -368 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 633 (633 - 633) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 98%\n ABG: 7.42/65/126/32/14\n Ve: 7.3 L/min\n PaO2 / FiO2: 315\n Physical Examination\n GEN: pleasant, awake, slightly confused but conversational\n HEENT: PERRL, EOM intact, MMM\n Neck: JVP at earlobe\n PULM: clear ant and laterally\n Heart: RRR, no murmurs\n ABD: soft, obese, normal BS\n EXT: 3+ pitting edema\n Labs / Radiology\n 194 K/uL\n 6.3 g/dL\n 152 mg/dL\n 0.4 mg/dL\n 32 mEq/L\n 3.3 mEq/L\n 7 mg/dL\n 109 mEq/L\n 150 mEq/L\n 20.0 %\n 3.4 K/uL\n [image002.jpg]\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n 01:04 PM\n 06:05 PM\n 04:49 AM\n WBC\n 3.8\n 4.3\n 6.1\n 3.4\n Hct\n 24.1\n 24.5\n 23\n 24.9\n 20.0\n Plt\n 161\n 181\n 235\n 194\n Cr\n 0.4\n 0.3\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 37\n 38\n 37\n 44\n Glucose\n 144\n 122\n 152\n 169\n 172\n 152\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL, PO4:1.3 mg/dL\n Fluid analysis / Other labs: BNP 1800\n Imaging: LENI: no DVT\n Diaphragm Fluoro: paralyzed R hemi diaphragm\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Respiratory failure: . Patient remains on vent and has failed SBT.\n Currently appears to be component of hypercarbic resp failure likely\n from cental apnea as well as mild pulm edema. Furthermore, she has\n mechanical deficits with chronic R hemidiaphragm. In addition, pt has\n had hypoxia as well. Hypoxia may be atelecatsis or vol overload; PE\n in differential but hypoxia does improve with PEEP which would not be\n consistent with PE. LENI on neg for DVT. Her resp issues are\n likely a combination of OSA, CO2 retention and her hospital course has\n also been complicated by right lung collapse, R mainstem intubation.\n - try another pressure support trial today\n - goal I/O 1-2L neg today with lasix drip\n - continue flovent, albuterol, atrovent\n - LENI\ns neg for DVT\n # Hct drop: Hct from 24 to 20 this morning; however, all other cell\n lines are slightly down as well. She has been hemodynamically stable\n and no reports of bleeding. I suspect dilutional\n - repeat CBC\n - if persistant, guaiac all stools, transfuse for HCT<21\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - continue to try PS trials, although continues to become hypercarbic\n likely central apnea\n - if does well try Passey-Muir valve\n - continue Unasyn () and Fluconazole () for ppx for tracheal\n tear for goal 10 day course\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns, but had an\n episode of afib with RVR last night.\n - BB restarted\n - coumadin being held given recent hemorrhage\n - not on asa left temporal hemorrhage\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - increase enalapril and hydralazine\n # Altered mental status\n Has been improved, but still frequently\n confused. h/o SAH/IPH, but now unclear etiology as no clear\n complaints. Likely hemorrage, prior hypoglycemic coma from which\n she did not recover and ICU delirium. Head CT unchanged, Chest CTA w/o\n PE, no evidence of MI, TTE w/ nl EF, UA unremarkable.\n - haldol\n - if more confused will decrease fentanyl\n # Hypernatremia: sodium cont to be elevated\n - continue free water flushes 250 cc Q4H\n # Fevers: no further fevers, cultures have been negative, c.diff neg on\n unasyn and fluconazole ppx for traceal tear\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:47 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671685,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. On , pt desatted\n with turning so emergent bedside bronch performed which required\n removal of large blood clot from trachea. ETT was repositioned, and the\n cuff was left with a leak purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out. Pt will need this in place for approx 8\n weeks\n Hypertension, benign\n Assessment:\n Known hypertensive,max sbp up to 180\ns ,hr 60-70\ns sinus.\n Action:\n On hydralazine,enalapril,and lopressor . on Lasix drip currently\n running @ 8mg/hr.\n Response:\n Sbp started trending down post Lasix drip/increased dose of meds,pt\n gets anxious and tearful at times,no pain,pt seems more oriented and\n appropriate.\n Plan:\n Monitor BP, cont the current management,goal fluid balance 1-2 l neg\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Trach vented. Received on A/C 350x16 40% +10peep. Lung sounds\n ronchorous .Sxn for thick white/yellow secretions. Q2-3 hrs;no\n desating,gets resp distress that easily clears with suction.\n Action:\n No vent changes overnight. on Lasix drip,suctioned as needed\n Response:\n Currently satting 93-97%.\n Plan:\n Cont to wean vent as tolerated, goal fluid balance 1-2L neg, pt has bed\n available at today. As per case management pt should\n leave from ICU by 10.00 am.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671682,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. On , pt desatted\n with turning so emergent bedside bronch performed which required\n removal of large blood clot from trachea. ETT was repositioned, and the\n cuff was left with a leak purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out. Pt will need this in place for approx 8\n weeks\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671469,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +5peep. Lung sounds\n rhoncherous .Sxn for white thin secretions Q2-3 hrs overnight;\n Action:\n Additional lasix dose given at 2100\n Response:\n Await response\n Plan:\n Cont to attempt to wean vent as tolerated. Monitor VBG and/or pt\n mental status to assess tolerance of vent weaning. Cont to sxn as\n needed.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671470,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16/ 40%/10. Lung sounds\n rhoncherous .Sxn for white thin secretions Q2-3 hrs overnight;\n Action:\n No vent changes overnight. Received Lasix 40mg IVP around 2100 w/ good\n response.\n Response:\n pending\n Plan:\n Cont to attempt to wean vent as tolerated. Monitor VBG and/or pt\n mental status to assess tolerance of vent weaning. Cont to sxn as\n needed.\n Pt is mouthing words appropriately, rarely getting anxious and asking\n for her husband.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671407,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. On , pt desatted\n with turning so emergent bedside bronch performed which required\n removal of large blood clot from trachea. ETT was repositioned, and the\n cuff was left with a leak purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out. Pt will need this in place for approx 8\n weeks\n Hypertension, benign\n Assessment:\n Pt has been hypertensive to 180\ns last few days,HR 50-70 sinus now,h/o\n a fib ,pt has been agitated intermittently\n Action:\n Contd hydralazine,metoprolol and enalapril,also recvd lasix 40 mg iv x1\n Response:\n Most of the day sbp 110-140,1 of sbp 175 which was right\n recorded during the time of suctioning,pt was very somnolent in the\n beginning of the shift (post haldol) and started getting agitated aroud\n 0930am,a wrist restraint has been applied to protect the tubes and\n lines which infact worsen her agitation,pt is alert and oriented x3,but\n gets confused intermittently,doing well off restraints\n Plan:\n Monitor BP, cont standing IV hydral, goal diuresis 1L neg,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 100% +10peep. Lung sounds\n rhoncherous .Sxn for thick white/yellow secretions. Q2-3 hrs\n overnight;no desating,gets resp distress that easily clears with\n suction\n Action:\n Fi02 weaned to 40%,chest USG to assess the diaphragm,recvd Lasix 40mg\n iv,A leni has been done to r/o DVT\n Response:\n sas 94-100%,no episode of acute desaytting,chest usg s/o rt\n diaphragmatic paralysis\n Plan:\n Cont to wean as tolerated,goal fluid balance 1L neg,vent rehab screen\n ongoing..\n Others:recevd 40 K this am for k 3.5.\n Tolerating the tube feed @goal.\n Husband was at bedside updated by MD and this RN\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670412,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:00 AM\n NON-INVASIVE VENTILATION - START 11:00 AM\n ARTERIAL LINE - START 11:32 AM\n BRONCHOSCOPY - At 01:00 PM\n NON-INVASIVE VENTILATION - STOP 02:10 PM\n OR SENT - At 04:35 PM\n BRONCHOSCOPY - At 04:37 PM\n INVASIVE VENTILATION - START 06:00 PM\n OR RECEIVED - At 06:27 PM\n s/p rigid bronch in OR with visualized 5cm tear in trachea; pt was\n intubated under fiberoptics\n \n - echo nl, EF >70%\n - head CT w/o change\n - chest CTA showed tracheal abnl, bronch showed tracheal webbing\n - pt taken to OR for fiberoptic intubation and rigid bronch which\n showed a 5cm tracheal tear; IP involved and recommended prolonged\n intubation to allow tear to heal as well as ppx abx\n - started on Unasyn and fluconazole ppx\n - OG tube placed, restarted on home dose of enalapril, nitro gtt weaned\n off\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 09:30 PM\n Ampicillin/Sulbactam (Unasyn) - 04:21 AM\n Infusions:\n Fentanyl - 80 mcg/hour\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:21 AM\n Metoprolol - 04:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 58 (58 - 94) bpm\n BP: 141/44(64) {137/41(64) - 199/77(89)} mmHg\n RR: 16 (10 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,034 mL\n 422 mL\n PO:\n TF:\n IVF:\n 2,034 mL\n 422 mL\n Blood products:\n Total out:\n 1,983 mL\n 485 mL\n Urine:\n 1,983 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 51 mL\n -63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (300 - 350) mL\n Vt (Spontaneous): 306 (306 - 306) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 98%\n ABG: 7.44/69/81./42/18\n Ve: 5.4 L/min\n PaO2 / FiO2: 203\n Physical Examination\n General Appearance: intubated, sedated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): self, place, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 164 K/uL\n 7.3 g/dL\n 179 mg/dL\n 0.4 mg/dL\n 42 mEq/L\n 3.1 mEq/L\n 16 mg/dL\n 99 mEq/L\n 147 mEq/L\n 23.3 %\n 6.7 K/uL\n [image002.jpg]\n 01:08 PM\n 02:33 PM\n 03:06 PM\n 06:22 PM\n 07:46 PM\n 08:47 PM\n 10:32 PM\n 01:13 AM\n 04:33 AM\n 05:02 AM\n WBC\n 6.7\n Hct\n 23.3\n Plt\n 164\n Cr\n 0.4\n TropT\n <0.01\n <0.01\n TCO2\n 42\n 45\n 47\n 50\n 46\n 50\n 48\n Glucose\n 179\n Other labs: PT / PTT / INR:14.1/24.9/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Lactic Acid:1.6 mmol/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL,\n PO4:1.5 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; now intubated after\n finding of traumatic tracheal tear.\n .\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation.\n - remain intubated x2 weeks to allow healing of tear\n - prophylactic antibiotics while intubated: Unasyn and Fluconazole\n - follow serial CXRs\n .\n # Hypercarbic respiratory failure with new right lung collapse - On CXR\n previously she had white out of the right lung with rightward tracheal\n deviation concerning for new right lung collapse, most likely \n mucous plugging given her thick secretions. ABG with acute on chronic\n respiratory acidosis, likely poor ventilation in the setting of\n acute right lung collapse.\n - serial ABGs via A-line\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n .\n # Altered mental status\n h/o SAH/IPH, but now unclear etiology as no\n clear complaints. Head CT unchanged, Chest CTA w/o PE, no evidence of\n MI, TTE w/ nl EF, UA unremarkable. Now intubated tracheal tear.\n .\n #Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her. Possibly intubation. Now intubated\n again tracheal tear.\n .\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n .\n #Paroxysmal Atrial fibrillation: in sinus rhythm on admission, does\n have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n .\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n .\n # HTN\n continues to be quite hypertensive\n -lasix as tolerated\n -holding acebutolol, enalapril while npo\n -consider hydralazine if hypertensives\n ICU Care\n Nutrition: NPO\n Glycemic Control: SQ Insulin\n fixed dose + SS\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 09:05 AM\n Arterial Line - 11:32 AM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer: IV PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670415,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:00 AM\n NON-INVASIVE VENTILATION - START 11:00 AM\n ARTERIAL LINE - START 11:32 AM\n BRONCHOSCOPY - At 01:00 PM\n NON-INVASIVE VENTILATION - STOP 02:10 PM\n OR SENT - At 04:35 PM\n BRONCHOSCOPY - At 04:37 PM\n INVASIVE VENTILATION - START 06:00 PM\n OR RECEIVED - At 06:27 PM\n s/p rigid bronch in OR with visualized 5cm tear in trachea; pt was\n intubated under fiberoptics\n \n - echo nl, EF >70%\n - head CT w/o change\n - chest CTA showed tracheal abnl, bronch showed tracheal webbing\n - pt taken to OR for fiberoptic intubation and rigid bronch which\n showed a 5cm tracheal tear; IP involved and recommended prolonged\n intubation to allow tear to heal as well as ppx abx\n - started on Unasyn and fluconazole ppx\n - OG tube placed, restarted on home dose of enalapril, nitro gtt weaned\n off\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 09:30 PM\n Ampicillin/Sulbactam (Unasyn) - 04:21 AM\n Infusions:\n Fentanyl - 80 mcg/hour\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:21 AM\n Metoprolol - 04:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 58 (58 - 94) bpm\n BP: 141/44(64) {137/41(64) - 199/77(89)} mmHg\n RR: 16 (10 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,034 mL\n 422 mL\n PO:\n TF:\n IVF:\n 2,034 mL\n 422 mL\n Blood products:\n Total out:\n 1,983 mL\n 485 mL\n Urine:\n 1,983 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 51 mL\n -63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (300 - 350) mL\n Vt (Spontaneous): 306 (306 - 306) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 98%\n ABG: 7.44/69/81./42/18\n Ve: 5.4 L/min\n PaO2 / FiO2: 203\n Physical Examination\n General Appearance: intubated, sedated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): self, place, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 164 K/uL\n 7.3 g/dL\n 179 mg/dL\n 0.4 mg/dL\n 42 mEq/L\n 3.1 mEq/L\n 16 mg/dL\n 99 mEq/L\n 147 mEq/L\n 23.3 %\n 6.7 K/uL\n [image002.jpg]\n 01:08 PM\n 02:33 PM\n 03:06 PM\n 06:22 PM\n 07:46 PM\n 08:47 PM\n 10:32 PM\n 01:13 AM\n 04:33 AM\n 05:02 AM\n WBC\n 6.7\n Hct\n 23.3\n Plt\n 164\n Cr\n 0.4\n TropT\n <0.01\n <0.01\n TCO2\n 42\n 45\n 47\n 50\n 46\n 50\n 48\n Glucose\n 179\n Other labs: PT / PTT / INR:14.1/24.9/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Lactic Acid:1.6 mmol/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL,\n PO4:1.5 mg/dL\n TTE - The left atrium is mildly dilated. Left ventricular wall\n thicknesses are normal. The left ventricular cavity size is normal. Due\n to suboptimal technical quality, a focal wall motion abnormality cannot\n be fully excluded. Overall left ventricular systolic function is normal\n (LVEF>55%). Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) are mildly thickened. There is a\n minimally increased gradient consistent with minimal aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. No mitral regurgitation is seen.\n NCHCT\n Continued evolution of left medial temporal intraparenchymal\n hemorrhage, without evidence of new hemorrhage.\n CTA Chest\n 1. Probable pulmonary hypertension. No emboli in the main,\n right, left, or lobar pulmonary arteries, peripheral circulation is not\n evaluated by this study. 2. Right lower lobe collapse and\n heterogeneous opacification in the right upper lobe and lingual, more\n likely aspiration than pneumonia at this stage, are sufficient to\n explain hypoxia. 3. Tracheomalacia. Upper tracheal mass or organized\n secretions or aspirated material. Bronchoscopy recommended. 4.\n Probably pulmonary arterial hypertension.\n Assessment and Plan\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; now intubated after\n finding of traumatic tracheal tear.\n .\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation.\n - remain intubated x2 weeks to allow healing of tear\n - prophylactic antibiotics while intubated: Unasyn and Fluconazole\n - follow serial CXRs\n .\n # Hypercarbic respiratory failure with new right lung collapse - On CXR\n previously she had white out of the right lung with rightward tracheal\n deviation concerning for new right lung collapse, most likely \n mucous plugging given her thick secretions. ABG with acute on chronic\n respiratory acidosis, likely poor ventilation in the setting of\n acute right lung collapse.\n - serial ABGs via A-line\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n .\n # Altered mental status\n h/o SAH/IPH, but now unclear etiology as no\n clear complaints. Head CT unchanged, Chest CTA w/o PE, no evidence of\n MI, TTE w/ nl EF, UA unremarkable. Now intubated tracheal tear.\n .\n #Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her. Possibly intubation. Now intubated\n again tracheal tear.\n .\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n .\n #Paroxysmal Atrial fibrillation: in sinus rhythm on admission, does\n have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n .\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n .\n # HTN\n continues to be quite hypertensive\n -lasix as tolerated\n -holding acebutolol, enalapril while npo\n -consider hydralazine if hypertensives\n ICU Care\n Nutrition: NPO\n Glycemic Control: SQ Insulin\n fixed dose + SS\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 09:05 AM\n Arterial Line - 11:32 AM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer: IV PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670433,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:00 AM\n NON-INVASIVE VENTILATION - START 11:00 AM\n ARTERIAL LINE - START 11:32 AM\n BRONCHOSCOPY - At 01:00 PM\n NON-INVASIVE VENTILATION - STOP 02:10 PM\n OR SENT - At 04:35 PM\n BRONCHOSCOPY - At 04:37 PM\n INVASIVE VENTILATION - START 06:00 PM\n OR RECEIVED - At 06:27 PM\n s/p rigid bronch in OR with visualized 5cm tear in trachea; pt was\n intubated under fiberoptics\n \n - echo nl, EF >70%\n - head CT w/o change\n - chest CTA showed tracheal abnl, bronch showed tracheal webbing\n - pt taken to OR for fiberoptic intubation and rigid bronch which\n showed a 5cm tracheal tear; IP involved and recommended prolonged\n intubation to allow tear to heal as well as ppx abx\n - started on Unasyn and fluconazole ppx\n - OG tube placed, restarted on home dose of enalapril, nitro gtt weaned\n off\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 09:30 PM\n Ampicillin/Sulbactam (Unasyn) - 04:21 AM\n Infusions:\n Fentanyl - 80 mcg/hour\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:21 AM\n Metoprolol - 04:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 58 (58 - 94) bpm\n BP: 141/44(64) {137/41(64) - 199/77(89)} mmHg\n RR: 16 (10 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,034 mL\n 422 mL\n PO:\n TF:\n IVF:\n 2,034 mL\n 422 mL\n Blood products:\n Total out:\n 1,983 mL\n 485 mL\n Urine:\n 1,983 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 51 mL\n -63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (300 - 350) mL\n Vt (Spontaneous): 306 (306 - 306) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 98%\n ABG: 7.44/69/81./42/18\n Ve: 5.4 L/min\n PaO2 / FiO2: 203\n Physical Examination\n General Appearance: intubated, sedated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): self, place, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 164 K/uL\n 7.3 g/dL\n 179 mg/dL\n 0.4 mg/dL\n 42 mEq/L\n 3.1 mEq/L\n 16 mg/dL\n 99 mEq/L\n 147 mEq/L\n 23.3 %\n 6.7 K/uL\n [image002.jpg]\n 01:08 PM\n 02:33 PM\n 03:06 PM\n 06:22 PM\n 07:46 PM\n 08:47 PM\n 10:32 PM\n 01:13 AM\n 04:33 AM\n 05:02 AM\n WBC\n 6.7\n Hct\n 23.3\n Plt\n 164\n Cr\n 0.4\n TropT\n <0.01\n <0.01\n TCO2\n 42\n 45\n 47\n 50\n 46\n 50\n 48\n Glucose\n 179\n Other labs: PT / PTT / INR:14.1/24.9/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Lactic Acid:1.6 mmol/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL,\n PO4:1.5 mg/dL\n TTE - The left atrium is mildly dilated. Left ventricular wall\n thicknesses are normal. The left ventricular cavity size is normal. Due\n to suboptimal technical quality, a focal wall motion abnormality cannot\n be fully excluded. Overall left ventricular systolic function is normal\n (LVEF>55%). Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) are mildly thickened. There is a\n minimally increased gradient consistent with minimal aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. No mitral regurgitation is seen.\n NCHCT\n Continued evolution of left medial temporal intraparenchymal\n hemorrhage, without evidence of new hemorrhage.\n CTA Chest\n 1. Probable pulmonary hypertension. No emboli in the main,\n right, left, or lobar pulmonary arteries, peripheral circulation is not\n evaluated by this study. 2. Right lower lobe collapse and\n heterogeneous opacification in the right upper lobe and lingual, more\n likely aspiration than pneumonia at this stage, are sufficient to\n explain hypoxia. 3. Tracheomalacia. Upper tracheal mass or organized\n secretions or aspirated material. Bronchoscopy recommended. 4.\n Probably pulmonary arterial hypertension.\n Assessment and Plan\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; now intubated after\n finding of traumatic tracheal tear.\n .\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation.\n - remain intubated x2 weeks to allow healing of tear\n - prophylactic antibiotics while intubated: Unasyn and Fluconazole\n - follow serial CXRs\n .\n # Hypercarbic respiratory failure with new right lung collapse - On CXR\n previously she had white out of the right lung with rightward tracheal\n deviation concerning for new right lung collapse, most likely \n mucous plugging given her thick secretions. ABG with acute on chronic\n respiratory acidosis, likely poor ventilation in the setting of\n acute right lung collapse.\n - serial ABGs via A-line\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n .\n # Altered mental status\n h/o SAH/IPH, but now unclear etiology as no\n clear complaints. Head CT unchanged, Chest CTA w/o PE, no evidence of\n MI, TTE w/ nl EF, UA unremarkable. Now intubated tracheal tear.\n .\n #Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her. Possibly intubation. Now intubated\n again tracheal tear.\n .\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n .\n #Paroxysmal Atrial fibrillation: in sinus rhythm on admission, does\n have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n .\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n .\n # HTN\n continues to be quite hypertensive\n -lasix as tolerated\n -holding acebutolol, enalapril while npo\n -consider hydralazine if hypertensives\n ICU Care\n Nutrition: NPO\n Glycemic Control: SQ Insulin\n fixed dose + SS\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 09:05 AM\n Arterial Line - 11:32 AM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer: IV PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-07 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 670437,
"text": "TITLE:\n Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:00 AM\n NON-INVASIVE VENTILATION - START 11:00 AM\n ARTERIAL LINE - START 11:32 AM\n BRONCHOSCOPY - At 01:00 PM\n NON-INVASIVE VENTILATION - STOP 02:10 PM\n OR SENT - At 04:35 PM\n BRONCHOSCOPY - At 04:37 PM\n INVASIVE VENTILATION - START 06:00 PM\n OR RECEIVED - At 06:27 PM\n s/p rigid bronch in OR with visualized 5cm tear in trachea; pt was\n intubated under fiberoptics\n History obtained from Medical records\n Patient unable to provide history: Sedated, intubated\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 09:30 PM\n Ampicillin/Sulbactam (Unasyn) - 04:21 AM\n Infusions:\n Fentanyl - 60 mcg/hour\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 04:21 AM\n Heparin Sodium (Prophylaxis) - 08:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37\nC (98.6\n HR: 65 (57 - 94) bpm\n BP: 141/44(64) {139/44(64) - 199/57(88)} mmHg\n RR: 19 (10 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,034 mL\n 774 mL\n PO:\n TF:\n IVF:\n 2,034 mL\n 774 mL\n Blood products:\n Total out:\n 1,983 mL\n 645 mL\n Urine:\n 1,983 mL\n 645 mL\n NG:\n Stool:\n Drains:\n Balance:\n 51 mL\n 129 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (300 - 350) mL\n Vt (Spontaneous): 306 (306 - 306) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 29 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 95%\n ABG: 7.48/61/54/42/18\n Ve: 6 L/min\n PaO2 / FiO2: 108\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: diffusely)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 7.3 g/dL\n 164 K/uL\n 179 mg/dL\n 0.4 mg/dL\n 42 mEq/L\n 3.1 mEq/L\n 16 mg/dL\n 99 mEq/L\n 147 mEq/L\n 22.8 %\n 6.7 K/uL\n [image002.jpg]\n 03:06 PM\n 06:22 PM\n 07:46 PM\n 08:47 PM\n 10:32 PM\n 01:13 AM\n 04:33 AM\n 05:02 AM\n 07:27 AM\n 09:27 AM\n WBC\n 6.7\n Hct\n 23.3\n 22.8\n Plt\n 164\n Cr\n 0.4\n TropT\n <0.01\n <0.01\n TCO2\n 47\n 50\n 46\n 50\n 48\n 47\n Glucose\n 179\n Other labs: PT / PTT / INR:14.1/24.9/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Lactic Acid:1.6 mmol/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL,\n PO4:1.5 mg/dL\n Assessment and Plan\n HYPERTENSION\n -BP better controlled today\n -on home dose enalapril\nTracheal tear\n -presumably related to prior intubation\n -IP following\n -cont intubation with distal positioning of tube and intentional air\n leak to allow healing.\n -Rest period above several weeks raising question of whether trache\n more optimal approach\n -careful maint of ETT position\n -empiric abx coverage inc anti-fungal coverage\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n -Acute on chronic hypercarbic respiratory failure\n -Resp alkalosis - breathing at set rate. Need to decrease set rate as\n overventilating presently.\n DIABETES MELLITUS (DM), TYPE II: consider d/c\ning oral hypoglycemics.\nLeft leg erythema:\n -Potential infection vs. DVT.\n -Follow-up ultrasound.\n Chest pain\n -EKG without changes\n -r/o MI\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 09:05 AM\n Arterial Line - 11:32 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670882,
"text": "Chief Complaint:\n 24 Hour Events:\n - IP put in trach in OR\n - Hypertensive post-op -- no pain, no nausea, increased bowel regimen\n -- did not have NGT placed, so did not get enalapril, instead\n double-dosed IV metoprolol overnight\n - weaning off vent: currently on Pressure Support\n - left message for PCP, call back tomorrow\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsMotrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 10:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:20 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 04:20 AM\n Other medications:\n Flowsheet Data as of 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38.2\nC (100.7\n HR: 65 (49 - 79) bpm\n BP: 141/44(64) {0/0(0) - 0/0(0)} mmHg\n RR: 25 (15 - 25) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,557 mL\n 176 mL\n PO:\n TF:\n IVF:\n 2,497 mL\n 176 mL\n Blood products:\n Total out:\n 1,435 mL\n 755 mL\n Urine:\n 1,435 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,122 mL\n -579 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 319 (298 - 319) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 109\n PIP: 20 cmH2O\n Plateau: 14 cmH2O\n Compliance: 87.5 cmH2O/mL\n SpO2: 96%\n ABG: 7.48/52/73./35/12\n Ve: 4.3 L/min\n PaO2 / FiO2: 183\n Physical Examination\n General Appearance: intubated, sedated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous, dull at bases ), no\n sub cutaneous emphysema\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Neurologic: sedated\n Labs / Radiology\n 151 K/uL\n 8.2 g/dL\n 106 mg/dL\n 0.4 mg/dL\n 35 mEq/L\n 3.5 mEq/L\n 8 mg/dL\n 105 mEq/L\n 147 mEq/L\n 25.9 %\n 6.4 K/uL\n [image002.jpg]\n 05:02 AM\n 07:27 AM\n 09:27 AM\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n 05:06 PM\n 04:10 AM\n WBC\n 3.9\n 6.4\n Hct\n 22.8\n 25.3\n 23.2\n 25\n 25.9\n Plt\n 147\n 151\n Cr\n 0.4\n 0.4\n 0.4\n TCO2\n 48\n 47\n 48\n 45\n 45\n 40\n Glucose\n 131\n 88\n 100\n 106\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; now intubated after\n finding of traumatic tracheal tear.\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - try SBT today, if does well try Passey-Muir valve\n - prophylactic antibiotics while intubated: Unasyn and Fluconazole\n - place NGT for feeding / medications\n # Hypercarbic respiratory failure with new right lung collapse - On CXR\n previously she had white out of the right lung with rightward tracheal\n deviation concerning for new right lung collapse, most likely \n mucous plugging given her thick secretions. ABG now with hypoxia in\n the setting of turning pt and right mainstem intubation (now s/p\n pulling back ET tube) and with metabolic alkalosis overventilation.\n - serial ABGs via A-line\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n # Rising temperature: ? impending infection. Increasing temperature,\n low-grade leukocytosis. Post-op from trachea.\n - Pan Cx, check stool for C.diff\n - consider LENIs to r/o DVT\n - continue current antibiotics, touch base w/ IP re: definite course\n # HCT drop: HCT now stable no melena. Hemolysis labs negative. Repeat\n CXR clearing w/o evidence of worsening effusions and given stable HCT,\n concern for intrathoracic bleeding is now low.\n - monitor HCT\n - guaiac stools\n # Altered mental status\n h/o SAH/IPH, but now unclear etiology as no\n clear complaints. Head CT unchanged, Chest CTA w/o PE, no evidence of\n MI, TTE w/ nl EF, UA unremarkable. Now intubated tracheal tear.\n #Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her. Possibly intubation. Now intubated\n again tracheal tear.\n - on Unasyn as for tracheal tear\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns w/p any nodal\n agents. In sinus rhythm on admission, does have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - continue enalapril, BB\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: heparin sc\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 670883,
"text": "TITLE:\n Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n SENT to OR for trache\n Much more alert & interactive this morning\n History obtained from Medical records\n Patient unable to provide history: Sedated, trached\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 10:00 PM\n Ampicillin/Sulbactam (Unasyn) - 10:47 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 07:30 AM\n Heparin Sodium (Prophylaxis) - 07:44 AM\n Pantoprazole (Protonix) - 07:45 AM\n Metoprolol - 10:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38.1\nC (100.5\n HR: 62 (54 - 79) bpm\n BP: 141/44(64) {0/0(0) - 0/0(0)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,557 mL\n 473 mL\n PO:\n TF:\n IVF:\n 2,497 mL\n 473 mL\n Blood products:\n Total out:\n 1,435 mL\n 985 mL\n Urine:\n 1,435 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,122 mL\n -513 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 302 (298 - 319) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 109\n PIP: 20 cmH2O\n SpO2: 96%\n ABG: 7.42/56/116/35/10\n Ve: 6.9 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trache\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n ant)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 8.2 g/dL\n 151 K/uL\n 106 mg/dL\n 0.4 mg/dL\n 35 mEq/L\n 3.5 mEq/L\n 8 mg/dL\n 105 mEq/L\n 147 mEq/L\n 25.9 %\n 6.4 K/uL\n [image002.jpg]\n 07:27 AM\n 09:27 AM\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n 05:06 PM\n 04:10 AM\n 10:33 AM\n WBC\n 3.9\n 6.4\n Hct\n 22.8\n 25.3\n 23.2\n 25\n 25.9\n Plt\n 147\n 151\n Cr\n 0.4\n 0.4\n 0.4\n TCO2\n 47\n 48\n 45\n 45\n 40\n 38\n Glucose\n 131\n 88\n 100\n 106\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\nTracheal tear\n -presumably occurred during intubation at start of prior admission\n -IP following\n -trache placed yesterday to bypass injured area\n -empiric abx coverage inc anti-fungal coverage\n\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n -Acute on chronic hypercarbic respiratory failure - likely OSA, ?OHS,\n ?element central\n -Resp alkalosis\n -wean vent\n HYPERTENSION\n -BP better controlled today\n -on home dose enalapril\n DIABETES MELLITUS (DM), TYPE II:\n -SSRI\nLeft leg erythema:\n -stable vs. border marking\nLow grade temp\n -new\n -is post trache placement which could be explanation\n -already on fluc and unasyn for trache/upper trach tear proph\n HYPERTENSION, BENIGN\nMental status\n -very alert & interactive this morning\n -wean sedation as tol\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670944,
"text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101.3 in this shift,increased secretions noted from the\n trach,liquid stool via the flexiseal.\n Action:\n Pan cultuered,\n Response:\n T current 100.8\n Plan:\n Follow fever curve,follow up on the cx data\n Tracheal Tear\n Assessment:\n Pt noted to have 5cm tracheal tear via rigid bronch in OR . Post\n procedure, pt was intubated using fiberoptics ,Trach in place,recevd\n the pt on capap 15/5\n Action:\n Suctioned as needed,contd prophylactic abx,weaned down to 12/5\n Response:\n Pt now with #8 adjustable neck flange portex trach (at 12.5 marked),pt\n deos have period of apnea with low minute volume.,now pt is resting on\n AC.\n Plan:\n Plan to wean vent as tolerated ,follow abg,\n Hypertension, benign\n Assessment:\n Sbp 150-200,dbp 40-50,hr 60\ns ,was anxious and restless at times,\n tearful this evening regarding herself and family\n Action:\n Pt. was given Fentanyl 50mcg x1 for pain ,was OOB to chair for few\n hours.\n Response:\n Sbp very labile,in sleep sbp in 150\ns but even a slight stimulation\n raises the blood pressure.Pt refused NG tube placement ,\n Plan:\n Plan to insert NG vs dhoboff tube,Resume po antihypertensives once NG\n is in.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670949,
"text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101.3 in this shift,increased secretions noted from the\n trach,liquid stool via the mushroom cath.\n Action:\n Pan cultured.\n Response:\n T current 100.8\n Plan:\n Follow fever curve,follow up on the cx data,\n Tracheal Tear\n Assessment:\n Pt noted to have 5cm tracheal tear via rigid bronch in OR . Post\n procedure, pt was intubated using fiberoptics ,Trach in place,recevd\n the pt on capap 15/5\n Action:\n Suctioned as needed,contd prophylactic abx,weaned down to 12/5\n Response:\n Pt now with #8 adjustable neck flange portex trach (at 12.5 marked),pt\n does have period of apnea with low minute volume.,now pt is resting on\n AC.\n Plan:\n Plan to wean vent as tolerated ,follow abg,\n Hypertension, benign\n Assessment:\n Sbp 150-200,dbp 40-50,hr 60\ns ,was anxious and restless at times,\n tearful this evening about herself and family\n Action:\n Pt. was given Fentanyl 50mcg this am and 25mcg this pm for pain ,was\n OOB to chair for few hours.received schd lopressor 10 mg iv x2 in this\n shift.\n Response:\n Sbp very labile,while sleeping sbp in 150\ns but even a slight\n stimulation raises the blood pressure.Pt refused NG tube placement ,\n Plan:\n Plan to insert NG vs dhoboff tube,Resume po antihypertensives once NG\n is in.\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 670950,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management: Airway problems: Allow small non-functional leak per\n IP.\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use\n Assessment of breathing comfort: Pt acknowledges dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Frequent alarms (Low min. ventilation, Apnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Comments:\n Initially unsuccessful in weaning PSV to 12, but later was able to\n tolerate for a few hours. Later developed repeated apnea periods with\n hypoventilation when asleep; ? CSA v anxiety v OHS. Resting on CMV now\n but attempt to return to CSV for the night and possibly wean to trach\n collar tomorrow.\n"
},
{
"category": "General",
"chartdate": "2103-03-06 00:00:00.000",
"description": "ICU Event Note",
"row_id": 670234,
"text": "TITLE:\n Clinician: Resident\n Left radial arterial line placed today at 11:40am in sterile\n fashion. Patient tolerated the procedure well, no complications.\n Total time spent: 10 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670940,
"text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101.3 in this shift,increased secretions noted from the\n trach,liquid stool via the flexiseal.\n Action:\n Pan cultuered,\n Response:\n T current 100.8\n Plan:\n Follow fever curve,follow up on the cx data\n Tracheal Tear\n Assessment:\n Pt noted to have 5cm tracheal tear via rigid bronch in OR . Post\n procedure, pt was intubated using fiberoptics ,Trach in place,recevd\n the pt on capap 15/5\n Action:\n Suctioned as needed,contd prophylactic abx,weaned down to 12/5\n Response:\n Pt now with #8 adjustable neck flange portex trach (at 12.5 marked),pt\n deos have period of apnea with low minute volume.,now pt is resting on\n AC.\n Plan:\n Plan to wean vent as tolerated ,follow abg,\n Hypertension, benign\n Assessment:\n Sbp 150-200,dbp 40-50,hr 60\ns ,was anxious and restless at times,\n Action:\n Pt. was given Fentanyl 50mcg x1 for pain ,was OOB to chair for few\n hours.\n Response:\n Sbp very labile,in sleep sbp in 150\ns but even a slight stimulation\n raises the blood pressure.Pt refused NG tube placement ,\n Plan:\n Plan to insert NG vs dhoboff tube,Resume po antihypertensives once NG\n is in.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671122,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. On , pt desatted\n with turning so emergent bedside bronch performed which required\n removal of large blood clot from trachea. ETT was repositioned, and the\n cuff was left with a leak purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out.\n Hypertension, benign\n Assessment:\n SBP 160\n 190\n Action:\n Initially held IV Lopressor d/t HR 50\ns, later BP 190\ns and HR 60\ns so\n gave 10mg IV Lopressor. Later able to give PO Enalapril once GI access\n w/ dobhoff.\n Response:\n HR dropped to low 40\ns @ times while pt sleeping after lopressor IV and\n Fentanyl doses. Held further doses of IV Lopressor. Awaiting BP\n response w/ PO enalapril.\n Plan:\n Pt now w/ NGT and ordered for enalapril PO.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +5peep. Lung sounds\n rhoncherous with diminished bases. Sxn for thick white/yellow\n secretions.\n Action:\n Attempted pt on CPAP 12/5peep, 40%. Monitored ABG\ns w/ vent changes.\n Placed Dobhoff @ bedside.\n Response:\n Worsening ABG w/ CPAP settings so placed back on A/C (see Metavision\n for labs). Dobhoff position confirmed by x-ray and TF started.\n Plan:\n Pt to remain on A/C overnight. ? attempt vent changes again tomorrow.\n Increase TF Q4H w/ goal rate 70cc/hr\n Lytes repleted in AM (K, Mg, Ca), all appropriate w/ afternoon labs.\n 1L D5W @ 100cc/hr for Na 150, repeat in afternoon was 145. Pt to\n receive 250cc FWB Q4H w/ tube feeds. Recheck lytes w/ AM labs.\n Fentanyl for lower back pain w/ good effect.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670523,
"text": "Events:pt was desating to mid 80\ns this am post turn,urgent bronch done\n at bedside,large clot was removed ,stable vent settings afterwards.ETT\n pulled and retaped,A picc line has been inserted by IR.Hct dropped to\n 22(from 28).recevd 250cc bolus for hypotension in this am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on ac 40%,10peep 16/350,sats high 90\ns,noted diminished\n breath sounds on the left side. Received on fent 60 and propofol 30\n Action:\n Pt had undergone bronch at bedside,suctioned as needed,weaned sedation,\n Response:\n Pt desatted to mid 80\ns post turn this am,didn\nt improve with\n suctioning,PIP were in 30\ns with diminished breath sounds on the left\n side,blood clot removed via the bronch,no episodes of desatting\n afterwards. Pco2 62 with most recent abg. There is air leak which is\n therapeutic,requiring frequent oral suction\n Plan:\n Will cont the current settings,plan for trach placement in Am(add on\n list)\n Anemia, other\n Assessment:\n HCT dropped to 22 from 28,no obvious bleeding,suctioned for bloody\n secretions,minimal bleeding noted during bronch,no obvious blood seen\n in the stool\n Action:\n Cycled HCT\n Response:\n Rpt hct 25\n Plan:\n Will follow hct q8h,\n Others:Family team meeting @4pm today\nplan for trach in am.\n HR 55-70,sinus to sinus brady\nevening dose of lopressor held (hr 55).\n SBP 120-180\ns,hypertensive with stimulation.\n K was repleted this am with 60meq kcl,rpt k 3.5.\n FS has been stable,not required any coverage.\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 670578,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt re4mains on currentn vent settings.See vent flow sheet for\n details. Pt having mod cuff leak due to decreased pressure in the ETT\n cuff. Pt maintaning vt's in the 300's. Will cont to monitor.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Tracheostomy planned; Comments: Trache planned for\n today.\n Reason for continuing current ventilatory support: Pending procedure /\n OR\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 671127,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: \n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Comments: Pt weaned on PSV for a little bit with some noted periods of\n apnea ? central sleep apnea. Pt placed back on A/C due to hypercarbic\n resp failure on PS wean. Will cont with vent support and cont to wean\n as tol.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671385,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 100% +10peep. Lung sounds\n rhoncherous .Sxn for thick white/yellow secretions. Q2-3 hrs\n overnight;no desating,gets resp distress that easily clears with\n suction\n Action:\n Fi02 weaned to 40%,chest USG to assess the diaphragm,recvd Lasix 40mg\n iv\n Response:\n No episode of resp distress,sas 94-100%,\n Plan:\n Cont to wean as tolerated,goal fluid balance 1L neg,vent rehab screen\n ongoing..\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670218,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n * pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis this AM.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 670311,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Expectorated / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Patient had bronchoscopic procedure twice today once @ bed\n site the second time in OR. Tracheal tear observed about 5cm in\n diameter. # 7.5 ETT inserted cuff is bellow the tear 23 cm @ lips\n Please do not rotate or displace ETT.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670373,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n * pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis yesterday. CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside today showing\n webbing likely from traumatic intubation. Pt. sent to OR for rigid\n Bronch, which exhibited 5cm tear of the posterior tracheal wall. The\n patient was intubated under fiberoptics and the ETT was placed past the\n area of the tear as to reduce friction to the tracheal lumen. The ETT\n is NOT TO BE REPOSITIONED, and must be handled with extreme caution as\n it is close to the and could easily slip into the right main\n stem bronchus causing lung collapse.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. received on vent post rigid bronch.\n Action:\n Pt. tolerating slow wean of FIO2 . Pt. received on 70%\n Response:\n CTA yesterday showing tracheomalacia and tracheal mass of unknown\n origin so bronch recommended by radiology. Bedside bronch performed\n with visualization of webbing of unknown etiology. Pt taken to OR for\n rigid bronch post intubation via fiberoptics. IP to perform bronch for\n better visualization and to determine diagnosis of questionable mass.\n Pt. was successfully weaned from 70% to present FIO2 of 40%. Pt. is\n suctioned for small amount of bloody mucoid plugs. This was self\n limiting.\n Plan:\n Pending results of OR procedure.\n Pt. is scheduled for a PICC line placement today. Blood sugars remain\n slightly elevated with 2 units of regular coverage provided twice\n through this shift.\n Social aspect is that pt\ns husband is upset regarding pt\ns tracheal\n tear during possible intubation. Plan to provide supportive\n environment.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671174,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. On , pt desatted\n with turning so emergent bedside bronch performed which required\n removal of large blood clot from trachea. ETT was repositioned, and the\n cuff was left with a leak purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out. Pt will need this in place for approx 8\n weeks\n Hypertension, benign\n Assessment:\n SBP conts to be high 160\n 190\n Action:\n IV Lopressor held x1 for rate in the 40\ns. ordered for hydralazine x1\n and q6hrs. 4am metoprolol was given, but\n dose w/good response\n Response:\n Responding very well to hydral dosing\n Plan:\n Pt now w/ NGT and ordered for enalapril PO as well as iv hydralazine.\n Consider d/cing metoprolol or decreasing dose as well as changing to\n po.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +5peep. Lung sounds\n rhoncherous .Sxn for thick white/yellow secretions.\n Action:\n No vent changes made overnight. Vbg and abg drawn to correlate.\n Response:\n Comfortable on vent overnigh\n Plan:\n attempt vent changes again tomorrow. Increase TF Q4H w/ goal rate\n 70cc/hr. ?removal of a line. Nbp w/40 pt difference. Resident on\n o/n deferred on d/cing aline for now\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671395,
"text": "Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan.\n 24 Hour Events:\n Increased enalapril, lopressor held for bradycardia, received lasix 40\n x3 started on pyridium. Lasted 3 hours on SBT. 7.38/60/38 returned to\n CMV\n Afib with RVR lopressor 10 IV and 25mg po returned to sinus.\n Hypoxic on SBT returned to CMV\n ARTERIAL LINE - STOP 08:00 AM\n URINE CULTURE - At 03:00 PM\n EKG - At 08:25 PM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin/Sulbactam (Unasyn) - 09:52 AM\n Infusions:\n Other ICU medications:\n Hydralazine - 06:00 PM\n Metoprolol - 08:40 PM\n Furosemide (Lasix) - 05:00 AM\n Haloperidol (Haldol) - 06:39 AM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n mag/kcl\n zopharan\n senna\n docusate\n unasyn\n fluconazole\n miconazole\n keppra\n RISS\n tylenol\n simvisatin\n PPI iv\n Albuterol\n chlorhex\n Enalapril 20mg qday\n Hydralizine 10mg iv Q6hr\n pyridium\n lopressor 25 \n fentyl 100mcg last 12 hours\n Changes to medical and family history:\n Pelase see H+P no changes\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.3\nC (99.2\n HR: 62 (60 - 124) bpm\n BP: 112/40(58) {101/33(50) - 183/112(117)} mmHg\n RR: 20 (14 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,669 mL\n 1,640 mL\n PO:\n TF:\n 779 mL\n 669 mL\n IVF:\n 1,050 mL\n 782 mL\n Blood products:\n Total out:\n 3,178 mL\n 1,045 mL\n Urine:\n 3,178 mL\n 1,045 mL\n NG:\n Stool:\n Drains:\n Balance:\n -509 mL\n 595 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 372 (230 - 372) mL\n PS : 0 cmH2O\n RR (Set): 16\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 80%\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n SpO2: 100%\n ABG: 7.38/60/38/37/7\n Ve: 6.5 L/min\n PaO2 / FiO2: 48\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trach\n Cardiovascular: RRR s1s2 no m/r/g\n Respiratory / Chest: Course BS ant/post no bronchial BS noted\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: no rash or erythema\n Ext: No edema noted\n Neurologic: Attentive, A+O x 3 no gross motor sensory deficits.\n Lines: Clean dry intact.\n Skin: Not assessed\n Labs / Radiology: Elevated persistent right HD, Plump vasculature no\n overt infiltrates.\n 7.9 g/dL\n 235 K/uL\n 169 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.5 mEq/L\n 7 mg/dL\n 105 mEq/L\n 147 mEq/L\n 24.9 %\n 6.1 K/uL\n [image002.jpg]\n 04:29 AM\n 11:49 AM\n 12:49 PM\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n WBC\n 3.8\n 4.3\n 6.1\n Hct\n 24.1\n 24.5\n 23\n 24.9\n Plt\n 161\n 181\n 235\n Cr\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 37\n 34\n 34\n 37\n 38\n 37\n Glucose\n 144\n 122\n 152\n 169\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.0 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Micro: Stool/urine/blood no growth to date\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure secondary to tracheal tear,\n S/P trach.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n -Acute on chronic hypercarbic respiratory failure - likely OSA, ?OHS,\n ?element central\n -wean vent as tolerated failed SBP yesterday\n -Will also check US sniff test to assess right diaphragm paralysis\nTracheal tear\n -presumably occurred during intubation at start of prior admission\n -IP following\n -trach in place to bypass injured area will need 6-8 weeks to heal\n -empiric abx coverage inc anti-fungal coverage 10 days of coverage\n hypoxemia\n -Unclear etiology, atelectasis/failure. PE lower on differential as\n responded to being placed back on vent.\n -Will diuresis\n -Will f/u 02 requirement if no improvement will consider CTPA\n -Will Check LE US\n -Check BNP\n -Will repeat ABG\n HYPERTENSION\n -BP better controlled today\n -Will continue enalapril\n -Continue Beta blocker\n -PRN hydralazine\n -Will start lasix with goal negative fluid balance 500cc-1L negative\n Will also help with BP.\n DIABETES MELLITUS (DM), TYPE II:\n -SSRI\nFever-Pan culture-Resolved\n -new\n -is post trach placement which could be explanation\n -already on fluc and unasyn for trach/upper trachea tear proph\nMental status\n -very alert & interactive this morning intermittently confused\n -Consider Haldol will follow closely.\n -review medications consider hold fentanyl\n -wean sedation as tolerated\n -Did have Head CT for MS changes on Tuesday of last week.\n Remainder of plan per resident note\n ICU Care\n Nutrition: Tube feeds\n Replete with Fiber (Full) - 01:50 AM 70 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ hep\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Screen vent unit.\n Total time spent:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with Dr.\n \ns note above, including the assessment and plan. I would\n emphasize and add the following points:\n 62 yr old female with PMH of afib, TIA, memory loss s/p hypoglycemic\n coma, chronic low back pain, anemia, GERD, asthma recently admitted\n with subarachnoid/intraparenchymal hemorrhage and readmitted\n to MICU with acute change in mental status . She is now MICU\n day 9 for acute hypercarbic respiratory failure due to tracheal tear\n requiring tracheostomy.\n Yesterday was put on PSV and tolerated it for three hours before\n desaturating to mid 80s requiring to be put back on ventilator. This AM\n had agitation treated with haldol. Currently alert, talkative, Tm\n 100.4, stable vitals, A/C 350 x 16, peep 10, 80% with sats of 99%.\n Lungs clear ant/lat. 2+ LE edema bilat, R>L. FiO2 being weaned down.\n Etiology of acute hypoxia is unclear but likely related to\n atelectasis/derecruitment. Also possibilities are change in positioning\n of trach with failure to ventilate transiently, acute CHF, or mucus\n plugging. Doubt acute PE but reasonable to look for LE DVT given her\n immobility\n recent CTA without PE. The right hemidiaphragm is elevated\n since admission (there are no old films) and needs to be evaluated for\n diaphragm paresis.\n Otherwise, had afib with RVR requiring lopressor. Now back in NSR.\n Patient is being screened for LTAC. Will remain in MICU. Full Code.\n Patient is critically ill. Time 35 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 03:37 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670226,
"text": "Chief Complaint: - ABG 7/16/141/114. Pt was somnolent during the day\n -> BiPAP restarted-> ABG returned to baseline\n Repeat ABG 7/26/61/105\n - Held NGT -> due for S+S \n - Gave zydis 5mg for agitation to initiate BiPAP\n - Persistently elevated BP >180, cont'd metoprolol, given trial of\n nitropaste, hydral 10mg x1, 20mg x2 -> little improvement -> started\n nitro gtt was difficult to obtain manually.\n - pt in discomfort, EKG w/o ischemic changes, cardiac enzymes obtained\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 11:00 PM\n NON-INVASIVE VENTILATION - STOP 01:00 AM\n NON-INVASIVE VENTILATION - START 01:20 AM\n NON-INVASIVE VENTILATION - STOP 04:30 AM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 2.5 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 11:15 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Metoprolol - 04:00 AM\n Hydralazine - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.8\nC (98.3\n HR: 91 (58 - 118) bpm\n BP: 175/50(79) {136/45(66) - 215/62(94)} mmHg\n RR: 29 (20 - 35) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134 kg\n Total In:\n 1,968 mL\n 206 mL\n PO:\n TF:\n IVF:\n 1,968 mL\n 206 mL\n Blood products:\n Total out:\n 1,730 mL\n 1,153 mL\n Urine:\n 1,730 mL\n 1,153 mL\n NG:\n Stool:\n Drains:\n Balance:\n 238 mL\n -947 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 272 (260 - 361) mL\n PC : 10 cmH2O\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.26/61/105/43/0\n Ve: 6 L/min\n PaO2 / FiO2: 300\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): self, place, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 172 K/uL\n 8.6 g/dL\n 124 mg/dL\n 0.5 mg/dL\n 43 mEq/L\n 3.6 mEq/L\n 12 mg/dL\n 98 mEq/L\n 148 mEq/L\n 28.8 %\n 6.0 K/uL\n [image002.jpg]\n 11:48 PM\n 05:22 AM\n 04:20 PM\n 03:27 AM\n 03:31 AM\n 05:18 AM\n 07:47 AM\n 01:30 PM\n 04:51 PM\n 03:56 AM\n WBC\n 6.5\n 8.2\n 6.0\n Hct\n 26.1\n 27.6\n 28.8\n Plt\n 196\n 201\n 172\n Cr\n 0.5\n 0.6\n 0.6\n 0.5\n TCO2\n 51\n 53\n 55\n 53\n 53\n 29\n Glucose\n 140\n 158\n 172\n 189\n 124\n Other labs: PT / PTT / INR:14.1/24.9/1.2, Differential-Neuts:78.9 %,\n Lymph:13.9 %, Mono:5.8 %, Eos:1.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.6\n mg/dL, Mg++:1.6 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n .\n # Hypercarbic respiratory failure with new right lung collapse - On CXR\n previously she had white out of the right lung with rightward tracheal\n deviation concerning for new right lung collapse, most likely \n mucous plugging given her thick secretions. ABG with acute on chronic\n respiratory acidosis, likely poor ventilation in the setting of\n acute right lung collapse.\n - A-line today given need for frequent ABGs and accurate BP\n measurements\n - BIPAP as needed\n - continue -tracheal suctioning as needed\n - check TTE today\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n .\n # Altered mental status\n h/o SAH/IPH, but now unclear etiology as no\n clear complaints.\n - check STAT Head CT to r/o worsening ICH\n - CTA Chest to r/o PE\n - cont r/o MI given concern for cardiac etiology\n - f/u TTE today\n - check UA/urine culture\n - recheck serum Na in PM to trend given hypernatremia\n .\n #Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her. Possibly intubation.\n -speech and swallow eval today\n -keep NPO for now\n .\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n .\n #Paroxysmal Atrial fibrillation: in sinus rhythm on admission, does\n have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n .\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n .\n # HTN\n continues to be quite hypertensive\n -lasix as tolerated\n -holding acebutolol, enalapril while npo\n -consider hydralazine if hypertensives\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 08:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670304,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n * pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis this AM. CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside today showing\n webbing likely from traumatic intubation. IP, however, feel pt needs to\n have rigid bronch in OR for better visualization of tracheal webbing/?\n mass.\n Hypertension, benign\n Assessment:\n Pt received on nitro gtt @ 1mcg/kg/min with SBPs via cuff ranging\n 180s-190s.\n Action:\n Nitro gtt titrated up to maintain SBP 160-180. Pt continued on 5mg IV\n lopressor. A-line placed by team showing ABPs in 200s systolic which\n required titration of nitro gtt up to 3mcg/kg/min at one point.\n Response:\n Able to wean nitro down as low as 0.7 mcg/kg/min with systolics\n 160-180. Nitro weaned off just prior to transfer to OR with SBPs\n remaining 150s-160s.\n Plan:\n Cont off nitro gtt as long as BPs are maintained 160-180 systolic. Cont\n with IV lopressor until pt able to receive PO anti-hypertensives.\n Restart nitro gtt if necessary to mainting SBPs 160-180.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on aerosol face mask @ 35% FiO2 with sats 88-92% and RR\n 20s-30s. Pt mal-appearing this AM, diaphoretic/hypertensive/Tachypneic.\n Action:\n Pt taken for CTA to r/o PE.\n Response:\n CTA showing tracheomalacia and tracheal mass of unknown origin so\n bronch recommended by radiology. Bedside bronch performed with\n visualization of webbing of unknown etiology. Pt taken to OR @ 1630 for\n rigid bronch post intubation via fiberoptics. IP to perform bronch for\n better visualization and to determine diagnosis of questionable mass.\n Plan:\n Pending results of OR procedure.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670305,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n * pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis this AM. CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside today showing\n webbing likely from traumatic intubation. IP, however, feel pt needs to\n have rigid bronch in OR for better visualization of tracheal webbing/?\n mass.\n Hypertension, benign\n Assessment:\n Pt received on nitro gtt @ 1mcg/kg/min with SBPs via cuff ranging\n 180s-190s.\n Action:\n Nitro gtt titrated up to maintain SBP 160-180. Pt continued on 5mg IV\n lopressor. A-line placed by team showing ABPs in 200s systolic which\n required titration of nitro gtt up to 3mcg/kg/min at one point.\n Response:\n Able to wean nitro down as low as 0.7 mcg/kg/min with systolics\n 160-180. Nitro weaned off just prior to transfer to OR with SBPs\n remaining 150s-160s.\n Plan:\n Cont off nitro gtt as long as BPs are maintained 160-180 systolic. Cont\n with IV lopressor until pt able to receive PO anti-hypertensives.\n Restart nitro gtt if necessary to mainting SBPs 160-180.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on aerosol face mask @ 35% FiO2 with sats 88-92% and RR\n 20s-30s. Pt mal-appearing this AM, diaphoretic/hypertensive/Tachypneic.\n Action:\n Pt taken for CTA to r/o PE.\n Response:\n CTA showing tracheomalacia and tracheal mass of unknown origin so\n bronch recommended by radiology. Bedside bronch performed with\n visualization of webbing of unknown etiology. Pt taken to OR @ 1630 for\n rigid bronch post intubation via fiberoptics. IP to perform bronch for\n better visualization and to determine diagnosis of questionable mass.\n Plan:\n Pending results of OR procedure.\n ------ Protected Section ------\n Patient received from OR @ approx 1815. Rigid bronch in OR revealed 5cm\n tear of the posterior tracheal wall. The patient was intubated under\n fiberoptics and the ETT was placed past the area of the tear as to\n reduce friction to the tracheal lumen. The ETT is NOT TO BE\n REPOSITIONED, and must be handled with extreme caution as it is close\n to the and could easily slip into the right main stem bronchus\n causing lung collapse.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:51 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670937,
"text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101.3 in this shift,increased secretions noted from the\n trach,liquid stool via the flexiseal.\n Action:\n Pan cultuered,\n Response:\n T current 100.8\n Plan:\n Follow fever curve,follow up on the cx data\n Tracheal Tear\n Assessment:\n Pt noted to have 5cm tracheal tear via rigid bronch in OR . Post\n procedure, pt was intubated using fiberoptics ,Trach in place,recevd\n the pt on capap 15/5\n Action:\n Suctioned as needed,contd prophylactic abx,weaned down to 12/5\n Response:\n Pt now with #8 adjustable neck flange portex trach (at 12.5 marked),pt\n deos have period of apnea with low minute volume.,now pt is resting on\n AC.\n Plan:\n Plan to wean vent as tolerated ,follow abg,\n Hypertension, benign\n Assessment:\n Sbp 150-200,dbp 40-50,hr 60\ns ,was anxoious and restless at times\n Action:\n Pt. was given Fentanyl 50mcg x1 for pain ,was OOB to chair for few\n hours.\n Response:\n Sbp very labile,in sleep sbp in 150\ns but even a slight stimulation\n raises the blood pressure.\n Plan:\n Plan to insert dobhuff tube. Resume Enalapril dosing. .\n PT refusing to insert the NG tube,attempted x2.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671159,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. On , pt desatted\n with turning so emergent bedside bronch performed which required\n removal of large blood clot from trachea. ETT was repositioned, and the\n cuff was left with a leak purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out.\n Hypertension, benign\n Assessment:\n SBP 160\n 190\n Action:\n Initially held IV Lopressor d/t HR 50\ns, later BP 190\ns and HR 60\ns so\n gave 10mg IV Lopressor. Later able to give PO Enalapril once GI access\n w/ dobhoff.\n Response:\n HR dropped to low 40\ns @ times while pt sleeping after lopressor IV and\n Fentanyl doses. Held further doses of IV Lopressor. Awaiting BP\n response w/ PO enalapril.\n Plan:\n Pt now w/ NGT and ordered for enalapril PO.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +5peep. Lung sounds\n rhoncherous with diminished bases. Sxn for thick white/yellow\n secretions.\n Action:\n Attempted pt on CPAP 12/5peep, 40%. Monitored ABG\ns w/ vent changes.\n Placed Dobhoff @ bedside.\n Response:\n Worsening ABG w/ CPAP settings so placed back on A/C (see Metavision\n for labs). Dobhoff position confirmed by x-ray and TF started.\n Plan:\n Pt to remain on A/C overnight. ? attempt vent changes again tomorrow.\n Increase TF Q4H w/ goal rate 70cc/hr\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 671285,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: \n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Patient switched to PSV , suctioned for minimal amount of\n thick white secretion .BS rhonchi,no ABG drawn\n # 8 with adjustable flange.\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670842,
"text": "Chief Complaint:\n 24 Hour Events:\n - IP put in trach in OR\n - Hypertensive post-op -- no pain, no nausea, increased bowel regimen\n -- did not have NGT placed, so did not get enalapril, instead\n double-dosed IV metoprolol overnight\n - weaning off vent: currently on Pressure Support\n - left message for PCP, call back tomorrow\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsMotrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 10:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:20 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 04:20 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38.2\nC (100.7\n HR: 65 (49 - 79) bpm\n BP: 141/44(64) {0/0(0) - 0/0(0)} mmHg\n RR: 25 (15 - 25) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,557 mL\n 176 mL\n PO:\n TF:\n IVF:\n 2,497 mL\n 176 mL\n Blood products:\n Total out:\n 1,435 mL\n 755 mL\n Urine:\n 1,435 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,122 mL\n -579 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 319 (298 - 319) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 109\n PIP: 20 cmH2O\n Plateau: 14 cmH2O\n Compliance: 87.5 cmH2O/mL\n SpO2: 96%\n ABG: 7.48/52/73./35/12\n Ve: 4.3 L/min\n PaO2 / FiO2: 183\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 151 K/uL\n 8.2 g/dL\n 106 mg/dL\n 0.4 mg/dL\n 35 mEq/L\n 3.5 mEq/L\n 8 mg/dL\n 105 mEq/L\n 147 mEq/L\n 25.9 %\n 6.4 K/uL\n [image002.jpg]\n 05:02 AM\n 07:27 AM\n 09:27 AM\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n 05:06 PM\n 04:10 AM\n WBC\n 3.9\n 6.4\n Hct\n 22.8\n 25.3\n 23.2\n 25\n 25.9\n Plt\n 147\n 151\n Cr\n 0.4\n 0.4\n 0.4\n TCO2\n 48\n 47\n 48\n 45\n 45\n 40\n Glucose\n 131\n 88\n 100\n 106\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670844,
"text": "Chief Complaint:\n 24 Hour Events:\n - IP put in trach in OR\n - Hypertensive post-op -- no pain, no nausea, increased bowel regimen\n -- did not have NGT placed, so did not get enalapril, instead\n double-dosed IV metoprolol overnight\n - weaning off vent: currently on Pressure Support\n - left message for PCP, call back tomorrow\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsMotrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 10:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:20 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 04:20 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38.2\nC (100.7\n HR: 65 (49 - 79) bpm\n BP: 141/44(64) {0/0(0) - 0/0(0)} mmHg\n RR: 25 (15 - 25) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,557 mL\n 176 mL\n PO:\n TF:\n IVF:\n 2,497 mL\n 176 mL\n Blood products:\n Total out:\n 1,435 mL\n 755 mL\n Urine:\n 1,435 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,122 mL\n -579 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 319 (298 - 319) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 109\n PIP: 20 cmH2O\n Plateau: 14 cmH2O\n Compliance: 87.5 cmH2O/mL\n SpO2: 96%\n ABG: 7.48/52/73./35/12\n Ve: 4.3 L/min\n PaO2 / FiO2: 183\n Physical Examination\n General Appearance: intubated, sedated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous, dull at bases ), no\n sub cutaneous emphysema\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Neurologic: sedated\n Labs / Radiology\n 151 K/uL\n 8.2 g/dL\n 106 mg/dL\n 0.4 mg/dL\n 35 mEq/L\n 3.5 mEq/L\n 8 mg/dL\n 105 mEq/L\n 147 mEq/L\n 25.9 %\n 6.4 K/uL\n [image002.jpg]\n 05:02 AM\n 07:27 AM\n 09:27 AM\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n 05:06 PM\n 04:10 AM\n WBC\n 3.9\n 6.4\n Hct\n 22.8\n 25.3\n 23.2\n 25\n 25.9\n Plt\n 147\n 151\n Cr\n 0.4\n 0.4\n 0.4\n TCO2\n 48\n 47\n 48\n 45\n 45\n 40\n Glucose\n 131\n 88\n 100\n 106\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670194,
"text": "Chief Complaint: - ABG 7/16/141/114. Pt was somnolent during the day\n -> BiPAP restarted-> ABG returned to baseline\n Repeat ABG 7/26/61/105\n - Held NGT -> due for S+S \n - Gave zydis 5mg for agitation to initiate BiPAP\n - Persistently elevated BP >180, cont'd metoprolol, given trial of\n nitropaste, hydral 10mg x1, 20mg x2 -> little improvement -> started\n nitro gtt was difficult to obtain manually.\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 11:00 PM\n NON-INVASIVE VENTILATION - STOP 01:00 AM\n NON-INVASIVE VENTILATION - START 01:20 AM\n NON-INVASIVE VENTILATION - STOP 04:30 AM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 2.5 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 11:15 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Metoprolol - 04:00 AM\n Hydralazine - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.8\nC (98.3\n HR: 91 (58 - 118) bpm\n BP: 175/50(79) {136/45(66) - 215/62(94)} mmHg\n RR: 29 (20 - 35) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134 kg\n Total In:\n 1,968 mL\n 206 mL\n PO:\n TF:\n IVF:\n 1,968 mL\n 206 mL\n Blood products:\n Total out:\n 1,730 mL\n 1,153 mL\n Urine:\n 1,730 mL\n 1,153 mL\n NG:\n Stool:\n Drains:\n Balance:\n 238 mL\n -947 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 272 (260 - 361) mL\n PC : 10 cmH2O\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.26/61/105/43/0\n Ve: 6 L/min\n PaO2 / FiO2: 300\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 172 K/uL\n 8.6 g/dL\n 124 mg/dL\n 0.5 mg/dL\n 43 mEq/L\n 3.6 mEq/L\n 12 mg/dL\n 98 mEq/L\n 148 mEq/L\n 28.8 %\n 6.0 K/uL\n [image002.jpg]\n 11:48 PM\n 05:22 AM\n 04:20 PM\n 03:27 AM\n 03:31 AM\n 05:18 AM\n 07:47 AM\n 01:30 PM\n 04:51 PM\n 03:56 AM\n WBC\n 6.5\n 8.2\n 6.0\n Hct\n 26.1\n 27.6\n 28.8\n Plt\n 196\n 201\n 172\n Cr\n 0.5\n 0.6\n 0.6\n 0.5\n TCO2\n 51\n 53\n 55\n 53\n 53\n 29\n Glucose\n 140\n 158\n 172\n 189\n 124\n Other labs: PT / PTT / INR:14.1/24.9/1.2, Differential-Neuts:78.9 %,\n Lymph:13.9 %, Mono:5.8 %, Eos:1.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.6\n mg/dL, Mg++:1.6 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 08:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670196,
"text": "Chief Complaint: - ABG 7/16/141/114. Pt was somnolent during the day\n -> BiPAP restarted-> ABG returned to baseline\n Repeat ABG 7/26/61/105\n - Held NGT -> due for S+S \n - Gave zydis 5mg for agitation to initiate BiPAP\n - Persistently elevated BP >180, cont'd metoprolol, given trial of\n nitropaste, hydral 10mg x1, 20mg x2 -> little improvement -> started\n nitro gtt was difficult to obtain manually.\n - pt in discomfort, EKG w/o ischemic changes, cardiac enzymes obtained\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 11:00 PM\n NON-INVASIVE VENTILATION - STOP 01:00 AM\n NON-INVASIVE VENTILATION - START 01:20 AM\n NON-INVASIVE VENTILATION - STOP 04:30 AM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 2.5 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 11:15 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Metoprolol - 04:00 AM\n Hydralazine - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.8\nC (98.3\n HR: 91 (58 - 118) bpm\n BP: 175/50(79) {136/45(66) - 215/62(94)} mmHg\n RR: 29 (20 - 35) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134 kg\n Total In:\n 1,968 mL\n 206 mL\n PO:\n TF:\n IVF:\n 1,968 mL\n 206 mL\n Blood products:\n Total out:\n 1,730 mL\n 1,153 mL\n Urine:\n 1,730 mL\n 1,153 mL\n NG:\n Stool:\n Drains:\n Balance:\n 238 mL\n -947 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 272 (260 - 361) mL\n PC : 10 cmH2O\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.26/61/105/43/0\n Ve: 6 L/min\n PaO2 / FiO2: 300\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 172 K/uL\n 8.6 g/dL\n 124 mg/dL\n 0.5 mg/dL\n 43 mEq/L\n 3.6 mEq/L\n 12 mg/dL\n 98 mEq/L\n 148 mEq/L\n 28.8 %\n 6.0 K/uL\n [image002.jpg]\n 11:48 PM\n 05:22 AM\n 04:20 PM\n 03:27 AM\n 03:31 AM\n 05:18 AM\n 07:47 AM\n 01:30 PM\n 04:51 PM\n 03:56 AM\n WBC\n 6.5\n 8.2\n 6.0\n Hct\n 26.1\n 27.6\n 28.8\n Plt\n 196\n 201\n 172\n Cr\n 0.5\n 0.6\n 0.6\n 0.5\n TCO2\n 51\n 53\n 55\n 53\n 53\n 29\n Glucose\n 140\n 158\n 172\n 189\n 124\n Other labs: PT / PTT / INR:14.1/24.9/1.2, Differential-Neuts:78.9 %,\n Lymph:13.9 %, Mono:5.8 %, Eos:1.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.6\n mg/dL, Mg++:1.6 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n .\n # Hypercarbic respiratory failure with new right lung collapse- On CXR\n this morning she had white out of the right lung with rightward\n tracheal deviation concerning for new right lung collapse, most likely\n mucous plugging given her thick secretions. ABG with acute on\n chronic respiratory acidosis, likely poor ventilation in the\n setting of acute right lung collapse.\n --tracheal suctioning\n -repeat CXR post NT suctioning\n -BIPAP as tolerated\n -likely will require intubation and bronchoscopy for deep suctioning\n - check TTE\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n .\n #Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her. Possibly intubation.\n -speech and swallow in the am\n -keep NPO for now\n .\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - Per neurology -> cont keppra for now\n -outpatient neurology follow up\n .\n #Paroxysmal Atrial fibrillation: in sinus rhythm on admission, does\n have limited bursts of afib\n -coumadin being held given recent hemorrhage\n -metoprolol IV prn for tachycardia/htn\n -not on asa left temporal hemorrhage\n .\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n .\n # HTN\n continues to be quite hypertensive\n -lasix as tolerated\n -holding acebutolol, enalapril while npo\n -consider hydralazine if hypertensives\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 08:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671215,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ABG 7.38/55/111 -> PS trial -> 7.32/64/83, so Pt felt to have central\n apnea and retaining CO2\n - Dobhoff placed and started TF/free water boluses\n - checked VBG (7.36/67/48/39) and ABG (7.40/59/133/38)\n - SBP persistently elevated as high as 190, gave 10 IV hydral with good\n result\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:23 PM\n Ampicillin/Sulbactam (Unasyn) - 04:29 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 12:03 AM\n Fentanyl - 12:04 AM\n Metoprolol - 04:29 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.2\nC (99\n HR: 53 (40 - 66) bpm\n BP: 180/57(86) {124/33(57) - 180/116(120)} mmHg\n RR: 16 (13 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,624 mL\n 654 mL\n PO:\n TF:\n 114 mL\n 275 mL\n IVF:\n 2,290 mL\n 279 mL\n Blood products:\n Total out:\n 420 mL\n 75 mL\n Urine:\n 420 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,204 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 182 (182 - 182) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 40\n PIP: 27 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.40/59/133/32/9\n Ve: 5.5 L/min\n PaO2 / FiO2: 332\n Physical Examination\n General Appearance: intubated, sedated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous, dull at bases ), no\n subcutaneous emphysema\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Neurologic: sedated\n Labs / Radiology\n 181 K/uL\n 7.7 g/dL\n 122 mg/dL\n 0.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 107 mEq/L\n 145 mEq/L\n 24.5 %\n 4.3 K/uL\n [image002.jpg]\n 04:10 AM\n 10:33 AM\n 04:18 AM\n 04:29 AM\n 11:49 AM\n 12:49 PM\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n WBC\n 6.4\n 3.6\n 3.8\n 4.3\n Hct\n 25.9\n 23.8\n 24.1\n 24.5\n Plt\n 151\n 154\n 161\n 181\n Cr\n 0.4\n 0.4\n 0.4\n 0.3\n TCO2\n 38\n 37\n 34\n 34\n 37\n 38\n Glucose\n 106\n 86\n 144\n 122\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - consider SBT today, if does well try Passey-Muir valve\n - continue Unasyn and Fluconazole for ppx for tracheal tear\n - continue to d/w patient regarding placing NGT for feeding /\n medications\n # Hypercarbic respiratory failure: Patient remains on vent. Her resp\n issues are likely a combination of OSA, CO2 retention andf her hospital\n course has also been complicated by right lung collapse, R mainstem\n intubation.\n - serial ABGs via A-line as needed, consider d/c A-line and use VBGs as\n needed\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n # Rising temperature: ? impending infection. Increasing temperature,\n low-grade leukocytosis. Post-op from trachea.\n - Pan Cx, check stool for C.diff\n - consider LENIs to r/o DVT\n - continue current antibiotics, touch base w/ IP re: definite course\n # Hypernatremia:\n - D5W at 75 cc/hr\n - if NGT placement, would do free water flushes\n - consider changing abx solution to D5W\n # HCT drop: HCT now stable no melena. Hemolysis labs negative. Repeat\n CXR clearing w/o evidence of worsening effusions and given stable HCT,\n concern for intrathoracic bleeding is now low.\n - monitor HCT\n - guaiac stools\n # Altered mental status\n Currently improved. h/o SAH/IPH, but now\n unclear etiology as no clear complaints. Head CT unchanged, Chest CTA\n w/o PE, no evidence of MI, TTE w/ nl EF, UA unremarkable.\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns w/p any nodal\n agents. In sinus rhythm on admission, does have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - continue enalapril, BB\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:00 PM 40 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670438,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:00 AM\n NON-INVASIVE VENTILATION - START 11:00 AM\n ARTERIAL LINE - START 11:32 AM\n BRONCHOSCOPY - At 01:00 PM\n NON-INVASIVE VENTILATION - STOP 02:10 PM\n OR SENT - At 04:35 PM\n BRONCHOSCOPY - At 04:37 PM\n INVASIVE VENTILATION - START 06:00 PM\n OR RECEIVED - At 06:27 PM\n s/p rigid bronch in OR with visualized 5cm tear in trachea; pt was\n intubated under fiberoptics\n \n - echo nl, EF >70%\n - head CT w/o change\n - chest CTA showed tracheal abnl, bronch showed tracheal webbing\n - pt taken to OR for fiberoptic intubation and rigid bronch which\n showed a 5cm tracheal tear; IP involved and recommended prolonged\n intubation to allow tear to heal as well as ppx abx\n - started on Unasyn and fluconazole ppx\n - OG tube placed, restarted on home dose of enalapril, nitro gtt weaned\n off\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 09:30 PM\n Ampicillin/Sulbactam (Unasyn) - 04:21 AM\n Infusions:\n Fentanyl - 80 mcg/hour\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:21 AM\n Metoprolol - 04:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 58 (58 - 94) bpm\n BP: 141/44(64) {137/41(64) - 199/77(89)} mmHg\n RR: 16 (10 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,034 mL\n 422 mL\n PO:\n TF:\n IVF:\n 2,034 mL\n 422 mL\n Blood products:\n Total out:\n 1,983 mL\n 485 mL\n Urine:\n 1,983 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 51 mL\n -63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (300 - 350) mL\n Vt (Spontaneous): 306 (306 - 306) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 28 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 98%\n ABG: 7.44/69/81./42/18\n Ve: 5.4 L/min\n PaO2 / FiO2: 203\n Physical Examination\n General Appearance: intubated, sedated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous, dull at bases ), no\n sub cutaneous emphysema\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Neurologic: sedated\n Labs / Radiology\n 164 K/uL\n 7.3 g/dL\n 179 mg/dL\n 0.4 mg/dL\n 42 mEq/L\n 3.1 mEq/L\n 16 mg/dL\n 99 mEq/L\n 147 mEq/L\n 23.3 %\n 6.7 K/uL\n [image002.jpg]\n 01:08 PM\n 02:33 PM\n 03:06 PM\n 06:22 PM\n 07:46 PM\n 08:47 PM\n 10:32 PM\n 01:13 AM\n 04:33 AM\n 05:02 AM\n WBC\n 6.7\n Hct\n 23.3\n Plt\n 164\n Cr\n 0.4\n TropT\n <0.01\n <0.01\n TCO2\n 42\n 45\n 47\n 50\n 46\n 50\n 48\n Glucose\n 179\n Other labs: PT / PTT / INR:14.1/24.9/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Lactic Acid:1.6 mmol/L, Ca++:8.2 mg/dL, Mg++:2.0 mg/dL,\n PO4:1.5 mg/dL\n TTE - The left atrium is mildly dilated. Left ventricular wall\n thicknesses are normal. The left ventricular cavity size is normal. Due\n to suboptimal technical quality, a focal wall motion abnormality cannot\n be fully excluded. Overall left ventricular systolic function is normal\n (LVEF>55%). Right ventricular chamber size and free wall motion are\n normal. The aortic valve leaflets (3) are mildly thickened. There is a\n minimally increased gradient consistent with minimal aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. No mitral regurgitation is seen.\n NCHCT\n Continued evolution of left medial temporal intraparenchymal\n hemorrhage, without evidence of new hemorrhage.\n CTA Chest\n 1. Probable pulmonary hypertension. No emboli in the main,\n right, left, or lobar pulmonary arteries, peripheral circulation is not\n evaluated by this study. 2. Right lower lobe collapse and\n heterogeneous opacification in the right upper lobe and lingual, more\n likely aspiration than pneumonia at this stage, are sufficient to\n explain hypoxia. 3. Tracheomalacia. Upper tracheal mass or organized\n secretions or aspirated material. Bronchoscopy recommended. 4.\n Probably pulmonary arterial hypertension.\n Assessment and Plan\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; now intubated after\n finding of traumatic tracheal tear.\n .\n # HCT drop: no melena. CXR with ? worsening pleural effusions, HCT drop\n and tracheal tear could be concerning for intrathoracic bleeding.\n - q 8 HCT\n - guaic stools\n - obtain hemolysis labs\n - repeat CXR, if truly worsening effusion will consider CT and\n thoracentesis\n .\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation.\n - remain intubated x2 weeks to allow healing of tear\n - prophylactic antibiotics while intubated: Unasyn and Fluconazole\n - follow serial CXRs\n .\n # Hypercarbic respiratory failure with new right lung collapse - On CXR\n previously she had white out of the right lung with rightward tracheal\n deviation concerning for new right lung collapse, most likely \n mucous plugging given her thick secretions. ABG now with hypoxia in\n the setting of turning pt and right mainstem intubation (now s/p\n pulling back ET tube) and with metabolic alkalosis overventilation.\n - repeat ABG: RR, consider inc Fi02 pending ABG results\n - serial ABGs via A-line\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n .\n # Altered mental status\n h/o SAH/IPH, but now unclear etiology as no\n clear complaints. Head CT unchanged, Chest CTA w/o PE, no evidence of\n MI, TTE w/ nl EF, UA unremarkable. Now intubated tracheal tear.\n .\n #Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her. Possibly intubation. Now intubated\n again tracheal tear.\n - on Unasyn as for tracheal tear\n .\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n .\n #Paroxysmal Atrial fibrillation: in sinus rhythm on admission, does\n have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n .\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n .\n # HTN\n was HTN yesterday, BP lower in the afternoon and evening in\n the setting of propofol, however pt remains with large pulse pressure.\n Enalapril was started last night\n - cont enalapril\n ICU Care\n Nutrition: NPO\n Glycemic Control: SQ Insulin\n fixed dose + SS\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 09:05 AM\n Arterial Line - 11:32 AM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer: IV PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 670206,
"text": "TITLE:\n Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 11:00 PM\n NON-INVASIVE VENTILATION - STOP 01:00 AM\n NON-INVASIVE VENTILATION - START 01:20 AM\n NON-INVASIVE VENTILATION - STOP 04:30 AM\n - Hydralazine & nitro drip for HTN\n - chest discomfort - EKG and r/o\n History obtained from Medical records\n Patient unable to provide history: confused\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 1.8 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 11:15 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Metoprolol - 04:00 AM\n Hydralazine - 05:15 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 35.8\nC (96.5\n HR: 93 (65 - 118) bpm\n BP: 158/43(70) {136/43(66) - 215/62(94)} mmHg\n RR: 28 (20 - 35) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134 kg\n Total In:\n 1,968 mL\n 264 mL\n PO:\n TF:\n IVF:\n 1,968 mL\n 264 mL\n Blood products:\n Total out:\n 1,730 mL\n 1,153 mL\n Urine:\n 1,730 mL\n 1,153 mL\n NG:\n Stool:\n Drains:\n Balance:\n 238 mL\n -889 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 272 (272 - 361) mL\n PC : 10 cmH2O\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 16 cmH2O\n SpO2: 91%\n ABG: 7.26/61/105/43/0\n Ve: 6 L/min\n PaO2 / FiO2: 300\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): self, place, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 8.6 g/dL\n 172 K/uL\n 124 mg/dL\n 0.5 mg/dL\n 43 mEq/L\n 3.6 mEq/L\n 12 mg/dL\n 98 mEq/L\n 148 mEq/L\n 28.8 %\n 6.0 K/uL\n [image002.jpg]\n 11:48 PM\n 05:22 AM\n 04:20 PM\n 03:27 AM\n 03:31 AM\n 05:18 AM\n 07:47 AM\n 01:30 PM\n 04:51 PM\n 03:56 AM\n WBC\n 6.5\n 8.2\n 6.0\n Hct\n 26.1\n 27.6\n 28.8\n Plt\n 196\n 201\n 172\n Cr\n 0.5\n 0.6\n 0.6\n 0.5\n TCO2\n 51\n 53\n 55\n 53\n 53\n 29\n Glucose\n 140\n 158\n 172\n 189\n 124\n Other labs: PT / PTT / INR:14.1/24.9/1.2, CK / CKMB / Troponin-T:18//,\n Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8 %, Eos:1.4 %, Lactic\n Acid:0.6 mmol/L, Ca++:8.6 mg/dL, Mg++:1.6 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n HYPERTENSION\n -more hypertensive than usual\n -currently on ntg gtt, hydralazine\n -anxiety/pain vs. cardiac event\n -CTA r/o PE\n DIABETES MELLITUS (DM), TYPE II\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n -Acute on chronic hypercarbic respiratory failure\n -Decomp at rehab after didn\nt put on bipap overnight\n -Assess for extubation.\n -Diuresis with lasix and acetazolamide\n -Hold narcotics/sedatives.\n DIABETES MELLITUS (DM), TYPE II: consider d/c\ning oral hypoglycemics.\nLeft leg erythema:\n -Potential infection vs. DVT.\n -Follow-up ultrasound.\n Chest pain\n -EKG without changes\n -r/o MI\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 08:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670208,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670209,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "General",
"chartdate": "2103-03-07 00:00:00.000",
"description": "Family Meeting Note",
"row_id": 670516,
"text": "TITLE: Family meeting note\n ICU team ( - attending, - resident, -nurse)\n and Dr. \n Interventional Pulmonary met with the family\n (husband, sister, son, [daughter remote on phone]) to discuss Mrs.\n \ns current medical state. The tracheal mucousal tear,\n discovered yesterday, was discussed in detail along with option for\n management including trache to rest/bypass the area. Family asked many\n questions which were addressed in detail. They are in agreement with\n trache to bypass/rest the tear given competing option of maintaining\n ETT/heavy sedation for 7-10 days with risk of ETT migration, greater\n risk of VAP, etc. Given the patient\ns underlying hypercarbic\n respiratory failure and need for reintubation in past, extubation and\n conservative therapy (pure observation) would be risky since\n reintubation, especially emergently, could extend the tear/perf into\n esophagus or cause the flap to occlude the airway.\n Time spent 65min\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670930,
"text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101.3 in this shift,increased secretions noted from the\n trach,liquid stool via the flexiseal.\n Action:\n Pan cultuered,\n Response:\n T current 100.8\n Plan:\n Follow fever curve,follow up on the cx data\n Tracheal Tear\n Assessment:\n Pt noted to have 5cm tracheal tear via rigid bronch in OR . Post\n procedure, pt was intubated using fiberoptics ,Trach in place,recevd\n the pt on capap 15/5\n Action:\n Suctioned as needed,contd prophylactic abx,weaned down to 12/5\n Response:\n Pt now with #8 adjustable neck flange portex trach (at 12.5 marked),pt\n deos have period of apnea with low minute volume.\n Plan:\n Plan to wean vent as tolerated ,follow abg,\n Hypertension, benign\n Assessment:\n Sbp 150-200,dbp 40-50,hr 60\ns ,was anxoious and restless at times\n Action:\n Pt. was given Fentanyl 50mcg x1 for pain ,was OOB to chair for few\n hours.\n Response:\n Sbp very labile,in sleep sbp in 150\ns but even a slight stimulation\n raises the blood pressure.\n Plan:\n Plan to insert dobhuff tube. Resume Enalapril dosing. .\n PT refusing to insert the NG tube,attempted x2.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670834,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. The ETT is NOT TO BE\n REPOSITIONED, and must be handled with extreme caution as it is close\n to the and could easily slip into the right main stem bronchus\n causing lung collapse. On , pt desatted with turning so emergent\n bedside bronch performed which required removal of large blood clot\n from trachea. ETT was repositioned, and the cuff was left with a leak\n purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out.\n Tracheal Tear\n Assessment:\n Pt noted to have 5cm tracheal tear via rigid bronch in OR . Post\n procedure, pt was intubated using fiberoptics with plan to have\n tracheostomy.\n Action:\n Pt went to OR yesterday for rigid bronch/open tracheostomy.\n Response:\n Pt now with #8 adjustable neck flange portex trach remains off sedation\n and tolerated wean to CPAP.\n Plan:\n Wean pt from vent to trach mask as tolerated, as absence of ventilation\n will better allow for tracheal tear to heal.\n Hypertension, benign\n Assessment:\n During this shift SBP remains elevated in the 160-180\n Action:\n Pt. was given Fentanyl 50mcg x4. Pt\ns Lopressor dose was increased from\n 5mg iv q6hr to 10mg iv q6hrs.\n Response:\n SBPs remains 170\ns post lopressor and fentanyl but slowly creeping up\n into 190s.\n Plan:\n Plan to insert dobhuff tube. Resume Enalapril dosing. .\n Potassium repleted, 40meq iv given last evening at 2100 and then again\n 40meq iv given this am at 0600.\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670846,
"text": "Chief Complaint:\n 24 Hour Events:\n - IP put in trach in OR\n - Hypertensive post-op -- no pain, no nausea, increased bowel regimen\n -- did not have NGT placed, so did not get enalapril, instead\n double-dosed IV metoprolol overnight\n - weaning off vent: currently on Pressure Support\n - left message for PCP, call back tomorrow\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsMotrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 10:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:20 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 04:20 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38.2\nC (100.7\n HR: 65 (49 - 79) bpm\n BP: 141/44(64) {0/0(0) - 0/0(0)} mmHg\n RR: 25 (15 - 25) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,557 mL\n 176 mL\n PO:\n TF:\n IVF:\n 2,497 mL\n 176 mL\n Blood products:\n Total out:\n 1,435 mL\n 755 mL\n Urine:\n 1,435 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,122 mL\n -579 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 319 (298 - 319) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 109\n PIP: 20 cmH2O\n Plateau: 14 cmH2O\n Compliance: 87.5 cmH2O/mL\n SpO2: 96%\n ABG: 7.48/52/73./35/12\n Ve: 4.3 L/min\n PaO2 / FiO2: 183\n Physical Examination\n General Appearance: intubated, sedated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous, dull at bases ), no\n sub cutaneous emphysema\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Neurologic: sedated\n Labs / Radiology\n 151 K/uL\n 8.2 g/dL\n 106 mg/dL\n 0.4 mg/dL\n 35 mEq/L\n 3.5 mEq/L\n 8 mg/dL\n 105 mEq/L\n 147 mEq/L\n 25.9 %\n 6.4 K/uL\n [image002.jpg]\n 05:02 AM\n 07:27 AM\n 09:27 AM\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n 05:06 PM\n 04:10 AM\n WBC\n 3.9\n 6.4\n Hct\n 22.8\n 25.3\n 23.2\n 25\n 25.9\n Plt\n 147\n 151\n Cr\n 0.4\n 0.4\n 0.4\n TCO2\n 48\n 47\n 48\n 45\n 45\n 40\n Glucose\n 131\n 88\n 100\n 106\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; now intubated after\n finding of traumatic tracheal tear.\n .\n # HCT drop: HCT now stable no melena. Hemolysis labs negative. Repeat\n CXR clearing w/o evidence of worsening effusions and given stable HCT,\n concern for intrathoracic bleeding is now low.\n - monitor HCT\n - guaiac stools.\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal.\n - tracheostomy today\n - prophylactic antibiotics while intubated: Unasyn and Fluconazole\n .\n # Hypercarbic respiratory failure with new right lung collapse - On CXR\n previously she had white out of the right lung with rightward tracheal\n deviation concerning for new right lung collapse, most likely \n mucous plugging given her thick secretions. ABG now with hypoxia in\n the setting of turning pt and right mainstem intubation (now s/p\n pulling back ET tube) and with metabolic alkalosis overventilation.\n - serial ABGs via A-line\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n # Altered mental status\n h/o SAH/IPH, but now unclear etiology as no\n clear complaints. Head CT unchanged, Chest CTA w/o PE, no evidence of\n MI, TTE w/ nl EF, UA unremarkable. Now intubated tracheal tear.\n #Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her. Possibly intubation. Now intubated\n again tracheal tear.\n - on Unasyn as for tracheal tear\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns w/p any nodal\n agents. In sinus rhythm on admission, does have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - continue enalapril\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: heparin sc\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 670990,
"text": "Demographics\n Day of mechanical ventilation: 5\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: \n Size: 8.0mm\n Cuff\n Airway problems: persistent cuff leak\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments: mdi as ordered/some airtrapping noted\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet\n breathing/breathing pattern more irratic now that she is awake\n Assessment of breathing comfort: No claim of dyspnea)\n Trigger work assessment: Triggering synchronously, Frequent failed\n trigger efforts\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Plan wean to psv in the am. Cuff leak noted with sml volume loss.\n Flange marked at 12.5.\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671263,
"text": "Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n CMV 7.38/55/11 PST 7.32/64/83 central component to apnea.\n VBG correlated A59 V 67 .04 change in pH.\n Doboff placed\n IV hydralazine for HTN with effect\n FEVER - 101.3\nF - 12:00 PM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:23 PM\n Ampicillin/Sulbactam (Unasyn) - 10:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 12:04 AM\n Metoprolol - 04:29 AM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n mag/kcl\n zopharan\n metoprol 10 q 6 hr (D\n senna\n docusate\n unasyn\n fluconazole\n miconazole\n keppra\n RISS\n tylenol\n simvisatin\n PPI iv\n Albuterol\n chlorhex\n Enalapril 20mg qday\n Hydralizine 10mg iv Q6hr\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:unremarkable\n Flowsheet Data as of 11:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 68 (40 - 82) bpm\n BP: 133/32(56) {124/31(56) - 180/116(120)} mmHg\n RR: 19 (14 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,624 mL\n 1,233 mL\n PO:\n TF:\n 114 mL\n 449 mL\n IVF:\n 2,290 mL\n 524 mL\n Blood products:\n Total out:\n 420 mL\n 148 mL\n Urine:\n 420 mL\n 148 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,204 mL\n 1,085 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 182 (182 - 182) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 40\n PIP: 36 cmH2O\n Plateau: 24 cmH2O\n SpO2: 96%\n ABG: 7.40/59/133/32/9\n Ve: 5.1 L/min\n PaO2 / FiO2: 332\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trache\n Cardiovascular: RRR s1s2 no m/r/g\n Respiratory / Chest: clear anteriorly\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: no rash or erythema\n Neurologic: Attentive, A+O x 3 no gross motor sensory deficits.\n Lines: Clean dry intact.\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology: Chest port - No focal infiltrates ? RML\n atelectasis, sharp angles, PICC line not in place\n 7.7 g/dL\n 181 K/uL\n 122 mg/dL\n 0.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 107 mEq/L\n 145 mEq/L\n 24.5 %\n 4.3 K/uL\n [image002.jpg]\n 04:10 AM\n 10:33 AM\n 04:18 AM\n 04:29 AM\n 11:49 AM\n 12:49 PM\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n WBC\n 6.4\n 3.6\n 3.8\n 4.3\n Hct\n 25.9\n 23.8\n 24.1\n 24.5\n Plt\n 151\n 154\n 161\n 181\n Cr\n 0.4\n 0.4\n 0.4\n 0.3\n TCO2\n 38\n 37\n 34\n 34\n 37\n 38\n Glucose\n 106\n 86\n 144\n 122\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Micro-Stool neg Cdiff, Urine neg, and blood neg from 24^th\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\nTracheal tear\n -presumably occurred during intubation at start of prior admission\n -IP following\n -trach placed yesterday to bypass injured area\n -empiric abx coverage inc anti-fungal coverage 10 days of coverage\n\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n -Acute on chronic hypercarbic respiratory failure - likely OSA, ?OHS,\n ?element central\n -Resp alkalosis\n -wean vent\n -Confirmed with gas pre and post CPAP\n HYPERTENSION\n -BP better controlled today\n -Will start enalapril when NG in place\n -PRN hydralazine\n -Will start lasix with goal negative fluid balance 500cc-1L negative\n Will also help with BP.\n DIABETES MELLITUS (DM), TYPE II:\n -SSRI\nLeft leg erythema:\n -No change chronic per husband\n culture-Resolved\n -new\n -is post trach placement which could be explanation\n -already on fluc and unasyn for trach/upper trachea tear proph\nMental status\n -very alert & interactive this morning intermittently confused\n -Consider Haldol will follow closely.\n -review medications consider hold fentanyl\n -wean sedation as tolerated\n -Did have Head CT for MS changes on Tuesday of last week.\n Remainder of plan per resident note\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM-Pull back 1cm.\n Prophylaxis:\n DVT: SQ hep\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition : Screen on Monday for LTAC placement\n Patient is critically ill. Total time spent: 32 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671266,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. On , pt desatted\n with turning so emergent bedside bronch performed which required\n removal of large blood clot from trachea. ETT was repositioned, and the\n cuff was left with a leak purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out. Pt will need this in place for approx 8\n weeks\n Hypertension, benign\n Assessment:\n SBP conts to be high 160\n 180\n Action:\n Dc\nd A-line, Hydralazine standing doses given, enalapril increased to\n 20mg daily, Dc\nd Lopressor IV, Furosemide 40mg IV x1.\n Response:\n SBP remains 180\ns-160\ns at this time, awaiting response from evening PO\n enalapril dose. Responding well to IV lasix.\n Plan:\n Monitor BP, cont standing IV hydral, diuresing w/ goal -500cc to -1L\n for 24Hrs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +5peep. Lung sounds\n rhoncherous .Sxn for thick white/yellow secretions.\n Action:\n Attempted to wean to Psup 12/5peep, frequent sxn for sm amts thin white\n secretions that do cause desat to mid 80\ns and induce pt to cough\n vigorously.\n Response:\n Plan:\n Cont to attempt to wean vent as tolerated. Monitor VBG and/or pt\n mental status to assess tolerance of vent weaning. Cont to sxn as\n needed.\n Today c/o bladder pain/discomfort, started Phenazopyridine and sent\n urine for cx. Also later c/o abd discomfort and nausea; stopped TF\n and gave zofran IV. Also c/o back pain/discomfort but team wants to\n avoid fentanyl to see if mental status/confusion improves, so gave\n 650mg PO Tylenol.\n ? screen for rehab tomorrow. Should be able to go to an Acute\n respiratory rehab tomorrow or the day after.\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671336,
"text": "Chief Complaint: hypercarbic resp failure\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:00 AM\n URINE CULTURE - At 03:00 PM\n EKG - At 08:25 PM\n - increased enalapril dose, held metoprolol\n - given lasix 40mg iv with good effect on urine output and fluid\n balance, repeated in PM, another dose this AM\n - started pyridium for bladder spasm\n - given fioricet x1 for migraine symptoms\n - attempted PSV, lasted ~3hrs but ABG 7.38/60/38 --> returned to AC\n - went into afib/rvr at , ecg unchanged, given lopressor 10mg iv x1\n followed by 25mg po with good effect, back to nsr\n Patient unable to provide history: Encephalopathy\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin/Sulbactam (Unasyn) - 03:54 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Hydralazine - 06:00 PM\n Metoprolol - 08:40 PM\n Heparin Sodium (Prophylaxis) - 12:42 AM\n Furosemide (Lasix) - 05:00 AM\n Haloperidol (Haldol) - 06:39 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 72 (61 - 124) bpm\n BP: 131/112(117) {123/31(56) - 183/112(117)} mmHg\n RR: 16 (14 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,669 mL\n 443 mL\n PO:\n TF:\n 779 mL\n 107 mL\n IVF:\n 1,050 mL\n 206 mL\n Blood products:\n Total out:\n 3,178 mL\n 735 mL\n Urine:\n 3,178 mL\n 735 mL\n NG:\n Stool:\n Drains:\n Balance:\n -509 mL\n -292 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 372 (230 - 372) mL\n PS : 0 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n SpO2: 100%\n ABG: 7.38/60/38/37/7\n Ve: 6 L/min\n PaO2 / FiO2: 38\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 235 K/uL\n 7.9 g/dL\n 169 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.5 mEq/L\n 7 mg/dL\n 105 mEq/L\n 147 mEq/L\n 24.9 %\n 6.1 K/uL\n [image002.jpg]\n 04:29 AM\n 11:49 AM\n 12:49 PM\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n WBC\n 3.8\n 4.3\n 6.1\n Hct\n 24.1\n 24.5\n 23\n 24.9\n Plt\n 161\n 181\n 235\n Cr\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 37\n 34\n 34\n 37\n 38\n 37\n Glucose\n 144\n 122\n 152\n 169\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.0 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Imaging: CXR: poor inspiratory effort, but compared to prior CXR,\n slightly more edema, no effusions, no infiltrate\n Microbiology: : Stool, urine, blood: NGTD\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - continue to try PS trials, although continues to become hypercarbic\n likely central apnea\n - if does well try Passey-Muir valve\n - continue Unasyn () and Fluconazole () for ppx for tracheal\n tear for goal 10 day course\n # Respiratory failure: Currently appears to be component of hypercarbic\n resp failure likely from cental apnea as well as mild pulm edema.\n Patient remains on vent. Her resp issues are likely a combination of\n OSA, CO2 retention andf her hospital course has also been complicated\n by right lung collapse, R mainstem intubation.\n - use VBGs as needed\n - goal I/O 500-1L neg today\n - continue flovent, albuterol, atrovent\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns, but had an\n episode of afib with RVR last night.\n - holding BB given low HR, but may need intermittent nodal agents\n - coumadin being held given recent hemorrhage\n - not on asa left temporal hemorrhage\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - continue enalapril, and hydralazine\n # Altered mental status\n Has been improved, but still frequently\n confused. h/o SAH/IPH, but now unclear etiology as no clear complaints.\n Head CT unchanged, Chest CTA w/o PE, no evidence of MI, TTE w/ nl EF,\n UA unremarkable.\n - did receive haldol this AM for agitation\n # Hypernatremia:\n - continue free water flushes 250 cc Q4H\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n # Rising temperature: Has been afebrile for >48 hrs.\n - Post-op from trachea.\n - f/u Cx data, check stool for C.diff\n -# HCT drop: HCT now stable no melena. Hemolysis labs negative.\n Repeat CXR clearing w/o evidence of worsening effusions and given\n stable HCT, concern for intrathoracic bleeding is now low.\n - monitor HCT\n - guaiac stools\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671337,
"text": "Chief Complaint: hypercarbic resp failure\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:00 AM\n URINE CULTURE - At 03:00 PM\n EKG - At 08:25 PM\n - increased enalapril dose, held metoprolol\n - given lasix 40mg iv with good effect on urine output and fluid\n balance, repeated in PM, another dose this AM\n - started pyridium for bladder spasm\n - given fioricet x1 for migraine symptoms\n - attempted PSV, lasted ~3hrs but ABG 7.38/60/38 --> returned to AC\n - went into afib/rvr at , ecg unchanged, given lopressor 10mg iv x1\n followed by 25mg po with good effect, back to nsr\n Patient unable to provide history: Encephalopathy\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin/Sulbactam (Unasyn) - 03:54 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Hydralazine - 06:00 PM\n Metoprolol - 08:40 PM\n Heparin Sodium (Prophylaxis) - 12:42 AM\n Furosemide (Lasix) - 05:00 AM\n Haloperidol (Haldol) - 06:39 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 72 (61 - 124) bpm\n BP: 131/112(117) {123/31(56) - 183/112(117)} mmHg\n RR: 16 (14 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,669 mL\n 443 mL\n PO:\n TF:\n 779 mL\n 107 mL\n IVF:\n 1,050 mL\n 206 mL\n Blood products:\n Total out:\n 3,178 mL\n 735 mL\n Urine:\n 3,178 mL\n 735 mL\n NG:\n Stool:\n Drains:\n Balance:\n -509 mL\n -292 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 372 (230 - 372) mL\n PS : 0 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n SpO2: 100%\n ABG: 7.38/60/38/37/7\n Ve: 6 L/min\n PaO2 / FiO2: 38\n Physical Examination\n GEN: very somnolent (just received haldol), but opens eyes to command\n HEENT: clear secretions in back of mouth\n PULM: clear ant and laterally\n Heart: distant heart sounds, RRR, no murmurs\n ABD: obese, soft, NT\n EXT: 2+ edema\n Labs / Radiology\n 235 K/uL\n 7.9 g/dL\n 169 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.5 mEq/L\n 7 mg/dL\n 105 mEq/L\n 147 mEq/L\n 24.9 %\n 6.1 K/uL\n [image002.jpg]\n 04:29 AM\n 11:49 AM\n 12:49 PM\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n WBC\n 3.8\n 4.3\n 6.1\n Hct\n 24.1\n 24.5\n 23\n 24.9\n Plt\n 161\n 181\n 235\n Cr\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 37\n 34\n 34\n 37\n 38\n 37\n Glucose\n 144\n 122\n 152\n 169\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.0 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Imaging: CXR: poor inspiratory effort, but compared to prior CXR,\n slightly more edema, no effusions, no infiltrate\n Microbiology: : Stool, urine, blood: NGTD\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - continue to try PS trials, although continues to become hypercarbic\n likely central apnea\n - if does well try Passey-Muir valve\n - continue Unasyn () and Fluconazole () for ppx for tracheal\n tear for goal 10 day course\n # Respiratory failure: Currently appears to be component of hypercarbic\n resp failure likely from cental apnea as well as mild pulm edema.\n Patient remains on vent. Her resp issues are likely a combination of\n OSA, CO2 retention andf her hospital course has also been complicated\n by right lung collapse, R mainstem intubation.\n - use VBGs as needed\n - goal I/O 500-1L neg today\n - continue flovent, albuterol, atrovent\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns, but had an\n episode of afib with RVR last night.\n - holding BB given low HR, but may need intermittent nodal agents\n - coumadin being held given recent hemorrhage\n - not on asa left temporal hemorrhage\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - continue enalapril, and hydralazine\n # Altered mental status\n Has been improved, but still frequently\n confused. h/o SAH/IPH, but now unclear etiology as no clear complaints.\n Head CT unchanged, Chest CTA w/o PE, no evidence of MI, TTE w/ nl EF,\n UA unremarkable.\n - did receive haldol this AM for agitation\n # Hypernatremia:\n - continue free water flushes 250 cc Q4H\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n # Rising temperature: Has been afebrile for >48 hrs.\n - Post-op from trachea.\n - f/u Cx data, check stool for C.diff\n -# HCT drop: HCT now stable no melena. Hemolysis labs negative.\n Repeat CXR clearing w/o evidence of worsening effusions and given\n stable HCT, concern for intrathoracic bleeding is now low.\n - monitor HCT\n - guaiac stools\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671356,
"text": "Chief Complaint: hypercarbic resp failure\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:00 AM\n URINE CULTURE - At 03:00 PM\n EKG - At 08:25 PM\n - increased enalapril dose, held metoprolol\n - given lasix 40mg iv with good effect on urine output and fluid\n balance, repeated in PM, another dose this AM\n - started pyridium for bladder spasm\n - given fioricet x1 for migraine symptoms\n - attempted PSV, lasted ~3hrs but ABG 7.38/60/38 --> returned to AC\n - went into afib/rvr at , ecg unchanged, given lopressor 10mg iv x1\n followed by 25mg po with good effect, back to nsr\n Patient unable to provide history: Encephalopathy\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin/Sulbactam (Unasyn) - 03:54 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Hydralazine - 06:00 PM\n Metoprolol - 08:40 PM\n Heparin Sodium (Prophylaxis) - 12:42 AM\n Furosemide (Lasix) - 05:00 AM\n Haloperidol (Haldol) - 06:39 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 72 (61 - 124) bpm\n BP: 131/112(117) {123/31(56) - 183/112(117)} mmHg\n RR: 16 (14 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,669 mL\n 443 mL\n PO:\n TF:\n 779 mL\n 107 mL\n IVF:\n 1,050 mL\n 206 mL\n Blood products:\n Total out:\n 3,178 mL\n 735 mL\n Urine:\n 3,178 mL\n 735 mL\n NG:\n Stool:\n Drains:\n Balance:\n -509 mL\n -292 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 372 (230 - 372) mL\n PS : 0 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n SpO2: 100%\n ABG: 7.38/60/38/37/7\n Ve: 6 L/min\n PaO2 / FiO2: 38\n Physical Examination\n GEN: very somnolent (just received haldol), but opens eyes to command\n HEENT: clear secretions in back of mouth\n PULM: clear ant and laterally\n Heart: distant heart sounds, RRR, no murmurs\n ABD: obese, soft, NT\n EXT: 2+ edema\n Labs / Radiology\n 235 K/uL\n 7.9 g/dL\n 169 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.5 mEq/L\n 7 mg/dL\n 105 mEq/L\n 147 mEq/L\n 24.9 %\n 6.1 K/uL\n [image002.jpg]\n 04:29 AM\n 11:49 AM\n 12:49 PM\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n WBC\n 3.8\n 4.3\n 6.1\n Hct\n 24.1\n 24.5\n 23\n 24.9\n Plt\n 161\n 181\n 235\n Cr\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 37\n 34\n 34\n 37\n 38\n 37\n Glucose\n 144\n 122\n 152\n 169\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.0 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Imaging: CXR: poor inspiratory effort, but compared to prior CXR,\n slightly more edema, no effusions, no infiltrate\n Microbiology: : Stool, urine, blood: NGTD\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - continue to try PS trials, although continues to become hypercarbic\n likely central apnea\n - if does well try Passey-Muir valve\n - continue Unasyn () and Fluconazole () for ppx for tracheal\n tear for goal 10 day course\n # Respiratory failure: Currently appears to be component of hypercarbic\n resp failure likely from cental apnea as well as mild pulm edema.\n Patient remains on vent. Her resp issues are likely a combination of\n OSA, CO2 retention andf her hospital course has also been complicated\n by right lung collapse, R mainstem intubation.\n - use VBGs as needed\n - goal I/O 500-1L neg today\n - continue flovent, albuterol, atrovent\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns, but had an\n episode of afib with RVR last night.\n - holding BB given low HR, but may need intermittent nodal agents\n - coumadin being held given recent hemorrhage\n - not on asa left temporal hemorrhage\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - continue enalapril, and hydralazine\n # Altered mental status\n Has been improved, but still frequently\n confused. h/o SAH/IPH, but now unclear etiology as no clear complaints.\n Head CT unchanged, Chest CTA w/o PE, no evidence of MI, TTE w/ nl EF,\n UA unremarkable.\n - did receive haldol this AM for agitation\n # Hypernatremia:\n - continue free water flushes 250 cc Q4H\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n # Rising temperature: Has been afebrile for >48 hrs.\n - Post-op from trachea.\n - f/u Cx data, check stool for C.diff\n -# HCT drop: HCT now stable no melena. Hemolysis labs negative.\n Repeat CXR clearing w/o evidence of worsening effusions and given\n stable HCT, concern for intrathoracic bleeding is now low.\n - monitor HCT\n - guaiac stools\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671358,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:00 AM\n URINE CULTURE - At 03:00 PM\n EKG - At 08:25 PM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin/Sulbactam (Unasyn) - 09:52 AM\n Infusions:\n Other ICU medications:\n Hydralazine - 06:00 PM\n Metoprolol - 08:40 PM\n Furosemide (Lasix) - 05:00 AM\n Haloperidol (Haldol) - 06:39 AM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.3\nC (99.2\n HR: 62 (60 - 124) bpm\n BP: 112/40(58) {101/33(50) - 183/112(117)} mmHg\n RR: 20 (14 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,669 mL\n 1,640 mL\n PO:\n TF:\n 779 mL\n 669 mL\n IVF:\n 1,050 mL\n 782 mL\n Blood products:\n Total out:\n 3,178 mL\n 1,045 mL\n Urine:\n 3,178 mL\n 1,045 mL\n NG:\n Stool:\n Drains:\n Balance:\n -509 mL\n 595 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 372 (230 - 372) mL\n PS : 0 cmH2O\n RR (Set): 16\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 80%\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n SpO2: 100%\n ABG: 7.38/60/38/37/7\n Ve: 6.5 L/min\n PaO2 / FiO2: 48\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 7.9 g/dL\n 235 K/uL\n 169 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.5 mEq/L\n 7 mg/dL\n 105 mEq/L\n 147 mEq/L\n 24.9 %\n 6.1 K/uL\n [image002.jpg]\n 04:29 AM\n 11:49 AM\n 12:49 PM\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n WBC\n 3.8\n 4.3\n 6.1\n Hct\n 24.1\n 24.5\n 23\n 24.9\n Plt\n 161\n 181\n 235\n Cr\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 37\n 34\n 34\n 37\n 38\n 37\n Glucose\n 144\n 122\n 152\n 169\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.0 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:50 AM 70 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671360,
"text": "Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Increased enalapril, lopressor held for bradycardia, received lasix 40\n x3 started on pyridium. Lasted 3 hours on SBT. 7.38/60/38 returned to\n CMV\n Afib with RVR lopressor 10 IV and 25 po returned to sinus.\n Hypoxic on SBT returned to CMV\n ARTERIAL LINE - STOP 08:00 AM\n URINE CULTURE - At 03:00 PM\n EKG - At 08:25 PM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin/Sulbactam (Unasyn) - 09:52 AM\n Infusions:\n Other ICU medications:\n Hydralazine - 06:00 PM\n Metoprolol - 08:40 PM\n Furosemide (Lasix) - 05:00 AM\n Haloperidol (Haldol) - 06:39 AM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n mag/kcl\n zopharan\n senna\n docusate\n unasyn\n fluconazole\n miconazole\n keppra\n RISS\n tylenol\n simvisatin\n PPI iv\n Albuterol\n chlorhex\n Enalapril 20mg qday\n Hydralizine 10mg iv Q6hr\n pyridium\n lopressor 25 \n fentyl 100mcg last 12 hours\n Changes to medical and family history:\n Pelase see H+P no changes\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.3\nC (99.2\n HR: 62 (60 - 124) bpm\n BP: 112/40(58) {101/33(50) - 183/112(117)} mmHg\n RR: 20 (14 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,669 mL\n 1,640 mL\n PO:\n TF:\n 779 mL\n 669 mL\n IVF:\n 1,050 mL\n 782 mL\n Blood products:\n Total out:\n 3,178 mL\n 1,045 mL\n Urine:\n 3,178 mL\n 1,045 mL\n NG:\n Stool:\n Drains:\n Balance:\n -509 mL\n 595 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 372 (230 - 372) mL\n PS : 0 cmH2O\n RR (Set): 16\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 80%\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n SpO2: 100%\n ABG: 7.38/60/38/37/7\n Ve: 6.5 L/min\n PaO2 / FiO2: 48\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trache\n Cardiovascular: RRR s1s2 no m/r/g\n Respiratory / Chest: clear anteriorly\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: no rash or erythema\n Neurologic: Attentive, A+O x 3 no gross motor sensory deficits.\n Lines: Clean dry intact.\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology: Elevated persistent right HD, Plump vasculature no\n overt infiltrates.\n 7.9 g/dL\n 235 K/uL\n 169 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.5 mEq/L\n 7 mg/dL\n 105 mEq/L\n 147 mEq/L\n 24.9 %\n 6.1 K/uL\n [image002.jpg]\n 04:29 AM\n 11:49 AM\n 12:49 PM\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n WBC\n 3.8\n 4.3\n 6.1\n Hct\n 24.1\n 24.5\n 23\n 24.9\n Plt\n 161\n 181\n 235\n Cr\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 37\n 34\n 34\n 37\n 38\n 37\n Glucose\n 144\n 122\n 152\n 169\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.0 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Micro: Stool/urine/blood no growth to date\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure. Failed SBP yes\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n -Acute on chronic hypercarbic respiratory failure - likely OSA, ?OHS,\n ?element central\n -Resp alkalosis\n -wean vent\n -Confirmed with gas pre and post CPAP\n -Will also check US sniff test to assess right diaphragm\nTracheal tear\n -presumably occurred during intubation at start of prior admission\n -IP following\n -trach placed yesterday to bypass injured area\n -empiric abx coverage inc anti-fungal coverage 10 days of coverage\n hypoxemia\n -Unclear etiology, atelectasis/failure/PE on differential\n -Will diuresis\n -Will f/u 02 requirement if no improvement will consider CTPA\n -Will Check LE US\n -Check BNP\n -Will repeat ABG\n HYPERTENSION\n -BP better controlled today\n -Will continue enalapril\n -Continue Beta blocker\n -PRN hydralazine\n -Will start lasix with goal negative fluid balance 500cc-1L negative\n Will also help with BP.\n DIABETES MELLITUS (DM), TYPE II:\n -SSRI\nFever-Pan culture-Resolved\n -new\n -is post trach placement which could be explanation\n -already on fluc and unasyn for trach/upper trachea tear proph\nMental status\n -very alert & interactive this morning intermittently confused\n -Consider Haldol will follow closely.\n -review medications consider hold fentanyl\n -wean sedation as tolerated\n -Did have Head CT for MS changes on Tuesday of last week.\n Remainder of plan per resident note\n ICU Care\n Nutrition: Tube feeds\n Replete with Fiber (Full) - 01:50 AM 70 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ hep\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Screen vent unit.\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671362,
"text": "Chief Complaint: hypercarbic resp failure\n 24 Hour Events:\n ARTERIAL LINE - STOP 08:00 AM\n URINE CULTURE - At 03:00 PM\n EKG - At 08:25 PM\n - increased enalapril dose, held metoprolol\n - given lasix 40mg iv with good effect on urine output and fluid\n balance, repeated in PM, another dose this AM\n - started pyridium for bladder spasm\n - given fioricet x1 for migraine symptoms\n - attempted PSV, lasted ~3hrs but ABG 7.38/60/38 --> returned to AC\n - went into afib/rvr at , ecg unchanged, given lopressor 10mg iv x1\n followed by 25mg po with good effect, back to nsr\n Patient unable to provide history: Encephalopathy\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin/Sulbactam (Unasyn) - 03:54 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Hydralazine - 06:00 PM\n Metoprolol - 08:40 PM\n Heparin Sodium (Prophylaxis) - 12:42 AM\n Furosemide (Lasix) - 05:00 AM\n Haloperidol (Haldol) - 06:39 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 38\nC (100.4\n HR: 72 (61 - 124) bpm\n BP: 131/112(117) {123/31(56) - 183/112(117)} mmHg\n RR: 16 (14 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,669 mL\n 443 mL\n PO:\n TF:\n 779 mL\n 107 mL\n IVF:\n 1,050 mL\n 206 mL\n Blood products:\n Total out:\n 3,178 mL\n 735 mL\n Urine:\n 3,178 mL\n 735 mL\n NG:\n Stool:\n Drains:\n Balance:\n -509 mL\n -292 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 372 (230 - 372) mL\n PS : 0 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 24 cmH2O\n Plateau: 21 cmH2O\n SpO2: 100%\n ABG: 7.38/60/38/37/7\n Ve: 6 L/min\n PaO2 / FiO2: 38\n Physical Examination\n GEN: very somnolent (just received haldol), but opens eyes to command\n HEENT: clear secretions in back of mouth\n PULM: clear ant and laterally\n Heart: distant heart sounds, RRR, no murmurs\n ABD: obese, soft, NT\n EXT: 2+ edema\n Labs / Radiology\n 235 K/uL\n 7.9 g/dL\n 169 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.5 mEq/L\n 7 mg/dL\n 105 mEq/L\n 147 mEq/L\n 24.9 %\n 6.1 K/uL\n [image002.jpg]\n 04:29 AM\n 11:49 AM\n 12:49 PM\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n WBC\n 3.8\n 4.3\n 6.1\n Hct\n 24.1\n 24.5\n 23\n 24.9\n Plt\n 161\n 181\n 235\n Cr\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 37\n 34\n 34\n 37\n 38\n 37\n Glucose\n 144\n 122\n 152\n 169\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.0 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Imaging: CXR: poor inspiratory effort, but compared to prior CXR,\n slightly more edema, no effusions, no infiltrate\n Microbiology: : Stool, urine, blood: NGTD\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - continue to try PS trials, although continues to become hypercarbic\n likely central apnea\n - if does well try Passey-Muir valve\n - continue Unasyn () and Fluconazole () for ppx for tracheal\n tear for goal 10 day course\n # Respiratory failure: . Patient remains on vent and has failed SBT.\n Currently appears to be component of hypercarbic resp failure likely\n from cental apnea as well as mild pulm edema. In addition, pt has had\n hypoxia as well. Hypoxia may be atelecatsis or vol overload; PE in\n differential but hypoxia does improve with PEEP which would not be\n consistent with PE. Her resp issues are likely a combination of OSA,\n CO2 retention andf her hospital course has also been complicated by\n right lung collapse, R mainstem intubation.\n - repeat ABG\n - goal I/O 1L neg today\n - continue flovent, albuterol, atrovent\n - U/S diaphragm to assess for paralyzed right diaphragm given\n persistant elevated rt diaphragm on CXR\n - obtain BNP\n - obtain LENI\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns, but had an\n episode of afib with RVR last night.\n - BB restarted\n - coumadin being held given recent hemorrhage\n - not on asa left temporal hemorrhage\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - continue enalapril, and hydralazine\n # Altered mental status\n Has been improved, but still frequently\n confused. h/o SAH/IPH, but now unclear etiology as no clear complaints.\n Likely hemorrage, prior hypoglycemic coma from which she did not\n recover and ICU delirium. Head CT unchanged, Chest CTA w/o PE, no\n evidence of MI, TTE w/ nl EF, UA unremarkable.\n - did receive haldol this AM for agitation\n - haldol\n - if more confused with fentanyl\n # Hypernatremia: sodium cont to be 147\n - continue free water flushes 250 cc Q4H\n # Fevers: no further fevers, cultures have been negative, c.diff neg on\n unasyn and fluconazole ppx for traceal tear\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n -# HCT drop: HCT now stable no melena. Hemolysis labs negative.\n Repeat CXR clearing w/o evidence of worsening effusions and given\n stable HCT, concern for intrathoracic bleeding is now low.\n - monitor HCT\n - guaiac stools\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671382,
"text": "Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note, including assessment and plan.\n 24 Hour Events:\n Increased enalapril, lopressor held for bradycardia, received lasix 40\n x3 started on pyridium. Lasted 3 hours on SBT. 7.38/60/38 returned to\n CMV\n Afib with RVR lopressor 10 IV and 25mg po returned to sinus.\n Hypoxic on SBT returned to CMV\n ARTERIAL LINE - STOP 08:00 AM\n URINE CULTURE - At 03:00 PM\n EKG - At 08:25 PM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:27 PM\n Ampicillin/Sulbactam (Unasyn) - 09:52 AM\n Infusions:\n Other ICU medications:\n Hydralazine - 06:00 PM\n Metoprolol - 08:40 PM\n Furosemide (Lasix) - 05:00 AM\n Haloperidol (Haldol) - 06:39 AM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n mag/kcl\n zopharan\n senna\n docusate\n unasyn\n fluconazole\n miconazole\n keppra\n RISS\n tylenol\n simvisatin\n PPI iv\n Albuterol\n chlorhex\n Enalapril 20mg qday\n Hydralizine 10mg iv Q6hr\n pyridium\n lopressor 25 \n fentyl 100mcg last 12 hours\n Changes to medical and family history:\n Pelase see H+P no changes\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.3\nC (99.2\n HR: 62 (60 - 124) bpm\n BP: 112/40(58) {101/33(50) - 183/112(117)} mmHg\n RR: 20 (14 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,669 mL\n 1,640 mL\n PO:\n TF:\n 779 mL\n 669 mL\n IVF:\n 1,050 mL\n 782 mL\n Blood products:\n Total out:\n 3,178 mL\n 1,045 mL\n Urine:\n 3,178 mL\n 1,045 mL\n NG:\n Stool:\n Drains:\n Balance:\n -509 mL\n 595 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 372 (230 - 372) mL\n PS : 0 cmH2O\n RR (Set): 16\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 80%\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n SpO2: 100%\n ABG: 7.38/60/38/37/7\n Ve: 6.5 L/min\n PaO2 / FiO2: 48\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trach\n Cardiovascular: RRR s1s2 no m/r/g\n Respiratory / Chest: Course BS ant/post no bronchial BS noted\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: no rash or erythema\n Ext: No edema noted\n Neurologic: Attentive, A+O x 3 no gross motor sensory deficits.\n Lines: Clean dry intact.\n Skin: Not assessed\n Labs / Radiology: Elevated persistent right HD, Plump vasculature no\n overt infiltrates.\n 7.9 g/dL\n 235 K/uL\n 169 mg/dL\n 0.4 mg/dL\n 37 mEq/L\n 3.5 mEq/L\n 7 mg/dL\n 105 mEq/L\n 147 mEq/L\n 24.9 %\n 6.1 K/uL\n [image002.jpg]\n 04:29 AM\n 11:49 AM\n 12:49 PM\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n 07:22 PM\n 09:05 PM\n 03:45 AM\n WBC\n 3.8\n 4.3\n 6.1\n Hct\n 24.1\n 24.5\n 23\n 24.9\n Plt\n 161\n 181\n 235\n Cr\n 0.4\n 0.3\n 0.4\n 0.4\n TCO2\n 37\n 34\n 34\n 37\n 38\n 37\n Glucose\n 144\n 122\n 152\n 169\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.0 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Micro: Stool/urine/blood no growth to date\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure secondary to tracheal tear,\n S/P trach.\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n -Acute on chronic hypercarbic respiratory failure - likely OSA, ?OHS,\n ?element central\n -wean vent as tolerated failed SBP yesterday\n -Will also check US sniff test to assess right diaphragm paralysis\nTracheal tear\n -presumably occurred during intubation at start of prior admission\n -IP following\n -trach in place to bypass injured area will need 6-8 weeks to heal\n -empiric abx coverage inc anti-fungal coverage 10 days of coverage\n hypoxemia\n -Unclear etiology, atelectasis/failure. PE lower on differential as\n responded to being placed back on vent.\n -Will diuresis\n -Will f/u 02 requirement if no improvement will consider CTPA\n -Will Check LE US\n -Check BNP\n -Will repeat ABG\n HYPERTENSION\n -BP better controlled today\n -Will continue enalapril\n -Continue Beta blocker\n -PRN hydralazine\n -Will start lasix with goal negative fluid balance 500cc-1L negative\n Will also help with BP.\n DIABETES MELLITUS (DM), TYPE II:\n -SSRI\nFever-Pan culture-Resolved\n -new\n -is post trach placement which could be explanation\n -already on fluc and unasyn for trach/upper trachea tear proph\nMental status\n -very alert & interactive this morning intermittently confused\n -Consider Haldol will follow closely.\n -review medications consider hold fentanyl\n -wean sedation as tolerated\n -Did have Head CT for MS changes on Tuesday of last week.\n Remainder of plan per resident note\n ICU Care\n Nutrition: Tube feeds\n Replete with Fiber (Full) - 01:50 AM 70 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ hep\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Screen vent unit.\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 670511,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments: per I.P. a continous cuff leak.\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Tracheostomy planned\n Reason for continuing current ventilatory support: Pending procedure /\n OR; Comments: unstable a/w\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Interventional radiology\n no complications\n Bedside Procedures:\n Bronchoscopy\n Comments: per I.P. ett was pulled back to the 21cm at teeth. leave a\n small cuff leak.\n Plan trach soon.\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 671316,
"text": "TITLE:\n Demographics\n Day of mechanical ventilation: 7\n Ideal body weight: 56.7\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tracheostomy tube:\n Type: Cuffed, Adjustable Neck Flange\n Manufacturer: \n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems: s/p tracheal tear, adjustable tube @\n 12.5 cm; Positional leak around cuff\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: A/C 350x16/1.0/+10 peep\n Visual assessment of breathing pattern: Accessory muscle use, Frequent\n desaturation episodes\n Assessment of breathing comfort: Pt acknowledges dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: freq high RR ~30\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: MDI albuterol x2; RSBI held d/t fi02\n Comments: Periods of desaturation/agitation, will attempt to optimize\n vent settings\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670160,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\n .\n She was just discharged yesterday from MICU course for altered\n mental status and hypercarbia. Her altered mental status was likely\n multifactorial to include medications (diazepam, percocet) and\n hypercarbia OSA and sleep hypoventilation. She returned to baseline\n on discharge. Her hypercarbia was thought related to her COPD and\n likely newly diagnosed sleep disordered breathing. She underwent a\n sleep study and was discharged on BiPAP to follow up in sleep clinic\n for a complete sleep study.\n .\n She was found somnolent this morning, was not placed on BiPaP last\n night. Sent to for CO2 115. At placed on BiPap with\n excellent response and transferred to . On the EMS she was taken off\n BIPAP and placed on high flow oxygen. By arrival she was altered with\n saturations in 70s. She was trialed on CPAP with no success and bagged\n to try and take off CO2 with no success and subsequently intubated and\n admitted to MICU. CTH negative.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Extubated . On and off bipap since. Sats 88-96%. Noted to have\n shallow respirations while off bipap. Cough congested but not\n productive. LS rhonchorous.\n Action:\n Furosemide 40mg IV x1, Zyprexa disintegrating tab x1 for comfort w/\n bipap, encouraged C&DB, Chest PT done, AM CXR, 35% cool aerosol face\n mask when off bipap.\n Response:\n LS unchanged. Only tolerated Bipap for 1-3hrs @ a time. Responded well\n to lasix. Zyprexa w/ good short term effect.\n Plan:\n Continue chest PT and encourage C&DB. Plan for ECHO and ? speech and\n swallow today. F/u on CXR results.\n Hypertension, benign\n Assessment:\n SBP rarely < 180 overnight (NBP taken on calf).\n Action:\n Standing Lopressor 5mg IV Q6H, Hydralazine IV 10mg and later 20mg, 40mg\n IV lasix\n Response:\n Little to no change in BP. Best results came following Lasix.\n Plan:\n Results following 20mg IV hydralazine to be determined (still infusing\n @ this time).\n Coccyx reddened but intact, barrier cream applied. Mepilex in place to\n small stage two on buttocks. Yeast looking rash in perineal area,\n miconizole applied. Left lower extremety, cellulitic appearance, looks\n to be improving.\n Had LENI\ns of bilat. Lower extrem. Negative.\n Repleting lytes w/ 20mEq KCl in 250ccD5W, 2grams Magnesium Sulfate, and\n ? 500cc infusion of D5W for Na 148.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670514,
"text": "Events:pt was desating to mid 80\ns this am post turn,urgent bronch done\n at bedside,large clot was removed ,stable vent settings afterwards.ETT\n pulled and retaped,A picc line has been inserted by IR.Hct dropped to\n 22(from 28).recevd 250cc bolus for hypotension in this am\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on ac 40%,10peep 16/350,sats high 90\ns,noted diminished\n breath sounds on the left side. Received on fent 60 and propofol 30\n Action:\n Pt had undergone bronch at bedside,suctioned as needed,able to wean\n sedation a bit\n Response:\n Pt desatted to mid 80\ns post turn this am,didn\nt improve with\n suctioning,PIP were in 30\ns with diminished breath sounds on the left\n side,blood clot removed via the bronch,no episodes of desatting\n afterwards. Pco2 62 with most recent abg.\n Plan:\n Will cont the current settings,famiuly team meeting today?possible\n trach in am\n Anemia, other\n Assessment:\n HCT dropped to 22 from 28,no obvious bleeding,suctioned for bloody\n secretions,minimal bleeding noted during bronch,no obvious blood seen\n in the stool\n Action:\n Cycled HCT\n Response:\n Rpt hct 25\n Plan:\n Will follow hct q8h,\n Others:Family team meeting @4pm today\nplan for trach in am.\n HR 55-70,sinus to sinus brady\nevening dose of lopressor (hr 55).\n SBP 120-180\ns,hypertensive with stimulation.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670976,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. The ETT is NOT TO BE\n REPOSITIONED, and must be handled with extreme caution as it is close\n to the and could easily slip into the right main stem bronchus\n causing lung collapse. On , pt desatted with turning so emergent\n bedside bronch performed which required removal of large blood clot\n from trachea. ETT was repositioned, and the cuff was left with a leak\n purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out.\n Tracheal Tear\n Assessment:\n Noted to have 5cm tracheal tear via rigid bronch in OR . Received\n on\n Action:\n Response:\n Plan:\n Wean pt from vent to trach mask as tolerated, as absence of ventilation\n will better allow for tracheal tear to heal.\n Hypertension, benign\n Assessment:\n During this shift SBP remains elevated in the 160-180\n Action:\n Pt. was given Fentanyl 50mcg x4. Pt\ns Lopressor dose was increased from\n 5mg iv q6hr to 10mg iv q6hrs.\n Response:\n SBPs remains 170\ns post lopressor and fentanyl but slowly creeping up\n into 190s.\n Plan:\n Plan to insert dobhuff tube. Resume Enalapril dosing. .\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670979,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. The ETT is NOT TO BE\n REPOSITIONED, and must be handled with extreme caution as it is close\n to the and could easily slip into the right main stem bronchus\n causing lung collapse. On , pt desatted with turning so emergent\n bedside bronch performed which required removal of large blood clot\n from trachea. ETT was repositioned, and the cuff was left with a leak\n purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out.\n Hypertension, benign\n Assessment:\n When patient awake and at rest SBP 160-170. With anxiety SBP up to\n 180-190. HR 60\ns. C/o back pain.\n Action:\n Pt. was given Fentanyl 50mcg x2. Lopressor 10mg IV q6hrs.\n Response:\n Stated relief from pain medication. SBP down to 140\ns after lopressor\n with HR down to 40\ns and patient sleeping comfortably.\n Plan:\n Plan to insert dobhoff tube vs. NGT. Resume Enalapril dosing. .\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Received patient febrile 100.7. Temperature trending up to 101.2.\n Action:\n Pancultured yesterday. Given 650mg Tylenol suppository. Fluconazole and\n ampicillin given.\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +5peep. Lung sounds\n rhoncherous with diminished bases.\n Action:\n No vent changes overnight. Suctioned for scant amounts of thick, pale,\n yellow, sputum.\n Response:\n RR 16-19 with sats 93-98%.\n Plan:\n Trial Cpap today with overall goal wean pt from vent to trach mask as\n tolerated, as absence of ventilation will better allow for tracheal\n tear to heal.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670980,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. The ETT is NOT TO BE\n REPOSITIONED, and must be handled with extreme caution as it is close\n to the and could easily slip into the right main stem bronchus\n causing lung collapse. On , pt desatted with turning so emergent\n bedside bronch performed which required removal of large blood clot\n from trachea. ETT was repositioned, and the cuff was left with a leak\n purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out.\n Hypertension, benign\n Assessment:\n When patient awake and at rest SBP 160-170. With anxiety SBP up to\n 180-190. HR 60\ns. C/o back pain.\n Action:\n Pt. was given Fentanyl 50mcg x2. Lopressor 10mg IV q6hrs.\n Response:\n Stated relief from pain medication. SBP down to 140\ns after lopressor\n with HR down to 40\ns and patient sleeping comfortably.\n Plan:\n Plan to insert dobhoff tube vs. NGT. Resume Enalapril dosing. .\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Received patient febrile 100.7. Temperature trending up to 101.2.\n Action:\n Pancultured yesterday. Given 650mg Tylenol suppository. Fluconazole and\n ampicillin given.\n Response:\n Plan:\n Continue with prophylactic antibiotics while intubated s/p tracheal\n tear. F/u on cultures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +5peep. Lung sounds\n rhoncherous with diminished bases.\n Action:\n No vent changes overnight. Suctioned for scant amounts of thick, pale,\n yellow, sputum.\n Response:\n RR 16-19 with sats 93-98%.\n Plan:\n Trial CPAP today with overall goal wean pt from vent to trach mask as\n tolerated, as absence of ventilation will better allow for tracheal\n tear to heal.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671255,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. On , pt desatted\n with turning so emergent bedside bronch performed which required\n removal of large blood clot from trachea. ETT was repositioned, and the\n cuff was left with a leak purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out. Pt will need this in place for approx 8\n weeks\n Hypertension, benign\n Assessment:\n SBP conts to be high 160\n 190\n Action:\n IV Lopressor held x1 for rate in the 40\ns. ordered for hydralazine x1\n and q6hrs. 4am metoprolol was given, but\n dose w/good response\n Response:\n Responding very well to hydral dosing\n Plan:\n Pt now w/ NGT and ordered for enalapril PO as well as iv hydralazine.\n Consider d/cing metoprolol or decreasing dose as well as changing to\n po.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +5peep. Lung sounds\n rhoncherous .Sxn for thick white/yellow secretions.\n Action:\n No vent changes made overnight. Vbg and abg drawn to correlate.\n Response:\n Comfortable on vent overnigh\n Plan:\n attempt vent changes again tomorrow. Increase TF Q4H w/ goal rate\n 70cc/hr. ?removal of a line. Nbp w/40 pt difference. Resident on\n o/n deferred on d/cing aline for now\n ? screen for rehab tomorrow. Should be able to go to an Acute\n respiratory rehab tomorrow or the day after.\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670195,
"text": "Chief Complaint: - ABG 7/16/141/114. Pt was somnolent during the day\n -> BiPAP restarted-> ABG returned to baseline\n Repeat ABG 7/26/61/105\n - Held NGT -> due for S+S \n - Gave zydis 5mg for agitation to initiate BiPAP\n - Persistently elevated BP >180, cont'd metoprolol, given trial of\n nitropaste, hydral 10mg x1, 20mg x2 -> little improvement -> started\n nitro gtt was difficult to obtain manually.\n 24 Hour Events:\n NON-INVASIVE VENTILATION - START 11:00 PM\n NON-INVASIVE VENTILATION - STOP 01:00 AM\n NON-INVASIVE VENTILATION - START 01:20 AM\n NON-INVASIVE VENTILATION - STOP 04:30 AM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Nitroglycerin - 2.5 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 11:15 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Metoprolol - 04:00 AM\n Hydralazine - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.8\nC (98.3\n HR: 91 (58 - 118) bpm\n BP: 175/50(79) {136/45(66) - 215/62(94)} mmHg\n RR: 29 (20 - 35) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134 kg\n Total In:\n 1,968 mL\n 206 mL\n PO:\n TF:\n IVF:\n 1,968 mL\n 206 mL\n Blood products:\n Total out:\n 1,730 mL\n 1,153 mL\n Urine:\n 1,730 mL\n 1,153 mL\n NG:\n Stool:\n Drains:\n Balance:\n 238 mL\n -947 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 272 (260 - 361) mL\n PC : 10 cmH2O\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.26/61/105/43/0\n Ve: 6 L/min\n PaO2 / FiO2: 300\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 172 K/uL\n 8.6 g/dL\n 124 mg/dL\n 0.5 mg/dL\n 43 mEq/L\n 3.6 mEq/L\n 12 mg/dL\n 98 mEq/L\n 148 mEq/L\n 28.8 %\n 6.0 K/uL\n [image002.jpg]\n 11:48 PM\n 05:22 AM\n 04:20 PM\n 03:27 AM\n 03:31 AM\n 05:18 AM\n 07:47 AM\n 01:30 PM\n 04:51 PM\n 03:56 AM\n WBC\n 6.5\n 8.2\n 6.0\n Hct\n 26.1\n 27.6\n 28.8\n Plt\n 196\n 201\n 172\n Cr\n 0.5\n 0.6\n 0.6\n 0.5\n TCO2\n 51\n 53\n 55\n 53\n 53\n 29\n Glucose\n 140\n 158\n 172\n 189\n 124\n Other labs: PT / PTT / INR:14.1/24.9/1.2, Differential-Neuts:78.9 %,\n Lymph:13.9 %, Mono:5.8 %, Eos:1.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.6\n mg/dL, Mg++:1.6 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n .\n # Hypercarbic respiratory failure with new right lung collapse- On CXR\n this morning she had white out of the right lung with rightward\n tracheal deviation concerning for new right lung collapse, most likely\n mucous plugging given her thick secretions. ABG with acute on\n chronic respiratory acidosis, likely poor ventilation in the\n setting of acute right lung collapse.\n --tracheal suctioning\n -repeat CXR post NT suctioning\n -BIPAP as tolerated\n -likely will require intubation and bronchoscopy for deep suctioning\n - check TTE\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n .\n #Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her. Possibly intubation.\n -speech and swallow in the am\n -keep NPO for now\n .\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - Per neurology -> cont keppra for now\n -outpatient neurology follow up\n .\n #Paroxysmal Atrial fibrillation: in sinus rhythm on admission, does\n have limited bursts of afib\n -coumadin being held given recent hemorrhage\n -metoprolol IV prn for tachycardia/htn\n -not on asa left temporal hemorrhage\n .\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n .\n # HTN\n continues to be quite hypertensive\n -lasix as tolerated\n -holding acebutolol, enalapril while npo\n -consider hydralazine if hypertensives\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 08:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670367,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n * pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis this AM. CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside today showing\n webbing likely from traumatic intubation. IP, however, feel pt needs to\n have rigid bronch in OR for better visualization of tracheal webbing/?\n mass.\n Hypertension, benign\n Assessment:\n Pt received on nitro gtt @ 1mcg/kg/min with SBPs via cuff ranging\n 180s-190s.\n Action:\n Nitro gtt titrated up to maintain SBP 160-180. Pt continued on 5mg IV\n lopressor. A-line placed by team showing ABPs in 200s systolic which\n required titration of nitro gtt up to 3mcg/kg/min at one point.\n Response:\n Able to wean nitro down as low as 0.7 mcg/kg/min with systolics\n 160-180. Nitro weaned off just prior to transfer to OR with SBPs\n remaining 150s-160s.\n Plan:\n Cont off nitro gtt as long as BPs are maintained 160-180 systolic. Cont\n with IV lopressor until pt able to receive PO anti-hypertensives.\n Restart nitro gtt if necessary to mainting SBPs 160-180.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on aerosol face mask @ 35% FiO2 with sats 88-92% and RR\n 20s-30s. Pt mal-appearing this AM, diaphoretic/hypertensive/Tachypneic.\n Action:\n Pt taken for CTA to r/o PE.\n Response:\n CTA showing tracheomalacia and tracheal mass of unknown origin so\n bronch recommended by radiology. Bedside bronch performed with\n visualization of webbing of unknown etiology. Pt taken to OR @ 1630 for\n rigid bronch post intubation via fiberoptics. IP to perform bronch for\n better visualization and to determine diagnosis of questionable mass.\n Plan:\n Pending results of OR procedure.\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-10 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671078,
"text": "Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Febrile to 101.3 refused NG tube. Few secretions\n FEVER - 101.3\nF - 12:00 PM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:08 PM\n Ampicillin/Sulbactam (Unasyn) - 10:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:02 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Pantoprazole (Protonix) - 08:00 AM\n Fentanyl - 08:00 AM\n Other medications:\n mag/kcl\n zopharan\n metoprol 10 q 6 hr\n senna\n docusate\n fent bolus not given\n unasyn\n fluconazole\n miconazole\n keppra\n RISS\n tylenol\n simvisatin\n PPI iv\n Albuterol\n chlorhex\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.6\nC (99.6\n HR: 56 (51 - 63) bpm\n BP: 151/63(84) {148/41(72) - 169/63(84)} mmHg\n RR: 13 (11 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 1,000 mL\n 568 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n 568 mL\n Blood products:\n Total out:\n 1,270 mL\n 199 mL\n Urine:\n 770 mL\n 199 mL\n NG:\n Stool:\n Drains:\n Balance:\n -270 mL\n 369 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 328 (328 - 328) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 128\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 96%\n ABG: 7.41/57/87./34/8\n Ve: 7 L/min\n PaO2 / FiO2: 220\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trache\n Cardiovascular: RRR s1s2 no m/r/g\n Respiratory / Chest: clear anteriorly\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: no rash or erythema\n Neurologic: Attentive, A+O x 3 no gross motor sensory deficits.\n Lines: Clean dry intact.\n Labs / Radiology\n 7.5 g/dL\n 154 K/uL\n 86 mg/dL\n 0.4 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 7 mg/dL\n 109 mEq/L\n 150 mEq/L\n 23.8 %\n 3.6 K/uL\n [image002.jpg]\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n 05:06 PM\n 04:10 AM\n 10:33 AM\n 04:18 AM\n 04:29 AM\n WBC\n 3.9\n 6.4\n 3.6\n Hct\n 25.3\n 23.2\n 25\n 25.9\n 23.8\n Plt\n 147\n 151\n 154\n Cr\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 48\n 45\n 45\n 40\n 38\n 37\n Glucose\n 131\n 88\n 100\n 106\n 86\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\nTracheal tear\n -presumably occurred during intubation at start of prior admission\n -IP following\n -trache placed yesterday to bypass injured area\n -empiric abx coverage inc anti-fungal coverage 10 days of coverage\n\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n -Acute on chronic hypercarbic respiratory failure - likely OSA, ?OHS,\n ?element central\n -Resp alkalosis\n -wean vent\n -Suspect central cause will check gas pre and post CPAP\n HYPERTENSION\n -BP better controlled today\n -Will start enalapril when NG in place\n DIABETES MELLITUS (DM), TYPE II:\n -SSRI\nLeft leg erythema:\n -No change chronic per husband\n culture\n -new\n -is post trache placement which could be explanation\n -already on fluc and unasyn for trache/upper trach tear proph\n -Will pull A-line today\nMental status\n -very alert & interactive this morning\n -wean sedation as tol\n Remainder of plan per resident note.\n ICU Care\n Nutrition: Will start tube feeds. Will replace free water when NG in\n place.\n Glycemic Control:\n Lines:\n Arterial Line - 11:32 AM Will d\nc today\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: Heprin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-10 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671080,
"text": "Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Febrile to 101.3 refused NG tube. Few secretions\n FEVER - 101.3\nF - 12:00 PM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:08 PM\n Ampicillin/Sulbactam (Unasyn) - 10:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:02 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Pantoprazole (Protonix) - 08:00 AM\n Fentanyl - 08:00 AM\n Other medications:\n mag/kcl\n zopharan\n metoprol 10 q 6 hr\n senna\n docusate\n fent bolus not given\n unasyn\n fluconazole\n miconazole\n keppra\n RISS\n tylenol\n simvisatin\n PPI iv\n Albuterol\n chlorhex\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.6\nC (99.6\n HR: 56 (51 - 63) bpm\n BP: 151/63(84) {148/41(72) - 169/63(84)} mmHg\n RR: 13 (11 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 1,000 mL\n 568 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n 568 mL\n Blood products:\n Total out:\n 1,270 mL\n 199 mL\n Urine:\n 770 mL\n 199 mL\n NG:\n Stool:\n Drains:\n Balance:\n -270 mL\n 369 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 328 (328 - 328) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 128\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 96%\n ABG: 7.41/57/87./34/8\n Ve: 7 L/min\n PaO2 / FiO2: 220\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trache\n Cardiovascular: RRR s1s2 no m/r/g\n Respiratory / Chest: clear anteriorly\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: no rash or erythema\n Neurologic: Attentive, A+O x 3 no gross motor sensory deficits.\n Lines: Clean dry intact.\n Labs / Radiology\n 7.5 g/dL\n 154 K/uL\n 86 mg/dL\n 0.4 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 7 mg/dL\n 109 mEq/L\n 150 mEq/L\n 23.8 %\n 3.6 K/uL\n [image002.jpg]\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n 05:06 PM\n 04:10 AM\n 10:33 AM\n 04:18 AM\n 04:29 AM\n WBC\n 3.9\n 6.4\n 3.6\n Hct\n 25.3\n 23.2\n 25\n 25.9\n 23.8\n Plt\n 147\n 151\n 154\n Cr\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 48\n 45\n 45\n 40\n 38\n 37\n Glucose\n 131\n 88\n 100\n 106\n 86\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\nTracheal tear\n -presumably occurred during intubation at start of prior admission\n -IP following\n -trach placed yesterday to bypass injured area\n -empiric abx coverage inc anti-fungal coverage 10 days of coverage\n\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n -Acute on chronic hypercarbic respiratory failure - likely OSA, ?OHS,\n ?element central\n -Resp alkalosis\n -wean vent\n -Suspect central cause will check gas pre and post CPAP\n HYPERTENSION\n -BP better controlled today\n -Will start enalapril when NG in place\n DIABETES MELLITUS (DM), TYPE II:\n -SSRI\nLeft leg erythema:\n -No change chronic per husband\n culture\n -new\n -is post trach placement which could be explanation\n -already on fluc and unasyn for trach/upper trachea tear proph\n -Will pull A-line today\nMental status\n -very alert & interactive this morning\n -wean sedation as tol\n Remainder of plan per resident note.\n ICU Care\n Nutrition: Will start tube feeds. Will replace free water when NG in\n place.\n Glycemic Control:\n Lines:\n Arterial Line - 11:32 AM Will d\nc today\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: Heprin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent: 40 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671311,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. On , pt desatted\n with turning so emergent bedside bronch performed which required\n removal of large blood clot from trachea. ETT was repositioned, and the\n cuff was left with a leak purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out. Pt will need this in place for approx 8\n weeks\n Hypertension, benign\n Assessment:\n SBP conts to be high 160\n 180\n Action:\n Hydralazine standing doses given, enalapril increased to 20mg daily\n yesterday. Another 40 mg iv lasix. Pt having raf to the 150\n metoprolol 10 mg iv and po restarted. Po2 low on psv, back to rest on\n a/c for the night\n Response:\n SBP remains 180\ns-160\ns at this time, awaiting response from evening PO\n enalapril dose. Responding well to IV lasix. Converted back to nsr\n after placed back on a/c\n Plan:\n Monitor BP, cont standing IV hydral, diuresing w/ goal -500cc to -1L\n for 24Hrs. Repeat Lytes @ 2000pm.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +5peep. Lung sounds\n rhoncherous .Sxn for thick white/yellow secretions. Q2-3 hrs overnight;\n desatting frequently w/min secretions, coming back up on own until this\n am, sats in the mid 80\ns unable to raise despite 100% fio2 10 peep.\n Action:\n CXR this am showing pt more wet. Additional lasix sdose given at 0500\n Response:\n Await response\n Plan:\n Cont to attempt to wean vent as tolerated. Monitor VBG and/or pt\n mental status to assess tolerance of vent weaning. Cont to sxn as\n needed.\n"
},
{
"category": "Nutrition",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 670269,
"text": "Subjective\n Patient unable to answer questions at this time.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm (estimated)\n 134 kg\n 134 kg ( 08:00 PM)\n 49\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 236 %\n 76 kg\n Diagnosis: asthma/CPOD exacerbation\n PMH : OSA/Sleep hypoventilation- b/l CO2 70-80s\n Left Temporal Intraparenchymal hemorrhage\n COPD- no prior h/o tobacco use, + secondhand exposure\n afib- was on coumadin for last few years\n TIA- had prior episodes of flashes of light going across her visual\n field, was placed on plavix.\n Dementia- secondary to diabetic coma\n Chronic Low Back Pain\n Anemia\n GERD\n Type 2 DM\n Food allergies and intolerances: No known food allergies\n Pertinent medications: NS @ 10 mL/hr, 20 mEq KCl repletion, D5W IV\n bolus, Magnesium sulfate (2g repletion), RISS, Glargine, Heparin,\n Pantoprazole, Nitroglycerin drip, Hydralazine, others noted\n Labs:\n Value\n Date\n Glucose\n 124 mg/dL\n 03:56 AM\n Glucose Finger Stick\n 258\n 12:00 PM\n BUN\n 12 mg/dL\n 03:56 AM\n Creatinine\n 0.5 mg/dL\n 03:56 AM\n Sodium\n 148 mEq/L\n 03:56 AM\n Potassium\n 3.6 mEq/L\n 03:56 AM\n Chloride\n 98 mEq/L\n 03:56 AM\n TCO2\n 43 mEq/L\n 03:56 AM\n PO2 (arterial)\n 86 mm Hg\n 02:33 PM\n PCO2 (arterial)\n 116 mm Hg\n 02:33 PM\n pH (arterial)\n 7.17 units\n 02:33 PM\n CO2 (Calc) arterial\n 45 mEq/L\n 02:33 PM\n Calcium non-ionized\n 8.6 mg/dL\n 03:56 AM\n Phosphorus\n 3.4 mg/dL\n 03:56 AM\n Magnesium\n 1.6 mg/dL\n 03:56 AM\n WBC\n 6.0 K/uL\n 03:56 AM\n Hgb\n 8.6 g/dL\n 03:56 AM\n Hematocrit\n 28.8 %\n 03:56 AM\n FSBG: 147, 258\n Current diet order / nutrition support: Diet: NPO\n Skin: stage II decubitis ulcer on buttocks\n GI: soft/obese, (+) bs; (+) loose bm \n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, respiratory status\n Estimated Nutritional Needs based on adjusted weight\n Calories: 1520-1900 (BEE x or / 20-25 cal/kg)\n Protein: 99-114 (1.3-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Excessive\n Estimation of current intake: Inadequate\n Specifics:\n 62 YO female with recent admission for subarachnoid/intraparenchymal\n hemorrhage \n . Readmitted to MICU \n with acute change\n in mental status likely due to medications and hypercarbia OSA and\n sleep hypoventilation. Patient now presents intubated hypercarbic\n respiratory failure complicated by right sided lung collapse. Patient\n extubated with noted coughing and desaturation after sips of thin\n liquids therefore kept NPO. S+S evaluation deferred today due to\n respiratory status\n patient has been on/off Bi-PAP mask. Bronchoscopy\n at beside showed webbing, question mass. Plan for rigid\n bronchoscopy and intubation in OR. Patient has been NPO x 3 days, if\n unable to begin po diet within 2 days, will need nutrition support.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If able to extubate patient, consult SLP for S+S evaluation\n before starting po diet\n 2. If unable to extubate patient or SLP recommend NPO; recommend\n tube feeding\n a. Obtain enteral access\n b. Tube feeding recommendations: Replete with Fiber @ 10 mL/hr,\n advance by 10mL q4hr to goal of 70 mL/hr to provide 1680 kcal and 104 g\n protein.\n Check chemistry 10 panel daily\n Monitor FSBG especially if nutrition support started\n Will follow to check plan\n , Dietetic Intern\n"
},
{
"category": "Nutrition",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 670270,
"text": "Subjective\n Patient unable to answer questions at this time.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm (estimated)\n 134 kg\n 134 kg ( 08:00 PM)\n 49\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 236 %\n 76 kg\n Diagnosis: asthma/CPOD exacerbation\n PMH : OSA/Sleep hypoventilation- b/l CO2 70-80s\n Left Temporal Intraparenchymal hemorrhage\n COPD- no prior h/o tobacco use, + secondhand exposure\n afib- was on coumadin for last few years\n TIA- had prior episodes of flashes of light going across her visual\n field, was placed on plavix.\n Dementia- secondary to diabetic coma\n Chronic Low Back Pain\n Anemia\n GERD\n Type 2 DM\n Food allergies and intolerances: No known food allergies\n Pertinent medications: NS @ 10 mL/hr, 20 mEq KCl repletion, D5W IV\n bolus, Magnesium sulfate (2g repletion), RISS, Glargine, Heparin,\n Pantoprazole, Nitroglycerin drip, Hydralazine, others noted\n Labs:\n Value\n Date\n Glucose\n 124 mg/dL\n 03:56 AM\n Glucose Finger Stick\n 258\n 12:00 PM\n BUN\n 12 mg/dL\n 03:56 AM\n Creatinine\n 0.5 mg/dL\n 03:56 AM\n Sodium\n 148 mEq/L\n 03:56 AM\n Potassium\n 3.6 mEq/L\n 03:56 AM\n Chloride\n 98 mEq/L\n 03:56 AM\n TCO2\n 43 mEq/L\n 03:56 AM\n PO2 (arterial)\n 86 mm Hg\n 02:33 PM\n PCO2 (arterial)\n 116 mm Hg\n 02:33 PM\n pH (arterial)\n 7.17 units\n 02:33 PM\n CO2 (Calc) arterial\n 45 mEq/L\n 02:33 PM\n Calcium non-ionized\n 8.6 mg/dL\n 03:56 AM\n Phosphorus\n 3.4 mg/dL\n 03:56 AM\n Magnesium\n 1.6 mg/dL\n 03:56 AM\n WBC\n 6.0 K/uL\n 03:56 AM\n Hgb\n 8.6 g/dL\n 03:56 AM\n Hematocrit\n 28.8 %\n 03:56 AM\n FSBG: 147, 258\n Current diet order / nutrition support: Diet: NPO\n Skin: stage II decubitis ulcer on buttocks\n GI: soft/obese, (+) bs; (+) loose bm \n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, respiratory status\n Estimated Nutritional Needs based on adjusted weight\n Calories: 1520-1900 (BEE x or / 20-25 cal/kg)\n Protein: 99-114 (1.3-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Excessive\n Estimation of current intake: Inadequate\n Specifics:\n 62 YO female with recent admission for subarachnoid/intraparenchymal\n hemorrhage \n . Readmitted to MICU \n with acute change\n in mental status likely due to medications and hypercarbia OSA and\n sleep hypoventilation. Patient now presents intubated hypercarbic\n respiratory failure complicated by right sided lung collapse. Patient\n extubated with noted coughing and desaturation after sips of thin\n liquids therefore kept NPO. S+S evaluation deferred today due to\n respiratory status\n patient has been on/off Bi-PAP mask. Bronchoscopy\n at beside showed webbing, question mass. Plan for rigid\n bronchoscopy and intubation in OR. Patient has been NPO x 3 days, if\n unable to begin po diet within 2 days, will need nutrition support.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If able to extubate patient, consult SLP for S+S evaluation\n before starting po diet\n 2. If unable to extubate patient or SLP recommend NPO; recommend\n tube feeding\n a. Obtain enteral access\n b. Tube feeding recommendations: Replete with Fiber @ 10 mL/hr,\n advance by 10mL q4hr to goal of 70 mL/hr to provide 1680 kcal and 104 g\n protein.\n Check chemistry 10 panel daily\n Monitor FSBG especially if nutrition support started\n Will follow to check plan\n , Dietetic Intern\n ------ Protected Section ------\n Agree with above assessment and plan. Page if questions *\n ------ Protected Section Addendum Entered By: , RD,\n on: 16:36 ------\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670276,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n * pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis this AM. CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside today showing\n webbing likely from traumatic intubation. IP, however, feel pt needs to\n have rigid bronch in OR for better visualization of tracheal webbing/?\n mass.\n Hypertension, benign\n Assessment:\n Pt received on nitro gtt @ 1mcg/kg/min with SBPs via cuff ranging\n 180s-190s.\n Action:\n Nitro gtt titrated up to maintain SBP 160-180. Pt continued on 5mg IV\n lopressor. A-line placed by team showing ABPs in 200s systolic which\n required titration of nitro gtt up to 3mcg/kg/min at one point.\n Response:\n Able to wean nitro down as low as 0.7 mcg/kg/min with systolics\n 160-180. Nitro weaned off just prior to transfer to OR with SBPs\n remaining 150s-160s.\n Plan:\n Cont off nitro gtt as long as BPs are maintained 160-180 systolic. Cont\n with IV lopressor until pt able to receive PO anti-hypertensives.\n Restart nitro gtt if necessary to mainting SBPs 160-180.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on aerosol face mask @ 35% FiO2 with sats 88-92% and RR\n 20s-30s. Pt mal-appearing this AM, diaphoretic/hypertensive/Tachypneic.\n Action:\n Pt taken for CTA to r/o PE.\n Response:\n CTA showing tracheomalacia and tracheal mass of unknown origin so\n bronch recommended by radiology. Bedside bronch performed with\n visualization of webbing of unknown etiology. Pt taken to OR @ 1630 for\n rigid bronch post intubation via fiberoptics. IP to perform bronch for\n better visualization and to determine diagnosis of questionable mass.\n Plan:\n Pending results of OR procedure.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670696,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. The ETT is NOT TO BE\n REPOSITIONED, and must be handled with extreme caution as it is close\n to the and could easily slip into the right main stem bronchus\n causing lung collapse. On , pt desatted with turning so emergent\n bedside bronch performed which required removal of large blood clot\n from trachea. ETT was repositioned, and the cuff was left with a leak\n purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm flexible trach was placed.\n Tracheobronchial Disease/ Tracheal Tear\n Assessment:\n Pt noted to have 5cm tracheal tear via rigid bronch in OR .\n Action:\n Pt\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-10 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671073,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n FEVER - 101.3\nF - 12:00 PM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:08 PM\n Ampicillin/Sulbactam (Unasyn) - 10:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:02 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Pantoprazole (Protonix) - 08:00 AM\n Fentanyl - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.6\nC (99.6\n HR: 56 (51 - 63) bpm\n BP: 151/63(84) {148/41(72) - 169/63(84)} mmHg\n RR: 13 (11 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 1,000 mL\n 568 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n 568 mL\n Blood products:\n Total out:\n 1,270 mL\n 199 mL\n Urine:\n 770 mL\n 199 mL\n NG:\n Stool:\n Drains:\n Balance:\n -270 mL\n 369 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 328 (328 - 328) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 128\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 96%\n ABG: 7.41/57/87./34/8\n Ve: 7 L/min\n PaO2 / FiO2: 220\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 7.5 g/dL\n 154 K/uL\n 86 mg/dL\n 0.4 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 7 mg/dL\n 109 mEq/L\n 150 mEq/L\n 23.8 %\n 3.6 K/uL\n [image002.jpg]\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n 05:06 PM\n 04:10 AM\n 10:33 AM\n 04:18 AM\n 04:29 AM\n WBC\n 3.9\n 6.4\n 3.6\n Hct\n 25.3\n 23.2\n 25\n 25.9\n 23.8\n Plt\n 147\n 151\n 154\n Cr\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 48\n 45\n 45\n 40\n 38\n 37\n Glucose\n 131\n 88\n 100\n 106\n 86\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671240,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:23 PM\n Ampicillin/Sulbactam (Unasyn) - 10:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 12:04 AM\n Metoprolol - 04:29 AM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 68 (40 - 82) bpm\n BP: 133/32(56) {124/31(56) - 180/116(120)} mmHg\n RR: 19 (14 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,624 mL\n 1,233 mL\n PO:\n TF:\n 114 mL\n 449 mL\n IVF:\n 2,290 mL\n 524 mL\n Blood products:\n Total out:\n 420 mL\n 148 mL\n Urine:\n 420 mL\n 148 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,204 mL\n 1,085 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 182 (182 - 182) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 40\n PIP: 36 cmH2O\n Plateau: 24 cmH2O\n SpO2: 96%\n ABG: 7.40/59/133/32/9\n Ve: 5.1 L/min\n PaO2 / FiO2: 332\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 7.7 g/dL\n 181 K/uL\n 122 mg/dL\n 0.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 107 mEq/L\n 145 mEq/L\n 24.5 %\n 4.3 K/uL\n [image002.jpg]\n 04:10 AM\n 10:33 AM\n 04:18 AM\n 04:29 AM\n 11:49 AM\n 12:49 PM\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n WBC\n 6.4\n 3.6\n 3.8\n 4.3\n Hct\n 25.9\n 23.8\n 24.1\n 24.5\n Plt\n 151\n 154\n 161\n 181\n Cr\n 0.4\n 0.4\n 0.4\n 0.3\n TCO2\n 38\n 37\n 34\n 34\n 37\n 38\n Glucose\n 106\n 86\n 144\n 122\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671241,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ABG 7.38/55/111 -> PS trial -> 7.32/64/83, so Pt felt to have central\n apnea and retaining CO2\n - Dobhoff placed and started TF/free water boluses\n - checked VBG (7.36/67/48/39) and ABG (7.40/59/133/38)\n - SBP persistently elevated as high as 190, gave 10 IV hydral with good\n result\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:23 PM\n Ampicillin/Sulbactam (Unasyn) - 04:29 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 12:03 AM\n Fentanyl - 12:04 AM\n Metoprolol - 04:29 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.2\nC (99\n HR: 53 (40 - 66) bpm\n BP: 180/57(86) {124/33(57) - 180/116(120)} mmHg\n RR: 16 (13 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,624 mL\n 654 mL\n PO:\n TF:\n 114 mL\n 275 mL\n IVF:\n 2,290 mL\n 279 mL\n Blood products:\n Total out:\n 420 mL\n 75 mL\n Urine:\n 420 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,204 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 182 (182 - 182) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 40\n PIP: 27 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.40/59/133/32/9\n Ve: 5.5 L/min\n PaO2 / FiO2: 332\n Physical Examination\n General Appearance: trached and responsive, but confused\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous, dull at bases ), no\n subcutaneous emphysema\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Labs / Radiology\n 181 K/uL\n 7.7 g/dL\n 122 mg/dL\n 0.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 107 mEq/L\n 145 mEq/L\n 24.5 %\n 4.3 K/uL\n [image002.jpg]\n 04:10 AM\n 10:33 AM\n 04:18 AM\n 04:29 AM\n 11:49 AM\n 12:49 PM\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n WBC\n 6.4\n 3.6\n 3.8\n 4.3\n Hct\n 25.9\n 23.8\n 24.1\n 24.5\n Plt\n 151\n 154\n 161\n 181\n Cr\n 0.4\n 0.4\n 0.4\n 0.3\n TCO2\n 38\n 37\n 34\n 34\n 37\n 38\n Glucose\n 106\n 86\n 144\n 122\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n CXR: improved compared to prior, no clear infiltrate or edema\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - try PS trials, if does well try Passey-Muir valve\n - continue Unasyn () and Fluconazole () for ppx for tracheal\n tear for goal 10 day course\n # Hypercarbic respiratory failure: Patient remains on vent. Her resp\n issues are likely a combination of OSA, CO2 retention andf her hospital\n course has also been complicated by right lung collapse, R mainstem\n intubation.\n - use VBGs as needed\n - continue flovent, albuterol, atrovent\n # Rising temperature: Has been afebrile for >48 hrs.\n - Post-op from trachea.\n - Pan Cx, check stool for C.diff\n # Hypernatremia:\n - currently resolved\n -# HCT drop: HCT now stable no melena. Hemolysis labs negative.\n Repeat CXR clearing w/o evidence of worsening effusions and given\n stable HCT, concern for intrathoracic bleeding is now low.\n - monitor HCT\n - guaiac stools\n # Altered mental status\n Currently improved. h/o SAH/IPH, but now\n unclear etiology as no clear complaints. Head CT unchanged, Chest CTA\n w/o PE, no evidence of MI, TTE w/ nl EF, UA unremarkable.\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns w/p any nodal\n agents. In sinus rhythm on admission, does have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - not on asa left temporal hemorrhage\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - continue enalapril, and hydralazine\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:00 PM 40 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 671243,
"text": "Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n CMV 7.38/55/11 PST 7.32/64/83 central component to apnea.\n VBG correlated A59 V 67 .04 change in pH.\n Doboff placed\n IV hydralazine for HTN with effect\n FEVER - 101.3\nF - 12:00 PM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:23 PM\n Ampicillin/Sulbactam (Unasyn) - 10:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 12:04 AM\n Metoprolol - 04:29 AM\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n mag/kcl\n zopharan\n metoprol 10 q 6 hr (D\n senna\n docusate\n unasyn\n fluconazole\n miconazole\n keppra\n RISS\n tylenol\n simvisatin\n PPI iv\n Albuterol\n chlorhex\n Enalapril 20mg qday\n Hydralizine 10mg iv Q6hr\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:unremarkable\n Flowsheet Data as of 11:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 68 (40 - 82) bpm\n BP: 133/32(56) {124/31(56) - 180/116(120)} mmHg\n RR: 19 (14 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,624 mL\n 1,233 mL\n PO:\n TF:\n 114 mL\n 449 mL\n IVF:\n 2,290 mL\n 524 mL\n Blood products:\n Total out:\n 420 mL\n 148 mL\n Urine:\n 420 mL\n 148 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,204 mL\n 1,085 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 182 (182 - 182) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 40\n PIP: 36 cmH2O\n Plateau: 24 cmH2O\n SpO2: 96%\n ABG: 7.40/59/133/32/9\n Ve: 5.1 L/min\n PaO2 / FiO2: 332\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trache\n Cardiovascular: RRR s1s2 no m/r/g\n Respiratory / Chest: clear anteriorly\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+\n Skin: no rash or erythema\n Neurologic: Attentive, A+O x 3 no gross motor sensory deficits.\n Lines: Clean dry intact.\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology: Chest port - No focal infiltrates ? RML\n atelectasis, sharp angles, PICC line not in place\n 7.7 g/dL\n 181 K/uL\n 122 mg/dL\n 0.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 107 mEq/L\n 145 mEq/L\n 24.5 %\n 4.3 K/uL\n [image002.jpg]\n 04:10 AM\n 10:33 AM\n 04:18 AM\n 04:29 AM\n 11:49 AM\n 12:49 PM\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n WBC\n 6.4\n 3.6\n 3.8\n 4.3\n Hct\n 25.9\n 23.8\n 24.1\n 24.5\n Plt\n 151\n 154\n 161\n 181\n Cr\n 0.4\n 0.4\n 0.4\n 0.3\n TCO2\n 38\n 37\n 34\n 34\n 37\n 38\n Glucose\n 106\n 86\n 144\n 122\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Micro-Stool neg Cdiff, Urine neg, and blood neg from 24th\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\nTracheal tear\n -presumably occurred during intubation at start of prior admission\n -IP following\n -trach placed yesterday to bypass injured area\n -empiric abx coverage inc anti-fungal coverage 10 days of coverage\n\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n -Acute on chronic hypercarbic respiratory failure - likely OSA, ?OHS,\n ?element central\n -Resp alkalosis\n -wean vent\n -Confirmed with gas pre and post CPAP\n HYPERTENSION\n -BP better controlled today\n -Will start enalapril when NG in place\n -PRN hydralazine\n -Will start lasix with goal negative fluid balance 500cc-1L negative\n Will also help with BP.\n DIABETES MELLITUS (DM), TYPE II:\n -SSRI\nLeft leg erythema:\n -No change chronic per husband\n culture-Resolved\n -new\n -is post trach placement which could be explanation\n -already on fluc and unasyn for trach/upper trachea tear proph\nMental status\n -very alert & interactive this morning intermittently confused\n -Consider Haldol will follow closely.\n -review medications consider hold fentanyl\n -wean sedation as tol\n -Did have Head CT for MS changes on Tuesday of last week.\n Remainder of plan per resident note\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:00 PM 50 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:00 PM-Pull back 1cm.\n Prophylaxis:\n DVT: SQ hep\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Screen on Monday for Vent Unit.\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 670356,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Possible Tracheostomy.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Pending procedure / OR, Cannot manage secretions, Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670693,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. The ETT is NOT TO BE\n REPOSITIONED, and must be handled with extreme caution as it is close\n to the and could easily slip into the right main stem bronchus\n causing lung collapse. On , pt desatted with turning so emergent\n bedside bronch performed which required removal of large blood clot\n from trachea. ETT was repositioned, and the cuff was left with a leak\n purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm flexible trach was placed.\n Tracheobronchial Disease, Other (Trachea / Bronchus, including injury)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671198,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.3\nF - 12:00 PM\n \n - still somewhat hypertensive 160-180's\n - refused NGT\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsMotrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:08 PM\n Ampicillin/Sulbactam (Unasyn) - 04:08 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:45 AM\n Heparin Sodium (Prophylaxis) - 12:37 AM\n Fentanyl - 12:44 AM\n Metoprolol - 06:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.3\nC (99.2\n HR: 60 (53 - 65) bpm\n BP: 151/63(84) {148/41(72) - 169/63(84)} mmHg\n RR: 16 (11 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 1,000 mL\n 176 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n 176 mL\n Blood products:\n Total out:\n 1,270 mL\n 128 mL\n Urine:\n 770 mL\n 128 mL\n NG:\n Stool:\n Drains:\n Balance:\n -270 mL\n 48 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 328 (302 - 328) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 128\n PIP: 25 cmH2O\n Plateau: 20 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 96%\n ABG: 7.41/57/87./34/8\n Ve: 5.5 L/min\n PaO2 / FiO2: 220\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 154 K/uL\n 7.5 g/dL\n 86 mg/dL\n 0.4 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 7 mg/dL\n 109 mEq/L\n 150 mEq/L\n 23.8 %\n 3.6 K/uL\n [image002.jpg]\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n 05:06 PM\n 04:10 AM\n 10:33 AM\n 04:18 AM\n 04:29 AM\n WBC\n 3.9\n 6.4\n 3.6\n Hct\n 25.3\n 23.2\n 25\n 25.9\n 23.8\n Plt\n 147\n 151\n 154\n Cr\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 48\n 45\n 45\n 40\n 38\n 37\n Glucose\n 131\n 88\n 100\n 106\n 86\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.2 mg/dL\n Microbiology: C. Diff neg X 1\n Blood Cx: NGTD in all cxs\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - consider SBT today, if does well try Passey-Muir valve\n - continue Unasyn and Fluconazole for ppx for tracheal tear\n - continue to d/w patient regarding placing NGT for feeding /\n medications\n # Hypercarbic respiratory failure: Patient remains on vent. Her resp\n issues are likely a combination of OSA, CO2 retention andf her hospital\n course has also been complicated by right lung collapse, R mainstem\n intubation.\n - serial ABGs via A-line as needed\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n # Rising temperature: ? impending infection. Increasing temperature,\n low-grade leukocytosis. Post-op from trachea.\n - Pan Cx, check stool for C.diff\n - consider LENIs to r/o DVT\n - continue current antibiotics, touch base w/ IP re: definite course\n # Hypernatremia:\n - D5W at 75 cc/hr\n - if NGT placement, wiould do free water flushes\n - consider changing abx solution to D5W\n # HCT drop: HCT now stable no melena. Hemolysis labs negative. Repeat\n CXR clearing w/o evidence of worsening effusions and given stable HCT,\n concern for intrathoracic bleeding is now low.\n - monitor HCT\n - guaiac stools\n # Altered mental status\n Currently improved. h/o SAH/IPH, but now\n unclear etiology as no clear complaints. Head CT unchanged, Chest CTA\n w/o PE, no evidence of MI, TTE w/ nl EF, UA unremarkable.\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns w/p any nodal\n agents. In sinus rhythm on admission, does have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - continue enalapril, BB\n ICU Care\n Nutrition: d/w pt regarding NGT placement\n Glycemic Control:\n Lines:\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671208,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ABG 7.38/55/111 -> PS trial -> 7.32/64/83, so Pt felt to have central\n apnea and retaining CO2\n - Dobhoff placed and started TF/free water boluses\n - checked VBG (7.36/67/48/39) and ABG (7.40/59/133/38)\n - SBP persistently elevated as high as 190, gave 10 IV hydral with good\n result\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:23 PM\n Ampicillin/Sulbactam (Unasyn) - 04:29 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 12:03 AM\n Fentanyl - 12:04 AM\n Metoprolol - 04:29 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.2\nC (99\n HR: 53 (40 - 66) bpm\n BP: 180/57(86) {124/33(57) - 180/116(120)} mmHg\n RR: 16 (13 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 2,624 mL\n 654 mL\n PO:\n TF:\n 114 mL\n 275 mL\n IVF:\n 2,290 mL\n 279 mL\n Blood products:\n Total out:\n 420 mL\n 75 mL\n Urine:\n 420 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,204 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 182 (182 - 182) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 40\n PIP: 27 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.40/59/133/32/9\n Ve: 5.5 L/min\n PaO2 / FiO2: 332\n Physical Examination\n General Appearance: intubated, sedated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous, dull at bases ), no\n sub cutaneous emphysema\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Neurologic: sedated\n Labs / Radiology\n 181 K/uL\n 7.7 g/dL\n 122 mg/dL\n 0.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 6 mg/dL\n 107 mEq/L\n 145 mEq/L\n 24.5 %\n 4.3 K/uL\n [image002.jpg]\n 04:10 AM\n 10:33 AM\n 04:18 AM\n 04:29 AM\n 11:49 AM\n 12:49 PM\n 03:04 PM\n 08:42 PM\n 02:47 AM\n 03:06 AM\n WBC\n 6.4\n 3.6\n 3.8\n 4.3\n Hct\n 25.9\n 23.8\n 24.1\n 24.5\n Plt\n 151\n 154\n 161\n 181\n Cr\n 0.4\n 0.4\n 0.4\n 0.3\n TCO2\n 38\n 37\n 34\n 34\n 37\n 38\n Glucose\n 106\n 86\n 144\n 122\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - consider SBT today, if does well try Passey-Muir valve\n - continue Unasyn and Fluconazole for ppx for tracheal tear\n - continue to d/w patient regarding placing NGT for feeding /\n medications\n # Hypercarbic respiratory failure: Patient remains on vent. Her resp\n issues are likely a combination of OSA, CO2 retention andf her hospital\n course has also been complicated by right lung collapse, R mainstem\n intubation.\n - serial ABGs via A-line as needed, consider d/c A-line and use VBGs as\n needed\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n # Rising temperature: ? impending infection. Increasing temperature,\n low-grade leukocytosis. Post-op from trachea.\n - Pan Cx, check stool for C.diff\n - consider LENIs to r/o DVT\n - continue current antibiotics, touch base w/ IP re: definite course\n # Hypernatremia:\n - D5W at 75 cc/hr\n - if NGT placement, would do free water flushes\n - consider changing abx solution to D5W\n # HCT drop: HCT now stable no melena. Hemolysis labs negative. Repeat\n CXR clearing w/o evidence of worsening effusions and given stable HCT,\n concern for intrathoracic bleeding is now low.\n - monitor HCT\n - guaiac stools\n # Altered mental status\n Currently improved. h/o SAH/IPH, but now\n unclear etiology as no clear complaints. Head CT unchanged, Chest CTA\n w/o PE, no evidence of MI, TTE w/ nl EF, UA unremarkable.\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns w/p any nodal\n agents. In sinus rhythm on admission, does have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - continue enalapril, BB\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:00 PM 40 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670263,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n * pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis this AM. CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside today showing\n webbing likely from traumatic intubation. IP, however, feel pt needs to\n have rigid bronch in OR for better visualization of tracheal webbing/?\n mass.\n Hypertension, benign\n Assessment:\n Pt received on nitro gtt @ 1mcg/kg/min with SBPs via cuff ranging\n 180s-190s.\n Action:\n Nitro gtt titrated up to maintain SBP 160-180. Pt continued on 5mg IV\n lopressor. A-line placed by team showing ABPs in 200s systolic which\n required titration of nitro gtt up to 3mcg/kg/min at one point.\n Response:\n Able to wean nitro down as low as 0.7 mcg/kg/min with systolics\n 160-180.\n Plan:\n Cont nitro gtt until BPs maintained 160-180 systolic. Cont with IV\n lopressor until pt able to receive POs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on aerosol face mask @ 35% FiO2 with sats 88-92% and RR\n 20s-30s. Pt mal-appearing this AM, diaphoretic/hypertensive/Tachypneic.\n Action:\n Pt taken for CTA to r/o PE.\n Response:\n CTA showing tracheomalacia and tracheal mass of unknown origin so\n bronch recommended by radiology. Bedside bronch performed with\n visualization of webbing of unknown etiology.\n Plan:\n Pt to be taken to OR for rigid bronch post intubation via fiberoptics.\n IP to perform bronch for better visualization and to determine\n diagnosis.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670656,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.\n * pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis this AM. CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside today showing\n webbing likely from traumatic intubation. IP, however, feel pt needs to\n have rigid bronch in OR for better visualization of tracheal webbing/?\n mass. Rigid bronch in OR revealed 5cm tear of the posterior tracheal\n wall. The patient was intubated under fiberoptics and the ETT was\n placed past the area of the tear as to reduce friction to the tracheal\n lumen. The ETT is NOT TO BE REPOSITIONED, and must be handled with\n extreme caution as it is close to the and could easily slip into\n the right main stem bronchus causing lung collapse.\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 671044,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.3\nF - 12:00 PM\n \n - still somewhat hypertensive 160-180's\n - refused NGT\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsMotrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:08 PM\n Ampicillin/Sulbactam (Unasyn) - 04:08 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:45 AM\n Heparin Sodium (Prophylaxis) - 12:37 AM\n Fentanyl - 12:44 AM\n Metoprolol - 06:02 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.3\nC (99.2\n HR: 60 (53 - 65) bpm\n BP: 151/63(84) {148/41(72) - 169/63(84)} mmHg\n RR: 16 (11 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 1,000 mL\n 176 mL\n PO:\n TF:\n IVF:\n 1,000 mL\n 176 mL\n Blood products:\n Total out:\n 1,270 mL\n 128 mL\n Urine:\n 770 mL\n 128 mL\n NG:\n Stool:\n Drains:\n Balance:\n -270 mL\n 48 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n Vt (Spontaneous): 328 (302 - 328) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 128\n PIP: 25 cmH2O\n Plateau: 20 cmH2O\n Compliance: 29.2 cmH2O/mL\n SpO2: 96%\n ABG: 7.41/57/87./34/8\n Ve: 5.5 L/min\n PaO2 / FiO2: 220\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 154 K/uL\n 7.5 g/dL\n 86 mg/dL\n 0.4 mg/dL\n 34 mEq/L\n 3.6 mEq/L\n 7 mg/dL\n 109 mEq/L\n 150 mEq/L\n 23.8 %\n 3.6 K/uL\n [image002.jpg]\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n 05:06 PM\n 04:10 AM\n 10:33 AM\n 04:18 AM\n 04:29 AM\n WBC\n 3.9\n 6.4\n 3.6\n Hct\n 25.3\n 23.2\n 25\n 25.9\n 23.8\n Plt\n 147\n 151\n 154\n Cr\n 0.4\n 0.4\n 0.4\n 0.4\n TCO2\n 48\n 45\n 45\n 40\n 38\n 37\n Glucose\n 131\n 88\n 100\n 106\n 86\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:0.6 mmol/L, LDH:203\n IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.2 mg/dL\n Microbiology: C. Diff neg X 1\n Blood Cx: NGTD in all cxs\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n TRACHEOBRONCHIAL DISEASE, OTHER (TRACHEA / BRONCHUS, INCLUDING\n INJURY)\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; found to have\n traumatic tracheal tear now s/p trach.\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal. Now s/p tracheostomy.\n - consider SBT today, if does well try Passey-Muir valve\n - continue Unasyn and Fluconazole for ppx for tracheal tear\n - continue to d/w patient regarding placing NGT for feeding /\n medications\n # Hypercarbic respiratory failure: Patient remains on vent. Her resp\n issues are likely a combination of OSA, CO2 retention andf her hospital\n course has also been complicated by right lung collapse, R mainstem\n intubation.\n - serial ABGs via A-line as needed\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n # Rising temperature: ? impending infection. Increasing temperature,\n low-grade leukocytosis. Post-op from trachea.\n - Pan Cx, check stool for C.diff\n - consider LENIs to r/o DVT\n - continue current antibiotics, touch base w/ IP re: definite course\n # Hypernatremia:\n - D5W at 75 cc/hr\n - if NGT placement, wiould do free water flushes\n - consider changing abx solution to D5W\n # HCT drop: HCT now stable no melena. Hemolysis labs negative. Repeat\n CXR clearing w/o evidence of worsening effusions and given stable HCT,\n concern for intrathoracic bleeding is now low.\n - monitor HCT\n - guaiac stools\n # Altered mental status\n Currently improved. h/o SAH/IPH, but now\n unclear etiology as no clear complaints. Head CT unchanged, Chest CTA\n w/o PE, no evidence of MI, TTE w/ nl EF, UA unremarkable.\n # Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her.\n - on Unasyn as for tracheal tear\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns w/p any nodal\n agents. In sinus rhythm on admission, does have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - continue enalapril, BB\n ICU Care\n Nutrition: d/w pt regarding NGT placement\n Glycemic Control:\n Lines:\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671418,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. On , pt desatted\n with turning so emergent bedside bronch performed which required\n removal of large blood clot from trachea. ETT was repositioned, and the\n cuff was left with a leak purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out. Pt will need this in place for approx 8\n weeks\n Hypertension, benign\n Assessment:\n Pt has been hypertensive to 180\ns last few days,HR 50-70 sinus now,h/o\n a fib ,pt has been agitated intermittently\n Action:\n Contd hydralazine,metoprolol and enalapril,also recvd lasix 40 mg iv x1\n Response:\n Most of the day sbp 110-150,1 of sbp 175 which was right\n recorded during the time of suctioning,pt was very somnolent in the\n beginning of the shift (post haldol) and started getting agitated aroud\n 0930am,a wrist restraint has been applied to protect the tubes and\n lines which infact worsen her agitation,pt is alert and oriented x3,but\n gets confused intermittently,doing well off restraints\n Plan:\n Monitor BP, cont standing IV hydral, goal diuresis 1L neg,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 100% +10peep. Lung sounds\n rhoncherous .Sxn for thick white/yellow secretions. Q2-3 hrs\n overnight;no desating,gets resp distress that easily clears with\n suction ,BNP 1820.\n Action:\n Fi02 weaned to 40%,chest USG to assess the diaphragm,recvd Lasix 40mg\n iv,A leni has been done to r/o DVT\n Response:\n sas 94-100%,no episode of acute desating,chest usg s/o rt diaphragmatic\n paralysis,\n Plan:\n Cont to wean as tolerated,goal fluid balance 1L neg,vent rehab screen\n ongoing..\n Others:recevd 40 meq K this am for k 3.5.Rpt level pending\n Tolerating the tube feed @goal.\n Husband was at bedside updated by MD and this RN.\n NA was 150,free water flush increased to 250cc q6h,rpt lytes pending.\n On SSRI and lantus,fs 270 &192,received coverage.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671419,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. On , pt desatted\n with turning so emergent bedside bronch performed which required\n removal of large blood clot from trachea. ETT was repositioned, and the\n cuff was left with a leak purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out. Pt will need this in place for approx 8\n weeks\n Hypertension, benign\n Assessment:\n Pt has been hypertensive to 180\ns last few days,HR 50-70 sinus now,h/o\n a fib ,pt has been agitated intermittently\n Action:\n Contd hydralazine,metoprolol and enalapril,also recvd lasix 40 mg iv x1\n Response:\n Most of the day sbp 110-150,1 of sbp 175 which was right\n recorded during the time of suctioning,pt was very somnolent in the\n beginning of the shift (post haldol) and started getting agitated aroud\n 0930am,a wrist restraint has been applied to protect the tubes and\n lines which infact worsen her agitation,pt is alert and oriented x3,but\n gets confused intermittently,doing well off restraints\n Plan:\n Monitor BP, cont standing IV hydral, goal diuresis 1L neg,will hold off\n fentanyl.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 100% +10peep. Lung sounds\n roncherous .Sxn for thick white/yellow secretions. Q2-3 hrs;no\n desating,gets resp distress that easily clears with suction ,BNP 1820.\n Action:\n Fi02 weaned to 40%,chest USG to assess the diaphragm,recvd Lasix 40mg\n iv,A leni has been done to r/o DVT\n Response:\n sats 94-100%,no episode of acute desating,chest usg s/o rt\n diaphragmatic paralysis,\n Plan:\n Cont to wean as tolerated,goal fluid balance 1L neg,vent rehab screen\n ongoing..\n Others:recevd 40 meq K this am for k 3.5.Rpt level pending\n Tolerating the tube feed @goal.\n Husband was at bedside updated by MD and this RN.\n NA was 150,free water flush increased to 250cc q6h,rpt lytes pending.\n On SSRI and lantus,fs 270 &192,received coverage.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671429,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. On , pt desatted\n with turning so emergent bedside bronch performed which required\n removal of large blood clot from trachea. ETT was repositioned, and the\n cuff was left with a leak purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out. Pt will need this in place for approx 8\n weeks\n Hypertension, benign\n Assessment:\n Pt has been hypertensive to 180\ns last few days,HR 50-70 sinus now,h/o\n a fib ,pt has been agitated intermittently\n Action:\n Contd hydralazine,metoprolol and enalapril,also recvd lasix 40 mg iv x1\n Response:\n Most of the day sbp 110-150,1 of sbp 175 which was right\n recorded during the time of suctioning,pt was very somnolent in the\n beginning of the shift (post haldol) and started getting agitated aroud\n 0930am,a wrist restraint has been applied to protect the tubes and\n lines which infact worsen her agitation,pt is alert and oriented x3,but\n gets confused intermittently,doing well off restraints\n Plan:\n Monitor BP, cont standing IV hydral, goal diuresis 1L neg,will hold off\n fentanyl.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 100% +10peep. Lung sounds\n ronchorous .Sxn for thick white/yellow secretions. Q2-3 hrs;no\n desating,gets resp distress that easily clears with suction ,BNP 1820.\n Action:\n Fi02 weaned to 40%,chest USG to assess the diaphragm,recvd Lasix 40mg\n iv,A leni has been done to r/o DVT\n Response:\n sats 94-100%,no episode of acute desating,chest usg s/o rt\n diaphragmatic paralysis,Tv 100-600cc.\n Plan:\n Cont to wean as tolerated,goal fluid balance 1L neg,vent rehab screen\n ongoing..\n Others:recevd 40 meq K this am for k 3.5.Rpt level pending\n Tolerating the tube feed @goal.\n Husband &son at bedside updated by MD and this RN.\n NA was 150,free water flush increased to 250cc q6h,rpt lytes pending.\n On SSRI and lantus,fs 270 &192,received coverage.\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 670143,
"text": "Ventilation Assessment\n Non-invasive ventilation assessment: Tolerated well\n Comments: Patient placed on NIV throughout the night shift. Tolerated\n 2-3hrs at a time.\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Expectorated / Small\n Comments: Patient has congested productive cough.\n Plan\n Next 24-48 hours: NIV as needed.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670480,
"text": "Events:pt was desating to mid 80\ns this am post turn,urgent bronch done\n at bedside,large clot was removed ,stable vent settings afterwards.ETT\n pulled and retaped,A picc line has been inserted by IR.Hct dropped to\n 22(from 28)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on ac 40%,10peep 16/350,sats high 90\ns,noted diminished\n breath sounds on the left side. Received on fent 60 and propofol 30\n Action:\n Pt had undergone bronch at bedside,suctioned as needed,able to wean\n sedation a bit\n Response:\n Pt desatted to mid 80\ns post turn this am,didn\nt improve with\n suctioning,PIP were in 30\ns with diminished breath sounds on the left\n side,blood clot removed via the bronch,no episodes of desatting\n afterwards.\n Plan:\n Will cont the current settings,famiuly team meeting today?possible\n trach in am\n Anemia, other\n Assessment:\n HCT dropped to 22 from 28,no obvious bleeding,suctioned for bloody\n secretions,minimal bleeding noted during bronch,no obvious blood seen\n in the stool\n Action:\n Cycled HCT\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670623,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 10:00 AM\n PICC LINE - START 02:00 PM\n - Hct stable and hemolysis labs negative\n - IP recs for trach tomorrow morning. Basically, because pt requires\n bipap and has OSA and frequent intubations risk of tracheal perf would\n be great in her, so it is safer to electively trach at this point. Per\n Dr. , trach would be in for at least 8 weeks\n - Pt has a mass on OSH chest CT in L hilum at location of bleed. This\n will need to be assessed with contrast CT after trach placed\n - Family meeting with Dr. and Dr. . Family's questions\n answered successfully and completely\n - Family requesting MICU team to call PCP . \n \n - Family requesting to speak with Case Manager.\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:36 PM\n Ampicillin/Sulbactam (Unasyn) - 04:18 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Metoprolol - 10:30 AM\n Heparin Sodium (Prophylaxis) - 12:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.4\nC (99.4\n HR: 56 (52 - 75) bpm\n BP: 141/44(64) {0/0(0) - 0/0(0)} mmHg\n RR: 16 (15 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 1,994 mL\n 504 mL\n PO:\n TF:\n IVF:\n 1,994 mL\n 504 mL\n Blood products:\n Total out:\n 1,255 mL\n 265 mL\n Urine:\n 1,255 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n 739 mL\n 239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 98%\n ABG: 7.46/61/77./39/16\n Ve: 4.9 L/min\n PaO2 / FiO2: 195\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 147 K/uL\n 7.5 g/dL\n 88 mg/dL\n 0.4 mg/dL\n 39 mEq/L\n 3.0 mEq/L\n 13 mg/dL\n 103 mEq/L\n 148 mEq/L\n 23.2 %\n 3.9 K/uL\n [image002.jpg]\n 01:13 AM\n 04:33 AM\n 05:02 AM\n 07:27 AM\n 09:27 AM\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n WBC\n 6.7\n 3.9\n Hct\n 23.3\n 22.8\n 25.3\n 23.2\n Plt\n 164\n 147\n Cr\n 0.4\n 0.4\n 0.4\n TCO2\n 50\n 48\n 47\n 48\n 45\n 45\n Glucose\n 179\n 131\n 88\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:1.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; now intubated after\n finding of traumatic tracheal tear.\n .\n # HCT drop: no melena. CXR with ? worsening pleural effusions, HCT drop\n and tracheal tear could be concerning for intrathoracic bleeding.\n - q 8 HCT\n - guaic stools\n - obtain hemolysis labs\n - repeat CXR, if truly worsening effusion will consider CT and\n thoracentesis\n .\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation.\n - remain intubated x2 weeks to allow healing of tear\n - prophylactic antibiotics while intubated: Unasyn and Fluconazole\n - follow serial CXRs\n .\n # Hypercarbic respiratory failure with new right lung collapse - On CXR\n previously she had white out of the right lung with rightward tracheal\n deviation concerning for new right lung collapse, most likely \n mucous plugging given her thick secretions. ABG now with hypoxia in\n the setting of turning pt and right mainstem intubation (now s/p\n pulling back ET tube) and with metabolic alkalosis overventilation.\n - repeat ABG: RR, consider inc Fi02 pending ABG results\n - serial ABGs via A-line\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n # Altered mental status\n h/o SAH/IPH, but now unclear etiology as no\n clear complaints. Head CT unchanged, Chest CTA w/o PE, no evidence of\n MI, TTE w/ nl EF, UA unremarkable. Now intubated tracheal tear.\n .\n #Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her. Possibly intubation. Now intubated\n again tracheal tear.\n - on Unasyn as for tracheal tear\n .\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n .\n #Paroxysmal Atrial fibrillation: in sinus rhythm on admission, does\n have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n .\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n .\n # HTN\n was HTN yesterday, BP lower in the afternoon and evening in\n the setting of propofol, however pt remains with large pulse pressure.\n Enalapril was started last night\n - cont enalapril\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:05 AM\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670624,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 10:00 AM\n PICC LINE - START 02:00 PM\n - Hct stable and hemolysis labs negative\n - IP recs for trach tomorrow morning. Basically, because pt requires\n bipap and has OSA and frequent intubations risk of tracheal perf would\n be great in her, so it is safer to electively trach at this point. Per\n Dr. , trach would be in for at least 8 weeks\n - Pt has a mass on OSH chest CT in L hilum at location of bleed. This\n will need to be assessed with contrast CT after trach placed\n - Family meeting with Dr. and Dr. . Family's questions\n answered successfully and completely\n - Family requesting MICU team to call PCP . \n \n - Family requesting to speak with Case Manager.\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:36 PM\n Ampicillin/Sulbactam (Unasyn) - 04:18 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Metoprolol - 10:30 AM\n Heparin Sodium (Prophylaxis) - 12:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.4\nC (99.4\n HR: 56 (52 - 75) bpm\n BP: 141/44(64) {0/0(0) - 0/0(0)} mmHg\n RR: 16 (15 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 1,994 mL\n 504 mL\n PO:\n TF:\n IVF:\n 1,994 mL\n 504 mL\n Blood products:\n Total out:\n 1,255 mL\n 265 mL\n Urine:\n 1,255 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n 739 mL\n 239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 98%\n ABG: 7.46/61/77./39/16\n Ve: 4.9 L/min\n PaO2 / FiO2: 195\n Physical Examination\n General Appearance: intubated, sedated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous, dull at bases ), no\n sub cutaneous emphysema\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Neurologic: sedated\n Labs / Radiology\n 147 K/uL\n 7.5 g/dL\n 88 mg/dL\n 0.4 mg/dL\n 39 mEq/L\n 3.0 mEq/L\n 13 mg/dL\n 103 mEq/L\n 148 mEq/L\n 23.2 %\n 3.9 K/uL\n [image002.jpg]\n 01:13 AM\n 04:33 AM\n 05:02 AM\n 07:27 AM\n 09:27 AM\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n WBC\n 6.7\n 3.9\n Hct\n 23.3\n 22.8\n 25.3\n 23.2\n Plt\n 164\n 147\n Cr\n 0.4\n 0.4\n 0.4\n TCO2\n 50\n 48\n 47\n 48\n 45\n 45\n Glucose\n 179\n 131\n 88\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:1.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; now intubated after\n finding of traumatic tracheal tear.\n .\n # HCT drop: HCT now stable no melena. Hemolysis labs negative. Repeat\n CXR clearing w/o evidence of worsening effusions and given stable HCT,\n concern for intrathoracic bleeding is now low.\n - monitor HCT\n - guaic stools.\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal.\n - tracheostomy today\n - prophylactic antibiotics while intubated: Unasyn and Fluconazole\n .\n # Hypercarbic respiratory failure with new right lung collapse - On CXR\n previously she had white out of the right lung with rightward tracheal\n deviation concerning for new right lung collapse, most likely \n mucous plugging given her thick secretions. ABG now with hypoxia in\n the setting of turning pt and right mainstem intubation (now s/p\n pulling back ET tube) and with metabolic alkalosis overventilation.\n - serial ABGs via A-line\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n # Altered mental status\n h/o SAH/IPH, but now unclear etiology as no\n clear complaints. Head CT unchanged, Chest CTA w/o PE, no evidence of\n MI, TTE w/ nl EF, UA unremarkable. Now intubated tracheal tear.\n .\n #Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her. Possibly intubation. Now intubated\n again tracheal tear.\n - on Unasyn as for tracheal tear\n .\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n .\n #Paroxysmal Atrial fibrillation: in sinus rhythm on admission, does\n have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n .\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n .\n # HTN\n was HTN yesterday, BP lower in the afternoon and evening in\n the setting of propofol, however pt remains with large pulse pressure.\n Enalapril was started last night\n - cont enalapril\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:05 AM\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670630,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 10:00 AM\n PICC LINE - START 02:00 PM\n - Hct stable and hemolysis labs negative\n - IP recs for trach tomorrow morning. Basically, because pt requires\n bipap and has OSA and frequent intubations risk of tracheal perf would\n be great in her, so it is safer to electively trach at this point. Per\n Dr. , trach would be in for at least 8 weeks\n - Pt has a mass on OSH chest CT in L hilum at location of bleed. This\n will need to be assessed with contrast CT after trach placed\n - Family meeting with Dr. and Dr. . Family's questions\n answered successfully and completely\n - Family requesting MICU team to call PCP . \n \n - Family requesting to speak with Case Manager.\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:36 PM\n Ampicillin/Sulbactam (Unasyn) - 04:18 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Metoprolol - 10:30 AM\n Heparin Sodium (Prophylaxis) - 12:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.4\nC (99.4\n HR: 56 (52 - 75) bpm\n BP: 141/44(64) {0/0(0) - 0/0(0)} mmHg\n RR: 16 (15 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 1,994 mL\n 504 mL\n PO:\n TF:\n IVF:\n 1,994 mL\n 504 mL\n Blood products:\n Total out:\n 1,255 mL\n 265 mL\n Urine:\n 1,255 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n 739 mL\n 239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 98%\n ABG: 7.46/61/77./39/16\n Ve: 4.9 L/min\n PaO2 / FiO2: 195\n Physical Examination\n General Appearance: intubated, sedated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous, dull at bases ), no\n sub cutaneous emphysema\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Neurologic: sedated\n Labs / Radiology\n 147 K/uL\n 7.5 g/dL\n 88 mg/dL\n 0.4 mg/dL\n 39 mEq/L\n 3.0 mEq/L\n 13 mg/dL\n 103 mEq/L\n 148 mEq/L\n 23.2 %\n 3.9 K/uL\n [image002.jpg]\n 01:13 AM\n 04:33 AM\n 05:02 AM\n 07:27 AM\n 09:27 AM\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n WBC\n 6.7\n 3.9\n Hct\n 23.3\n 22.8\n 25.3\n 23.2\n Plt\n 164\n 147\n Cr\n 0.4\n 0.4\n 0.4\n TCO2\n 50\n 48\n 47\n 48\n 45\n 45\n Glucose\n 179\n 131\n 88\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:1.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; now intubated after\n finding of traumatic tracheal tear.\n .\n # HCT drop: HCT now stable no melena. Hemolysis labs negative. Repeat\n CXR clearing w/o evidence of worsening effusions and given stable HCT,\n concern for intrathoracic bleeding is now low.\n - monitor HCT\n - guaic stools.\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal.\n - tracheostomy today\n - prophylactic antibiotics while intubated: Unasyn and Fluconazole\n .\n # Hypercarbic respiratory failure with new right lung collapse - On CXR\n previously she had white out of the right lung with rightward tracheal\n deviation concerning for new right lung collapse, most likely \n mucous plugging given her thick secretions. ABG now with hypoxia in\n the setting of turning pt and right mainstem intubation (now s/p\n pulling back ET tube) and with metabolic alkalosis overventilation.\n - serial ABGs via A-line\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n # Altered mental status\n h/o SAH/IPH, but now unclear etiology as no\n clear complaints. Head CT unchanged, Chest CTA w/o PE, no evidence of\n MI, TTE w/ nl EF, UA unremarkable. Now intubated tracheal tear.\n .\n #Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her. Possibly intubation. Now intubated\n again tracheal tear.\n - on Unasyn as for tracheal tear\n .\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n .\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns w/p any nodal\n agents. In sinus rhythm on admission, does have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n .\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n .\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\ns. Enalapril was held\n this am.\n - restart enalapril\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:05 AM\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670659,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. The ETT is NOT TO BE\n REPOSITIONED, and must be handled with extreme caution as it is close\n to the and could easily slip into the right main stem bronchus\n causing lung collapse. On , pt desatted with turning so emergent\n bedside bronch performed which required removal of large blood clot\n from trachea. ETT was repositioned, and the cuff was left with a leak\n purposefully.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670747,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. The ETT is NOT TO BE\n REPOSITIONED, and must be handled with extreme caution as it is close\n to the and could easily slip into the right main stem bronchus\n causing lung collapse. On , pt desatted with turning so emergent\n bedside bronch performed which required removal of large blood clot\n from trachea. ETT was repositioned, and the cuff was left with a leak\n purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out.\n Tracheal Tear\n Assessment:\n Pt noted to have 5cm tracheal tear via rigid bronch in OR . Post\n procedure, pt was intubated using fiberoptics with plan to have\n tracheostomy.\n Action:\n Pt went to OR today for rigid bronch/open tracheostomy.\n Response:\n Pt now with #8 adjustable neck flange portex trach. Has been weaned off\n sedation, but remains on CMV on vent.\n Plan:\n Wean pt from vent to trach mask as tolerated, as absence of ventilation\n will better allow for tracheal tear to heal.\n Hypertension, benign\n Assessment:\n This AM pt with SBPs via art line ranging 120s-150s with elevation at\n times of stimulation/pain. Post OR procedure, pt with SBPs ranging\n 170s-200s.\n Action:\n Pt given boluses propofol for ? HTN pain but with little response\n so 5mg IV lopressor given and 50mcg IV fentanyl.\n Response:\n SBPs down to 150s post lopressor and fentanyl but slowly creeping up\n into 170s-180s so another dose 50mcg fent given for subjective c/o pain\n and SBPs down again into 160s.\n Plan:\n Cont with enalapril for BP control. Give IV lopressor as long as HR>60,\n if not, to ask MD if it should be administered. If pt remains\n bradycardic, may consider administration of IV hydral for extreme HTN.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670660,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. The ETT is NOT TO BE\n REPOSITIONED, and must be handled with extreme caution as it is close\n to the and could easily slip into the right main stem bronchus\n causing lung collapse. On , pt desatted with turning so emergent\n bedside bronch performed which required removal of large blood clot\n from trachea. ETT was repositioned, and the cuff was left with a leak\n purposefully.\n Tracheobronchial Disease, Other (Trachea / Bronchus, including injury)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670666,
"text": "Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 10:00 AM\n PICC LINE - START 02:00 PM\n - Hct stable and hemolysis labs negative\n - IP recs for trach tomorrow morning. Basically, because pt requires\n bipap and has OSA and frequent intubations risk of tracheal perf would\n be great in her, so it is safer to electively trach at this point. Per\n Dr. , trach would be in for at least 8 weeks\n - Pt has a mass on OSH chest CT in L hilum at location of bleed. This\n will need to be assessed with contrast CT after trach placed\n - Family meeting with Dr. and Dr. . Family's questions\n answered successfully and completely\n - Family requesting MICU team to call PCP . \n \n - Family requesting to speak with Case Manager.\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:36 PM\n Ampicillin/Sulbactam (Unasyn) - 04:18 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 AM\n Metoprolol - 10:30 AM\n Heparin Sodium (Prophylaxis) - 12:33 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.4\nC (99.4\n HR: 56 (52 - 75) bpm\n BP: 141/44(64) {0/0(0) - 0/0(0)} mmHg\n RR: 16 (15 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 1,994 mL\n 504 mL\n PO:\n TF:\n IVF:\n 1,994 mL\n 504 mL\n Blood products:\n Total out:\n 1,255 mL\n 265 mL\n Urine:\n 1,255 mL\n 265 mL\n NG:\n Stool:\n Drains:\n Balance:\n 739 mL\n 239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 98%\n ABG: 7.46/61/77./39/16\n Ve: 4.9 L/min\n PaO2 / FiO2: 195\n Physical Examination\n General Appearance: intubated, sedated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous, dull at bases ), no\n sub cutaneous emphysema\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+\n Skin: Cool\n Neurologic: sedated\n Labs / Radiology\n 147 K/uL\n 7.5 g/dL\n 88 mg/dL\n 0.4 mg/dL\n 39 mEq/L\n 3.0 mEq/L\n 13 mg/dL\n 103 mEq/L\n 148 mEq/L\n 23.2 %\n 3.9 K/uL\n [image002.jpg]\n 01:13 AM\n 04:33 AM\n 05:02 AM\n 07:27 AM\n 09:27 AM\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n WBC\n 6.7\n 3.9\n Hct\n 23.3\n 22.8\n 25.3\n 23.2\n Plt\n 164\n 147\n Cr\n 0.4\n 0.4\n 0.4\n TCO2\n 50\n 48\n 47\n 48\n 45\n 45\n Glucose\n 179\n 131\n 88\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:1.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n ANEMIA, OTHER\n HYPERTENSION, BENIGN\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure; now intubated after\n finding of traumatic tracheal tear.\n .\n # HCT drop: HCT now stable no melena. Hemolysis labs negative. Repeat\n CXR clearing w/o evidence of worsening effusions and given stable HCT,\n concern for intrathoracic bleeding is now low.\n - monitor HCT\n - guaiac stools.\n # Tracheal tear - Found on CTA chest done , flexible brochoscopy\n showed webbing, rigid bronch showed traumatic tear; now s/p fiberoptic\n intubation. Will be trach\ned today with plan for 8 weeks with\n tracheostomy to allow tracheal tear to heal.\n - tracheostomy today\n - prophylactic antibiotics while intubated: Unasyn and Fluconazole\n .\n # Hypercarbic respiratory failure with new right lung collapse - On CXR\n previously she had white out of the right lung with rightward tracheal\n deviation concerning for new right lung collapse, most likely \n mucous plugging given her thick secretions. ABG now with hypoxia in\n the setting of turning pt and right mainstem intubation (now s/p\n pulling back ET tube) and with metabolic alkalosis overventilation.\n - serial ABGs via A-line\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n # Altered mental status\n h/o SAH/IPH, but now unclear etiology as no\n clear complaints. Head CT unchanged, Chest CTA w/o PE, no evidence of\n MI, TTE w/ nl EF, UA unremarkable. Now intubated tracheal tear.\n #Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her. Possibly intubation. Now intubated\n again tracheal tear.\n - on Unasyn as for tracheal tear\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - per neurology -> cont keppra for now\n - outpatient neurology follow up\n #Paroxysmal Atrial fibrillation: HR currently in 60\ns w/p any nodal\n agents. In sinus rhythm on admission, does have limited bursts of afib\n - coumadin being held given recent hemorrhage\n - metoprolol IV prn for tachycardia/htn\n - not on asa left temporal hemorrhage\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n # HTN\n BP variable , had been hypertensive two days ago requiring\n nitro drip at which point she was transitioned back to her home dose of\n enalapril. However, she then had low BP and high pulse pressure\n yesterday early morning in the setting of propofol, but then normalized\n throughout the day with BP\ns 130\ns-160\ns/40-60\n - continue enalapril\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:05 AM\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 670667,
"text": "TITLE:\n Chief Complaint: respiratory failure, tracheal tear\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BRONCHOSCOPY - At 10:00 AM\n PICC LINE - START 02:00 PM\n - family meeting last evening (see event note)\n - stable o/n\n - going for trache today\n History obtained from Medical records\n Patient unable to provide history: Sedated, ett\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Fluconazole - 08:36 PM\n Ampicillin/Sulbactam (Unasyn) - 04:18 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 10:30 AM\n Heparin Sodium (Prophylaxis) - 12:33 AM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.1\nC (98.8\n HR: 49 (49 - 75) bpm\n BP: 141/44(64) {0/0(0) - 0/0(0)} mmHg\n RR: 16 (15 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134.1 kg\n Height: 65 Inch\n Total In:\n 1,994 mL\n 1,137 mL\n PO:\n TF:\n IVF:\n 1,994 mL\n 1,077 mL\n Blood products:\n Total out:\n 1,255 mL\n 358 mL\n Urine:\n 1,255 mL\n 358 mL\n NG:\n Stool:\n Drains:\n Balance:\n 739 mL\n 779 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 350 (350 - 350) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 23 cmH2O\n Plateau: 14 cmH2O\n Compliance: 87.5 cmH2O/mL\n SpO2: 95%\n ABG: 7.46/61/77./39/16\n Ve: 4 L/min\n PaO2 / FiO2: 195\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: ), cuff leak\n Abdominal: Soft, Non-tender, Bowel sounds present\n Musculoskeletal: Unable to stand\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n 7.5 g/dL\n 147 K/uL\n 88 mg/dL\n 0.4 mg/dL\n 39 mEq/L\n 3.0 mEq/L\n 13 mg/dL\n 103 mEq/L\n 148 mEq/L\n 23.2 %\n 3.9 K/uL\n [image002.jpg]\n 01:13 AM\n 04:33 AM\n 05:02 AM\n 07:27 AM\n 09:27 AM\n 11:29 AM\n 02:57 PM\n 05:41 PM\n 04:10 AM\n 04:22 AM\n WBC\n 6.7\n 3.9\n Hct\n 23.3\n 22.8\n 25.3\n 23.2\n Plt\n 164\n 147\n Cr\n 0.4\n 0.4\n 0.4\n TCO2\n 50\n 48\n 47\n 48\n 45\n 45\n Glucose\n 179\n 131\n 88\n Other labs: PT / PTT / INR:13.5/25.8/1.2, CK / CKMB /\n Troponin-T:16//<0.01, Differential-Neuts:78.9 %, Lymph:13.9 %, Mono:5.8\n %, Eos:1.4 %, Fibrinogen:479 mg/dL, Lactic Acid:1.6 mmol/L, LDH:203\n IU/L, Ca++:8.1 mg/dL, Mg++:1.8 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\nTracheal tear\n -presumably related to intubation at start of prior admission\n -IP following\n -cont intubation with distal positioning of tube and intentional air\n leak to allow healing\n -careful maint of ETT position\n -empiric abx coverage inc anti-fungal coverage\n -for trache\n\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n -Acute on chronic hypercarbic respiratory failure\n -Resp alkalosis\n HYPERTENSION\n -BP better controlled today\n -on home dose enalapril\n DIABETES MELLITUS (DM), TYPE II: consider d/c\ning oral hypoglycemics.\nLeft leg erythema:\n -Potential infection vs. DVT.\n Mental status\n -following commands\n -will be able to wean sedation once trached so will be better able to\n assess\n -head CT negative\n Chest pain\n -EKG without changes\n -r/o MI\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:05 AM\n Arterial Line - 11:32 AM\n PICC Line - 02:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 50 minutes\n"
},
{
"category": "Nutrition",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 670668,
"text": "Subjective\n Patient unable to answer questions at this time.\n Objective\n Food allergies and intolerances: no known food allergies\n Pertinent medications: Fentanyl, 500 mL D5 bolus, 40 mEq Potassium\n Chloride repletion, 15 mmol Potassium Phosphate repletion, NS @ 10\n mL/hr, ABX, Pantoprazole, Glargine, RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 88 mg/dL\n 04:10 AM\n Glucose Finger Stick\n 135\n 10:00 AM\n BUN\n 13 mg/dL\n 04:10 AM\n Creatinine\n 0.4 mg/dL\n 04:10 AM\n Sodium\n 148 mEq/L\n 04:10 AM\n Potassium\n 3.0 mEq/L\n 04:10 AM\n Chloride\n 103 mEq/L\n 04:10 AM\n TCO2\n 39 mEq/L\n 04:10 AM\n PO2 (arterial)\n 77. mm Hg\n 04:22 AM\n PCO2 (arterial)\n 61 mm Hg\n 04:22 AM\n pH (arterial)\n 7.46 units\n 04:22 AM\n pH (urine)\n 5.5 units\n 09:25 PM\n CO2 (Calc) arterial\n 45 mEq/L\n 04:22 AM\n Calcium non-ionized\n 8.1 mg/dL\n 04:10 AM\n Phosphorus\n 1.3 mg/dL\n 04:10 AM\n Magnesium\n 1.8 mg/dL\n 04:10 AM\n WBC\n 3.9 K/uL\n 04:10 AM\n Hgb\n 7.5 g/dL\n 04:10 AM\n Hematocrit\n 23.2 %\n 04:10 AM\n Current diet order / nutrition support: NPO\n GI: Abd soft/obese; (+) bs\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, respiratory status\n Estimation of previous intake: Excessive\n Estimation of current intake: Inadequate\n Specifics:\n 62 YO female admitted with hypercarbic respiratory failure complicated\n by right lung collapse. Patient s/p rigid brochoscopy and intubation in\n OR () and found to have 5.5 cm tear in posterior tracheal wall.\n Patient continues to be intubated with plan for trach in OR this AM.\n Patient has been NPO X 5 days\n per discussion with MD, plan to place\n NGT after procedure and start nutrition support through tube feeds.\n Agree with plan for nutrition support and recommend tube feeds provide\n 100% of patient\ns estimated nutritional needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations once enteral access obtained: Replete with\n Fiber @ 10 mL/hr, advance by 10 mL/hr q4hr to goal of 70 mL/hr to\n provide 1680 kcal and 104 g protein.\n Monitor hydration and lytes, replete as needed.\n Monitor FSBG.\n Recommend repeat S+S evaluation once medically possible to evaluate\n patient\ns ability to take po\n Will continue to follow.\n Comments:\n"
},
{
"category": "Nutrition",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 670672,
"text": "Subjective\n Patient unable to answer questions at this time.\n Objective\n Food allergies and intolerances: no known food allergies\n Pertinent medications: Fentanyl drip, 40 mEq Potassium Chloride\n repletion, 15 mmol Potassium Phosphate repletion, NS @ 10 mL/hr, ABX,\n Pantoprazole, Glargine 10 units at HS, RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 88 mg/dL\n 04:10 AM\n Glucose Finger Stick\n 135\n 10:00 AM\n BUN\n 13 mg/dL\n 04:10 AM\n Creatinine\n 0.4 mg/dL\n 04:10 AM\n Sodium\n 148 mEq/L\n 04:10 AM\n Potassium\n 3.0 mEq/L\n 04:10 AM\n Chloride\n 103 mEq/L\n 04:10 AM\n TCO2\n 39 mEq/L\n 04:10 AM\n PO2 (arterial)\n 77. mm Hg\n 04:22 AM\n PCO2 (arterial)\n 61 mm Hg\n 04:22 AM\n pH (arterial)\n 7.46 units\n 04:22 AM\n pH (urine)\n 5.5 units\n 09:25 PM\n CO2 (Calc) arterial\n 45 mEq/L\n 04:22 AM\n Calcium non-ionized\n 8.1 mg/dL\n 04:10 AM\n Phosphorus\n 1.3 mg/dL\n 04:10 AM\n Magnesium\n 1.8 mg/dL\n 04:10 AM\n WBC\n 3.9 K/uL\n 04:10 AM\n Hgb\n 7.5 g/dL\n 04:10 AM\n Hematocrit\n 23.2 %\n 04:10 AM\n Current diet order / nutrition support: NPO\n GI: Abd soft/obese; (+) bs\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, respiratory status\n Estimation of previous intake: Excessive\n Estimation of current intake: Inadequate\n Specifics:\n 62 YO female admitted with hypercarbic respiratory failure complicated\n by right lung collapse. Patient s/p rigid brochoscopy and intubation in\n IR () and found to have 5.5 cm tear in posterior tracheal wall.\n Patient continues to be intubated with plan for trach in OR this AM.\n Patient has been NPO X 5 days\n per discussion with MD, plan to place\n NGT after procedure and start nutrition support through tube feeds.\n Agree with plan for nutrition support and recommend tube feeds provide\n 100% of patient\ns estimated nutritional needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations once enteral access obtained: Replete with\n Fiber @ 10 mL/hr, advance by 10 mL/hr q4hr to goal of 70 mL/hr to\n provide 1680 kcal and 104 g protein.\n Monitor hydration and lytes, replete as needed.\n Monitor FSBG.\n Recommend repeat S+S evaluation once medically possible to evaluate\n patient\ns ability to take po\n Will continue to follow.\n Comments:\n"
},
{
"category": "Nutrition",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 670675,
"text": "Subjective\n Patient unable to answer questions at this time.\n Objective\n Food allergies and intolerances: no known food allergies\n Pertinent medications: Fentanyl drip, 40 mEq Potassium Chloride\n repletion, 15 mmol Potassium Phosphate repletion, NS @ 10 mL/hr, ABX,\n Pantoprazole, Glargine 10 units at HS, RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 88 mg/dL\n 04:10 AM\n Glucose Finger Stick\n 135\n 10:00 AM\n BUN\n 13 mg/dL\n 04:10 AM\n Creatinine\n 0.4 mg/dL\n 04:10 AM\n Sodium\n 148 mEq/L\n 04:10 AM\n Potassium\n 3.0 mEq/L\n 04:10 AM\n Chloride\n 103 mEq/L\n 04:10 AM\n TCO2\n 39 mEq/L\n 04:10 AM\n PO2 (arterial)\n 77. mm Hg\n 04:22 AM\n PCO2 (arterial)\n 61 mm Hg\n 04:22 AM\n pH (arterial)\n 7.46 units\n 04:22 AM\n pH (urine)\n 5.5 units\n 09:25 PM\n CO2 (Calc) arterial\n 45 mEq/L\n 04:22 AM\n Calcium non-ionized\n 8.1 mg/dL\n 04:10 AM\n Phosphorus\n 1.3 mg/dL\n 04:10 AM\n Magnesium\n 1.8 mg/dL\n 04:10 AM\n WBC\n 3.9 K/uL\n 04:10 AM\n Hgb\n 7.5 g/dL\n 04:10 AM\n Hematocrit\n 23.2 %\n 04:10 AM\n Current diet order / nutrition support: NPO\n GI: Abd soft/obese; (+) bs; (+) golden liquid stool ()\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, respiratory status\n Estimation of previous intake: Excessive\n Estimation of current intake: Inadequate\n Specifics:\n 62 YO female admitted with hypercarbic respiratory failure complicated\n by right lung collapse. Patient s/p rigid brochoscopy and intubation in\n OR () and found to have 5.5 cm tear in posterior tracheal wall.\n Patient continues to be intubated with plan for trach in OR this AM.\n Patient has been NPO X 5 days\n per discussion with MD, plan to place\n NGT after procedure and start nutrition support through tube feeds.\n Agree with plan for nutrition support and recommend tube feeds provide\n 100% of patient\ns estimated nutritional needs. Noted low Phos and low\n K\n repletions given. RN, propofol will not be restarted after\n procedure.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations once enteral access obtained: Replete with\n Fiber @ 10 mL/hr, advance by 10 mL/hr q4hr to goal of 70 mL/hr to\n provide 1680 kcal and 104 g protein.\n Monitor hydration\n Monitor lytes especially K and Phos; re-check and replete as needed.\n Monitor FSBG.\n Will continue to follow.\n , Dietetic Intern\n"
},
{
"category": "Nutrition",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 670677,
"text": "Subjective\n Patient unable to answer questions at this time.\n Objective\n Food allergies and intolerances: no known food allergies\n Pertinent medications: Fentanyl drip, 40 mEq Potassium Chloride\n repletion, 15 mmol Potassium Phosphate repletion, NS @ 10 mL/hr, ABX,\n Pantoprazole, Glargine 10 units at HS, RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 88 mg/dL\n 04:10 AM\n Glucose Finger Stick\n 135\n 10:00 AM\n BUN\n 13 mg/dL\n 04:10 AM\n Creatinine\n 0.4 mg/dL\n 04:10 AM\n Sodium\n 148 mEq/L\n 04:10 AM\n Potassium\n 3.0 mEq/L\n 04:10 AM\n Chloride\n 103 mEq/L\n 04:10 AM\n TCO2\n 39 mEq/L\n 04:10 AM\n PO2 (arterial)\n 77. mm Hg\n 04:22 AM\n PCO2 (arterial)\n 61 mm Hg\n 04:22 AM\n pH (arterial)\n 7.46 units\n 04:22 AM\n pH (urine)\n 5.5 units\n 09:25 PM\n CO2 (Calc) arterial\n 45 mEq/L\n 04:22 AM\n Calcium non-ionized\n 8.1 mg/dL\n 04:10 AM\n Phosphorus\n 1.3 mg/dL\n 04:10 AM\n Magnesium\n 1.8 mg/dL\n 04:10 AM\n WBC\n 3.9 K/uL\n 04:10 AM\n Hgb\n 7.5 g/dL\n 04:10 AM\n Hematocrit\n 23.2 %\n 04:10 AM\n Current diet order / nutrition support: NPO\n GI: Abd soft/obese; (+) bs; (+) golden liquid stool ()\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, respiratory status\n Estimation of previous intake: Excessive\n Estimation of current intake: Inadequate\n Specifics:\n 62 YO female admitted with hypercarbic respiratory failure complicated\n by right lung collapse. Patient s/p rigid brochoscopy and intubation in\n OR () and found to have 5.5 cm tear in posterior tracheal wall.\n Patient continues to be intubated with plan for trach in OR this AM.\n Patient has been NPO X 5 days\n per discussion with MD, plan to place\n NGT after procedure and start nutrition support through tube feeds.\n Agree with plan for nutrition support and recommend tube feeds provide\n 100% of patient\ns estimated nutritional needs. Noted low Phos and low\n K\n repletions given. RN, propofol will not be restarted after\n procedure.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations once enteral access obtained: Replete with\n Fiber @ 10 mL/hr, advance by 10 mL/hr q4hr to goal of 70 mL/hr to\n provide 1680 kcal and 104 g protein.\n Monitor hydration\n Monitor lytes especially K and Phos; re-check and replete as needed.\n Monitor FSBG.\n Will continue to follow.\n , Dietetic Intern\n ------ Protected Section ------\n Agree with above assessment and plan. Page if questions *\n ------ Protected Section Addendum Entered By: , RD,\n on: 11:47 ------\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670137,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\n .\n She was just discharged yesterday from MICU course for altered\n mental status and hypercarbia. Her altered mental status was likely\n multifactorial to include medications (diazepam, percocet) and\n hypercarbia OSA and sleep hypoventilation. She returned to baseline\n on discharge. Her hypercarbia was thought related to her COPD and\n likely newly diagnosed sleep disordered breathing. She underwent a\n sleep study and was discharged on BiPAP to follow up in sleep clinic\n for a complete sleep study.\n .\n She was found somnolent this morning, was not placed on BiPaP last\n night. Sent to for CO2 115. At placed on BiPap with\n excellent response and transferred to . On the EMS she was taken off\n BIPAP and placed on high flow oxygen. By arrival she was altered with\n saturations in 70s. She was trialed on CPAP with no success and bagged\n to try and take off CO2 with no success and subsequently intubated and\n admitted to MICU. CTH negative.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Extubated . On and off bipap since. Sats 88-96%. Noted to have\n shallow respirations while off bipap. Cough congested but not\n productive. LS rhonchorous.\n Action:\n Furosemide 40mg IV x1, Zyprexa disintegrating tab x1 for comfort w/\n bipap, encouraged C&DB, Chest PT done, AM CXR, 35% cool aerosol face\n mask when off bipap.\n Response:\n CXR with some improvement after chest PT and sxning. LS unchanged.\n Only tolerated Bipap for 1-3hrs @ a time. Responded well to lasix.\n Zyprexa w/ good short term effect.\n Plan:\n Continue chest PT and encourage C&DB. Plan for ECHO and ? speech and\n swallow today.\n Coccyx reddened but intact, barrier cream applied. Mepilex in place to\n small stage two on buttocks. Yeast looking rash in perineal area,\n miconizole applied. Left lower extremety, cellulitic appearance, looks\n to be improving.\n Had LENI\ns of bilat. Lower extrem. Negative.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670605,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n * pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis yesterday. CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside today showing\n webbing likely from traumatic intubation. Pt. sent to OR for rigid\n Bronch, which exhibited 5cm tear of the posterior tracheal wall. The\n patient was intubated under fiberoptics and the ETT was placed past the\n area of the tear as to reduce friction to the tracheal lumen. The ETT\n is NOT TO BE REPOSITIONED, and must be handled with extreme caution as\n it is close to the and could easily slip into the right main\n stem bronchus causing lung collapse.\n Pt was desating yesterday to mid 80\ns post turn,urgent bronch done at\n bedside,large clot was removed ,stable vent settings afterwards.ETT\n pulled and retaped . A picc line has been inserted by IR.Hct dropped to\n 22.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on ac 40%,10peep 16/350,sats high 90\ns,noted rhonchus\n breath sounds . Pt is receiving fent 60 and propofol 30\n Action:\n Pt had undergone bronch yesterday at bedside,suctioned as needed,weaned\n sedation, Pt. has air leak present which is unchanged throughout this\n shift.\n Response:\n Pt. maintains airleak which is planned. Pt. has been suctioned for\n moderate amt\ns of clear to slight pink tinged secretions. ETT maintains\n position at 21cm at the lip. Strict orders NOT TO REPOSITION TUBE\n Pt.\n has been turned with three nurses to maintain tube safety.\n Plan:\n Will cont the current settings,plan for trach placement today (Pt. is a\n add on case)\n HR 55-70,sinus to sinus brady am dose of lopressor held this am for\n (hr 52)..\n K was repleted this am with 40meq kcl,rpt k 3.0.\n FS has been stable,not required any coverage.\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 670745,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Comments: Per IP, permit mild leak.\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thin\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Periods of agitation but no\n indications of respiratory distress.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Comments:\n Pt tp OR today for tracheostomy; #8 Portex with adjustable flange at\n 12.5. PEEP weaned without incident. Will attempt to convert to CSV in\n AM and then to trach collar if appropriate.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670796,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. The ETT is NOT TO BE\n REPOSITIONED, and must be handled with extreme caution as it is close\n to the and could easily slip into the right main stem bronchus\n causing lung collapse. On , pt desatted with turning so emergent\n bedside bronch performed which required removal of large blood clot\n from trachea. ETT was repositioned, and the cuff was left with a leak\n purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out.\n Tracheal Tear\n Assessment:\n Pt noted to have 5cm tracheal tear via rigid bronch in OR . Post\n procedure, pt was intubated using fiberoptics with plan to have\n tracheostomy.\n Action:\n Pt went to OR today for rigid bronch/open tracheostomy.\n Response:\n Pt now with #8 adjustable neck flange portex trach. Has been weaned off\n sedation, but remains on CMV on vent.\n Plan:\n Wean pt from vent to trach mask as tolerated, as absence of ventilation\n will better allow for tracheal tear to heal.\n Hypertension, benign\n Assessment:\n This AM pt with SBPs via art line ranging 120s-150s with elevation at\n times of stimulation/pain. Post OR procedure, pt with SBPs ranging\n 170s-200s.\n Action:\n Pt given boluses propofol for ? HTN pain but with little response\n so 5mg IV lopressor given and 50mcg IV fentanyl.\n Response:\n SBPs down to 150s post lopressor and fentanyl but slowly creeping up\n into 170s-180s so another dose 50mcg fent given for subjective c/o pain\n and SBPs down again into 160s.\n Plan:\n Cont with enalapril for BP control. Give IV lopressor as long as HR>60,\n if not, to ask MD if it should be administered. If pt remains\n bradycardic, may consider administration of IV hydral for extreme HTN.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671027,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. The ETT is NOT TO BE\n REPOSITIONED, and must be handled with extreme caution as it is close\n to the and could easily slip into the right main stem bronchus\n causing lung collapse. On , pt desatted with turning so emergent\n bedside bronch performed which required removal of large blood clot\n from trachea. ETT was repositioned, and the cuff was left with a leak\n purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out.\n Hypertension, benign\n Assessment:\n When patient awake and at rest SBP 160-170. With anxiety SBP up to\n 180-190. HR 60\ns. C/o back pain.\n Action:\n Pt. was given Fentanyl 50mcg x2. Lopressor 10mg IV q6hrs. Held am dose\n x2hrs 2/2 HR <60.\n Response:\n Stated relief from pain medication. SBP down to 140\ns after lopressor\n with HR down to 40\ns and patient sleeping comfortably.\n Plan:\n Plan to insert dobhoff tube vs. NGT. Resume Enalapril dosing. If unable\n to obtain GI access need PRN hydralazine order.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Received patient febrile 100.7. Temperature trending up to 101.2.\n Action:\n Pancultured yesterday. Given 650mg Tylenol suppository. Fluconazole and\n ampicillin given.\n Response:\n Temperature down to 99.2. WBC 3.6.\n Plan:\n Continue with prophylactic antibiotics while intubated s/p tracheal\n tear. F/u on cultures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +5peep. Lung sounds\n rhoncherous with diminished bases.\n Action:\n No vent changes overnight. Suctioned for scant amounts of thick, pale,\n yellow, sputum.\n Response:\n RR 16-19 with sats 93-98%. ABG 7.41/57/88.\n Plan:\n Trial CPAP today with overall goal wean pt from vent to trach mask as\n tolerated, as absence of ventilation will better allow for tracheal\n tear to heal.\n * Awake most of night, short nap after fentanyl dosing.\n Anxious. Difficult to understand when mouthing. MAE. Following\n commands. Appears unaware of surroundings and what is going on.\n * Hct 23.8 down from 25.9. No signs of bleeding.\n * Abdomen obese with + bowel sounds. Small amount of liquid,\n brown stool. Urine output 10-20cc/hr, yellow and clear. MD aware. No\n fluids or diuresis at this time. Creat unchanged @0.4.\n * NPO until GI access obtained. NA 150. Fingersticks q6hrs with\n SSRI. Given half dose of glargine last night.\n * Full code. Husband and daughter in visiting last night.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671133,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. On , pt desatted\n with turning so emergent bedside bronch performed which required\n removal of large blood clot from trachea. ETT was repositioned, and the\n cuff was left with a leak purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out.\n Hypertension, benign\n Assessment:\n SBP 160\n 190\n Action:\n Initially held IV Lopressor d/t HR 50\ns, later BP 190\ns and HR 60\ns so\n gave 10mg IV Lopressor. Later able to give PO Enalapril once GI access\n w/ dobhoff.\n Response:\n HR dropped to low 40\ns @ times while pt sleeping after lopressor IV and\n Fentanyl doses. Held further doses of IV Lopressor. Awaiting BP\n response w/ PO enalapril.\n Plan:\n Pt now w/ NGT and ordered for enalapril PO.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +5peep. Lung sounds\n rhoncherous with diminished bases. Sxn for thick white/yellow\n secretions.\n Action:\n Attempted pt on CPAP 12/5peep, 40%. Monitored ABG\ns w/ vent changes.\n Placed Dobhoff @ bedside.\n Response:\n Worsening ABG w/ CPAP settings so placed back on A/C (see Metavision\n for labs). Dobhoff position confirmed by x-ray and TF started.\n Plan:\n Pt to remain on A/C overnight. ? attempt vent changes again tomorrow.\n Increase TF Q4H w/ goal rate 70cc/hr\n Lytes repleted in AM (K, Mg, Ca), all appropriate w/ afternoon labs.\n 1L D5W @ 100cc/hr for Na 150, repeat in afternoon was 145, so gtt\n turned off @ 1800pm. Pt to receive 100cc FWB Q6H w/ tube feeds.\n Recheck lytes w/ AM labs.\n Fentanyl for lower back pain w/ good effect.\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 671185,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: \n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n :\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High pressure)\n Comments: only torwards the end of shift did she frequently alarm\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 671294,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.-\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. On , pt desatted\n with turning so emergent bedside bronch performed which required\n removal of large blood clot from trachea. ETT was repositioned, and the\n cuff was left with a leak purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out. Pt will need this in place for approx 8\n weeks\n Hypertension, benign\n Assessment:\n SBP conts to be high 160\n 180\n Action:\n Dc\nd A-line, Hydralazine standing doses given, enalapril increased to\n 20mg daily, Dc\nd Lopressor IV, Furosemide 40mg IV x1.\n Response:\n SBP remains 180\ns-160\ns at this time, awaiting response from evening PO\n enalapril dose. Responding well to IV lasix.\n Plan:\n Monitor BP, cont standing IV hydral, diuresing w/ goal -500cc to -1L\n for 24Hrs. Repeat Lytes @ 2000pm.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented via trach. Received on A/C 350x16 40% +5peep. Lung sounds\n rhoncherous .Sxn for thick white/yellow secretions.\n Action:\n Attempted to wean to Psup 12/5peep, frequent sxn for sm amts thin white\n secretions that do cause desat to mid 80\ns and induce pt to cough\n vigorously.\n Response:\n Pt states no difficulty breathing on Psup settings. VBG ???\n Plan:\n Cont to attempt to wean vent as tolerated. Monitor VBG and/or pt\n mental status to assess tolerance of vent weaning. Cont to sxn as\n needed.\n Today c/o bladder pain/discomfort, started Phenazopyridine and sent\n urine for cx. Also later c/o abd discomfort and nausea; stopped TF\n and gave zofran IV. Also c/o back pain/discomfort but team wants to\n avoid fentanyl to see if mental status/confusion improves, so gave\n 650mg PO Tylenol.\n ? screen for rehab tomorrow. Should be able to go to an Acute\n respiratory rehab tomorrow or the day after.\n"
},
{
"category": "Rehab Services",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Deferred Swallow Evaluation",
"row_id": 670247,
"text": "TITLE: DEFERRED BEDSIDE SWALLOW EVALUATION\n Thank you for referring this 62 yo F readmitted on after recent\n admission for subarachnoid hemorrhage /-. Readmitted with acute\n mental status change on chronic hypercarbic respiratory failure. Pt\n was extubated on . A few hours following extubation, pt was\n offered thin liquid, noted to have coughing and desaturation, made NPO\n and we were consulted to evaluate oral and pharyngeal swallow\n function. We were, however, not available over the weekend during\n which time pt\ns hospital course has been further complicated. Chest CT\n revealed probable pulmonary hypertension, RLL collapse and\n heterogeneous opacification in RUL and lingula suggestive of\n aspiration, tracheomalacia including upper tracheal mass or organized\n secretions or aspirated material, and probably pulmonary arterial\n hypertension. Continues to have altered mental status with repeat head\n CT pending.\n PMH includes:\n Afib\n TIA\n memory loss s/p hypoglycemic coma\n chronic low back pain\n anemia\n GERD\n asthma\n DEFERRED EVALUATION\n Pt just underwent bronchoscopy and is NPO for OR later today. She will\n be intubated in OR and likely ( MD) to be intubated for >24 hours.\n Inappropriate for PO evaluation at this time. Please reconsult when pt\n is extubated and stable for >24 hours. Pt should be able to tolerate\n periods on shovel mask or nasal cannula to promote PO intake. She\n should also be awake/alert for periods of at least 15-30 minutes at a\n time for PO intake. Pending bedside swallow evaluation, MD team\n encouraged to pursue alternative means of nutrition/hydration and\n medication (e.g., OGT/NGT vs. Dobbhoff vs. TPN). Q4 oral care while\n NPO.\n Whitmill, MS, CCC-SLP\n Pager #\n Total Time: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670253,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n * pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis this AM. CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside today showing\n webbing likely from traumatic intubation. IP, however, feel pt needs to\n have rigid bronch in OR for better visualization of tracheal webbing/?\n mass.\n Hypertension, benign\n Assessment:\n Pt received on nitro gtt @ 1mcg/kg/min with SBPs via cuff ranging\n 180s-190s.\n Action:\n Nitro gtt titrated up to maintain SBP 160-180. Pt continued on 5mg IV\n lopressor. A-line placed by team showing ABPs in 200s systolic which\n required titration of nitro gtt up to 3mcg/kg/min at one point.\n Response:\n Able to wean nitro down as low as\n Plan:\n Cont nitro gtt until BPs maintained 160-180 systolic\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670258,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n * pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis this AM. CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside today showing\n webbing likely from traumatic intubation. IP, however, feel pt needs to\n have rigid bronch in OR for better visualization of tracheal webbing/?\n mass.\n Hypertension, benign\n Assessment:\n Pt received on nitro gtt @ 1mcg/kg/min with SBPs via cuff ranging\n 180s-190s.\n Action:\n Nitro gtt titrated up to maintain SBP 160-180. Pt continued on 5mg IV\n lopressor. A-line placed by team showing ABPs in 200s systolic which\n required titration of nitro gtt up to 3mcg/kg/min at one point.\n Response:\n Able to wean nitro down as low as 0.7 mcg/kg/min with systolics\n 160-180.\n Plan:\n Cont nitro gtt until BPs maintained 160-180 systolic. Cont with IV\n lopressor until pt able to receive POs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on aerosol face mask @ 35% FiO2 with sats 88-92% and RR\n 20s-30s. Pt mal-appearing this AM, diaphoretic/hypertensive/Tachypneic.\n Action:\n Pt taken for CTA to r/o PE.\n Response:\n CTA showing\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670599,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n * pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis yesterday. CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside today showing\n webbing likely from traumatic intubation. Pt. sent to OR for rigid\n Bronch, which exhibited 5cm tear of the posterior tracheal wall. The\n patient was intubated under fiberoptics and the ETT was placed past the\n area of the tear as to reduce friction to the tracheal lumen. The ETT\n is NOT TO BE REPOSITIONED, and must be handled with extreme caution as\n it is close to the and could easily slip into the right main\n stem bronchus causing lung collapse.\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 670795,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems: Positional leak around cuff\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI done on 0 peep/ 5 ips 109. Will cont to monitor resp\n status\n Reason for continuing current ventilatory support: Cannot protect\n airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 671401,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: \n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Comments: patient has air filled bivonna trach cuff which which is\n positional to leaks.\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670475,
"text": "Events:pt was desating to mid 80\ns this am post turn,urgent bronch done\n at bedside,large clot was removed ,stable vent settings afterwards.ETT\n pulled and retaped,A picc line has been inserted by IR.hct dropped to\n 22(from 28)\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on ac 40%,10peep 16/350,sats high 90\ns,noted diminished\n breath sounds on the left side. Received on fent 60 and propofol 30\n Action:\n Pt had undergone bronch at bedside,suctioned as needed,able to wean\n sedation a bit\n Response:\n Pt desatted to mid 80\ns post turn this am,didn\nt improve with\n suctioning,PIP were in 30\ns with diminished breath sounds on the left\n side,blood clot removed via the bronch,no episodes of desatting\n afterwards.\n Plan:\n Pending results of OR procedure.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670737,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. The ETT is NOT TO BE\n REPOSITIONED, and must be handled with extreme caution as it is close\n to the and could easily slip into the right main stem bronchus\n causing lung collapse. On , pt desatted with turning so emergent\n bedside bronch performed which required removal of large blood clot\n from trachea. ETT was repositioned, and the cuff was left with a leak\n purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm flexible trach was placed.\n Tracheal Tear\n Assessment:\n Pt noted to have 5cm tracheal tear via rigid bronch in OR . Post\n procedure, pt was intubated using fiberoptics with plan to have\n tracheostomy.\n Action:\n Pt went to OR today for rigid bronch/open tracheostomy.\n Response:\n Pt now with #8 flexible trach. Has been weaned off sedation, but\n remains on CMV on vent.\n Plan:\n Wean pt from vent to trach mask as tolerated, as absence of ventilation\n will better allow for tracheal tear to heal.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670739,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure.\n Pt had CTA chest to r/o PE and CT head for\n mal-appearance/HTN/diaphoresis AM of . CTA chest showing mass in\n posterior region of trachea so s/p bronch at bedside showing webbing\n likely from traumatic intubation. Pt then sent to OR for rigid bronch\n which revealed 5cm tear of the posterior tracheal wall. The patient was\n intubated under fiberoptics and the ETT was placed past the area of the\n tear as to reduce friction to the tracheal lumen. The ETT is NOT TO BE\n REPOSITIONED, and must be handled with extreme caution as it is close\n to the and could easily slip into the right main stem bronchus\n causing lung collapse. On , pt desatted with turning so emergent\n bedside bronch performed which required removal of large blood clot\n from trachea. ETT was repositioned, and the cuff was left with a leak\n purposefully.\n On , the patient was taken to the OR for rigid bronch and open\n trach. A #8mm adjustable neck flange portex trach was placed with the\n trach at apporx 12.5cm out.\n Tracheal Tear\n Assessment:\n Pt noted to have 5cm tracheal tear via rigid bronch in OR . Post\n procedure, pt was intubated using fiberoptics with plan to have\n tracheostomy.\n Action:\n Pt went to OR today for rigid bronch/open tracheostomy.\n Response:\n Pt now with #8 adjustable neck flange portex trach. Has been weaned off\n sedation, but remains on CMV on vent.\n Plan:\n Wean pt from vent to trach mask as tolerated, as absence of ventilation\n will better allow for tracheal tear to heal.\n Hypertension, benign\n Assessment:\n This AM pt with SBPs via art line ranging 120s-150s with elevation at\n times of stimulation/pain. Post OR procedure, pt with SBPs ranging\n 170s-200s.\n Action:\n Pt given boluses propofol for ? HTN pain but with little response\n so 5mg IV lopressor given and 50mcg IV fentanyl.\n Response:\n SBPs down to 150s post lopressor and fentanyl but slowly creeping up\n into 170s-180s so another dose 50mcg fent given for subjective c/o pain\n and SBPs down again into 160s.\n Plan:\n Cont with enalapril for BP control. Give IV lopressor as long as HR>60,\n if not, to ask MD if it should be administered. If pt remains\n bradycardic, may consider administration of IV hydral for extreme HTN.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670906,
"text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101.3 in this shift,increased secretions noted from the\n trach,liquid stool via the flexiseal.\n Action:\n Pan cultuered,\n Response:\n T current 100.8\n Plan:\n Follow fever curve,follow up on the cx data\n Tracheal Tear\n Assessment:\n Pt noted to have 5cm tracheal tear via rigid bronch in OR . Post\n procedure, pt was intubated using fiberoptics ,Trach in place,recevd\n the pt on capap 15/5\n Action:\n Suctioned as needed,contd prophylactic abx,weaned down to 12/5\n Response:\n Pt now with #8 adjustable neck flange portex trach (at 12.5 marked),pt\n deos have period of apnea with low minute volume.\n Plan:\n Plan to wean vent as tolerated ,follow abg,\n Hypertension, benign\n Assessment:\n Sbp 150-200,dbp 40-50,hr 60\ns ,was anxoious and restless at times\n Action:\n Pt. was given Fentanyl 50mcg x1 for pain ,was OOB to chair for few\n hours.\n Response:\n Sbp very labile,in sleep sbp in 150\ns but even a slight stimulation\n raises the blood pressure.\n Plan:\n Plan to insert dobhuff tube. Resume Enalapril dosing. .\n"
},
{
"category": "Echo",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Report",
"row_id": 101885,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Hypoxemia.\nWeight (lb): 290\nBP (mm Hg): 170/50\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 11:53\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Minimally increased\ngradient c/w minimal AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened. There is a minimally increased gradient\nconsistent with minimal aortic valve stenosis. No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. No mitral regurgitation\nis seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-03-13 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1075704,
"text": " 7:07 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pls eval interval change\n Admitting Diagnosis: ASTHMA/COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with tracheal tear s/p trach now with sudden desat\n REASON FOR THIS EXAMINATION:\n pls eval interval change\n ______________________________________________________________________________\n WET READ: JXKc TUE 8:43 PM\n Interval improvement in aeration of the lung bases bilaterally, with mild\n residual bibasilar opacities, may reflect atelectasis. There is persistent\n elevation of the right hemidiaphragm. Vague opacity is seen in the right mid\n lung, may reflect atelectasis; though, developing consolidation can't be\n excluded. NG tube partially coiled in stomch, unchanged. -jkang.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY OF WITH COMPARISON STUDY OF EARLIER THE\n SAME DATE\n\n INDICATION: Oxygen desaturation.\n\n FINDINGS: Indwelling devices are unchanged in position. Cardiac silhouette\n is mildly enlarged, and there is improvement in degree of perihilar edema with\n minimal interstitial edema remaining. Marked improved aeration at the lung\n bases, particularly on the left. Ill-defined round opacity in right midlung\n is apparently new, and could be due to focal atelectasis, aspiration, or\n developing infectious pneumonia. Persistent elevation of right hemidiaphragm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-03-07 00:00:00.000",
"description": "FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE",
"row_id": 1074600,
"text": " 1:15 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: l dl picc, coiled @ brachealcephalic vein. need ir to reposi\n Admitting Diagnosis: ASTHMA/COPD EXACERBATION\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with picc\n REASON FOR THIS EXAMINATION:\n l dl picc, coiled @ brachealcephalic vein. need ir to repositon.\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE EXCHANGE / REPOSITIONING\n\n INDICATION: Malposition of indwelling PICC line.\n\n A timeout was performed documenting patient identity.\n\n RADIOLOGIST: Dr. performed the procedure, Dr. attending\n radiologist supervised.\n\n TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was\n advanced through the indwelling left arm PICC line, and subsequently into the\n SVC under fluoroscopic guidance. The old PICC line was then removed and a\n peel-away sheath was then placed over the guidewire. A new double lumen PICC\n line measuring 46 cm in length was then placed through the peel- away sheath\n with its tip positioned in the SVC under fluoroscopic guidance. Position of\n the catheter was confirmed by a fluoroscopic spot film of the chest.\n The peel-away sheath and guidewire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied.\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new\n double lumen PICC line. Final internal length is 46 cm, with the tip\n positioned in the SVC. The line is ready to use.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-03-07 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1074571,
"text": " 10:33 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: worsening infiltrate (blood in lungs?)\n Admitting Diagnosis: ASTHMA/COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with tracheal tear, sm blood on suctioning, 5 pt HCT drop.\n REASON FOR THIS EXAMINATION:\n worsening infiltrate (blood in lungs?)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old female tracheal tear and small amount of blood on\n suctioning with 5-point hematocrit drop. Evaluate infiltrate.\n\n COMPARISON: Portable radiograph from earlier the same day.\n\n FINDINGS: The distal tip of the endotracheal tube is approximately 4 cm from\n the carina. There is a newly placed central venous line from the left upper\n extremity approach. The course of the catheter is notable for kinking in the\n left brachiocephalic vein and termination within the left brachiocephalic\n vein. No complications or pneumothorax are identified.\n\n Probable retrocardiac atelectasis is unchanged from prior. Atelectasis is\n also noted at the right lung base. Obliteration of the left costophrenic\n sinus is consistent with pleural effusion. There is no right sided pleural\n effusion.\n\n Findings were discussed with the IV team at the time of interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-03-05 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1074214,
"text": " 4:57 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: re-eval new right lung white out\n Admitting Diagnosis: ASTHMA/COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with hypercarbic respiratory failure\n REASON FOR THIS EXAMINATION:\n re-eval new right lung white out\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hypercarbic respiratory failure. Reevaluation.\n\n COMPARISON: , 4:23 a.m.\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. Unchanged reduction in volume of the right hemithorax with upper lobe\n homogeneous consolidation. Unchanged normal morphologic situation in the left\n lung.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-03-06 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1074495,
"text": " 8:56 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: OGT placement.\n Admitting Diagnosis: ASTHMA/COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old intubated female.\n REASON FOR THIS EXAMINATION:\n OGT placement.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of a patient intubated with placement of\n the orogastric tube.\n\n Portable AP chest radiograph was compared to prior study obtained the same day\n earlier at 4:37 a.m.\n\n The ET tube tip is too low on the current study being at the origin of the\n right main bronchus and should be repositioned. Minimal amount of mediastinal\n air is demonstrated to the right of the trachea. The NG tube tip is in the\n stomach. Compared to the prior study, there is interval deterioration of the\n lung base appearance with new right basal opacity as well as worsening of the\n left retrocardiac opacity consistent with interval development of\n atelectasis/aspiration accompanied by pleural effusion. Note is made that the\n left costophrenic angle was not included in the field of view. No\n pneumothorax is demonstrated within the limitations of the current study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-03-09 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1074958,
"text": " 11:20 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for change\n Admitting Diagnosis: ASTHMA/COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n eval for change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:37 A.M. ON \n\n HISTORY: Hypoxia, evaluate for change.\n\n IMPRESSION: AP chest compared to and , 3:46 a.m.\n\n New opacification in right lung base and rightward mediastinal shift indicate\n new right lower lobe collapse. Milder atelectasis at the left base is stable.\n There may also have been increase in overall heart size, particularly the\n right atrium, given rise to questions about elevated right heart pressure.\n Tracheostomy tube unchanged in standard placement. Left PIC line ends in the\n left brachiocephalic vein.\n\n Dr. was paged, covered by Dr. to report these findings at the\n time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-03-05 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1074243,
"text": " 10:46 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for interval change\n Admitting Diagnosis: ASTHMA/COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with COPD, OSA, and mucous plugging and right lung collapse\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Collapse, to evaluate for change.\n\n FINDINGS: In comparison with the earlier study, there has been substantial\n re-expansion of the right lung, presumably from expectoration of a mucus plug.\n The trachea appears much more midline than on the previous study.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2103-03-11 00:00:00.000",
"description": "Report",
"row_id": 290725,
"text": "Atrial fibrillation with rapid ventricular response.\nLead(s) unsuitable for analysis: V6\nNonspecific ST-T changes\nSince previous tracing of , rapid atrial fibrillation, and further ST-T\nwave changes are present\n\n"
},
{
"category": "ECG",
"chartdate": "2103-03-06 00:00:00.000",
"description": "Report",
"row_id": 290726,
"text": "Baseline artifact. Sinus rhythm. Minor ST-T wave abnormalities. Since the\nprevious tracing the heart rate has decreased.\n\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 669956,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on bipap most of the night, started to be coughing at early am\n having small-moderate amount of secretions, rhonchorous. Denies chest\n pain during cough but foley leaks whenever she coughs. Sats > 88%;\n oriented x1, following commands but non-sensical intermittently\n Action:\n Off bipap at 0300, face tent 40% - ABG done; diuresed with Lasix 40\n mg\n put out 320 cc after Lasix IV, continues on acetazolamide q8hrs\n Response:\n Sats 91-92% on 40% FiO2 face tent; 7.29/105/65\n Plan:\n Coughing exercise; bipap whenever she sleeps; continue diuretics\n Patient\ns daughter visited last night, updates given\n New PIV placed LFA g20\n Hct stable at 27.8\n Hypertensive to the 180\ns when awake but 130\ns when sleeping. SB down\n low 40\n lopressor held. need hydralaszine for hypertension.\n Foley changed to Fr20\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 669860,
"text": "Chief Complaint: Acute on chronic hypercarbic respiratory failure\n HPI: 62 year-old woman with AF, TIA, DM (hypoglycemic coma) recent\n intra-cranial hemorrhage admitted about 2 weeks ago with mental status\n changes felt due to hypercarbia. Felt due to OSA/OHS, and underwent\n sleep study with preliminary settings of 20/8. After discharge not\n given BIPAP, then somnulent in the morning. Sent to Hospital\n with pCO2 and did well with BiPAP. Transferred to , but in\n transent did not continue with BIPAP. On arrival pH 7.25/152/70.\n Overnight apneic due to alkalosis. Maintained on AC (apneic on PS).\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:15 PM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:47 AM\n Other medications: RISS, Xalatan, glipizide, rosiglitazone, acebutalol,\n Keppra, simvastatin, PPI, fluticasone, Peridex\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38.2\nC (100.7\n HR: 73 (62 - 79) bpm\n BP: 160/51(79) {128/41(62) - 160/105(114)} mmHg\n RR: 22 (10 - 24) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134 kg\n Total In:\n 3,035 mL\n 80 mL\n PO:\n TF:\n IVF:\n 35 mL\n 80 mL\n Blood products:\n Total out:\n 200 mL\n 340 mL\n Urine:\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,835 mL\n -260 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 400) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 14\n PEEP: 10 cmH2O\n FiO2: 30%\n RSBI: 101\n PIP: 28 cmH2O\n Plateau: 30 cmH2O\n Compliance: 14 cmH2O/mL\n SpO2: 92%\n ABG: 7.37/85./59/44/18\n Ve: 6.5 L/min\n PaO2 / FiO2: 197\n Physical Examination\n Obese, intubated. Responds somewhat to voice and sternal rub but not\n following commands.\n RRR, S1s2 ?right sided S3. No murmur.\n Lungs clear anteriorly\n Decreased bowels sounds\n 1+ edema. Left leg with erythema, marked boundaries. Both sides warm.\n Labs / Radiology\n 8.3 g/dL\n 196 K/uL\n 140 mg/dL\n 0.5 mg/dL\n 44 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 101 mEq/L\n 148 mEq/L\n 26.1 %\n 6.5 K/uL\n [image002.jpg] Last ABG: 7.37/85/59\n 09:01 PM\n 11:48 PM\n 05:22 AM\n WBC\n 6.5\n Hct\n 26.1\n Plt\n 196\n Cr\n 0.5\n TCO2\n 49\n 51\n Glucose\n 140\n Other labs: PT / PTT / INR:14.1/24.9/1.2, Differential-Neuts:78.9 %,\n Lymph:13.9 %, Mono:5.8 %, Eos:1.4 %, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL,\n PO4:2.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE ON CHRONIC\n -Acute on chronic hypercarbic respiratory failure\n -Decomp at rehab after didn\nt put on bipap overnight\n -Assess for extubation.\n -Diuresis with lasix and acetazolamide\n -Hold narcotics/sedatives.\n DIABETES MELLITUS (DM), TYPE II: consider d/c\ning oral hypoglycemics.\nHypertension:\n -Follow with diuresis\n -continue beta-blockade.\nLeft leg erythema:\n -Potential infection vs. DVT.\n -Follow-up ultrasound.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:34 PM, a second PIV\n Prophylaxis:\n DVT: heparin\n Stress ulcer: PPI\n VAP: Bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 669875,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\n .\n She was just discharged yesterday from MICU course for altered\n mental status and hypercarbia. Her altered mental status was likely\n multifactorial to include medications (diazepam, percocet) and\n hypercarbia OSA and sleep hypoventilation. She returned to baseline\n on discharge. Her hypercarbia was thought related to her COPD and\n likely newly diagnosed sleep disordered breathing. She underwent a\n sleep study and was discharged on BiPAP to follow up in sleep clinic\n for a complete sleep study.\n .\n She was found somnolent this morning, was not placed on BiPaP last\n night. Sent to for CO2 115. At placed on BiPap with\n excellent response and transferred to . On the EMS she was taken off\n BIPAP and placed on high flow oxygen. By arrival she was altered with\n saturations in 70s. She was trialed on CPAP with no success and bagged\n to try and take off CO2 with no success and subsequently intubated and\n admitted to MICU. CTH negative.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received intubated, awake and following commands, bilateral wrist\n immobilizer in place. Patient intermittently restless and anxious,\n wanted to take tube out and have drink of juice/water, initial ABG upon\n arrival at MICU 7.54/55/48; lung sounds clear, dim at bases, suctioned\n small amount of whitish yellow secretions; slightly febrile 100.9\n Action:\n Vent settings changed from 30% 400x24 peep 5 to 350 x 10 since patient\n was very alkalotic\n Response:\n Recent ABG 7.38/85/59 FiO2 increased to 40% insetting of desaturation\n low 80\n responded well > 90; slept intermittently\n placed on PS\n this am at around 0530\n O2 sats ranges 89-92% will continue to\n monitor\n Plan:\n ? extubation; recheck ABG\n NSR with occasional ectopy, history of afib\n not on coumadin in\n setting of recent intracranial bleed; BP stable 130-150\ns; weakly\n palpable pedal pulses. + edema of lower extremities\n Bowel sounds present, no bowel movement. OGT in place, patent but will\n need to confirm with early am CXR\n On glipizide and RISS, coverage given for FS 180 at MN\n Foley in place, yellow urine with sediments\n Coccyx reddened but intact, barrier cream applied. Turn q2hrs\n R buttocks with stage 2 abrasion ? Pressure ulcer\n meriplex foam\n dressing placed. No drainage noted. LLE ? cellulitis, reddened and warm\n to touch. Marked, for LENI\ns today\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 669878,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\n .\n She was just discharged yesterday from MICU course for altered\n mental status and hypercarbia. Her altered mental status was likely\n multifactorial to include medications (diazepam, percocet) and\n hypercarbia OSA and sleep hypoventilation. She returned to baseline\n on discharge. Her hypercarbia was thought related to her COPD and\n likely newly diagnosed sleep disordered breathing. She underwent a\n sleep study and was discharged on BiPAP to follow up in sleep clinic\n for a complete sleep study.\n .\n She was found somnolent this morning, was not placed on BiPaP last\n night. Sent to for CO2 115. At placed on BiPap with\n excellent response and transferred to . On the EMS she was taken off\n BIPAP and placed on high flow oxygen. By arrival she was altered with\n saturations in 70s. She was trialed on CPAP with no success and bagged\n to try and take off CO2 with no success and subsequently intubated and\n admitted to MICU. CTH negative.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received intubated, awake and following commands, bilateral wrist\n immobilizer in place. Sats 90-92% on PS . LS rhonchorus,\n diminished at bases. Sxned infrequently for small, thick secretions.\n Action:\n Pt extubated. Placed on 40% humidified face tent. Encouraged coughing\n and deep breathing.\n Response:\n Well tolerated for first couple of hours. Tried sips of H2O and\n paitent noted to cough/choke, and desat to low 80\ns. Also, raspy,\n congested voice noted after this.\n Plan:\n Cont. to monitor sats. Encourage coughing and deep breathing. Monitor\n O2 need. Likely plan for speech and swallow if further attempts at\n thickened liquids, when appropriate do not do well. Plan for ECHO.\n One self-limiting, short lived episode of Afib to 140-150\n One med. Soft, loose, stool.\n On glipizide and RISS, coverage given for FS 180 at MN\n Foley in place, yellow urine with sediment. Given 20mg iv Lasix, plan\n to give Dilurel when able to tolerated PO\n Coccyx reddened but intact, barrier cream applied. Mepilex in place to\n small, pink stage two on buttocks.\n Had LENI\ns of bilat. Lower extrem. Negative.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 669951,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on bipap most of the night, started to be coughing at early am\n having small-moderate amount of secretions, rhonchorous. Denies chest\n pain during cough but foley leaks whenever she coughs. Sats > 88%;\n oriented x1, following commands but non-sensical intermittently\n Action:\n Off bipap at 0300, face tent 40% - ABG done; diuresed with Lasix 40\n mg\n put out 320 cc after Lasix IV, continues on acetazolamide q8hrs\n Response:\n Sats 91-92% on 40% FiO2 face tent; 7.29/105/65\n Plan:\n Coughing exercise; bipap whenever she sleeps; continue diuretics\n Patient\ns daughter visited last night, updates given\n New PIV placed LFA g20\n Hct stable at 27.8\n Hypertensive to the 180\ns when awake but 130\ns when sleeping. SB down\n low 40\n lopressor held. need hydralaszine for hypertension.\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-05 00:00:00.000",
"description": "ICU Fellow Progress Note - MICU",
"row_id": 670061,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 62 y/o F w/OSA/OHS, adm with hypercarbic respiratory failure.\n 24 Hour Events:\n Extubated yesterday morning.\n Yesterday had some water and seemed to aspirate, desaturated after that\n but improved.\n Erythema on left leg, LENI negative.\n This morning, had ABG that was 7.27/114/62 (off bipap x30 minutes). CXR\n with R sided collapse. Back on bipap ABG 7.27/111/67 (on bipap x45\n minutes). NT suctioned with removal of significant secretions.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:40 PM\n Heparin Sodium (Prophylaxis) - 07:48 AM\n Other medications:\n insulin sliding scale and fixed dose, simvastatin, protonix,\n fluticasone, SQ heparin, peridex, metoprolol, keppra, diamox\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.7\n HR: 59 (54 - 125) bpm\n BP: 133/43(65) {127/39(61) - 183/115(122)} mmHg\n RR: 28 (6 - 32) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134 kg\n Total In:\n 2,114 mL\n 1,151 mL\n PO:\n TF:\n IVF:\n 2,114 mL\n 1,151 mL\n Blood products:\n Total out:\n 1,180 mL\n 595 mL\n Urine:\n 1,180 mL\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n 934 mL\n 556 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 260 (204 - 260) mL\n PC : 10 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 0 cmH2O\n SpO2: 93%\n ABG: 7.27/111/67/42/18\n Ve: 6 L/min\n PaO2 / FiO2: 191\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, bipap mask on\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bilateral bases R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+, erythema RLE improved based on\n marking from yesterday\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Not assessed\n Labs / Radiology\n 8.3 g/dL\n 201 K/uL\n 172 mg/dL\n 0.6 mg/dL\n 42\n 5.2\n 14\n 95\n 142 mEq/L\n 27.6 %\n 8.2 K/uL\n [image002.jpg]\n 09:01 PM\n 11:48 PM\n 05:22 AM\n 04:20 PM\n 03:27 AM\n 03:31 AM\n 05:18 AM\n 07:47 AM\n WBC\n 6.5\n 8.2\n Hct\n 26.1\n 27.6\n Plt\n 196\n 201\n Cr\n 0.5\n 0.6\n 0.6\n TCO2\n 49\n 51\n 53\n 55\n 53\n Glucose\n 140\n 158\n 172\n 189\n Other labs: PT / PTT / INR:14.1/24.9/1.2, Differential-Neuts:78.9 %,\n Lymph:13.9 %, Mono:5.8 %, Eos:1.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.2\n mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Imaging: CXR with R sided collapse and tracheal deviation\n Assessment and Plan\n 63 y/o F w/altered mental status secondary to hypoglycemic coma many\n years ago, adm with acute on chronic hypercarbic respiratory failure\n now complicated by R sided lung collapse. Still hypoxic and\n hypercarbic likely due to collapse. Will continue NT suctioning and\n repeat CXR but will likely need intubation/bronchoscopy. Will continue\n gentle diuresis.\n In terms of possible aspiration event, will place NGT today.\n Speech/swallow eval.\n RLE erythema is improving. No evidence of clot. Will continue to\n follow.\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 08:20 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n ------ Protected Section ------\n Extubated yesterday AM. On BiPAP last PM\n hypoxemic this AM\n CXR\n showed atelectasis\n had PT with improvement in oxygenation and repeat\n film showed substantial improvement.\n Continuing Chest Physical Therapy and increasing activity level.\n Does not currently seem like bronchoscopy will be necessary.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:32 ------\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-05 00:00:00.000",
"description": "ICU Fellow Progress Note - MICU",
"row_id": 670063,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 62 y/o F w/OSA/OHS, adm with hypercarbic respiratory failure.\n 24 Hour Events:\n Extubated yesterday morning.\n Yesterday had some water and seemed to aspirate, desaturated after that\n but improved.\n Erythema on left leg, LENI negative.\n This morning, had ABG that was 7.27/114/62 (off bipap x30 minutes). CXR\n with R sided collapse. Back on bipap ABG 7.27/111/67 (on bipap x45\n minutes). NT suctioned with removal of significant secretions.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:40 PM\n Heparin Sodium (Prophylaxis) - 07:48 AM\n Other medications:\n insulin sliding scale and fixed dose, simvastatin, protonix,\n fluticasone, SQ heparin, peridex, metoprolol, keppra, diamox\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.7\n HR: 59 (54 - 125) bpm\n BP: 133/43(65) {127/39(61) - 183/115(122)} mmHg\n RR: 28 (6 - 32) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134 kg\n Total In:\n 2,114 mL\n 1,151 mL\n PO:\n TF:\n IVF:\n 2,114 mL\n 1,151 mL\n Blood products:\n Total out:\n 1,180 mL\n 595 mL\n Urine:\n 1,180 mL\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n 934 mL\n 556 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 260 (204 - 260) mL\n PC : 10 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 0 cmH2O\n SpO2: 93%\n ABG: 7.27/111/67/42/18\n Ve: 6 L/min\n PaO2 / FiO2: 191\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, bipap mask on\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bilateral bases R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+, erythema RLE improved based on\n marking from yesterday\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Not assessed\n Labs / Radiology\n 8.3 g/dL\n 201 K/uL\n 172 mg/dL\n 0.6 mg/dL\n 42\n 5.2\n 14\n 95\n 142 mEq/L\n 27.6 %\n 8.2 K/uL\n [image002.jpg]\n 09:01 PM\n 11:48 PM\n 05:22 AM\n 04:20 PM\n 03:27 AM\n 03:31 AM\n 05:18 AM\n 07:47 AM\n WBC\n 6.5\n 8.2\n Hct\n 26.1\n 27.6\n Plt\n 196\n 201\n Cr\n 0.5\n 0.6\n 0.6\n TCO2\n 49\n 51\n 53\n 55\n 53\n Glucose\n 140\n 158\n 172\n 189\n Other labs: PT / PTT / INR:14.1/24.9/1.2, Differential-Neuts:78.9 %,\n Lymph:13.9 %, Mono:5.8 %, Eos:1.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.2\n mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Imaging: CXR with R sided collapse and tracheal deviation\n Assessment and Plan\n 63 y/o F w/altered mental status secondary to hypoglycemic coma many\n years ago, adm with acute on chronic hypercarbic respiratory failure\n now complicated by R sided lung collapse. Still hypoxic and\n hypercarbic likely due to collapse. Will continue NT suctioning and\n repeat CXR but will likely need intubation/bronchoscopy. Will continue\n gentle diuresis.\n In terms of possible aspiration event, will place NGT today.\n Speech/swallow eval.\n RLE erythema is improving. No evidence of clot. Will continue to\n follow.\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 08:20 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n ------ Protected Section ------\n Extubated yesterday AM. On BiPAP last PM\n hypoxemic this AM\n CXR\n showed atelectasis\n had PT with improvement in oxygenation and repeat\n film showed substantial improvement.\n Continuing Chest Physical Therapy and increasing activity level.\n Does not currently seem like bronchoscopy will be necessary.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:32 ------\n Patient seen and evaluated with fellow. Remainder of plan as detailed\n above by Dr. \n ------ Protected Section Addendum Entered By: , MD\n on: 13:40 ------\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 670044,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:16 AM\n Extubated in the morning\n Concern for possible aspiration after extubation, kept NPO during the\n day\n Changed medications to IV and d/c'd oral diabetes medications while NPO\n -ordered for speech and swallow for tuesday\n -Left lower extremity ultrasound -> no DVT, erythema of left leg\n improved with elevation\n -Echocardiogram was not done\n -given lasix 20mg IV with little urine output -> given lasix 40mg IV x2\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:40 PM\n Heparin Sodium (Prophylaxis) - 12:42 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.2\nC (98.9\n HR: 61 (54 - 125) bpm\n BP: 157/43(69) {127/39(61) - 180/115(122)} mmHg\n RR: 23 (6 - 32) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134 kg\n Total In:\n 2,090 mL\n 650 mL\n PO:\n TF:\n IVF:\n 2,090 mL\n 650 mL\n Blood products:\n Total out:\n 1,180 mL\n 495 mL\n Urine:\n 1,180 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 910 mL\n 155 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Spontaneous): 204 (204 - 304) mL\n PS : 10 cmH2O\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 0 cmH2O\n SpO2: 91%\n ABG: 7.27/114/62/42/19\n Ve: 5.2 L/min\n PaO2 / FiO2: 207\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 201 K/uL\n 8.3 g/dL\n 172 mg/dL\n 0.6 mg/dL\n 42 mEq/L\n 5.2 mEq/L\n 14 mg/dL\n 95 mEq/L\n 142 mEq/L\n 27.6 %\n 8.2 K/uL\n [image002.jpg]\n 09:01 PM\n 11:48 PM\n 05:22 AM\n 04:20 PM\n 03:27 AM\n 03:31 AM\n 05:18 AM\n WBC\n 6.5\n 8.2\n Hct\n 26.1\n 27.6\n Plt\n 196\n 201\n Cr\n 0.5\n 0.6\n 0.6\n TCO2\n 49\n 51\n 53\n 55\n Glucose\n 140\n 158\n 172\n Other labs: PT / PTT / INR:14.1/24.9/1.2, Differential-Neuts:78.9 %,\n Lymph:13.9 %, Mono:5.8 %, Eos:1.4 %, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.5 mg/dL\n Fluid analysis / Other labs: 7.27/114/62/55\n Imaging: RLE Duplex: No evidence of left lower extremity DVT.\n CXR:\n ET tube tip is 4.8 cm above the carina. The tip is abutting the right\n tracheal wall. Increased opacity in the left base is due to increasing\n atelectasis. There is mild engorgement of the pulmonary vasculature\n with no\n over CHF.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n .\n # Hypercarbic respiratory failure with new right lung collapse- On CXR\n this morning she had white out of the right lung with rightward\n tracheal deviation concerning for new right lung collapse, most likely\n mucous plugging given her thick secretions. ABG with acute on\n chronic respiratory acidosis, likely poor ventilation in the\n setting of acute right lung collapse.\n --tracheal suctioning\n -repeat CXR post NT suctioning\n -BIPAP as tolerated\n -likely will require intubation and bronchoscopy for deep suctioning\n - check TTE\n - continue diuresis with lasix as tolerated\n - continue flovent, albuterol, atrovent\n .\n #Concern for aspiration\n post extubation she had couging and\n desaturation with one sip of water very concerning for aspiration which\n would be problem for her. Possibly intubation.\n -speech and swallow in the am\n -keep NPO for now\n .\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix for one month at least, f/u with\n neurosurgery\n - Per neurology -> cont keppra for now\n -outpatient neurology follow up\n .\n #Paroxysmal Atrial fibrillation: in sinus rhythm on admission, does\n have limited bursts of afib\n -coumadin being held given recent hemorrhage\n -metoprolol IV prn for tachycardia/htn\n -not on asa left temporal hemorrhage\n .\n #Type II DM\n -glargine/hiss\n -holding oral agents while npo\n .\n # HTN\n continues to be quite hypertensive\n -lasix as tolerated\n -holding acebutolol, enalapril while npo\n -consider hydralazine if hypertensives\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 08:20 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Protonix\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-05 00:00:00.000",
"description": "ICU Fellow Progress Note - MICU",
"row_id": 670031,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 62 y/o F w/OSA/OHS, adm with hypercarbic respiratory failure.\n 24 Hour Events:\n Extubated yesterday morning.\n Yesterday had some water and seemed to aspirate, desaturated after that\n but improved.\n Erythema on left leg, LENI negative.\n This morning, had ABG that was 7.27/114/62 (off bipap x30 minutes). CXR\n with R sided collapse. Back on bipap ABG 7.27/111/67 (on bipap x45\n minutes). NT suctioned with removal of significant secretions.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:40 PM\n Heparin Sodium (Prophylaxis) - 07:48 AM\n Other medications:\n insulin sliding scale and fixed dose, simvastatin, protonix,\n fluticasone, SQ heparin, peridex, metoprolol, keppra, diamox\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.7\n HR: 59 (54 - 125) bpm\n BP: 133/43(65) {127/39(61) - 183/115(122)} mmHg\n RR: 28 (6 - 32) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 134 kg (admission): 134 kg\n Total In:\n 2,114 mL\n 1,151 mL\n PO:\n TF:\n IVF:\n 2,114 mL\n 1,151 mL\n Blood products:\n Total out:\n 1,180 mL\n 595 mL\n Urine:\n 1,180 mL\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n 934 mL\n 556 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 260 (204 - 260) mL\n PC : 10 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 0 cmH2O\n SpO2: 93%\n ABG: 7.27/111/67/42/18\n Ve: 6 L/min\n PaO2 / FiO2: 191\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, bipap mask on\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bilateral bases R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 2+, Left: 2+, erythema RLE improved based on\n marking from yesterday\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Not assessed\n Labs / Radiology\n 8.3 g/dL\n 201 K/uL\n 172 mg/dL\n 0.6 mg/dL\n 42\n 5.2\n 14\n 95\n 142 mEq/L\n 27.6 %\n 8.2 K/uL\n [image002.jpg]\n 09:01 PM\n 11:48 PM\n 05:22 AM\n 04:20 PM\n 03:27 AM\n 03:31 AM\n 05:18 AM\n 07:47 AM\n WBC\n 6.5\n 8.2\n Hct\n 26.1\n 27.6\n Plt\n 196\n 201\n Cr\n 0.5\n 0.6\n 0.6\n TCO2\n 49\n 51\n 53\n 55\n 53\n Glucose\n 140\n 158\n 172\n 189\n Other labs: PT / PTT / INR:14.1/24.9/1.2, Differential-Neuts:78.9 %,\n Lymph:13.9 %, Mono:5.8 %, Eos:1.4 %, Lactic Acid:0.6 mmol/L, Ca++:8.2\n mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL\n Imaging: CXR with R sided collapse and tracheal deviation\n Assessment and Plan\n 63 y/o F w/altered mental status secondary to hypoglycemic coma many\n years ago, adm with acute on chronic hypercarbic respiratory failure\n now complicated by R sided lung collapse. Still hypoxic and\n hypercarbic likely due to collapse. Will continue NT suctioning and\n repeat CXR but will likely need intubation/bronchoscopy. Will continue\n gentle diuresis.\n In terms of possible aspiration event, will place NGT today.\n Speech/swallow eval.\n RLE erythema is improving. No evidence of clot. Will continue to\n follow.\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale, Blood sugar well\n controlled\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 08:20 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 669998,
"text": "Comments: Pt. tolerated BIPAP till 3am. Hypercarbic and acidotic on\n ABGs. Pt. placed on NIV, tolerating well.\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Nasotrachial Suction / Small\n Plan:\n Next 24-48 hours: NIV as tolerated.\n Respiratory Care Shift Procedures\n Bedside Procedures:\n ABG puncture (0330/0500)\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-04 00:00:00.000",
"description": "Physician Resident/Attending Admission Note - MICU",
"row_id": 669818,
"text": "Chief Complaint: Acute on chronic hypercarbic respiratory failure\n HPI:\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\n .\n She was just discharged yesterday from MICU course for altered\n mental status and hypercarbia. Her altered mental status was likely\n multifactorial to include medications (diazepam, percocet) and\n hypercarbia OSA and sleep hypoventilation. She returned to baseline\n on discharge. Her hypercarbia was thought related to her COPD and\n likely newly diagnosed sleep disordered breathing. She underwent a\n sleep study and was discharged on BiPAP to follow up in sleep clinic\n for a complete sleep study.\n .\n She was found somnolent this morning, was not placed on BiPaP last\n night. Sent to for CO2 115. At placed on BiPap with\n excellent response and transferred to . On the EMS she was taken off\n BIPAP and placed on high flow oxygen. By arrival she was altered with\n saturations in 70s. She was trialed on CPAP with no success and bagged\n to try and take off CO2 with no success and subsequently intubated and\n admitted to MICU. CTH negative.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n CURRENT MEDICATIONS: Discharge meds from DC summ\n 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:\n 2-4 Puffs Inhalation Q4H (every 4 hours) as needed.\n 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff\n Inhalation (2 times a day).\n 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)\n injection Injection TID (3 times a day).\n 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID\n (4 times a day) as needed.\n 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)\n Capsule, Delayed Release(E.C.) PO DAILY (Daily).\n 6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY\n (Daily).\n 7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2\n times a day).\n 8. Acebutolol 200 mg Capsule Sig: One (1) Capsule PO BID (2\n times a day).\n 9. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY\n (Daily).\n 10. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a\n day).\n 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6\n hours) as needed.\n 12. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,\n Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for\n agitation.\n 13. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H\n (every 8 hours): both eyes.\n 14. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS\n (at bedtime): both eyes.\n 15. Humalog/Regular insulin sliding scale\n per protocol qACHS\n 16. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.\n Past medical history:\n Family history:\n Social History:\n OSA/Sleep hypoventilation- b/l CO2 70-80s\n Left Temporal Intraparenchymal hemorrhage\n COPD- no prior h/o tobacco use, + secondhand exposure\n afib- was on coumadin for last few years\n TIA- had prior episodes of flashes of light going across her\n visual field, was placed on plavix.\n Dementia- secondary to diabetic coma\n Chronic Low Back Pain\n Anemia\n GERD\n nc\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives with husband until recent admission, used to\n work as the press secretary to a state senator in the state\n house. no tob/etoh or illicits.\n Review of systems:\n Flowsheet Data as of 12:40 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 77 (62 - 77) bpm\n BP: 143/105(114) {139/41(64) - 145/105(114)} mmHg\n RR: 17 (16 - 21) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134 kg\n Total In:\n 3,035 mL\n 6 mL\n PO:\n TF:\n IVF:\n 35 mL\n 6 mL\n Blood products:\n Total out:\n 200 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,835 mL\n 6 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 350 (350 - 400) mL\n RR (Set): 10\n RR (Spontaneous): 3\n PEEP: 5 cmH2O\n FiO2: 30%\n PIP: 42 cmH2O\n Plateau: 30 cmH2O\n Compliance: 14 cmH2O/mL\n SpO2: 94%\n ABG: 7.37/85./59//18\n Ve: 5.4 L/min\n PaO2 / FiO2: 197\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, NG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), distant heart sounds\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: b/l)\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Sedated, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A4/18/ 09:01 PM\n \n 10:20 P4/18/ 11:48 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TC02\n 49\n 51\n Imaging: CXR- line in place, no acute change\n Microbiology: blood cx pending\n ECG: no ischemic changes\n Assessment and Plan\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n .\n # Acute on chronic hypercarbic respiratory failure- patient has\n baseline elevated PCO2 of 70-80s which is well compensated based on pH\n of 7.35 and bicarbonate of 43. Patient meets criteria for OSA bases on\n pulse oximetry sleep study.\n - plan to keep on AC overnight, decrease TV and RR to allow hypercarbia\n to trend towards baseline given alkalosis then switch to pressure\n support and once pulling good tidal volume and gas at\n baseline>>>extubate\n - check TTE\n - consider diuresis with acetazolamide/furosemide\n - consider theophylline to stimulate respiratory drive\n - wean up on Fi02 to if hypoxemia as needed\n - continue flovent, albuterol, atrovent\n - if patient continues to fail on BIPAP will likely need tracheostomy\n .\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix\n - Per neurology -> cont keppra for now\n .\n #Paroxysmal Atrial fibrillation: in sinus rhythm on admission\n -coumadin being held given recent hemorrhage\n -not on rate control as outpt\n .\n #Type II DM - has had recent up titration of her diabetes regimen.\n Blood sugars poorly controlled here despite adding back her glipizide,\n avandia. Januvia not on formulary.\n - glargine at 10units to attempt to improve glycemic control\n - hiss\n .\n # HTN\n - continue acebutolol\n - Hold enalapril given hyperkalemia\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Insulin infusion\n Lines:\n 18 Gauge - 08:34 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 62F obesity, AF, TIA, prior hypoglycemic\n coma, recent SAH/IPH c/b intubation and slow vent wean readmitted with\n change in mental status and hypercarbia. Baseline pCO2 around 90, seen\n by sleep and dx with at least moderate OSA, started on autoset 20/8 and\n sent to rehab. Hypercarbic to 115 at rehab, started on BiPAP (stopped\n by EMS, placed on NRB) and sent to ED. Failed CPAP in ED, eventually\n intubated after VBG showed pCO2 of 150. Head CT stable.\n Exam notable for Tm 100.0 BP 145/45 HR 70 RR 22 with sat 92 on VAC\n 400x24 (7.56/55/48). Obese woman, awake, follows simple commands.\n Distant BS B. RRR s1s2. 3+ edema. Labs notable for WBC 7K, HCT 32, K+\n 4.4, HCO3 46, Cr 0.6. CXR with low volumes.\n Agree with plan to manage acute-on-chronic hypercarbic respiratory\n failure with VAC (target Ve 3.5L) with increase in FiO2 to 0.4 and\n transition to PSV overnight. She is critically alkalotic on her current\n settings, will need to place arterial line to monitor pCO2 overnight\n and will limit sedation to optimize ventilation. She may also have a\n component of R>L heart failure, will check echo and start lasix with\n diamox to effect negative fluid balance and keep HCO3 in the high 30s -\n low 40s. Will consider starting thoephylline at low dose as a\n respiratory stimulant in AM. Will need to transition to NPPV if able to\n be extubated. Off anticoagulation for AF given recent SAH/IPH. Will\n continue glargine / RISS insulin while intubated. Mental status is\n baseline per ICU team and husband. start FW boluses for\n hypernatremia, and low-carb TFs for nutritional support. Remainder of\n plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 06:33 ------\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 669819,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\n .\n She was just discharged yesterday from MICU course for altered\n mental status and hypercarbia. Her altered mental status was likely\n multifactorial to include medications (diazepam, percocet) and\n hypercarbia OSA and sleep hypoventilation. She returned to baseline\n on discharge. Her hypercarbia was thought related to her COPD and\n likely newly diagnosed sleep disordered breathing. She underwent a\n sleep study and was discharged on BiPAP to follow up in sleep clinic\n for a complete sleep study.\n .\n She was found somnolent this morning, was not placed on BiPaP last\n night. Sent to for CO2 115. At placed on BiPap with\n excellent response and transferred to . On the EMS she was taken off\n BIPAP and placed on high flow oxygen. By arrival she was altered with\n saturations in 70s. She was trialed on CPAP with no success and bagged\n to try and take off CO2 with no success and subsequently intubated and\n admitted to MICU. CTH negative.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Hypercarbic CO2 of 139, lethargic upon arrival at ED. Sedated with\n propofol but became hypotensive to the 80\ns switched to versed 6 mgs\n /hr. stable vital signs upon arrival at MICU\n sats > 95% denies pain.\n Awake and following commands, bilateral wrist immobilizer in place.\n Patient intermittently restless and anxious, wanted to take tube out\n and have drink of juice/water, initial ABG upon arrival at MICU\n 7.54/55/48; lung sounds clear, dim at bases, suctioned small amount of\n whitish yellow secretions; slightly febrile 100.9\n Action:\n Vent settings changed from 30% 400x24 peep 5 to 350 x 10 since patient\n was very alkalotic\n Response:\n Recent ABG 7.38/85/59 FiO2 increased to 40% insetting of desaturation\n low 80\n responded well > 90; slept intermittently\n placed on PS\n this am at around 0530\n O2 sats ranges 89-92% will continue to\n monitor\n Plan:\n ? extubation; recheck ABG\n NSR with occasional ectopy, history of afib\n not on coumadin in\n setting of recent intracranial bleed; BP stable 130-150\ns; weakly\n palpable pedal pulses. + edema of lower extremities\n Bowel sounds present, no bowel movement. OGT in place, patent but will\n need to confirm with early am CXR\n On glipizide and RISS, coverage given for FS 180 at MN\n Foley in place, yellow urine with sediments\n Coccyx reddened but intact, barrier cream applied. Turn q2hrs\n R buttocks with stage 2 abrasion ? Pressure ulcer\n meriplex foam\n dressing placed. No drainage noted. LLE ? cellulitis, reddened and warm\n to touch. Marked, for LENI\ns today.\n Patient\ns husband came with her, updates given. Left past MN, will call\n in am for updates\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 669991,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on bipap most of the night, started to be coughing at early am\n having small-moderate amount of secretions, rhonchorous. Denies chest\n pain during cough but foley leaks whenever she coughs. Sats > 88%;\n oriented x1, following commands but non-sensical intermittently\n Action:\n Off bipap at 0300, face tent 40% - ABG done; diuresed with Lasix 40\n mg\n put out 320 cc after Lasix IV, continues on acetazolamide q8hrs\n Response:\n Sats 91-92% on 40% FiO2 face tent; 7.29/105/65 then 7.27/114/62,\n refusing bipap again\n received zyprexa 5 mgs x1, CXR this am showed RL\n white out ? plugged off and had R lung collapse ? bronchoscopy\n Plan:\n Coughing exercise; bipap whenever she sleeps but will end up getting\n intubated if ABG continues to gets worse; continue diuretics\n Patient\ns daughter visited last night, updates given\n New PIV placed LFA g20\n Hct stable at 27.8\n Hypertensive to the 180\ns when awake but 130\ns when sleeping. SB down\n low 40\n lopressor held. need hydralaszine for hypertension.\n Foley changed to Fr20\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-03-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 670092,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Patient on & off Non-Invasive ventilation. Last ABG\n 7.26-61-105-0-91% ON 40% Cool mist. . Nasally suctioned 3 times during\n day shift for moderate amount of secretion .Will be using NIV\n intermittently as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 669973,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 11:16 AM\n Extubated in the morning\n Concern for possible aspiration after extubation, kept NPO during the\n day\n Changed medications to IV and d/c'd oral diabetes medications while NPO\n -ordered for speech and swallow for tuesday\n -Left lower extremity ultrasound -> no DVT, erythema of left leg\n improved with elevation\n -Echocardiogram was not done\n -given lasix 20mg IV with little urine output -> given lasix 40mg IV x2\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:40 PM\n Heparin Sodium (Prophylaxis) - 12:42 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.2\nC (98.9\n HR: 61 (54 - 125) bpm\n BP: 157/43(69) {127/39(61) - 180/115(122)} mmHg\n RR: 23 (6 - 32) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134 kg\n Total In:\n 2,090 mL\n 650 mL\n PO:\n TF:\n IVF:\n 2,090 mL\n 650 mL\n Blood products:\n Total out:\n 1,180 mL\n 495 mL\n Urine:\n 1,180 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 910 mL\n 155 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Spontaneous): 204 (204 - 304) mL\n PS : 10 cmH2O\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 0 cmH2O\n SpO2: 91%\n ABG: 7.27/114/62/42/19\n Ve: 5.2 L/min\n PaO2 / FiO2: 207\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 201 K/uL\n 8.3 g/dL\n 172 mg/dL\n 0.6 mg/dL\n 42 mEq/L\n 5.2 mEq/L\n 14 mg/dL\n 95 mEq/L\n 142 mEq/L\n 27.6 %\n 8.2 K/uL\n [image002.jpg]\n 09:01 PM\n 11:48 PM\n 05:22 AM\n 04:20 PM\n 03:27 AM\n 03:31 AM\n 05:18 AM\n WBC\n 6.5\n 8.2\n Hct\n 26.1\n 27.6\n Plt\n 196\n 201\n Cr\n 0.5\n 0.6\n 0.6\n TCO2\n 49\n 51\n 53\n 55\n Glucose\n 140\n 158\n 172\n Other labs: PT / PTT / INR:14.1/24.9/1.2, Differential-Neuts:78.9 %,\n Lymph:13.9 %, Mono:5.8 %, Eos:1.4 %, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.5 mg/dL\n Fluid analysis / Other labs: 7.27/114/62/55\n Imaging: RLE Duplex: No evidence of left lower extremity DVT.\n CXR:\n ET tube tip is 4.8 cm above the carina. The tip is abutting the right\n tracheal wall. Increased opacity in the left base is due to increasing\n atelectasis. There is mild engorgement of the pulmonary vasculature\n with no\n over CHF.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DIABETES MELLITUS (DM), TYPE II\n 62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with subarachnoid\n hemorrhage readmitted with acute change in mental status \n acute on chronic hypercarbic respiratory failure\n .\n # Acute on chronic hypercarbic respiratory failure- patient has\n baseline elevated PCO2 of 70-80s which is well compensated based on pH\n of 7.35 and bicarbonate of 43. Patient meets criteria for OSA bases on\n pulse oximetry sleep study.\n - plan to keep on AC overnight, decrease TV and RR to allow hypercarbia\n to trend towards baseline given alkalosis then switch to pressure\n support and once pulling good tidal volume and gas at\n baseline>>>extubate\n - check TTE\n - consider diuresis with acetazolamide/furosemide\n - consider theophylline to stimulate respiratory drive\n - wean up on Fi02 to if hypoxemia as needed\n - continue flovent, albuterol, atrovent\n - if patient continues to fail on BIPAP will likely need tracheostomy\n .\n # Recent Left temporal hemorrhage - unclear etiology, less likely due\n to trauma, more likely HTN and anticoagulation. No evidence of\n rebleeding or new bleed on head CT.\n - cont to monitor clinically\n - continue to hold coumadin, plavix\n - Per neurology -> cont keppra for now\n .\n #Paroxysmal Atrial fibrillation: in sinus rhythm on admission\n -coumadin being held given recent hemorrhage\n -not on rate control as outpt\n .\n #Type II DM - has had recent up titration of her diabetes regimen.\n Blood sugars poorly controlled here despite adding back her glipizide,\n avandia. Januvia not on formulary.\n - glargine at 10units to attempt to improve glycemic control\n - hiss\n .\n # HTN\n - continue acebutolol\n - Hold enalapril given hyperkalemia\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:34 PM\n 20 Gauge - 08:20 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 669897,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\n .\n She was just discharged yesterday from MICU course for altered\n mental status and hypercarbia. Her altered mental status was likely\n multifactorial to include medications (diazepam, percocet) and\n hypercarbia OSA and sleep hypoventilation. She returned to baseline\n on discharge. Her hypercarbia was thought related to her COPD and\n likely newly diagnosed sleep disordered breathing. She underwent a\n sleep study and was discharged on BiPAP to follow up in sleep clinic\n for a complete sleep study.\n .\n She was found somnolent this morning, was not placed on BiPaP last\n night. Sent to for CO2 115. At placed on BiPap with\n excellent response and transferred to . On the EMS she was taken off\n BIPAP and placed on high flow oxygen. By arrival she was altered with\n saturations in 70s. She was trialed on CPAP with no success and bagged\n to try and take off CO2 with no success and subsequently intubated and\n admitted to MICU. CTH negative.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received intubated, awake and following commands, bilateral wrist\n restraints in place. Sats 90-92% on PS . LS rhonchorus,\n diminished at bases. Sxned infrequently for small, thick secretions.\n Action:\n Pt extubated. Placed on 40% humidified face tent. Encouraged coughing\n and deep breathing. Later had to increase O2 to 70% after trying sips\n of water.\n Response:\n Well tolerated for first couple of hours. Tried sips of H2O and\n paitent noted to cough/choke, and desat to low 80\ns. Also, raspy,\n congested voice noted after this.\n Plan:\n Cont. to monitor sats. Encourage coughing and deep breathing. Monitor\n O2 need. Likely plan for speech and swallow if further attempts at\n thickened liquids, when appropriate do not do well. Plan for ECHO.\n One self-limiting, short lived episode of Afib to 140-150\n One med. Soft, loose, stool.\n PO meds changed to IV.\n Foley in place, yellow urine with sediment. Given 20mg iv Lasix x1,\n little effect. Given 40mg iv, plan to give iv Diurel.\n Coccyx reddened but intact, barrier cream applied. Mepilex in place to\n small, pink stage two on buttocks.\n Had LENI\ns of bilat. Lower extrem. Negative.\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 670068,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\n .\n She was just discharged yesterday from MICU course for altered\n mental status and hypercarbia. Her altered mental status was likely\n multifactorial to include medications (diazepam, percocet) and\n hypercarbia OSA and sleep hypoventilation. She returned to baseline\n on discharge. Her hypercarbia was thought related to her COPD and\n likely newly diagnosed sleep disordered breathing. She underwent a\n sleep study and was discharged on BiPAP to follow up in sleep clinic\n for a complete sleep study.\n .\n She was found somnolent this morning, was not placed on BiPaP last\n night. Sent to for CO2 115. At placed on BiPap with\n excellent response and transferred to . On the EMS she was taken off\n BIPAP and placed on high flow oxygen. By arrival she was altered with\n saturations in 70s. She was trialed on CPAP with no success and bagged\n to try and take off CO2 with no success and subsequently intubated and\n admitted to MICU. CTH negative.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Extubated yesterday. On and off bipap yesterday and last night. Sats\n 88-98%. Ntsxned for mod. amounts of tan, thick secretions. Noted to\n have shallow respirations while off bipap. Also, very sleepy, only\n arousing to stimuli. Abg off bipap for ~4 hours 7.16/141/114. Thus\n placed back on bipap, monitoring abg\ns, ? need for intubation. CXR\n today with entire right lung white out.\n Action:\n Back and forth between face tent and bipap. Chest PT. Encouraged\n coughing and deep breathing. NT sxned prn. Abg\ns prn.\n Response:\n CXR with some improvement after chest PT and sxning. Rising CO2 off\n bipap. Continued coughing and need for sxning. ? Need for intubation.\n Plan:\n Cont. to monitor abg\ns NT sxning prn. Chest PT and coughing deep\n breathing as appropriate.. Plan for ECHO Tue.\n Plan for speech and swallow on Tue.\n Two loose, brown stools.\n Coccyx reddened but intact, barrier cream applied. Mepilex in place to\n small, pink stage two on buttocks.\n Had LENI\ns of bilat. Lower extrem. Negative.\n"
},
{
"category": "Physician ",
"chartdate": "2103-03-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 669844,
"text": "Chief Complaint: Acute on chronic hypercarbic respiratory failure\n HPI: 62 year-old woman with AF, TIA, DM (hypoglycemic coma) recent\n intra-cranial hemorrhage admitted about 2 weeks ago with mental status\n changes felt due to hypercarbia. Felt due to OSA/OHS, and underwent\n sleep study with preliminary settings of 20/8. After discharge not\n given BIPAP, then somnulent in the morning. Sent to Hospital\n with pCO2 and did well with BiPAP. Transferred to , but in\n transent did not continue with BIPAP. On arrival pH 7.25/152/70.\n Overnight apneic due to alkalosis. Maintained on AC (apneic on PS).\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:15 PM\n Allergies:\n Motrin (Oral) (Ibuprofen)\n Anaphylaxis;\n Latex\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:47 AM\n Other medications: RISS, Xalatan, glipizide, rosiglitazone, acebutalol,\n Keppra, simvastatin, PPI, fluticasone, Peridex\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38.2\nC (100.7\n HR: 73 (62 - 79) bpm\n BP: 160/51(79) {128/41(62) - 160/105(114)} mmHg\n RR: 22 (10 - 24) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 134 kg (admission): 134 kg\n Total In:\n 3,035 mL\n 80 mL\n PO:\n TF:\n IVF:\n 35 mL\n 80 mL\n Blood products:\n Total out:\n 200 mL\n 340 mL\n Urine:\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,835 mL\n -260 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 350 (350 - 400) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 14\n PEEP: 10 cmH2O\n FiO2: 30%\n RSBI: 101\n PIP: 28 cmH2O\n Plateau: 30 cmH2O\n Compliance: 14 cmH2O/mL\n SpO2: 92%\n ABG: 7.37/85./59/44/18\n Ve: 6.5 L/min\n PaO2 / FiO2: 197\n Physical Examination\n Obese, intubated. Responds somewhat to voice and sternal rub but not\n following commands.\n RRR, S1s2 ?right sided S3. No murmur.\n Lungs clear anteriorly\n Decreased bowels sounds\n 1+ edema. Left leg with erythema, marked boundaries. Both sides warm.\n Labs / Radiology\n 8.3 g/dL\n 196 K/uL\n 140 mg/dL\n 0.5 mg/dL\n 44 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 101 mEq/L\n 148 mEq/L\n 26.1 %\n 6.5 K/uL\n [image002.jpg] Last ABG: 7.37/85/59\n 09:01 PM\n 11:48 PM\n 05:22 AM\n WBC\n 6.5\n Hct\n 26.1\n Plt\n 196\n Cr\n 0.5\n TCO2\n 49\n 51\n Glucose\n 140\n Other labs: PT / PTT / INR:14.1/24.9/1.2, Differential-Neuts:78.9 %,\n Lymph:13.9 %, Mono:5.8 %, Eos:1.4 %, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL,\n PO4:2.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Acute on chronic\n hypercarbic respiratory failure, now on PS. Check ABG on the\n settings. Diuresis with lasix and acetazolamide with goal diuresis -2\n L/day. Hold narcotics/sedatives. Will not use progesterone,\n acetazolamide until she definitively fails BiPAP. If extubate, will\n extubate to BIPAP.\n DIABETES MELLITUS (DM), TYPE II: consider d/c\ning oral hypoglycemics.\n Hypertension: Follow with diuresis, continue beta-blockade.\n Left leg erythema: Potential infection vs. DVT. Follow-up ultrasound.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:34 PM, a second PIV\n Prophylaxis:\n DVT: heparin\n Stress ulcer: PPI\n VAP: Bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 669794,
"text": "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic\n low back pain, anemia, GERD, asthma recently admitted with\n subarachnoid/intraparenchymal hemorrhage and readmitted to\n MICU with acute change in mental status being readmitted\n with acute hypercarbic respiratory failure.\n .\n She was just discharged yesterday from MICU course for altered\n mental status and hypercarbia. Her altered mental status was likely\n multifactorial to include medications (diazepam, percocet) and\n hypercarbia OSA and sleep hypoventilation. She returned to baseline\n on discharge. Her hypercarbia was thought related to her COPD and\n likely newly diagnosed sleep disordered breathing. She underwent a\n sleep study and was discharged on BiPAP to follow up in sleep clinic\n for a complete sleep study.\n .\n She was found somnolent this morning, was not placed on BiPaP last\n night. Sent to for CO2 115. At placed on BiPap with\n excellent response and transferred to . On the EMS she was taken off\n BIPAP and placed on high flow oxygen. By arrival she was altered with\n saturations in 70s. She was trialed on CPAP with no success and bagged\n to try and take off CO2 with no success and subsequently intubated and\n admitted to MICU. CTH negative.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Hypercarbic CO2 of 139, lethargic upon arrival at ED. Sedated with\n propofol but became hypotensive to the 80\ns switched to versed 6 mgs\n /hr. stable vital signs upon arrival at MICU\n sats > 95% denies pain.\n Awake and following commands, bilateral wrist immobilizer in place.\n Patient intermittently restless and anxious, wanted to take tube out\n and have drink of juice/water, initial ABG upon arrival at MICU\n 7.54/55/48; lung sounds clear, dim at bases, suctioned small amount of\n whitish yellow secretions; slightly febrile 100.9\n Action:\n Vent settings changed from 30% 400x24 peep 5 to 350 x 10 since patient\n was very alkalotic\n Response:\n Recent ABG 7.38/85/59 FiO2 increased to 40% insetting of desaturation\n low 80\n responded well > 90; slept intermittently\n placed on PS\n this am at around 0530\n O2 sats ranges 89-92% will continue to\n monitor\n Plan:\n ? extubation; recheck ABG\n NSR with occasional ectopy, history of afib\n not on coumadin in\n setting of recent intracranial bleed; BP stable 130-150\ns; weakly\n palpable pedal pulses. + edema of lower extremities\n Bowel sounds present, no bowel movement. OGT in place, patent but will\n need to confirm with early am CXR\n On glipizide and RISS, coverage given for FS 180 at MN\n Foley in place, yellow urine with sediments\n Coccyx reddened but intact, barrier cream applied. Turn q2hrs\n R buttocks with stage 2 abrasion ? Pressure ulcer\n meriplex foam\n dressing placed. No drainage noted. LLE ? cellulitis, reddened and warm\n to touch. Marked, for LENI\ns today.\n Patient\ns husband came with her, updates given. Left past MN, will call\n in am for updates\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 669965,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on bipap most of the night, started to be coughing at early am\n having small-moderate amount of secretions, rhonchorous. Denies chest\n pain during cough but foley leaks whenever she coughs. Sats > 88%;\n oriented x1, following commands but non-sensical intermittently\n Action:\n Off bipap at 0300, face tent 40% - ABG done; diuresed with Lasix 40\n mg\n put out 320 cc after Lasix IV, continues on acetazolamide q8hrs\n Response:\n Sats 91-92% on 40% FiO2 face tent; 7.29/105/65\n Plan:\n Coughing exercise; bipap whenever she sleeps; continue diuretics\n Patient\ns daughter visited last night, updates given\n New PIV placed LFA g20\n Hct stable at 27.8\n Hypertensive to the 180\ns when awake but 130\ns when sleeping. SB down\n low 40\n lopressor held. need hydralaszine for hypertension.\n Foley changed to Fr20\n CXR this am showed RL white out ? plugged off and had R lung collapse ?\n bronchoscopy\n"
},
{
"category": "Nursing",
"chartdate": "2103-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 669967,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on bipap most of the night, started to be coughing at early am\n having small-moderate amount of secretions, rhonchorous. Denies chest\n pain during cough but foley leaks whenever she coughs. Sats > 88%;\n oriented x1, following commands but non-sensical intermittently\n Action:\n Off bipap at 0300, face tent 40% - ABG done; diuresed with Lasix 40\n mg\n put out 320 cc after Lasix IV, continues on acetazolamide q8hrs\n Response:\n Sats 91-92% on 40% FiO2 face tent; 7.29/105/65 then 7.27/114/62\n Plan:\n Coughing exercise; bipap whenever she sleeps; continue diuretics\n Patient\ns daughter visited last night, updates given\n New PIV placed LFA g20\n Hct stable at 27.8\n Hypertensive to the 180\ns when awake but 130\ns when sleeping. SB down\n low 40\n lopressor held. need hydralaszine for hypertension.\n Foley changed to Fr20\n CXR this am showed RL white out ? plugged off and had R lung collapse ?\n bronchoscopy\n"
}
] |
95,143 | 127,296 | The patient developed a moderate to large circumferential pericardial effusion, for which he underwent pericardiocentesis in the cath lab. Procedure was complicated by RV laceration. He became hemodynamically unstable with systolic blood pressure in the 60-80mmHg range, requiring dopamine and volume resuscitation. He was rushed to the operating room for mediastinal exploration and repair of right ventricle laceration. Overall he tolerated the procedure well, and post-operatively was transferred to the CVICU for observation and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis given the preoperative length of stay of greater than 24 hours. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. He did develop post-operative atrial fibrillation, and amiodarone was initiated. Chest tubes were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. | Thereis brief right atrial diastolic invagination.IMPRESSIOn: Moderate to large pericardial effusion. Normal ascending aortadiameter. Trivial MR.PERICARDIUM: Moderate pericardial effusion. There is right ventricular diastoliccollapse, consistent with impaired fillling/tamponade physiology. Normal interatrial septum. A right-sided central line ends in the proximal brachiocephalic vein. Mild(1+) mitral regurgitation is seen. Normal regionalLV systolic function. No RV diastolic collapse.Brief RA diastolic collapse.Conclusions:The left atrium is mildly dilated. Rule out effusion, pulmonary edema, tamponade, pneumothorax. Right axillary stent is noted. Two mediastinal and one right-sided chest tube are seen. Trivial mitral regurgitation is seen. There is mild regionalleft ventricular systolic dysfunction with hypokinesia of the mid and basalportions of the inferior wall. Mildly depressed LVEF.LV WALL MOTION: Regional LV wall motion abnormalities include: mid inferior -hypo; inferior apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Status post bilateral nephrectomies. There isa moderate sized pericardial effusion. There ismoderate symmetric left ventricular hypertrophy. Perihepatic fluid. Perihepatic fluid. Cholelithiasis. BorderlinePA systolic hypertension.PERICARDIUM: Moderate to large pericardial effusion. Trace perihepatic fluid. Left ventricular function. The aortic valve leaflets (3) are mildly thickened butaortic stenosis is not present. The aorta is of a normal caliber along its course. Left ventricular hypertrophy. 3. polycystic liver. There is borderline pulmonary arterysystolic hypertension. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). 2. cholelithiasis without cholecystitis. The portal vein is patent and demonstrates normal hepatopetal flow. Pericardial effusion. Pericardial effusion. B nephrectomies. There is trace perihepatic fluid. The diameters of aorta at the sinus, ascending and archlevels are normal. A vascular stent is noted, likely within the right subclavian/axillary vessels. Mild mitralannular calcification. Normal descending aorta diameter.AORTIC VALVE: Normal aortic valve leaflets (3). No overt tamponade butevidence of elevated intrapericardial pressures. Right ventricular function.Height: (in) 67Weight (lb): 140BSA (m2): 1.74 m2BP (mm Hg): 89/40HR (bpm): 112Status: InpatientDate/Time: at 14:55Test: TEE (Complete)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Mild regional LV systolic dysfunction. Tamponade.Height: (in) 71Weight (lb): 150BSA (m2): 1.87 m2BP (mm Hg): 155/104HR (bpm): 75Status: InpatientDate/Time: at 08:40Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The cardiac silhouette remains enlarged. TECHNIQUE: Contiguous axial images were obtained through the abdomen without the administration of IV contrast. 3. s/p b/l nephrectomy. 3. s/p b/l nephrectomy. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. FINDINGS: The patient is status post sternotomy with intact sternal wires. Thepatient appears to be in sinus rhythm. The left ventricular cavitysize is normal. Sinus tachycardia. Sinus rhythm. Sinus rhythm. T wave inversions persist. Moderate pericardial effusion with no overt mass effect on the heart. Cholelithiasis without evidence of cholecystitis. FINDINGS: The body of the pancreas appears normal and demonstrates a duct measuring 4 mm in caliber, the upper limit of normal. Normal LV cavity size. Pericardial effusion measuring 19 mm. Pericardial effusion measuring 19 mm. There is evidence of cholelithiasis. Right ventricular chamber sizeand free wall motion are normal. There is a moderate to large sized circumfirentialpericardial effusion. The most inferior edge of the right hepatic lobe was not included in the field of view. There are small left greater than right layering pleural effusions, mild cardiomegaly and mild interstitial pulmonary edema with a prominent azygos vein consistent with slightly increased hypervolemia. IMPRESSION: Enlargement of the cardiac silhouette suggestive of underlying pericardial effusion. There is a large circumferential pericardialeffusion with layered echogenic material c/w hemorrhage/thrombus. 5. splenomegaly. Hyperechoic material in the neck of the gallbladder is consistent with cholelithiasis. Splenomegaly. COMPARISON: PA and lateral radiograph of the chest from . Lateral ST-T wave changes could be dueto left ventricular hypertrophy and/or myocardial ischemia. Atelectasis at the right base is present. There issustained right atrial diastolic collapse, consistent with tamponadephysiology.Compared with the prior study (images reviewed) of , the pericardialeffusion is now larger with echogenic layered areas c/w hemorrhage/thrombus.Right atrial diastolic collapse is more prominent. The visualized intra-abdominal loops of bowel appear unremarkable. RV diastolic collapse, c/wimpaired fillling/tamponade physiology.GENERAL COMMENTS: A TEE was performed in the location listed above. Clinicalcorrelation is suggested. CT OF THE ABDOMEN: The visualized lung bases are clear with no focal consolidation, pleural effusion or pneumothorax. No right ventricular diastolic collapse is seen. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Cardiac surgery protocol. Cardiac surgery protocol. Right ventricular chamber size and free wallmotion are normal. Right ventricular chamber size and free wallmotion are normal. Endotracheal tube ends 4 cm above the carina. Regional left ventricular wall motion is normal. Effusion circumferential. Polycystic liver disease. Baseline artifact. The pulmonary vascularity is not engorged. The patient was undergeneral anesthesia throughout the procedure. CHF, evaluate heart size FINAL REPORT INDICATION: Possible pericardial effusion. Surgical clips are seen consistent with known bilateral nephrectomy. Voltage probablynormal for age. Tissue Doppler imagingsuggests an increased left ventricular filling pressure (PCWP>18mmHg). Slightly increased interstitial pulmonary edema. PATIENT/TEST INFORMATION:Indication: Evaluate residual pericardial effusion after drainage of approx 700cc.Height: (in) 70Weight (lb): 150BSA (m2): 1.85 m2BP (mm Hg): 117/60Status: InpatientDate/Time: at 13:00Test: Portable TTE (Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.PERICARDIUM: Large pericardial effusion. The lungs are clear without focal consolidation. IMPRESSION: 1. IMPRESSION: 1. Poor R wave progression couldbe due to left ventricular hypertrophy. The pancreatic head and pancreatic tail obscured by overlying soft tissue structures and bowel gas. | 11 | [
{
"category": "Radiology",
"chartdate": "2156-06-15 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1138595,
"text": " 3:50 PM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: assess for hemorrhage into cyst\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with polycystic liver dz, now w/ RUQ pain\n REASON FOR THIS EXAMINATION:\n assess for hemorrhage into cyst\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TUE 4:44 PM\n 1. Pericardial effusion measuring 19 mm.\n 2. Multiple cysts in both lobes of the liver c/w polycystic liver disease.\n 3. s/p b/l nephrectomy.\n 4. Perihepatic fluid.\n Discussed findings with Dr. at 4:41pm on .\n WET READ VERSION #1 TUE 4:16 PM\n 1. Pericardial effusion measuring 19 mm.\n 2. Multiple cysts in both lobes of the liver c/w polycystic liver disease.\n 3. s/p b/l nephrectomy.\n 4. Perihepatic fluid.\n Paged Dr. to notify him of results at 4:10pm.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old man with polycystic liver disease, who presents with\n right upper quadrant pain. Assess for hemorrhage into cyst.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous axial images were obtained through the abdomen without\n the administration of IV contrast. Multiplanar reformatted images (axial,\n coronal, sagittal) were generated and reviewed.\n\n CT OF THE ABDOMEN: The visualized lung bases are clear with no focal\n consolidation, pleural effusion or pneumothorax. The visualized heart shows a\n large pericardial effusion measuring 17 mm. There is no gross overall mass\n effect on the heart, however, the study is limited in the absence of IV\n contrast.\n\n Multiple cysts of varying sizes are noted within the right and left lobes of\n the liver consistent with polycystic liver disease. The most inferior edge of\n the right hepatic lobe was not included in the field of view. No\n hyperattenuated cyst is identified to suggest internal hemorrhage. There is\n evidence of cholelithiasis. The spleen and pancreas are unremarkable.\n Surgical clips are seen consistent with known bilateral nephrectomy. The\n visualized intra-abdominal loops of bowel appear unremarkable.\n\n There is trace perihepatic fluid. There is no free air within the abdomen.\n The intra-abdominal mesenteric and retroperitoneal lymph nodes do not meet CT\n size criteria for pathologic enlargement.\n\n OSSEOUS STRUCTURES: No lytic or sclerotic lesions suspicious for malignancy\n are identified.\n (Over)\n\n 3:50 PM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: assess for hemorrhage into cyst\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Moderate pericardial effusion with no overt mass effect on the heart.\n 2. Multiple cysts of varying sizes within right and left lobes of the liver\n consistent with polycystic liver disease with no evidence of hemorrhage into\n cyst.\n 3. Cholelithiasis.\n 4. Trace perihepatic fluid.\n\n Following placement of a wet read, all findings were once again discussed with\n Dr. at 4:56 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-06-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1139148,
"text": " 8:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?ptx after CT removal\n Admitting Diagnosis: RIGHT UPPER QUADRANT PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with pericardial drainage\n REASON FOR THIS EXAMINATION:\n ?ptx after CT removal\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post pericardial drainage, chest tube removed, check\n for pneumothorax.\n\n The cardiac silhouette remains enlarged. No pneumothorax is identified. Air\n bronchograms are noted at the left base indicating left lower lobe\n consolidation. Atelectasis at the right base is present. Right axillary\n stent is noted.\n\n IMPRESSION: No failure. Left lower lobe pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-06-15 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1138606,
"text": " 5:22 PM\n CHEST (PA & LAT) Clip # \n Reason: ? CHF, evaluate heart size\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with ? percicardial effusion\n REASON FOR THIS EXAMINATION:\n ? CHF, evaluate heart size\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Possible pericardial effusion.\n\n COMPARISON: None.\n\n PA AND LATERAL VIEWS OF THE CHEST: The heart is markedly enlarged with a\n globular configuration, concerning for underlying pericardial effusion or\n cardiomyopathy. The pulmonary vascularity is not engorged. A vascular stent\n is noted, likely within the right subclavian/axillary vessels. The lungs are\n clear without focal consolidation. No pleural effusion or pneumothorax is\n seen. There are multiple clips in the left retroperitoneum. No acute osseous\n abnormalities are seen.\n\n IMPRESSION: Enlargement of the cardiac silhouette suggestive of underlying\n pericardial effusion. Echocardiogram is recommended for further evaluation.\n No evidence of congestive heart failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-06-15 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1138566,
"text": " 1:31 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: assess for RUQ pathology, hemorrhagic cyst\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with RUQ pain, h/o polycystic liver dz\n REASON FOR THIS EXAMINATION:\n assess for RUQ pathology, hemorrhagic cyst\n ______________________________________________________________________________\n WET READ: JEKh TUE 2:56 PM\n 1. panc duct dilation 4mm; CBD normal.\n 2. cholelithiasis without cholecystitis.\n 3. polycystic liver.\n 4. B nephrectomies.\n 5. splenomegaly.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 41-year-old male with right upper quadrant pain and a history of\n polycystic liver disease.\n\n STUDY: Abdominal ultrasound.\n\n FINDINGS: The body of the pancreas appears normal and demonstrates a duct\n measuring 4 mm in caliber, the upper limit of normal. The pancreatic head and\n pancreatic tail obscured by overlying soft tissue structures and bowel gas.\n\n The liver demonstrates innumerable cystic appearing lesions with through\n transmission consistent with the patient's known history of polycystic\n disease. The portal vein is patent and demonstrates normal hepatopetal flow.\n\n The gallbladder is non-distended, shows no evidence of wall edema. The\n gallbladder wall measures 3 mm in thickness. Hyperechoic material in the neck\n of the gallbladder is consistent with cholelithiasis. The common bile duct\n measures 3 mm in caliber.\n\n The patient is status post bilateral nephrectomy; no fluid collections are\n noted in the kidney beds.\n\n The aorta is of a normal caliber along its course.\n\n The spleen is enlarged measuring 15.7 cm in its longest axis. No ascites is\n seen in the lower quadrants.\n\n IMPRESSION:\n 1. Cholelithiasis without evidence of cholecystitis.\n 2. Polycystic liver disease.\n 3. Status post bilateral nephrectomies.\n 4. Splenomegaly.\n (Over)\n\n 1:31 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: assess for RUQ pathology, hemorrhagic cyst\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-06-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1139077,
"text": " 4:10 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Fast track early extubation. Cardiac surgery protocol. Rule\n Admitting Diagnosis: RIGHT UPPER QUADRANT PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with Mediastinal Exploration\n REASON FOR THIS EXAMINATION:\n Fast track early extubation. Cardiac surgery protocol. Rule out effusion,\n pulmonary edema, tamponade, pneumothorax. with issues.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old man mediastinal exploration, fast track extubation.\n\n TECHNIQUE: Single supine view of the chest.\n\n COMPARISON: PA and lateral radiograph of the chest from .\n\n FINDINGS:\n The patient is status post sternotomy with intact sternal wires. Two\n mediastinal and one right-sided chest tube are seen. The NG tube passes\n beyond the GE junction, but the side port is at the level of the GE junction -\n NG tube should be advanced by 4 cm. Endotracheal tube ends 4 cm above the\n carina. There are small left greater than right layering pleural effusions,\n mild cardiomegaly and mild interstitial pulmonary edema with a prominent\n azygos vein consistent with slightly increased hypervolemia.\n A right-sided central line ends in the proximal brachiocephalic vein.\n\n IMPRESSION:\n 1. No evidence of pneumothorax.\n 2. Slightly increased interstitial pulmonary edema.\n 3. NGT should be advanced by 4 cm.\n\n Dr. was notified about the findings at the time of dictation.\n\n"
},
{
"category": "Echo",
"chartdate": "2156-06-18 00:00:00.000",
"description": "Report",
"row_id": 63752,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate residual pericardial effusion after drainage of approx 700cc.\nHeight: (in) 70\nWeight (lb): 150\nBSA (m2): 1.85 m2\nBP (mm Hg): 117/60\nStatus: Inpatient\nDate/Time: at 13:00\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: Large pericardial effusion. Effusion circumferential. Sustained\nRA diastolic collapse, c/w low filling pressures or early tamponade.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed with the\nhouseofficer caring for the patient.\n\nConclusions:\nThere is prominent symmetric left ventricular hypertrophy with normal cavity\nsize and global systolic function (LVEF>55%). Right ventricular chamber size\nand free wall motion are normal. There is a large circumferential pericardial\neffusion with layered echogenic material c/w hemorrhage/thrombus. There is\nsustained right atrial diastolic collapse, consistent with tamponade\nphysiology.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion is now larger with echogenic layered areas c/w hemorrhage/thrombus.\nRight atrial diastolic collapse is more prominent.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2156-06-18 00:00:00.000",
"description": "Report",
"row_id": 63692,
"text": "PATIENT/TEST INFORMATION:\nIndication: Stat sternotomy for tamponade. Left ventricular function. Pericardial effusion. Right ventricular function.\nHeight: (in) 67\nWeight (lb): 140\nBSA (m2): 1.74 m2\nBP (mm Hg): 89/40\nHR (bpm): 112\nStatus: Inpatient\nDate/Time: at 14:55\nTest: TEE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid inferior -\nhypo; inferior apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal descending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nPERICARDIUM: Moderate pericardial effusion. RV diastolic collapse, c/w\nimpaired fillling/tamponade physiology.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. There is mild regional\nleft ventricular systolic dysfunction with hypokinesia of the mid and basal\nportions of the inferior wall. Overall left ventricular systolic function is\nmildly depressed (LVEF= 45 %). Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Trivial mitral regurgitation is seen. There is\na moderate sized pericardial effusion. There is right ventricular diastolic\ncollapse, consistent with impaired fillling/tamponade physiology. Dr. \nwas notified in person of the results on at 1430 hours.\n\nPost tamponade relief and repair of the RV perforation there is no pericardial\neffusion and the tamponade is now resolved.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2156-06-16 00:00:00.000",
"description": "Report",
"row_id": 63693,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion. Tamponade.\nHeight: (in) 71\nWeight (lb): 150\nBSA (m2): 1.87 m2\nBP (mm Hg): 155/104\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 08:40\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler. Increased IVC diameter (>2.1cm) with <35% decrease\nduring respiration (estimated RA pressure (10-20mmHg).\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Normal regional\nLV systolic function. Overall normal LVEF (>55%). TDI E/e' >15, suggesting\nPCWP>18mmHg. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPERICARDIUM: Moderate to large pericardial effusion. No RV diastolic collapse.\nBrief RA diastolic collapse.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. The estimated right atrial pressure is 10-20mmHg. There is\nmoderate symmetric left ventricular hypertrophy. The left ventricular cavity\nsize is normal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging\nsuggests an increased left ventricular filling pressure (PCWP>18mmHg). There\nis no ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The diameters of aorta at the sinus, ascending and arch\nlevels are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse. Mild\n(1+) mitral regurgitation is seen. There is borderline pulmonary artery\nsystolic hypertension. There is a moderate to large sized circumfirential\npericardial effusion. No right ventricular diastolic collapse is seen. There\nis brief right atrial diastolic invagination.\n\nIMPRESSIOn: Moderate to large pericardial effusion. No overt tamponade but\nevidence of elevated intrapericardial pressures.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2156-06-18 00:00:00.000",
"description": "Report",
"row_id": 123982,
"text": "Sinus tachycardia. Left ventricular hypertrophy. Poor R wave progression could\nbe due to left ventricular hypertrophy. Lateral ST-T wave changes could be due\nto left ventricular hypertrophy and/or myocardial ischemia. Clinical\ncorrelation is suggested. Compared to the previous tracing of sinus\ntachycardia is new. The lateral ST-T wave changes are more pronounced\nsuggesting an ischemic process. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-06-15 00:00:00.000",
"description": "Report",
"row_id": 123983,
"text": "Sinus rhythm. Somewhat late R wave progression. Since the previous tracing\nthere is technical improvement. T wave inversions persist. Clinical\ncorrelation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2156-06-15 00:00:00.000",
"description": "Report",
"row_id": 123984,
"text": "Baseline artifact. Sinus rhythm. Late R wave progression. Voltage probably\nnormal for age. Lateral T wave inversions. Since the previous tracing\nof lateral T wave inversions are new.\nTRACING #1\n\n"
}
] |
86,645 | 143,608 | 56 year old male with a past medical history of cerebral atriaovenous malformation (AVM) staus post coiling with residual left sided hemipareisis and disorientation with known C. Diff colitis s/p day 4 of treatment with falgyl and spiked a temperature to 103.8 in the ED and vomiting and diarreha and leukocytosis, found to have sepsis due to a urinary tract infection and C. diff colitis. | Extensive vasogenic edema involving right hemisphere is unchanged since prior with extensive mass effect. 2. multiple BL renal hypodensities, two of which are of intermediate density, can further characterize with US, on nonemergent basis. Scattered mesenteric and retroperitoneal lymph nodes, which do not meet CT criteria for pathologic enlargement. FINDINGS: Post-surgical changes related to right-sided craniectomy and coiling are redemonstrated. Cardiomediastinal and hilar contours are within normal limits. Imaged intra-abdominal aorta and its branches are normal in caliber and are patent. Pancreas enhances homogeneously without ductal dilatation or peripancreatic fluid collection. minimal improvement of brain herniation throught the craniectomy defect since . In comparison to exam, there is minimal improvement of brain parenchyma herniation through the craniectomy defect. Multiple renal hypodensities, two of which measure of intermediate density, which can be further assessed with on non-emergent ultrasound, as indicated. Focal bilateral renal hypodensities are seen, many of which are too small to characterize, likely cysts. PORTABLE FRONTAL CHEST RADIOGRAPH: Minimal basilar opacities are better characterized on concurrent CT and are consistent with atelectasis. No definite new intracranial hemorrhage is seen. TECHNIQUE: MDCT-acquired contiguous images of the abdomen and pelvis were obtained without intravenous contrast at 5-mm slice thickness. Seminal vesicles are unremarkable. Kidneys enhance and excrete contrast symmetrically without hydronephrosis. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is seen. IMPRESSION: Minimal bibasilar atelectasis, though no evidence of pneumonia. The gallbladder is distended. TECHNIQUE: MDCT-acquired contiguous images through the head were obtained without intravenous contrast at 5-mm slice thickness. large parenchymal hematoma centered in right basal ganglia slightly smaller since prior. No pathologically enlarged pelvic or inguinal lymph node is seen. Spleen is unremarkable. Sigmoid colon is unremarkable. The liver demonstrates homogeneous enhancement without focal lesions. Normal ECG. No acute fracture. Heart is normal in size without pericardial effusion. The hepatic vasculature is patent. extensive surrounding edema and 10mm leftward midline shift persists. No calcified gallstones are noted. Compared to the previous tracing of nodiagnostic interim change. Small and large bowel loops are normal in caliber without evidence of bowel wall thickening or obstruction. However, no gallbladder wall edema or pericholecystic fluid collection is seen. no calcified gallstones. There is interval removal of the left ventricular drain. ( se 2, im 24) No vascular territorial infarction. Brain herniation through the craniectomy defect is minimally improved since prior. (Over) 12:47 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: any source of infection Contrast: OMNIPAQUE Amt: 130 FINAL REPORT (Cont) CT OF THE PELVIS: Foley catheter is in placed. IMPRESSION: Post-surgical changes related to right craniectomy and coiling. No confluent consolidation is identified to suggest pneumonia. No pulmonary edema or pleural effusions are identified. Adjacent tubular hyperattenuations reflect known underlying AV malformation along with cortical swelling. No acute CT findings to account for patient's clinical presentation. Hyperattenuating focus in the left frontal lobe is likely artifactual (2:19). Coronally and sagittally reformatted images were displayed. Coronally and sagittally reformatted images were displayed. There is persistent leftward shift of normally midline structures measuring 10 mm. Extensive streak artifact generated by right-sided coils slightly limits evaluation of the surrounding structures. Extensive right cerebral edema and persistent leftward shift of normally midline structures; some degree of uncal herniation and deformity on the right side midbrain and pons. Adrenal glands are normal. Intraparenchymal hematoma centered (Over) 12:48 PM CT HEAD W/O CONTRAST Clip # Reason: any source of infection FINAL REPORT (Cont) in right basal ganglia is slightly decreased in size since prior. Basal cisterns are patent. Imaged paranasal sinuses and mastoid air cells are well aerated. There is no evidence of intrahepatic or extrahepatic biliary ductal dilatation. There is no pneumothorax. Multiple tubular hyperdensities likely represents structures of known underlying AV malformation. 12:47 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: any source of infection Contrast: OMNIPAQUE Amt: 130 MEDICAL CONDITION: History: 56M with fever and abdominal pain sent in from Rehab REASON FOR THIS EXAMINATION: any source of infection No contraindications for IV contrast WET READ: TXCf SUN 1:55 PM 1. distended gallbadder without GB wall edema or pericholecystic fluid collection. known underlying AV malformation. No fracture. Small amount of air in the bladder likely relates to its placement. FINDINGS: CT OF THE ABDOMEN: Bibasilar areas of dependent atelectasis are noted. There is no free air or free fluid within the abdomen. | 4 | [
{
"category": "Radiology",
"chartdate": "2165-07-14 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1249611,
"text": " 12:47 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: any source of infection\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 56M with fever and abdominal pain sent in from Rehab\n REASON FOR THIS EXAMINATION:\n any source of infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TXCf SUN 1:55 PM\n 1. distended gallbadder without GB wall edema or pericholecystic fluid\n collection. no calcified gallstones.\n 2. multiple BL renal hypodensities, two of which are of intermediate density,\n can further characterize with US, on nonemergent basis.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with fever and abdominal pain.\n\n COMPARISONS: .\n\n TECHNIQUE: MDCT-acquired contiguous images of the abdomen and pelvis were\n obtained without intravenous contrast at 5-mm slice thickness. Coronally and\n sagittally reformatted images were displayed.\n\n FINDINGS:\n\n CT OF THE ABDOMEN:\n\n Bibasilar areas of dependent atelectasis are noted. Heart is normal in size\n without pericardial effusion. The liver demonstrates homogeneous enhancement\n without focal lesions. There is no evidence of intrahepatic or extrahepatic\n biliary ductal dilatation. The hepatic vasculature is patent. The\n gallbladder is distended. However, no gallbladder wall edema or\n pericholecystic fluid collection is seen. No calcified gallstones are noted.\n Spleen is unremarkable. Pancreas enhances homogeneously without ductal\n dilatation or peripancreatic fluid collection. Adrenal glands are normal.\n Kidneys enhance and excrete contrast symmetrically without hydronephrosis.\n Focal bilateral renal hypodensities are seen, many of which are too small to\n characterize, likely cysts. There is a 2.2 x 1.9 cm hypodense lesion arising\n from the interpolar region of the right kidney, measuring 29 Hounsfield units\n in attenuation (2:39). A 1.2 x 1.3 cm hypodense lesion in the lower pole of\n the left kidney measures 5 Hounsfield units in attenuation, compatible with a\n cyst (2:35). There is an additional 1.1 x 1.3 cm hypodense lesion in the\n upper pole of the left kidney measuring 23 Hounsfield units in attenuation\n (2:27). G-tube is in place. Small and large bowel loops are normal in\n caliber without evidence of bowel wall thickening or obstruction. Scattered\n mesenteric and retroperitoneal lymph nodes, which do not meet CT criteria for\n pathologic enlargement. There is no free air or free fluid within the\n abdomen. Imaged intra-abdominal aorta and its branches are normal in caliber\n and are patent.\n (Over)\n\n 12:47 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: any source of infection\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF THE PELVIS: Foley catheter is in placed. Small amount of air in the\n bladder likely relates to its placement. The rectum is prominent with\n air-fluid level. Sigmoid colon is unremarkable. Prostate gland is slightly\n enlarged. Seminal vesicles are unremarkable. No pathologically enlarged\n pelvic or inguinal lymph node is seen. There is no free air or free fluid\n within the pelvis.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is seen. No\n fracture.\n\n IMPRESSION:\n\n 1. No acute CT findings to account for patient's clinical presentation.\n\n 1. Multiple renal hypodensities, two of which measure of intermediate\n density, which can be further assessed with on non-emergent ultrasound, as\n indicated.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-07-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1249612,
"text": " 12:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: any source of infection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 56M with fever and abdominal pain sent in from Rehab\n REASON FOR THIS EXAMINATION:\n any source of infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TXCf SUN 1:34 PM\n s/p right craniectomy and coiling. minimal improvement of brain herniation\n throught the craniectomy defect since . large parenchymal hematoma\n centered in right basal ganglia slightly smaller since prior. known underlying\n AV malformation. extensive surrounding edema and 10mm leftward midline shift\n persists.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with fever and abdominal pain. Assess for source of\n infection.\n\n COMPARISONS: Multiple CT heads dating back to .\n\n TECHNIQUE: MDCT-acquired contiguous images through the head were obtained\n without intravenous contrast at 5-mm slice thickness. Coronally and\n sagittally reformatted images were displayed.\n\n FINDINGS:\n\n Post-surgical changes related to right-sided craniectomy and coiling are\n redemonstrated. Extensive streak artifact generated by right-sided coils\n slightly limits evaluation of the surrounding structures. Brain herniation\n through the craniectomy defect is minimally improved since prior. A large\n hematoma centered in the right basal ganglia measures 5.2 x 2.1 cm, previously\n 5.7 x 2.4 cm (2:20). Multiple tubular hyperdensities likely represents\n structures of known underlying AV malformation. Extensive vasogenic edema\n involving right hemisphere is unchanged since prior with extensive mass\n effect. There is persistent leftward shift of normally midline structures\n measuring 10 mm. Hyperattenuating focus in the left frontal lobe is likely\n artifactual (2:19). No definite new intracranial hemorrhage is seen. There\n is interval removal of the left ventricular drain. Ventricles are slightly\n prominent in size since prior.\n A new hypodense focus in the left frontal lobe is noted. ( se 2, im 24)\n No vascular territorial infarction. Basal cisterns are patent. Imaged\n paranasal sinuses and mastoid air cells are well aerated. No acute fracture.\n\n IMPRESSION:\n\n Post-surgical changes related to right craniectomy and coiling. In comparison\n to exam, there is minimal improvement of brain parenchyma\n herniation through the craniectomy defect. Intraparenchymal hematoma centered\n (Over)\n\n 12:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: any source of infection\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n in right basal ganglia is slightly decreased in size since prior. Adjacent\n tubular hyperattenuations reflect known underlying AV malformation along with\n cortical swelling.\n\n Extensive right cerebral edema and persistent leftward shift of normally\n midline structures; some degree of uncal herniation and deformity on the right\n side midbrain and pons.\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-07-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1249609,
"text": " 12:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulmonary infxn\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 56M with fever and abd pain\n REASON FOR THIS EXAMINATION:\n eval for pulmonary infxn\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old male with fever and abdominal pain. Assess for\n pneumonia.\n\n COMPARISON: Chest radiograph from and concurrent CT abdomen and\n pelvis from at 13:19.\n\n PORTABLE FRONTAL CHEST RADIOGRAPH: Minimal basilar opacities are better\n characterized on concurrent CT and are consistent with atelectasis. No\n confluent consolidation is identified to suggest pneumonia. There is no\n pneumothorax. No pulmonary edema or pleural effusions are identified.\n Cardiomediastinal and hilar contours are within normal limits.\n\n IMPRESSION: Minimal bibasilar atelectasis, though no evidence of pneumonia.\n\n"
},
{
"category": "ECG",
"chartdate": "2165-07-16 00:00:00.000",
"description": "Report",
"row_id": 255309,
"text": "Sinus rhythm. Normal ECG. Compared to the previous tracing of no\ndiagnostic interim change.\n\n"
}
] |
26,523 | 138,682 | (By issue) 1. Right lower extremity cellulitis and ulcerations - The patient was admitted to the Podiatry Service on for the cellulitis of the right lower extremity. On admission she was started on Vancomycin, Levaquin and Flagyl for broad coverage. Blood cultures and wound cultures were taken. Both grew out Escherichia coli. In order to more specifically cover, the patient's antibiotics were changed to Oxacillin and Ceftriaxone. The patient has also had hardware in her right ankle and because of the possibility that this was seated, the patient required surgery. Her Coumadin was discontinued and once her INR had decreased close to baseline, she was taken to the Operating Room for hardware removal. This was done on . Postoperatively the patient is stable on Oxacillin and Ceftriaxone until two days after the operation. Then due to concern for pneumonia her antibiotic coverage was changed to Zosyn and Vancomycin. She continued this for three days and then was only on Zosyn. Her right lower extremity was in a vacuum-assisted closure dressing and continued to improve, healing by secondary intention. She has been followed by Podiatry. Her left lower extremity ulcer also continued to improve. X-rays showed an old fracture without any changes in the left foot. The patient did not have any further signs of worsening cellulitis or infection of her extremities. 2. Respiratory - On , the patient developed hypoxia with an oxygen saturation of 80% on room air and hypertension with systolic blood pressure in the 190s. She was also complaining of a new productive cough. Chest x-ray done on that day was consistent with congestive heart failure and the patient was given Lasix. There is also question of a right lower lobe infiltrate on the chest x-ray, so Azithromycin was initially added to her regimen of Ceftriaxone and Oxacillin. On the same day, the patient also developed mental status changes which was possibly thought to be related to her hypoxia. At this point, due to concern for pneumonia and respiratory compromise, the patient's antibiotic coverage was changed to Vancomycin and Zosyn and she was transferred to the Intensive Care Unit for closer monitoring. She was never intubated. She was continued on Zosyn and Vancomycin and a sputum culture was obtained. The sputum culture showed and did not grow out any bacteria. The patient's respiratory status improved with decrease in oxygen requirements. Once the sputum culture was negative for any bacteria and there was no evidence of Methicillin-resistant Staphylococcus aureus her Vancomycin was discontinued. She was continued on Zosyn for treatment of possible aspiration pneumonia and for her cellulitis. 3. Congestive heart failure - The patient required Lasix intermittently for mild hypoxia and crackles on lung examination indicative of congestive heart failure. She was also on Zestril 20 mg b.i.d. initially and then titrated up for afterload reduction. Her blood pressure was labile but was controlled with Catapres, Lopressor, and Zestril. 4. Anticoagulation - The patient's Coumadin was discontinued as was previously mentioned in order to be taken to the Operating Room. While off Coumadin the patient was on a heparin drip for her history of deep vein thrombosis and pulmonary embolism. Once it was decided that no further procedures would be done by Podiatry she was restarted on Coumadin. Her heparin drip was continued until her INR would be in the goal range of 2 to 3. 5. Chronic back pain - The patient had chronic back for which she had been on Nubain at home. While in the hospital she was started on a morphine PCA. Initially there was no basal rate, however, the patient was not using the PCA and therefore basal rate was added. Plan was for the patient to have a morphine placed by Neurosurgery once her active acute issues are cleared. This will probably be done after discharge. She was also on Baclofen, Tizanidine and Vioxx for her pain. 6. Hypothyroidism - The patient was continued on Levoxyl. 7. Psyche - The patient was on Celexa and Klonopin. 8. Dysphagia - The patient had a swallowing study previously done in , in order to evaluate symptoms of dysphagia. This showed a possible offer for esophageal sphincter dysfunction, no further workup was done at the time. On this admission there is a question of aspiration pneumonia and the patient was re-evaluated by the swallowing service. Again there was no evidence of aspiration but evidence that there was upper esophageal dysfunction. The patient will require a gastroenterology follow up for workup and possible dilatation. For now, she will be on a soft diet with frequent liquids when eating. 9. Anemia - The patient has a history of chronic anemia requiring blood transfusions. While in the hospital she also had periods of time when her hematocrit was below 30. There were no signs of active bleeding. The iron studies showed a mixed picture with decreased iron and TIBC and elevated Ferritin. The patient's iron to TIBC ratio was low suggesting a possible combination of iron deficiency anemia, anemia of chronic disease and possibly anemia related to the patient's hypothyroidism. The patient was given blood transfusions as needed to maintain her hematocrit greater than 30, given her history of congestive heart failure. 10. Diabetes Type 2 - The patient was continued on a sliding scale of insulin. Her Metformin was held when she was not eating. It will be restarted when she is eating more stabilely. | HO aware.RESP: B/L BS diminished. BS hypoactive. Tol clears.Endo: BS 177, 193. BLE edema. Mg+ 1.7, repleted w/ 2amps of Mag IV.HEM: HCT 28.2, WNL. K+ 3.9, repleted w/ KCL 20meq IV. C/O nausea X2 relieved w/ zofran. Vomitting resolved w/ ATC Zofran 2mg IV. BS WNL. EKG and CXR showed CHF. Will recheck in AM. If remains stable will be called out in AM. L foot w/ dsg C/D/I, splint on. A 0.018 guidewire was advanced under fluoroscopic guidance until its tip was in the superior vena cava (SVC). K+=3.2, Mg+=1.7. Not repleted as of yet.HEM: HGB/HCT: 9.6/28.7, down from 32.4/10.9. BLE weakness, rigid, L>R. Afebrile, Tmax 99. HR 80's and sinus. PERRLA. PERRLA. Reoriented w/ good effect. Pos 1L for shift. Vomited x1 on and given Zofran. QRS 0.06 PR 0.16 QT 0.44. K+ this AM 3.2. Covered as per SS. Afebrile. PCA MSO4 and Heparin infusing w/abx. The film demonstrates the tip of the PICC line to be in the mid-SVC. Reinforced w/ DSD. PTT at 0515: 84.6, therapeutic at 2200U/hr of Heparin. PTT therapeutic at 76.3.ID: WBC unchanged at 20.7. PTT at 1800 42.1. Home O2 dependent. 12 lead ECG WNL. Adequate amt /hr. Small amt of serosanguinous drain from site. Morphine PCA w/ good relief; must remind to use.RESP: B/L BS diminished w/ rhonchi and rare E wheezing. Given Lasix w/o results. On ABX for foot infection, pneum?, UTI.GI: Abd obese, soft, hypoactive BS. +UTI. 0300: Hypertensive, SBP 190's, NSR, diaphoretic, c/o nausea. Will inform HO to tighten scale.GU: Foley intact draining concentrated , urine w/ sediment. Approp. Cr 1.1. Aspiration precautions in effect. No BM.GU: Foley C/D/I. Administer abx and monitor I&O's. Spec sent for CX. Placed on NRB mask. Pain to back well controlled w/ PCA. CT of abd today benign. Advance diet as can tolerate depending on abd films. HR 80-90 and sinus. Appears A&O x3.Resp: Lungs are clear to auscultation. Diet advanced to clear liquids as tol. On ABX X2. Using IS.CV: NSR, no ectopy. SBP labile, 80-150; hypotension during sleep, resolved when aroused. On , give lax. Pt instructed to expectorate into cup if able. RLE w/ ace and vac dsg intact. Next level at 1130.ID: Afebrile. Both kept elevated.GI: Abd obese, soft. BLE weakness and rigidity. Abd sono neg yesterday for obstruction. Order received to D/C Lisinopril and to change Metoprolol to 37.5mg PO TID. Given Zofran 2mg IVP given x2 with good effect. Next PTT due at MN.CV: NBP 130's-160's/70's-80's. Abd is soft, obese, hypoactive BS's. 2L NC satting 94-98%. Sinus rhythmNormal ECGSince previous tracing, slower heart rate The left brachial vein was patent and compressible. Peripheral neuropathy from waist down. Pt confused upon wakening. Given 6u Lispro sc.Pt has lumen PICC line in her left upper arm. No drainage noted.Labs: Hct this AM down to 28.7. The guidewire was removed. The stage II decubitus on the left heal is to have W-D dsg QD, which has been done by nsg this afternoon. A chest film was obtained. Hep at 2200U/hr. All pulses via doppler, present and strong. Received morphine 2mg for shift. Sinus rhythmConsider left atrial abnormalityOtherwise normal ECGSince previous tracing of , no significant change General: Pt admitted from West after having Surgical debriedment and hardware removal of R foot w/cellulitis. c/o pain to back, t/p, pillow wedges used PRN. at 2100. Both lumens of the PICC line were flushed. General: Pt had a good day today.Neuro: A&O x3.Resp: Lungs CTA. O2 2L via NC with sats 94-98%.CV: BP 130's/40's-80's. Heparin infusing at 1650u/hr upon arrival to unit. Peripheral neuropathy from the waist down and to finger tips. MAE. BP very labile. Redrawn at 1800 with results pending. Na+ remains low at 132 this am. Hypertensive at 0400 190/80, given AM meds at that time.Neuro: Pt very lethargic but mentating better. O2 weaned to 2L NC, satting 96-100%. The PICC line was trimmed to length and advanced over the guidewire. Pt is NPO at this time and did vomit a moderate amt of bile colored liquid with undigested food.Endo: FS at 1800 278. Cloudy, urine. The left upper arm was prepped and draped in standard sterile fashion. Passing gas. HOB at 45 degrees. CXR this afternoon. NPN 1900-0700:NEURO: A&OX3. NPN 1900-0700:NEURO: A&OX3. Pt is now on 4L o2 via NC and satting 92 to 96%. IMPRESSION: Successful placement of a 47 cm-long, 4-French, dual-lumen PICC line via the left brachial vein with its tip in the mid-SVC. D/C IVF sec to fluid volume overload as per chest x-ray. Results pending. Also NSS at 100/hr for 1000ml as Na+ was low this am. Pt is an insulin dep diabetic. 0300: aroused confused, "where am I." Pt has wound vac to right foot wound and a dsg on her left foot for a stage II decubitus. Hypertension resolved on it's own 15 min later. Pt only taking water. The line was hep-locked and a Stat-Lock was applied. +Nausea, no tenderness. If pt does have a BM we will send a cx for c. diff.as WBC continues to rise (21.1 today). ABD x-ray, done at bedside. No BM today. 7:23 AM PICC LINE PLACMENT SCH Clip # Reason: PICC line under fluro please for long term antibiotics Admitting Diagnosis: RLE CELLULITIS Contrast: OPTIRAY Amt: 5 ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * C1751 CATH ,/CENT/MID(NOT D C1894 INT.SHTH NOT/GUID,EP,NONLASER * **************************************************************************** MEDICAL CONDITION: 59 year old woman with infected ankle wound. Due to CHF maintainance fluid will be held and if needed fluid boluses will be given. | 9 | [
{
"category": "Radiology",
"chartdate": "2190-03-12 00:00:00.000",
"description": "CATH INFUSN,PER/CENT/MID(NOT DIAL)",
"row_id": 822927,
"text": " 7:23 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC line under fluro please for long term antibiotics\n Admitting Diagnosis: RLE CELLULITIS\n Contrast: OPTIRAY Amt: 5\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1751 CATH ,/CENT/MID(NOT D C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with infected ankle wound.\n REASON FOR THIS EXAMINATION:\n PICC line under fluro please for long term antibiotics\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old woman with infected ankle, requiring PICC line for IV\n antibiotics.\n\n PHYSICIANS PERFORMING THE PROCEDURE: Dr. .M. , radiology resident, and\n Dr. , the attending radiologist (who was present for the\n entire procedure).\n\n PROCEDURE/FINDINGS: The patient was placed supine on the angiography table.\n The left upper arm was prepped and draped in standard sterile fashion. Since\n no suitable veins were visible, ultrasound was used for localization of a\n suitable vein. The left brachial vein was patent and compressible.\n After local anesthesia with lidocaine 1% SQ, and under son guidance, a\n 21-gauge needle was advanced with its tip in the left brachial vein. A 0.018\n guidewire was advanced under fluoroscopic guidance until its tip was in the\n superior vena cava (SVC). The needle was exchanged for a 4-French introducer\n sheath. Based on the markers on the guidewire, it was determined that a length\n of 47 cm would be suitable. The PICC line was trimmed to length and advanced\n over the guidewire. The peel-away sheath was removed and discarded. The\n guidewire was removed. A chest film was obtained. The film demonstrates the\n tip of the PICC line to be in the mid-SVC. Both lumens of the PICC line were\n flushed. The line was hep-locked and a Stat-Lock was applied.\n\n COMPLICATIONS: The patient tolerated the procedure well, and there were no\n immediate post-procedure complications.\n\n IMPRESSION: Successful placement of a 47 cm-long, 4-French, dual-lumen PICC\n line via the left brachial vein with its tip in the mid-SVC. The line is ready\n for use.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-21 00:00:00.000",
"description": "Report",
"row_id": 1609353,
"text": "Order received to D/C Lisinopril and to change Metoprolol to 37.5mg PO TID. Also NSS at 100/hr for 1000ml as Na+ was low this am. Will recheck in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-22 00:00:00.000",
"description": "Report",
"row_id": 1609354,
"text": "NPN 1900-0700:\n\nNEURO: A&OX3. Approp. MAE. BLE weakness and rigidity. Peripheral neuropathy from the waist down and to finger tips. PERRLA. Pain to back well controlled w/ PCA. Received morphine 2mg for shift. 0300: aroused confused, \"where am I.\" Reoriented w/ good effect. HO aware.\n\nRESP: B/L BS diminished. Occasional rhonchi cleared by coughing and expectorating green sputum. 2L NC satting 94-98%. Home O2 dependent. No resp distress. Using IS.\n\nCV: NSR, no ectopy. QRS 0.06 PR 0.16 QT 0.44. BP very labile. 0300: Hypertensive, SBP 190's, NSR, diaphoretic, c/o nausea. 12 lead ECG WNL. No c/o chest pain. Afebrile. BS WNL. Hypertension resolved on it's own 15 min later. BLE edema. D/C IVF sec to fluid volume overload as per chest x-ray. Pos 1L for shift. Na+ remains low at 132 this am. K+ 3.9, repleted w/ KCL 20meq IV. Mg+ 1.7, repleted w/ 2amps of Mag IV.\n\nHEM: HCT 28.2, WNL. Hep at 2200U/hr. PTT therapeutic at 76.3.\n\nID: WBC unchanged at 20.7. Afebrile, Tmax 99. On ABX for foot infection, pneum?, UTI.\n\nGI: Abd obese, soft, hypoactive BS. C/O nausea X2 relieved w/ zofran. No vomitting. Abd sono neg yesterday for obstruction. Passing gas. No BM. On , give lax. Tol clears.\n\nEndo: BS 177, 193. Covered as per SS. Will inform HO to tighten scale.\n\nGU: Foley intact draining concentrated , urine w/ sediment. Cr 1.1.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-21 00:00:00.000",
"description": "Report",
"row_id": 1609351,
"text": "NPN 1900-0700:\nNEURO: A&OX3. PERRLA. BLE weakness, rigid, L>R. Peripheral neuropathy from waist down. c/o pain to back, t/p, pillow wedges used PRN. Morphine PCA w/ good relief; must remind to use.\n\nRESP: B/L BS diminished w/ rhonchi and rare E wheezing. Coughs prod large amts of thick, green, secretions. Spec sent for CX. O2 weaned to 2L NC, satting 96-100%. No resp distress throughout the night.\n\nCV: NSR, no ectopy. SBP labile, 80-150; hypotension during sleep, resolved when aroused. No edema. All pulses via doppler, present and strong. K+=3.2, Mg+=1.7. Not repleted as of yet.\n\nHEM: HGB/HCT: 9.6/28.7, down from 32.4/10.9. PTT at 0515: 84.6, therapeutic at 2200U/hr of Heparin. Next level at 1130.\n\nID: Afebrile. WBC increased from 15.3 to 21.1. On ABX X2. RLE w/ ace and vac dsg intact. Small amt of serosanguinous drain from site. Reinforced w/ DSD. L foot w/ dsg C/D/I, splint on. Both kept elevated.\n\nGI: Abd obese, soft. BS hypoactive. +Nausea, no tenderness. Vomitting resolved w/ ATC Zofran 2mg IV. NPO throughout the night. Aspiration precautions in effect. HOB at 45 degrees. ABD x-ray, done at bedside. at 2100. No BM.\n\nGU: Foley C/D/I. Cloudy, urine. +UTI. Adequate amt /hr. Cr=1.3.\n\n\nPLAN: Podiatry team to change dressings to feet. Advance diet as can tolerate depending on abd films. Con't pulm toileting.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-21 00:00:00.000",
"description": "Report",
"row_id": 1609352,
"text": "General: Pt had a good day today.\n\nNeuro: A&O x3.\n\nResp: Lungs CTA. Productive cough of milky, thick tan-brown sputum.Using incentive spirometer. CXR this afternoon. Results pending. O2 2L via NC with sats 94-98%.\n\nCV: BP 130's/40's-80's. HR 80's and sinus. No ectopy noted. No c/o CP/SOB.\n\nGU/GI: Foley patent draining clear yellow urine. Diet advanced to clear liquids as tol. Pt only taking water. Does not like juice or sweet things like jello. Offered broth but declined. No BM today. If pt does have a BM we will send a cx for c. diff.as WBC continues to rise (21.1 today). Pt states that she only moves her bowels every couple of weeks. CT of abd today benign. Given Zofran 2mg IVP given x2 with good effect. No vomiting today.\n\nPain: Pt has chronic back pain for which she has used 37mg PCA MSO4 since MN.\n\nEndo: FS at 1200=237, given 4u Humalog, at 1800=164, given 2u Humalog.Pt received D5NS at 125ml/hr x1 liter.\n\nWound care: Podiatry in to see pt today The wound on the right foot with the vacuum attached will be changed by podiatry tomorrow. The stage II decubitus on the left heal is to have W-D dsg QD, which has been done by nsg this afternoon. No drainage noted.\n\nLabs: Hct this AM down to 28.7. Redrawn at 1800 with results pending. Pt states that she usually receives a transfusion with Hct under 30. K+ this AM 3.2. Repleated with 40meq K+ PO this AM.\n\nSocial: Family visited this afternoon.\n\nPlan: Monitor pt overnight. If remains stable will be called out in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-03-20 00:00:00.000",
"description": "Report",
"row_id": 1609350,
"text": "General: Pt admitted from West after having Surgical debriedment and hardware removal of R foot w/cellulitis. Pt has wound vac to right foot wound and a dsg on her left foot for a stage II decubitus. Pt has decreased sensation and movement to Bilat LE's due to multiple back surgeries. Walks with a Canadian crutch. Pt is an insulin dep diabetic. Everything was going well until last night about MN when pt desatted to 83% with lungs sounding wet. Pt has sleep apnea and required vigorous sternal rub to waken. EKG and CXR showed CHF. Given Lasix w/o results. Pt confused upon wakening. Placed on NRB mask. This AM more alert but still slightly confused. Vomited x1 on and given Zofran. Hypertensive at 0400 190/80, given AM meds at that time.\n\nNeuro: Pt very lethargic but mentating better. Appears A&O x3.\n\nResp: Lungs are clear to auscultation. Pt instructed to expectorate into cup if able. Pt did vomit this evening and is sitting at a 90 degree angle to prevent aspiration. Pt is now on 4L o2 via NC and satting 92 to 96%. Heparin infusing at 1650u/hr upon arrival to unit. PTT at 1800 42.1. Heparin increased to 2000u/hr (20ml/hr). Next PTT due at MN.\n\nCV: NBP 130's-160's/70's-80's. HR 80-90 and sinus. NO c/o CP, SOB. Pt given her scheduled dose of Metoprolol this evening.\n\nGU/GI: Pt strait caths at home due to bowel/bladder disfunctin due to multiple back surgeries. Now with foley cath, draining clear yellow urine at about 30cc/hr. Abd is soft, obese, hypoactive BS's. Pt is NPO at this time and did vomit a moderate amt of bile colored liquid with undigested food.\n\nEndo: FS at 1800 278. Given 6u Lispro sc.\n\nPt has lumen PICC line in her left upper arm. PCA MSO4 and Heparin infusing w/abx. piggybacks. Due to CHF maintainance fluid will be held and if needed fluid boluses will be given. At this time UO is sufficient though concentrated.\n\nSocial: Husband visited shortly after admission but left when pt fell asleep. Called later to check on her. Will visit again tomorrow.\n\nPlan: Monitor resp status, urinary output. Administer abx and monitor I&O's. Develop plan of care for bilat LE wounds.\n"
},
{
"category": "ECG",
"chartdate": "2190-03-22 00:00:00.000",
"description": "Report",
"row_id": 134956,
"text": "Sinus rhythm\nNormal ECG\nSince previous tracing, slower heart rate\n\n"
},
{
"category": "ECG",
"chartdate": "2190-03-20 00:00:00.000",
"description": "Report",
"row_id": 134957,
"text": "Sinus rhythm\nConsider left atrial abnormality\nOtherwise normal ECG\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2190-03-11 00:00:00.000",
"description": "Report",
"row_id": 134958,
"text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , no atrial premature complex seen\n\n"
}
] |
5,495 | 142,471 | 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and chronic abd/back pain who presents with decreased po intake, diarrhea, lethargy and hypotension found to have colitis on CT. His hospital course showed a progressive decline in function where his mental status and physical condition slowly declined despite treatment of his medical problems. . AMS: Variable course over his stay, likely multifactorial with possible etiologies including narcotics, toxic/metabolic related to renal failure. It appears to be most consistent with delirium. Had CT head with contrast on , but this does not definitively r/o brain metastases. Neuro exam is nonfocal. BUN has improved over the last 10 days. At d/c continued to be AO X 1, but has remained clear on his intentions to not escalate care with the desire to return home and be with family. | On , UE showed RIJ occlusive thrombus, left subclavian nonocclusive thrombus, and left basilic vein occlusive thrombus. On , UE showed RIJ occlusive thrombus, left subclavian nonocclusive thrombus, and left basilic vein occlusive thrombus. # Prophylaxis: Coumadin, PPI . # Prophylaxis: Heparin sc tid, PPI . Ileus/partial SBO: Resolved. - po Vanc until - trend exam, image for worsening. - f/u PT recs - cont pain regimen #. - f/u PT recs - cont pain regimen #. - f/u PT recs - cont pain regimen #. - f/u PT recs - cont pain regimen #. Other ddx: diverticulitis vs ischemic, on vanc/zosyn/flagyl/PO vanc. ?palliative care consult if not already done. ?palliative care consult if not already done. ?palliative care consult if not already done. # Tranaminitis LFTs trending down. Had transient hypotension, resolved after 1L NS. On , UE showed RIJ occlusive thrombus, left subclavian nonocclusive thrombus, and left basilic vein occlusive thrombus. # Prophylaxis: Heparin sc tid, PPI . # Prophylaxis: Heparin sc tid, PPI . # Prophylaxis: Coumadin, PPI . # Prophylaxis: Coumadin, PPI . # Prophylaxis: Coumadin, PPI . # Prophylaxis: Coumadin, PPI . Other ddx: diverticulitis vs ischemic, on vanc/zosyn/flagyl/PO vanc. On , UE swelling was noted and dopplers showed RIJ occlusive thrombus, left subclavian nonocclusive thrombus, and left basilic vein occlusive thrombus. On , UE swelling was noted and dopplers showed RIJ occlusive thrombus, left subclavian nonocclusive thrombus, and left basilic vein occlusive thrombus. On , UE swelling was noted and dopplers showed RIJ occlusive thrombus, left subclavian nonocclusive thrombus, and left basilic vein occlusive thrombus. On , UE swelling was noted and dopplers showed RIJ occlusive thrombus, left subclavian nonocclusive thrombus, and left basilic vein occlusive thrombus. - bolus IVF prn to goal CVP>12 - wean pressors today as tolerated; has subclavian stenosis with difficult time to determine blood pressure, are weaning to mental status as well as blood pressures from legs - Vanc/Zosyn for possible diverticulitis/colitis - start empiric Flagyl and po Vanc for possible CDiff colitis - f/u blood/urine/stool cx no obvious source yet . 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and chronic abd/back pain who presents with decreased po intake, diarrhea, lethargy and hypotension found to have colitis on CT. Hypotension resolved, off pressors. 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and chronic abd/back pain who presents with decreased po intake, diarrhea, lethargy and hypotension found to have colitis on CT. Hypotension resolved, off pressors. The most accurate BP with rt thigh , h/o lt subclavian stenosis, HR 56 to 70s slow afib w/ occasional PVCs CVP 8-14 Action: Off Pressors, pm labs sent Response: SBP 90s- 130s off pressors w/ MAP remaining 50-70, CVP 8-14, wbc is 15.4, lactate trending down to 2.2,a gap 19 Plan: Monitor lactate/WBC, F/U culture results,continues to rise reconsult gen r/t ? Current intervention if any, listed below: Comments: 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and chronic abd/back pain who presents with decreased po intake, diarrhea, lethargy and hypotension found to have colitis on CT. DDx C.diff colitis, ischemic colitis, SBP. - bolus IVF prn to goal CVP>12 - wean pressors today as tolerated; has subclavian stenosis with difficult time to determine blood pressure, are weaning to mental status as well as blood pressures from legs - Vanc/Zosyn for possible diverticulitis/colitis - start empiric Flagyl and po Vanc for possible CDiff colitis - f/u blood/urine/stool cx no obvious source yet . Hypotension (not Shock) Assessment: Pt remains hypotensive and tachy in the 1teens, afebrile Action: He conts on levophed, neo, and vasopressin, zosyn, vanco and Flagyl Response: Able to wean the neo but unable to stop it Plan: Wean the pressors as able, cont antibiotics, f/u on clx Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney disease) Assessment: Pt is a PD patient, his lytes are stable, he is pressor dependant as above Action: There is talk about doing PD today even though he is on triple pressors but our team decided to hold off until he is more stable Response: Plan: f/u with PD tomorrow Pain control (acute pain, chronic pain) Assessment: Pt c/o pain mainly on his R side, states that he has been in pain since he has been here but is also confused telling me is pain free and a moment later saying that hehurts terribly Action: He was given 2 percocetts and an hour later he said that he was still in pain, then given 2 mg of IV morphine Response: He was able to fall asleep after the morphine, when he woke he was more confused but also said that he was comfortable Plan: The morphine was d/ced due to the confusion and dilaudid was added. Hypotension (not Shock) Assessment: Pt remains hypotensive and tachy in the 1teens, afebrile Action: He conts on levophed, neo, and vasopressin, zosyn, vanco and Flagyl Response: Able to wean the neo but unable to stop it Plan: Wean the pressors as able, cont antibiotics, f/u on clx Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney disease) Assessment: Pt is a PD patient, his lytes are stable, he is pressor dependant as above Action: There is talk about doing PD today even though he is on triple pressors but our team decided to hold off until he is more stable Response: Plan: f/u with PD tomorrow Pain control (acute pain, chronic pain) Assessment: Pt c/o pain mainly on his R side, states that he has been in pain since he has been here but is also confused telling me is pain free and a moment later saying that hehurts terribly Action: He was given 2 percocetts and an hour later he said that he was still in pain, then given 2 mg of IV morphine Response: He was able to fall asleep after the morphine, when he woke he was more confused but also said that he was comfortable Plan: The morphine was d/ced due to the confusion and dilaudid was added. Cannot exclude ischemia.Compared to the previous tracing of ST segment depression is slightlyless pronounced.TRACING #1 There is a partially imaged sclerotic focus in the T3 vertebral body, which is better assessed on the dedicated CT of the T-spine, performed concurrently. At L3-4 level, there is mild central canal stenosis secondary to facet joint hypertrophy and ligamentum flavum hypertrophy and disc bulge; mild right sided neural foraminal narrowing. FINDINGS: There are a few well-defined sclerotic lesions, noted in the thoracic spine, one in the anterior aspect of the T3, which measures 0.7 cm, and was barely visible on the prior torso CT sagittal reformations. At L5-S1 level, there is bilateral facet joint hypertrophy, and uncovertebral joint hypertrophy, leading to moderate left neural foraminal narrowing and mild canal stenosis. Midline sternotomy wires and mediastinal clips are again noted. Redemonstration of right hydronephrosis and double-J stent. Redemonstration of right hydronephrosis and double-J stent. IMPRESSION: New right IJ central venous catheter with tip in appropriate position. The right ureteral stent is again visualized. | 120 | [
{
"category": "Physician ",
"chartdate": "2145-03-04 00:00:00.000",
"description": "Attending Note",
"row_id": 365052,
"text": "TITLE: Attending note\n 78 yo man with severe vasculopathy, COPD, recent MI, metastatic\n carcinoid presented with abdominal pain, vomiting and diarrhea at home.\n Chronic PD and possible colonic perforation possible sources of\n peritonitis.\n Exam sig for pt awake, interactive, appropriate. No resp distress. Very\n uncomfortable with chronic right flank pain and nausea/vomiting. Mucosa\n moist. Crackles at bases and clear at apices with moderate air\n movement. Distant heart sounds. Abdomen hypoactive bowel sounds, soft,\n ND. Diffusely tender. No tenderness to percussion but clearly\n uncomfortable with palpation. No rebound/guarding. No edema. No rashes.\n Recent chest CT shows severe emphysema.\n Abd CT from : Right colon wall thickening.\n Inflamm/civertic/extension of tumor which is contiguous. Increase in\n hepatic mets, moderate right hydronephrosis which was present on CT\n . Right renal collecting system with new hemorrhage. Lung windows\n show tiny right pleural effusion, mild bibasilar atelectasis.\n CXR shows PVC and atypical pattern of pulmonary edema with underlying\n emphysema.\n septic shock: 3 pressors. Most likely source CDiff. Other\n ddx: diverticulitis vs ischemic, on vanc/zosyn/flagyl/PO vanc. Large\n volume resuscitation. Now on levophed, vasopressin, neosynephrine.\n Surgery felt no intervention necessary. Ischemia less likely\n considering lactate 1.4, stool guaiac neg, but he is at risk.\n o avoid further volume if possible considering depressed\n systolic and diastolic cardiac function and crackles on exam\n Pain: Can be attributable to blood in right\n kidney/collecting system around ureteral stent. Chronic component as\n well. Percocet if taking POs.\n Nausea: try zofran.\n ESRD - will discuss whether she can continue to use PD with\n renal- at the moment hypotensive on 3 pressors and no urgent\n indication.\n 40 minutes critical care time.\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365520,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - PICC request placed (did not get today)\n - NGT placed and TFs started\n - continued PD\n - PT c/s placed\n - cont vanc PO, flagyl/zosyn IV\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Vancomycin - 08:18 PM\n Piperacillin - 06:00 PM\n Metronidazole - 11:59 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:34 PM\n Hydromorphone (Dilaudid) - 10:06 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.2\n HR: 68 (68 - 87) bpm\n BP: 121/51(67) {102/45(60) - 137/92(99)} mmHg\n RR: 8 (7 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 4 (2 - 12)mmHg\n Total In:\n 1,109 mL\n 215 mL\n PO:\n 100 mL\n TF:\n 79 mL\n 144 mL\n IVF:\n 890 mL\n 72 mL\n Blood products:\n Total out:\n 1,530 mL\n -1,800 mL\n Urine:\n NG:\n 30 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -421 mL\n 2,015 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///19/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 237 K/uL\n 7.9 g/dL\n 112 mg/dL\n 8.0 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 53 mg/dL\n 101 mEq/L\n 136 mEq/L\n 25.5 %\n 14.3 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n 04:22 PM\n 03:23 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n 14.3\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n 23.7\n 25.5\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n 237\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n 8.0\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n 112\n Other labs: PT / PTT / INR:19.3/36.5/1.8, ALT / AST:1777/1426, Alk Phos\n / T Bili:139/0.2, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.3 g/dL, LDH:750 IU/L, Ca++:7.1 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.1 mg/dL\n Assessment and Plan\n HYPOTHERMIA\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365521,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - PICC request placed (did not get today)\n - NGT placed and TFs started\n - continued PD\n - PT c/s placed\n - cont vanc PO, flagyl/zosyn IV\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Vancomycin - 08:18 PM\n Piperacillin - 06:00 PM\n Metronidazole - 11:59 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:34 PM\n Hydromorphone (Dilaudid) - 10:06 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.2\n HR: 68 (68 - 87) bpm\n BP: 121/51(67) {102/45(60) - 137/92(99)} mmHg\n RR: 8 (7 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 4 (2 - 12)mmHg\n Total In:\n 1,109 mL\n 215 mL\n PO:\n 100 mL\n TF:\n 79 mL\n 144 mL\n IVF:\n 890 mL\n 72 mL\n Blood products:\n Total out:\n 1,530 mL\n -1,800 mL\n Urine:\n NG:\n 30 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -421 mL\n 2,015 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///19/\n Physical Examination\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 237 K/uL\n 7.9 g/dL\n 112 mg/dL\n 8.0 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 53 mg/dL\n 101 mEq/L\n 136 mEq/L\n 25.5 %\n 14.3 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n 04:22 PM\n 03:23 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n 14.3\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n 23.7\n 25.5\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n 237\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n 8.0\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n 112\n Other labs: PT / PTT / INR:19.3/36.5/1.8, ALT / AST:1777/1426, Alk Phos\n / T Bili:139/0.2, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.3 g/dL, LDH:750 IU/L, Ca++:7.1 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.1 mg/dL\n Assessment and Plan\n HYPOTHERMIA\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365523,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - PICC request placed (did not get today)\n - NGT placed and TFs started\n - continued PD\n - PT c/s placed\n - cont vanc PO, flagyl/zosyn IV\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Vancomycin - 08:18 PM\n Piperacillin - 06:00 PM\n Metronidazole - 11:59 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:34 PM\n Hydromorphone (Dilaudid) - 10:06 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.2\n HR: 68 (68 - 87) bpm\n BP: 121/51(67) {102/45(60) - 137/92(99)} mmHg\n RR: 8 (7 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 4 (2 - 12)mmHg\n Total In:\n 1,109 mL\n 215 mL\n PO:\n 100 mL\n TF:\n 79 mL\n 144 mL\n IVF:\n 890 mL\n 72 mL\n Blood products:\n Total out:\n 1,530 mL\n -1,800 mL\n Urine:\n NG:\n 30 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -421 mL\n 2,015 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///19/\n Physical Examination\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 237 K/uL\n 7.9 g/dL\n 112 mg/dL\n 8.0 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 53 mg/dL\n 101 mEq/L\n 136 mEq/L\n 25.5 %\n 14.3 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n 04:22 PM\n 03:23 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n 14.3\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n 23.7\n 25.5\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n 237\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n 8.0\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n 112\n Other labs: PT / PTT / INR:19.3/36.5/1.8, ALT / AST:1777/1426, Alk Phos\n / T Bili:139/0.2, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.3 g/dL, LDH:750 IU/L, Ca++:7.1 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.1 mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n .\n # Hypotension: Pt with lethargy, hypotension that has transiently\n responded to IV boluses but continues to require low dose levophed,\n then requiring three pressors. Pt is a vasculopath with complex\n arterial anatomy, recently discharged after NSTEMI. CT ruled out\n ruptured AAA and stool guaic was negative. Differential includes\n sepsis, hypovolemic, GI bleed, ischemic colitis, less likely to be MI\n or adrenal insufficiency. Most likely is sepsis in setting of colitis\n and peritonitis.\n - bolus IVF prn for hypotension, titrate to MS\n - pressors off ; has subclavian stenosis with difficult time to\n determine blood pressure, weaned to mental status as well as blood\n pressures from legs\n - Vanc/Zosyn for possible diverticulitis/colitis\n - Flagyl and po Vanc for possible CDiff colitis\n - f/u blood/urine/stool cx\n no obvious source yet\n .\n # Abd pain/diarrhea: Pt is a known vasculopath who p/w 2-3 days of dark\n loose stools and poor po intake after completing a course of Abx for\n PNA. Per family, no fevers at home but pt reports subjective chills.\n WBC ct of 20 and CT with colitis. Concern for C Diff colitis vs\n ischemic colitis, though may be less likely given normal lactate. SBP\n also possible, will send fluid from peritoneal cath. Pt was seen by\n gen and vasc surgery in ED, no plan for OR. Pt expressed goals of\n care to avoid heroic measures, confirmed by HCP.\n - following lactates\n - started empiric Flagyl & Po Vanc for c.diff, results pending\n - continue Vanc/Zosyn for possible diverticulitis and peritonitis\n - bisacodyl PR\n - per , can start to advance diet slowly with serial abd exams as\n long as making stool\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission, continue to follow\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: renal following, plan for PD\n - PD cath Cx\n no organisms seen on gram stain\n - f/u renal recs\n - continue Calcitriol\n - added epo and phos binder per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross\n - CVL and \n - PPI & trend hct, keep > 21\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: will need to place NG tube for TFs today\n .\n # Prophylaxis: Heparin sc tid, PPI\n .\n # Access: , d/c RIJ today and have PICC placed for long-term\n ABX and possible TPN\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365637,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain as well as nausea, vomiting and tarry diarrhea. Pt initially\n presented to with hypotension and mild hct drop. Pt\n underwent a CT Abd/Pelvis scan which revealed stable AAA and he was\n transferred to for further care. Of note, pt was discharged on\n after admission for NSTEMI & PNA. During that admission, pt was\n taken to cath and given co morbidities only the SVG-OM2 was\n angioplastied. He was treated with a 10day course of Ceftriaxone/Levo\n for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea.\n Code: DNR/DNI\n Events: back pain still present but better, continues on PD.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt is on 5cycles/day of PD.PD catheter has been clotting with fibrin\n clot for the last couple of days.\n Action:\n 1000 units of Heparin ordered for each bag of PD solution.\n Response:\n PD fluid running free, no sign of clots.\n Plan:\n Continue on scheduled PD runs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt continues to c/ and back pain.\n Action:\n Repositioned numerous times for pain relief.Hasnt needed any\n medication.Trying to avoid pain meds if possible but can have prn if\n needed.\n Response:\n Pain easily relieved after repositioning.Pain meds thought to have\n contributed to SBO.No BM this shift.\n Plan:\n Given pain meds when needed but assess carefully.\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 367852,
"text": "Chief Complaint:\n 24 Hour Events:\n - Transient hypotension after Oxycontin dose, resolved with 1 L NS\n - Pancultured\n - Mental status waxed and waned, ? temporal relationship to Oxycontin\n dosing\n - Oxycontin discontinued\n - retarted Simvastatin\n - Continued PD q 2 hours without change\n - Family meeting scheduled for 3 PM on \n - c/o pain in sacrum in the PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:28 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Nutritional Support: NPO\n Pain: Moderate\n Pain location: Sacrum\n Flowsheet Data as of 08:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.9\nC (96.7\n HR: 76 (55 - 84) bpm\n BP: 107/49(58) {71/30(45) - 164/120(95)} mmHg\n RR: 15 (11 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,731 mL\n 83 mL\n PO:\n TF:\n IVF:\n 1,731 mL\n 83 mL\n Blood products:\n Total out:\n 5,500 mL\n 100 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,769 mL\n -18 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Tender: diffusely\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm, sacral decub\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 368 K/uL\n 8.8 g/dL\n 108 mg/dL\n 6.5 mg/dL\n 30 mEq/L\n 4.4 mEq/L\n 29 mg/dL\n 101 mEq/L\n 139 mEq/L\n 27.6 %\n 7.0 K/uL\n [image002.jpg]\n 04:48 AM\n 03:44 AM\n WBC\n 6.7\n 7.0\n Hct\n 29.2\n 27.6\n Plt\n 388\n 368\n Cr\n 6.9\n 6.5\n Glucose\n 101\n 108\n Other labs: PT / PTT / INR:32.0/39.0/3.3, ALT / AST:26/18, Alk Phos / T\n Bili:106/0.2, Differential-Neuts:76.1 %, Lymph:15.8 %, Mono:5.7 %,\n Eos:1.9 %, Lactic Acid:1.7 mmol/L, Albumin:2.0 g/dL, LDH:236 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:6.3 mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Transferred to\n ICU for increased PD requirement.\n # AMS: variable course over his stay. likely multifactorial including\n narcotics, toxic/metabolic related to renal failure. It appears to be\n most consistent with delirium. Had CT head with contrast on , but\n this does not definitively r/o brain metastases. Neuro exam is\n nonfocal. BUN has improved over the last 10 days.\n - PD as per renal recs\n - cont pain management as is for now, but wean if possible\n - avoid any other sedating medications\n - consider head imaging, but presentation unlikely from stroke. ?\n relation to brain mets. None on CT head with contrast, but this is\n inferior to MRI.\n # ESRD on PD: renal following. Sent to ICU for increased PD care per\n renal.\n - appreciate renal rcs\n - continue Calcitriol, epo per renal recs\n # LE weakness: underwent workup for cord compression, including spine\n consult. Not felt to be related to cord compression. Likely related\n to decondition, pain, lethargy from ? toxic/metabolic. ? myopathy or\n paraneoplastic.\n - PT\n - pain control\n - consider neuro consult, EMG, though goals of care should be addressed\n first.\n #Back Pain: Chronic. Sclerotic lesions in T and L spine by CT and\n lesion on iliac by octreotide scan. Also contribution of degenerative\n changes and deconditioning. followed by P&P Care.\n - f/u PT recs\n - cont pain regimen\n #. RIJ and L subclavian thrombus: Pt INR 3.5 today. Pt with difficult\n access and difficult lab draws. Sensitivity to coumadin likely \n nutrition deficiencies.\n - holding coumadin goal INR . Will need minimum of 3 months.\n - cont to monitor for bleeding\n # Abdominal Pain/Colitis\n s/p 10 day course of zosyn. On PO vanco for\n presumptive c. diff until . Finished IV Vancomycin for peritonitis.\n Has continued diffuse TTP and guarding. Afebrile with no signs of\n infection. ? ischemic.\n - consider resending peritoneal fluid for culture, though no fever or\n leukocytosis\n - send lactate\n - po Vanc until \n - trend exam, image for worsening.\n # Metastatic Carcinoid: Pt followed by Hem/Onc. Pt had octreotide scan\n that showed increase in disease.\n - palliatie care recs\n - pain control\n - f/u with Dr. re: long term care goals\n # Anemia: Baseline hct in low 30s, stable in upper 20s after 1 unit\n transfused. Guaiac positive brown stool.\n - goal Hct >25\n - guaiac all stools\n - PPI & trend hct\n # Tranaminitis\n LFTs trending down. Previously thought to be from\n shocked liver. Likely combination of malignancy and shocked liver.\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat . Plavix was discontinued given therapeutic to\n supertherapeutic INR and no stent in last year.\n - continue Aspirin 325mg\n - metoprolol held for hypotension. Restart as BP tolerates.\n - restart statin\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n # Decubitus Ulcer: wound care\n # FEN: Cont regular diet with shakes\n # Prophylaxis: Coumadin, PPI\n # Access: PIV\n # Code: DNR/DNI, but pressors/CVL okay as per last ICU stay. Needs to\n be readdressed with pt/family and goals of with Dr. .\n # Communication: Patient & wife \n # Disposition: ICU for PD. be able to go straight from ICU to\n rehab.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 10:21 PM\n 18 Gauge - 12:12 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 367857,
"text": "Chief Complaint:\n 24 Hour Events:\n - Transient hypotension after Oxycontin dose, resolved with 1 L NS\n - Pancultured\n - Mental status waxed and waned, ? temporal relationship to Oxycontin\n dosing\n - Oxycontin discontinued\n - retarted Simvastatin\n - Continued PD q 2 hours without change\n - Family meeting scheduled for 3 PM on \n - c/o pain in sacrum in the PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:28 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Nutritional Support: NPO\n Pain: Moderate\n Pain location: Sacrum\n Flowsheet Data as of 08:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.9\nC (96.7\n HR: 76 (55 - 84) bpm\n BP: 107/49(58) {71/30(45) - 164/120(95)} mmHg\n RR: 15 (11 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,731 mL\n 83 mL\n PO:\n TF:\n IVF:\n 1,731 mL\n 83 mL\n Blood products:\n Total out:\n 5,500 mL\n 100 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,769 mL\n -18 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Tender: diffusely\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm, sacral decub\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 368 K/uL\n 8.8 g/dL\n 108 mg/dL\n 6.5 mg/dL\n 30 mEq/L\n 4.4 mEq/L\n 29 mg/dL\n 101 mEq/L\n 139 mEq/L\n 27.6 %\n 7.0 K/uL\n [image002.jpg]\n 04:48 AM\n 03:44 AM\n WBC\n 6.7\n 7.0\n Hct\n 29.2\n 27.6\n Plt\n 388\n 368\n Cr\n 6.9\n 6.5\n Glucose\n 101\n 108\n Other labs: PT / PTT / INR:32.0/39.0/3.3, ALT / AST:26/18, Alk Phos / T\n Bili:106/0.2, Differential-Neuts:76.1 %, Lymph:15.8 %, Mono:5.7 %,\n Eos:1.9 %, Lactic Acid:1.7 mmol/L, Albumin:2.0 g/dL, LDH:236 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:6.3 mg/dL\n 3:04 pm PERITONEAL FLUID PERITONEAL FLUID.\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n FLUID CULTURE (Preliminary):\n ANAEROBIC CULTURE (Preliminary):\n FUNGAL CULTURE (Preliminary):\nCLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ):\n Feces negative for C.difficile toxin A & B by EIA.\n (Reference Range-Negative).\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Transferred to\n ICU for increased PD requirement.\n # AMS: variable course over his stay. likely multifactorial including\n narcotics, toxic/metabolic related to renal failure. It appears to be\n most consistent with delirium. Had CT head with contrast on , but\n this does not definitively r/o brain metastases. Neuro exam is\n nonfocal. BUN has improved over the last 10 days.\n - PD as per renal recs\n - cont pain management as is for now, but wean if possible\n - avoid any other sedating medications\n - consider head imaging, but presentation unlikely from stroke. ?\n relation to brain mets. None on CT head with contrast, but this is\n inferior to MRI.\n # ESRD on PD: renal following. Sent to ICU for increased PD care per\n renal.\n - appreciate renal rcs\n - continue Calcitriol, epo per renal recs\n # LE weakness: underwent workup for cord compression, including spine\n consult. Not felt to be related to cord compression. Likely related\n to decondition, pain, lethargy from ? toxic/metabolic. ? myopathy or\n paraneoplastic.\n - PT\n - pain control\n - consider neuro consult, EMG, though goals of care should be addressed\n first.\n #Back Pain: Chronic. Sclerotic lesions in T and L spine by CT and\n lesion on iliac by octreotide scan. Also contribution of degenerative\n changes and deconditioning. followed by P&P Care.\n - f/u PT recs\n - cont pain regimen\n #. RIJ and L subclavian thrombus: Pt INR 3.5 today. Pt with difficult\n access and difficult lab draws. Sensitivity to coumadin likely \n nutrition deficiencies.\n - holding coumadin goal INR . Will need minimum of 3 months.\n - cont to monitor for bleeding\n # Abdominal Pain/Colitis\n s/p 10 day course of zosyn. On PO vanco for\n presumptive c. diff until . Finished IV Vancomycin for peritonitis.\n Has continued diffuse TTP and guarding. Afebrile with no signs of\n infection. ? ischemic.\n - consider resending peritoneal fluid for culture, though no fever or\n leukocytosis\n - send lactate\n - po Vanc until \n - trend exam, image for worsening.\n # Metastatic Carcinoid: Pt followed by Hem/Onc. Pt had octreotide scan\n that showed increase in disease.\n - palliatie care recs\n - pain control\n - f/u with Dr. re: long term care goals\n # Anemia: Baseline hct in low 30s, stable in upper 20s after 1 unit\n transfused. Guaiac positive brown stool.\n - goal Hct >25\n - guaiac all stools\n - PPI & trend hct\n # Tranaminitis\n LFTs trending down. Previously thought to be from\n shocked liver. Likely combination of malignancy and shocked liver.\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat . Plavix was discontinued given therapeutic to\n supertherapeutic INR and no stent in last year.\n - continue Aspirin 325mg\n - metoprolol held for hypotension. Restart as BP tolerates.\n - restart statin\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n # Decubitus Ulcer: wound care\n # FEN: Cont regular diet with shakes\n # Prophylaxis: Coumadin, PPI\n # Access: PIV\n # Code: DNR/DNI, but pressors/CVL okay as per last ICU stay. Needs to\n be readdressed with pt/family and goals of with Dr. .\n # Communication: Patient & wife \n # Disposition: ICU for PD. be able to go straight from ICU to\n rehab.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 10:21 PM\n 18 Gauge - 12:12 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 367858,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Planning family meeting at 3pm today. Had transient hypotension,\n resolved after 1L NS. Stopped oxycontin as seemed to cause AMS.\n Continued PD with q2h exchanges.\n BLOOD CULTURED - At 03:30 PM\n 1x unable to obtain 2nd\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:28 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36\nC (96.8\n HR: 81 (55 - 84) bpm\n BP: 140/60(79) {71/30(45) - 164/120(95)} mmHg\n RR: 10 (10 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,731 mL\n 83 mL\n PO:\n TF:\n IVF:\n 1,731 mL\n 83 mL\n Blood products:\n Total out:\n 5,500 mL\n -2,400 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,769 mL\n 2,483 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n L base)\n Abdominal: Soft, Bowel sounds present, Tender: RLQ with guarding\n Extremities: Right: 1+, Left: 1+, Cyanosis\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.8 g/dL\n 368 K/uL\n 108 mg/dL\n 6.5 mg/dL\n 30 mEq/L\n 4.4 mEq/L\n 29 mg/dL\n 101 mEq/L\n 139 mEq/L\n 27.6 %\n 7.0 K/uL\n [image002.jpg]\n 04:48 AM\n 03:44 AM\n WBC\n 6.7\n 7.0\n Hct\n 29.2\n 27.6\n Plt\n 388\n 368\n Cr\n 6.9\n 6.5\n Glucose\n 101\n 108\n Other labs: PT / PTT / INR:32.0/39.0/3.3, ALT / AST:26/18, Alk Phos / T\n Bili:106/0.2, Differential-Neuts:76.1 %, Lymph:15.8 %, Mono:5.7 %,\n Eos:1.9 %, Lactic Acid:1.7 mmol/L, Albumin:2.0 g/dL, LDH:236 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:6.3 mg/dL\n Assessment and Plan\n HYPOXEMIA\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n DELIRIUM / CONFUSION\n 78 y/o m with CAD, mx carcinoid, colitis with sepsis, ESRD on PD, here\n with AMS, slight hypotension, and abd pain.\n 1. AMS: Slightly related to oxycontin\n -avoid long acting meds, cont. standing tylenol and dilaudid prn\n 2. ESRD on PD:\n -discussing PD 4-6 times per day\n -calcitriol, epogen\n -goal positive 1L\n 3. Abd pain: ? C. Diff\n -cont. po vanco/flagyl until 6th\n -discuss pain regimen with palliative care\n -may be ischemic colitis, worsened with eating\n -PD fluid GS neg\n 4. Mx carcinoid: Interval progression of disease\n -readdress at family meeting\n 5. CAD: recent NSTEMI\n -cont. ASA, statin\n -start metoprolol 12.5 mg \n 6. sacral decub: wound care, turning\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 22 Gauge - 10:21 PM\n 18 Gauge - 12:12 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 367861,
"text": "Chief Complaint:\n 24 Hour Events:\n - Transient hypotension after Oxycontin dose, resolved with 1 L NS\n - Pancultured\n - Mental status waxed and waned, ? temporal relationship to Oxycontin\n dosing\n - Oxycontin discontinued\n - retarted Simvastatin\n - Continued PD q 2 hours without change\n - Family meeting scheduled for 3 PM on \n - c/o pain in sacrum in the PM\n - Resumed diet with improvement of mental status\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:28 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Nutritional Support: NPO\n Pain: Moderate\n Pain location: Sacrum\n Flowsheet Data as of 08:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.9\nC (96.7\n HR: 76 (55 - 84) bpm\n BP: 107/49(58) {71/30(45) - 164/120(95)} mmHg\n RR: 15 (11 - 38) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,731 mL\n 83 mL\n PO:\n TF:\n IVF:\n 1,731 mL\n 83 mL\n Blood products:\n Total out:\n 5,500 mL\n 100 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,769 mL\n -18 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Tender: diffusely\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm, sacral decub\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 368 K/uL\n 8.8 g/dL\n 108 mg/dL\n 6.5 mg/dL\n 30 mEq/L\n 4.4 mEq/L\n 29 mg/dL\n 101 mEq/L\n 139 mEq/L\n 27.6 %\n 7.0 K/uL\n [image002.jpg]\n 04:48 AM\n 03:44 AM\n WBC\n 6.7\n 7.0\n Hct\n 29.2\n 27.6\n Plt\n 388\n 368\n Cr\n 6.9\n 6.5\n Glucose\n 101\n 108\n Other labs: PT / PTT / INR:32.0/39.0/3.3, ALT / AST:26/18, Alk Phos / T\n Bili:106/0.2, Differential-Neuts:76.1 %, Lymph:15.8 %, Mono:5.7 %,\n Eos:1.9 %, Lactic Acid:1.7 mmol/L, Albumin:2.0 g/dL, LDH:236 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:6.3 mg/dL\n 3:04 pm PERITONEAL FLUID PERITONEAL FLUID.\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n FLUID CULTURE (Preliminary):\n ANAEROBIC CULTURE (Preliminary):\n FUNGAL CULTURE (Preliminary):\nCLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ):\n Feces negative for C.difficile toxin A & B by EIA.\n (Reference Range-Negative).\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n # AMS: Variable course over his stay, likely multifactorial with\n possible etiologies including narcotics, toxic/metabolic related to\n renal failure. It appears to be most consistent with delirium. Had CT\n head with contrast on , but this does not definitively r/o brain\n metastases. Neuro exam is nonfocal. BUN has improved over the last 10\n days.\n - PD as per renal recs\n - discuss pain regimen with P&PC\n - avoid any other sedating medications\n # ESRD on PD: Patient is a rapid transporter and requires 4 exchanges\n at 2 hour intervals daily.\n - Renal following\n - Fluid goal = slightly positive today\n - continue Calcitriol, epo per renal recs\n # LE weakness: underwent workup for cord compression, including spine\n consult. Not felt to be related to cord compression. Likely related\n to deconditioning, chronic pain, lethargy from ? toxic/metabolic. ?\n myopathy or paraneoplastic process.\n - PT consult\n - pain control\n - consider neuro consult, EMG, though goals of care should be addressed\n first.\n # Back Pain: Chronic. Sclerotic lesions in T and L spine by CT and\n lesion on iliac by octreotide scan. Also contribution of degenerative\n changes and deconditioning. followed by P&P Care.\n - f/u PT recs\n - cont pain regimen\n #. RIJ and L subclavian thrombus: Pt INR 3.5 today. Pt with difficult\n access and difficult lab draws. Sensitivity to coumadin likely \n nutrition deficiencies.\n - holding coumadin today\n - goal INR .\n - cont to monitor for bleeding\n # Abdominal Pain/Colitis\n s/p 10 day course of zosyn. On PO vanco for\n presumptive c. diff until , although cdiff toxin negative x 3.\n Finished IV Vancomycin for peritonitis. Has continued diffuse TTP and\n guarding. Afebrile with no signs of infection. ? ischemic, but lactate\n not elevated.\n - f/u peritoneal fluid culture from \n - send lactate\n - po Vanc until \n - trend exam, image for worsening.\n # Metastatic Carcinoid: Pt followed by Hem/Onc. Pt had octreotide scan\n that showed interval progression of disease.\n - palliative care following for symptomatic management\n - Dr. to address long term care goals at family meeting\n # Anemia: Baseline hct in low 30s, stable in upper 20s after 1 unit\n transfused. Guaiac positive brown stool.\n - goal Hct >25\n - guaiac all stools\n - PPI & trend hct\n # Tranaminitis\n LFTs trending down. Previously thought to be from\n shocked liver. Likely combination of malignancy and shocked liver.\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat . Plavix was discontinued given therapeutic to\n supertherapeutic INR and no stent in last year.\n - continue Aspirin 325mg, statin\n - resume beta-blocker now that hypotension resolved\n # Ureteral stent\n urology consulted for hyperdense finding in CT\n scan, thought to possibly be blood. Urology reviewed scan and did not\n think any intervention at this time was needed, especially in setting\n of this infection.\n # Decubitus Ulcer: as per wound care consult recommendations.\n # FEN: Cont regular diet with shake supplements.\n # Prophylaxis: Coumadin, PPI\n # Access: PIV\n # Code: DNR/DNI.\n # Communication: Patient & wife \n # Disposition: ICU, pending family meeting today at 3 PM with\n Oncology, P&PC to also attend.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 10:21 PM\n 18 Gauge - 12:12 PM\n Prophylaxis:\n DVT: Anticoagulated on coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 367829,
"text": "Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n PD exchange,alternating solutions with heparin and potassium added by\n RN. No abdominal pain, +bowel sounds.\n Action:\n Had 2 exchanges with last drain @0300. Left dry overnight.\n Response:\n Tolerated well. PD output clear yellow. -100-400cc balance.\n Plan:\n Continue PD exchange q2hrs with 2hr dwell x6/24hrs. Resume this\n morning. Add meds as ordered. F/u on cytology/cultures. Renal\n following.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stg on coccyx. No drainage.\n Action:\n Mepilex foam dressing applied.\n Response:\n Ongoing.\n Plan:\n Reconsult with wound care for treatment reccomendations.\n Delirium / confusion\n Assessment:\n Alert and oriented x2-3, but delirious. Following commands. MAE but\n weak and uncomfortable mets.\n Action:\n Ongoing assessment.\n Response:\n No change.\n Plan:\n Continue to monitor MS.\n Hypoxemia\n Assessment:\n Received patient on nasal prongs 4L. Lung sounds clear with diminished\n bases. No cough. No c/o SOB. RR 13-28.\n Action:\n Encouraged to cough and deep breathe.\n Response:\n Sats 100%. Resolved.\n Plan:\n Monitor respiratory status, wean o2 as tolerated.\n HR 69-80\ns SR with no ectopy. BP 115-164/46-63.\n Small amount of brown stool.\n Chronic back and sacral pain. Medicated x1 with 2mg dilaudid\n with effect. Has lidocaine patch QD, oxycontin was d/c\nd poosible\n effect of hypotension and patient becoming more lethargic. Ordered for\n lactulose QD.\n Afebrile. On po vanco for colitis. WBC wnl.\n DNR/DNI. Wife in last evening. Family mtg planned for 3pm\n today to discuss goals of care.\n Patient to be called out to the floor this morning but issue\n may remain as to the number of PD exchanges needed QD with short dwell\n times and being too much for the floor to handle.\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 367930,
"text": "Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n PD exchange, Q6H with heparin and potassium added by RN. No abdominal\n pain, +bowel sounds.\n Action:\n Pt had last PD instillation at 2300 and will be drained at 100. using\n 1.5% only for 2hr dwell time.\n Response:\n Tolerated well. PD output clear yellow.\n Plan:\n Continue PD exchange with 2hr dwell 4x per day. Will drain last PD\n exchange at 100. Cont PD as we are doing. Add meds as ordered. F/u\n on cytology/cultures. Renal following.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stg on coccyx. Sm amounts of purulent/bldy drainage noted. Pt\n stooling x2 liquid GUIAIC + stool, noted to dirty dressing\n Action:\n Cleansed with wound cleanser. Mepilex foam dressing changed x2,\n mushroom cath. Inserted for stool management. Frequent turning\n q2-3hrs.\n Response:\n Ongoing.\n Plan:\n Reconsult with wound care for treatment reccomendations. Cont.\n frequent skin care and turning.\n Delirium / confusion\n Assessment:\n Alert and oriented x2-3, but delirious. Following commands. MAE but\n weak and uncomfortable mets. C/o back pain and nausea.\n Asking for\nthe to take him\n Action:\n Ongoing assessment. Treated pain with Lidocaine patch and 2mg PO\n dilaudid x1 and Zofran for nausea.\n Response:\n No change. Pt noted to be more lethargic s/p pain medication.\n Plan:\n Continue to monitor MS.\n Hypoxemia\n Assessment:\n Received patient on nasal prongs 4L. Lung sounds clear with diminished\n bases. No cough. No c/o SOB. RR 13-28. Sating 98%\n Action:\n Encouraged to cough and deep breathe. Supplemental 02 removed.\n Response:\n Sats 100% on ra. Issue resolved.\n Plan:\n Monitor respiratory status.\n Afebrile. On po vanco for colitis. WBC wnl.\n DNR/DNI. Wife in this PM. Family mtg today involving\n Heme-Onc, Palliative care MD, and this RN regarding POC and code\n status. Discussed at length with pt\ns wife about poor prognosis of pt,\n and also discussed the option of being discharged to home with\n palliative services. Wife is interested in this, and would like to\n discuss this tomorrow with palliative care MD and pt when pt is more\n alert and oriented.\n Pt is c/o to floor, awaiting bed assignment.\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 367931,
"text": "Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n PD exchange, Q6H with heparin and potassium added by RN. No abdominal\n pain, +bowel sounds.\n Action:\n Pt had last PD instillation at 2300 and will be drained at 100. using\n 1.5% only for 2hr dwell time.\n Response:\n Tolerated well. PD output clear yellow.\n Plan:\n Continue PD exchange with 2hr dwell 4x per day. Will drain last PD\n exchange at 100. Cont PD as we are doing. Add meds as ordered. F/u\n on cytology/cultures. Renal following.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stg on coccyx. Sm amounts of purulent/bldy drainage noted. Pt\n stooling x2 liquid GUIAIC + stool, noted to dirty dressing\n Action:\n Cleansed with wound cleanser. Mepilex foam dressing changed x2,\n mushroom cath. Inserted for stool management. Frequent turning\n q2-3hrs.\n Response:\n Ongoing.\n Plan:\n Reconsult with wound care for treatment reccomendations. Cont.\n frequent skin care and turning.\n Delirium / confusion\n Assessment:\n Alert and oriented x2-3, but delirious. Following commands. MAE but\n weak and uncomfortable mets. C/o back pain and nausea.\n Asking for\nthe to take him\n Action:\n Ongoing assessment. Treated pain with Lidocaine patch and 2mg PO\n dilaudid x1 and Zofran for nausea.\n Response:\n No change. Pt noted to be more lethargic s/p pain medication.\n Plan:\n Continue to monitor MS.\n Hypoxemia\n Assessment:\n Received patient on nasal prongs 4L. Lung sounds clear with diminished\n bases. No cough. No c/o SOB. RR 13-28. Sating 98%\n Action:\n Encouraged to cough and deep breathe. Supplemental 02 removed.\n Response:\n Sats 100% on ra. Issue resolved.\n Plan:\n Monitor respiratory status.\n Afebrile. On po vanco for colitis. WBC wnl.\n DNR/DNI. Wife in this PM. Family mtg today involving\n Heme-Onc, Palliative care MD, and this RN regarding POC and code\n status. Discussed at length with pt\ns wife about poor prognosis of pt,\n and also discussed the option of being discharged to home with\n palliative services. Wife is interested in this, and would like to\n discuss this tomorrow with palliative care MD and pt when pt is more\n alert and oriented.\n Pt is c/o to floor, awaiting bed assignment.\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n SEPSIS\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 63.7 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH:\n CV-PMH: CAD, Hypertension\n Additional history: Carcinoid tumor with mets to liver, hyperlipidemia\n , CAD s/p CABG x4 in , s/p bilateral carotid endarterectomies,\n AAA measuring 5 cm on \n ESRD on PD since , s/p HD tunneled cath placement, sigmoid\n diverticulitis, BPH , H/o ruptured disk, s/p vasectomy, eye surgery,\n tonsillectomy.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:148\n D:61\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:44 AM\n Potassium:\n 4.4 mEq/L\n 03:44 AM\n Chloride:\n 101 mEq/L\n 03:44 AM\n CO2:\n 30 mEq/L\n 03:44 AM\n BUN:\n 29 mg/dL\n 03:44 AM\n Creatinine:\n 6.5 mg/dL\n 03:44 AM\n Glucose:\n 108 mg/dL\n 03:44 AM\n Hematocrit:\n 27.6 %\n 03:44 AM\n Finger Stick Glucose:\n 147\n 12:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 367820,
"text": "Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n PD exchange,alternating solutions with heparin and potassium added by\n RN. No abdominal pain, +bowel sounds.\n Action:\n Had 2 exchanges with last drain @0300. Left dry overnight.\n Response:\n Tolerated well. PD output clear yellow. -100-400cc balance.\n Plan:\n Continue PD exchange q2hrs with 2hr dwell x6/24hrs. Resume this\n morning. Add meds as ordered. F/u on cytology/cultures. Renal\n following.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stg on coccyx. No drainage.\n Action:\n Mepilex foam dressing applied.\n Response:\n Ongoing.\n Plan:\n Reconsult with wound care for treatment reccomendations.\n Delirium / confusion\n Assessment:\n Alert and oriented x2-3, but delirious. Following commands. MAE but\n weak and uncomfortable mets.\n Action:\n Ongoing assessment.\n Response:\n No change.\n Plan:\n Continue to monitor MS.\n Hypoxemia\n Assessment:\n Received patient on nasal prongs 4L. Lung sounds clear with diminished\n bases. No cough. No c/o SOB. RR 13-28.\n Action:\n Encouraged to cough and deep breathe.\n Response:\n Sats 100%. Resolved.\n Plan:\n Monitor respiratory status, wean o2 as tolerated.\n HR 69-80\ns SR with no ectopy. BP 115-164/46-63.\n Small amount of brown stool.\n Chronic back and sacral pain. Medicated x1 with 2mg dilaudid\n with effect. Has lidocaine patch QD, oxycontin was d/c\nd poosible\n effect of hypotension and patient becoming more lethargic. Ordered for\n lactulose QD.\n Afebrile. On po vanco for colitis. WBC wnl.\n DNR/DNI. Wife in last evening. Family mtg planned for 3pm\n today to discuss goals of care.\n Patient to be called out to the floor this morning but issue\n may remain as to the number of PD exchanges needed QD with short dwell\n times and being too much for the floor to handle.\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 367718,
"text": "TITLE:\n Chief Complaint: q 2 hr PD\n 24 Hour Events:\n - transferred from floor for q 2 hr PD\n - transient hypoxia intermittently overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 73 (62 - 84) bpm\n BP: 98/49(61) {85/42(51) - 137/67(83)} mmHg\n RR: 41 (9 - 41) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 100 mL\n 4,000 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n -4,000 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 388 K/uL\n 9.1 g/dL\n 101 mg/dL\n 6.9 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 36 mg/dL\n 100 mEq/L\n 138 mEq/L\n 29.2 %\n 6.7 K/uL\n [image002.jpg]\n 04:48 AM\n WBC\n 6.7\n Hct\n 29.2\n Plt\n 388\n Cr\n 6.9\n Glucose\n 101\n Other labs: ALT / AST:28/18, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:76.1 %, Lymph:15.8 %, Mono:5.7 %, Eos:1.9 %,\n Albumin:2.0 g/dL, LDH:236 IU/L, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL, PO4:5.9\n mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Now with\n ileus/SBO.\n .\n # AMS: variable course over his stay. likely multifactorial including\n narcotics, toxic/metabolic related to renal failure. It appears to be\n most consistent with delirium. Had CT head with contrast on , but\n this does not definitively r/o brain metastases. Neuro exam is\n nonfocal. BUN has improved over the last 10 days.\n - PD as per renal recs\n - cont pain management as is for now, but wean if possible\n - avoid any other sedating medications\n - consider head imaging, but presentation unlikely from stroke. ?\n relation to brain mets. None on CT head with contrast, but this is\n inferior to MRI.\n .\n # ESRD on PD: renal following. Sent to ICU for increased PD care per\n renal.\n - appreciate renal recs\n - continue Calcitriol, epo per renal recs\n .\n # LE weakness: underwent workup for cord compression, including spine\n consult. Not felt to be related to cord compression. Likely related\n to decondition, pain, lethargy from ? toxic/metabolic. ? myopathy.\n - PT\n - pain control\n - consider neuro consult, EMG, though goals of care should be addressed\n first.\n .\n #Back Pain: Chronic. Sclerotic lesions in T and L spine by CT and\n lesion on iliac by octreotide scan. Also contribution of degenerative\n changes and deconditioning. followed by P&P Care.\n - f/u PT recs\n - cont pain regimen\n .\n #. RIJ and L subclavian thrombus: Pt INR 3.5 today. Pt with difficult\n access and difficult lab draws. Sensitivity to coumadin likely \n nutrition deficiencies.\n - holding coumadin goal INR . Will need minimum of 3 months.\n - cont to monitor for bleeding\n .\n # Abdominal Pain/Colitis\n s/p 10 day course of zosyn. On PO vanco for\n presumptive c. diff until . Finished IV Vancomycin for peritonitis.\n Has continued diffuse TTP.\n - po Vanc until \n - trend exam, image for worsening.\n .\n #. Ileus/partial SBO: Resolved. tolerating regular diet. Pt clear by\n S&W.\n - cont to monitor\n .\n # Metastatic Carcinoid: Pt followed by Hem/Onc. Pt had octreotide scan\n that showed increase in disease.\n - palliative care recs\n - pain control\n - f/u with Dr. re: long term care goals\n .\n # Anemia: Baseline hct in low 30s, stable in upper 20s after 1 unit\n transfused. Guaiac was negative per resident report, but positive per\n nursing report.\n - goal Hct >25\n - guaiac all stools\n - PPI & trend hct\n .\n # Tranaminitis\n LFTs trending down. Previously thought to be from\n shocked liver. Likely combination of malignancy and shocked liver.\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat . Plavix was discontinued given therapeutic to\n supertherapeutic INR and no stent in last year.\n - continue Aspirin 325mg\n - metoprolol held for hypotension. Restart as BP tolerates.\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Decubitus Ulcer: wound care\n .\n # FEN: Cont regular diet with shakes\n .\n # Prophylaxis: Coumadin, PPI\n .\n # Access: PIV\n .\n # Code: DNR/DNI, but pressors/CVL okay as per last ICU stay. Needs to\n be readdressed with pt/family and goals of with Dr. .\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for PD. be able to go straight from ICU to\n rehab.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 10:21 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-22 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 367730,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 78 y/o m with CAD, recent NSTEMI with POBA, CRF on PD, mx carcinoid p/w\n abd pain and hct drop. CT abd at OSH showed colitis. Developed sepsis,\n finished 10d zosyn, vanco 2 weeks, po vanco for empiric C. Fiff\n coverage. Initially in MICU organge, went to floor , course c/b UE\n DVT, had some hypotension on that responded to IVF, had some\n diffuse weakness, imaging of spine showed no cord compression but\n advancing mx disease. Had increasing PD requirements for volume\n overload as well as uremia, so transferred to ICU for q2h PD.\n Overnight had slight hypoxia while sleeping.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n See resident note\n See resident note\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: see resident note\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, Weight loss\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: Dialysis\n Integumentary (skin): No(t) Rash\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: Anemia, Coagulopathy\n Neurologic: back pain, confusion\n Psychiatric / Sleep: Delirious\n Pain: Mild\n Pain location: back\n Flowsheet Data as of 09:47 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 35.4\nC (95.8\n HR: 74 (62 - 84) bpm\n BP: 104/89(93) {85/42(51) - 137/89(93)} mmHg\n RR: 23 (9 - 41) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 100 mL\n 4,000 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n -4,000 mL\n Respiratory\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///29/\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Rhonchorous: bases)\n Abdominal: Soft, Tender: diffuse with guarding\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person/place/date, Movement: Not assessed,\n Tone: Not assessed, +asterixis\n Labs / Radiology\n 388 K/uL\n 29.2 %\n 9.1 g/dL\n 101 mg/dL\n 6.9 mg/dL\n 36 mg/dL\n 29 mEq/L\n 100 mEq/L\n 4.4 mEq/L\n 138 mEq/L\n 6.7 K/uL\n [image002.jpg]\n 04:48 AM\n WBC\n 6.7\n Hct\n 29.2\n Plt\n 388\n Cr\n 6.9\n Glucose\n 101\n Other labs: ALT / AST:28/18, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:76.1 %, Lymph:15.8 %, Mono:5.7 %, Eos:1.9 %,\n Albumin:2.0 g/dL, LDH:236 IU/L, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL, PO4:5.9\n mg/dL\n Assessment and Plan\n HYPOXEMIA\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n DELIRIUM / CONFUSION\n 78 y/o m with CAD, carcinoid, with recent sepsis colitis.\n 1. AMS: Suspect delirium\n -currently fully oriented\n -cont PD\n -avoid sedation, avoid heavy narcotics\n 2. ESRD on PD\n -f/u renal recs\n 3. LE weakness: be critical illness myopathy\n -consider neuro eval\n 4. carcinoid: Worsening mx disease\n -cont. pain control\n 5. RUE thrombus: On coumadin\n -in setting of CVL\n -check INR\n 6. colitis: ? ischemic vs. infectious\n -cont. renal diet\n -avoid persistent hypotension\n 7. GOC: Dr. planning a family meeting\n 8. CAD, recent NSTEMI: cont. ASA\n -start statin\n -consider BB when BP stable\n 9. sacral decub: wound care c/s\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 22 Gauge - 10:21 PM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 367735,
"text": "TITLE:\n Chief Complaint: q 2 hr PD\n 24 Hour Events:\n - transferred from floor for q 2 hr PD\n - transient hypoxia intermittently overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 73 (62 - 84) bpm\n BP: 98/49(61) {85/42(51) - 137/67(83)} mmHg\n RR: 41 (9 - 41) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 100 mL\n 4,000 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n -4,000 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n GEN: NAD\n pulm: decreased BS on right, o/w no w/r/r\n Cv: hrrr, no m/r/g\n Abd: diffusely TTP with guarding\n Extr: bilateral 2+ LE edema\n Neuro: aox3\n Labs / Radiology\n 388 K/uL\n 9.1 g/dL\n 101 mg/dL\n 6.9 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 36 mg/dL\n 100 mEq/L\n 138 mEq/L\n 29.2 %\n 6.7 K/uL\n [image002.jpg]\n 04:48 AM\n WBC\n 6.7\n Hct\n 29.2\n Plt\n 388\n Cr\n 6.9\n Glucose\n 101\n Other labs: ALT / AST:28/18, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:76.1 %, Lymph:15.8 %, Mono:5.7 %, Eos:1.9 %,\n Albumin:2.0 g/dL, LDH:236 IU/L, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL, PO4:5.9\n mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Transferred to\n ICU for increased PD requirement.\n # AMS: variable course over his stay. likely multifactorial including\n narcotics, toxic/metabolic related to renal failure. It appears to be\n most consistent with delirium. Had CT head with contrast on , but\n this does not definitively r/o brain metastases. Neuro exam is\n nonfocal. BUN has improved over the last 10 days.\n - PD as per renal recs\n - cont pain management as is for now, but wean if possible\n - avoid any other sedating medications\n - consider head imaging, but presentation unlikely from stroke. ?\n relation to brain mets. None on CT head with contrast, but this is\n inferior to MRI.\n # ESRD on PD: renal following. Sent to ICU for increased PD care per\n renal.\n - appreciate renal recs\n - continue Calcitriol, epo per renal recs\n # LE weakness: underwent workup for cord compression, including spine\n consult. Not felt to be related to cord compression. Likely related\n to decondition, pain, lethargy from ? toxic/metabolic. ? myopathy or\n paraneoplastic.\n - PT\n - pain control\n - consider neuro consult, EMG, though goals of care should be addressed\n first.\n #Back Pain: Chronic. Sclerotic lesions in T and L spine by CT and\n lesion on iliac by octreotide scan. Also contribution of degenerative\n changes and deconditioning. followed by P&P Care.\n - f/u PT recs\n - cont pain regimen\n #. RIJ and L subclavian thrombus: Pt INR 3.5 today. Pt with difficult\n access and difficult lab draws. Sensitivity to coumadin likely \n nutrition deficiencies.\n - holding coumadin goal INR . Will need minimum of 3 months.\n - cont to monitor for bleeding\n # Abdominal Pain/Colitis\n s/p 10 day course of zosyn. On PO vanco for\n presumptive c. diff until . Finished IV Vancomycin for peritonitis.\n Has continued diffuse TTP and guarding. Afebrile with no signs of\n infection. ? ischemic.\n - consider resending peritoneal fluid for culture, though no fever or\n leukocytosis\n - send lactate\n - po Vanc until \n - trend exam, image for worsening.\n # Metastatic Carcinoid: Pt followed by Hem/Onc. Pt had octreotide scan\n that showed increase in disease.\n - palliative care recs\n - pain control\n - f/u with Dr. re: long term care goals\n # Anemia: Baseline hct in low 30s, stable in upper 20s after 1 unit\n transfused. Guaiac positive brown stool.\n - goal Hct >25\n - guaiac all stools\n - PPI & trend hct\n # Tranaminitis\n LFTs trending down. Previously thought to be from\n shocked liver. Likely combination of malignancy and shocked liver.\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat . Plavix was discontinued given therapeutic to\n supertherapeutic INR and no stent in last year.\n - continue Aspirin 325mg\n - metoprolol held for hypotension. Restart as BP tolerates.\n - restart statin\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n # Decubitus Ulcer: wound care\n # FEN: Cont regular diet with shakes\n # Prophylaxis: Coumadin, PPI\n # Access: PIV\n # Code: DNR/DNI, but pressors/CVL okay as per last ICU stay. Needs to\n be readdressed with pt/family and goals of with Dr. .\n # Communication: Patient & wife \n # Disposition: ICU for PD. be able to go straight from ICU to\n rehab.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 10:21 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 367817,
"text": "Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n PD exchange,alternating solutions with heparin and potassium added by\n RN. No abdominal pain, +bowel sounds.\n Action:\n Had 2 exchanges with last drain @0300. Left dry overnight.\n Response:\n Tolerated well. PD output clear.\n Plan:\n Continue PD exchange q2hrs with 2hr dwell x6/24hrs. Resume this\n morning. Add meds as ordered.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stg on coccyx. No drainage.\n Action:\n Mepilex foam dressing applied.\n Response:\n Ongoing.\n Plan:\n Reconsult with wound care for treatment reccomendations.\n Delirium / confusion\n Assessment:\n Alert and oriented x2-3, but delirious. Following commands. MAE but\n weak and uncomfortable mets.\n Action:\n Ongoing assessment.\n Response:\n No change.\n Plan:\n Continue to monitor MS.\n Hypoxemia\n Assessment:\n Arrived to floor on room air with sats 90% but extremities cool and\n pleth with poor waveform. Lung sounds clear with diminished bases. No\n cough. No c/o SOB. RR teens with some apneic periods.\n Action:\n Sats persistently low this morning. Added 50% face tent.\n Response:\n Sats improved to 100%.\n Plan:\n Monitor respiratory status, wean o2 as tolerated.\n HR 60-80\ns SR with rare ectopy. BP 86-137/42-67.\n Stool x2, brown but guiac +.\n Chronic back pain. Medicated x1 with 2mg dilaudid with\n effect. Has standing oxycontin and lidocaine patch.\n Afebrile. On po vanco for colitis. WBC wnl.\n DNR/DNI. No contact from wife. ?palliative care consult if\n not already done.\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 367711,
"text": "Mr. is a 78 yo male with PMh of CAD s/p CABG, metastatic\n carcinoid, ESRD on PD, chronic abd/back pain, and AAA who originally\n came in on with abdominal pain and has undergone a complicated\n course since. He presented to with hypotension and a\n hct drop, CT scan showed stable AAA and colitis, and worsening\n metastatic disease. Transferred to where surgery did not feel\n there were any acute surgical issues. Because of pressor dependent\n hypotension, he was admitted to the MICU where he was treated with po\n vanco and IV flagyl for presumptive cdiff (stool cultures were negative\n x 2). He was given zosyn empirically for colitis/diverticulitis and IV\n vancomycin for peritonitis. Peritoneal fluid had > 3500 WBCs, but\n culture was negative. He had an initial three pressor requirment. His\n PD was continued. He improved and was weaned off pressors by . He\n has since finished a 10 day course of zosyn for diverticulitis/colitis\n and a 2 week course IV vanc (completed ) for culture negative\n peritonitis. His PO vanc is planned for 2 weeks after cessation of his\n zosyn, to be completed on .\n .\n His recovery has been complicated by SBO vs ileus, requiring TPN over\n TF, which resolved on with successful advancment of diet. He has\n had significant pain requirments for severe back pain, eventually\n managed on gabapentin 100mg qhs, oxycontin 20 , standing tylenol,\n and dilaudid 2mg q 4 hours prn. Elevated LFTs thought shock He\n had an HCT drop to 23 from BL low 30s. He had one transfusion of pRBCs\n on and his HCT has been stable since. He was guaiac negative. He\n was transferred to the floor on .\n .\n On , UE showed RIJ occlusive thrombus, left subclavian nonocclusive\n thrombus, and left basilic vein occlusive thrombus. He had a RIJ CVL\n had already been removed. His right PICC was removed at that time. He\n was started on coumadin.\n In addition to pain, he has had progressive generalized weakness.\n There was a concern for cord compression. A CT of his C-T-L spine on\n showed sclerotic lesions concerning for new malignancy in his T\n and L spine. Octreotide scan showed increasing carcinoid tumor burden\n in liver, pelvic bone, posterior musculature abd wall, but not in his\n spine. The CT was without contrast out of concern for harming his\n kidneys and making PD no longer an option. The patient refused MRI.\n There was no cord compression by exam and spine consult did not think\n his exam was consistent with cord compression.\n He is being transferred to the MICU now to increased need for PD\n dialysis. His PD schedule was increased to q 2 hrs by renal to\n encephalopathy with worsening asterixis and hyperreflexivity thought\n uremia. He is DNR/DNI though accepted pressors and CVL during this\n admission. He currently complains of back pain and pain in his sacral\n decube. He denies any other pain, CP, SOB.\n .\n Regarding his metastatic carcinoid, his outpatient oncologist, Dr. \n has been involved. He was started on octreotide 50mcg TID sq which was\n subsequently discontinued out of concern for hypotension. There is\n currently an ongoing discussion between Dr. and the patient and\n family regarding goals of care and his possible appropriateness for\n hospice.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n PD exchange,alternating solutions with heparin and potassium added by\n RN. No abdominal pain, +bowel sounds.\n Action:\n Had 2 exchanges with last drain @0400. Left dry overnight.\n Response:\n Tolerated well. PD output clear.\n Plan:\n Continue PD exchange q2hrs with 2hr dwell x6/24hrs. Resume this\n morning. Add meds as ordered.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stg on coccyx. No drainage.\n Action:\n Mepilex foam dressing applied.\n Response:\n Ongoing.\n Plan:\n Need reconsult with wound care for treatment reccomendations.\n Delirium / confusion\n Assessment:\n Alert and oriented x3, but delirious. Following commands. MAE but weak\n and uncomfortable mets.\n Action:\n Ongoing assessment.\n Response:\n No change.\n Plan:\n Continue to monitor MS.\n Hypoxemia\n Assessment:\n Arrived to floor on room air with sats 90% but extremities cool and\n pleth with poor waveform. Lung sounds clear with diminished bases. No\n cough. No c/o SOB. RR teens with some apneic periods.\n Action:\n Sats persistently low this morning. Added 50% face tent.\n Response:\n Sats improved to 100%.\n Plan:\n Monitor respiratory status, wean o2 as tolerated.\n HR 60-80\ns SR with rare ectopy. BP 86-137/42-67.\n Stool x2, brown but guiac +.\n Chronic back pain. Medicated x1 with 2mg dilaudid with\n effect. Has standing oxycontin and lidocaine patch.\n Afebrile. On po vanco for colitis. WBC wnl.\n DNR/DNI. No contact from wife. ?palliative care consult if\n not already done.\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 367712,
"text": "Mr. is a 78 yo male with PMh of CAD s/p CABG, metastatic\n carcinoid, ESRD on PD, chronic abd/back pain, and AAA who originally\n came in on with abdominal pain and has undergone a complicated\n course since. He presented to with hypotension and a\n hct drop, CT scan showed stable AAA and colitis, and worsening\n metastatic disease. Transferred to where surgery did not feel\n there were any acute surgical issues. Because of pressor dependent\n hypotension, he was admitted to the MICU where he was treated with po\n vanco and IV flagyl for presumptive cdiff (stool cultures were negative\n x 2). He was given zosyn empirically for colitis/diverticulitis and IV\n vancomycin for peritonitis. Peritoneal fluid had > 3500 WBCs, but\n culture was negative. He had an initial three pressor requirment. His\n PD was continued. He improved and was weaned off pressors by . He\n has since finished a 10 day course of zosyn for diverticulitis/colitis\n and a 2 week course IV vanc (completed ) for culture negative\n peritonitis. His PO vanc is planned for 2 weeks after cessation of his\n zosyn, to be completed on .\n .\n His recovery has been complicated by SBO vs ileus, requiring TPN over\n TF, which resolved on with successful advancment of diet. He has\n had significant pain requirments for severe back pain, eventually\n managed on gabapentin 100mg qhs, oxycontin 20 , standing tylenol,\n and dilaudid 2mg q 4 hours prn. Elevated LFTs thought shock He\n had an HCT drop to 23 from BL low 30s. He had one transfusion of pRBCs\n on and his HCT has been stable since. He was guaiac negative. He\n was transferred to the floor on .\n .\n On , UE showed RIJ occlusive thrombus, left subclavian nonocclusive\n thrombus, and left basilic vein occlusive thrombus. He had a RIJ CVL\n had already been removed. His right PICC was removed at that time. He\n was started on coumadin.\n In addition to pain, he has had progressive generalized weakness.\n There was a concern for cord compression. A CT of his C-T-L spine on\n showed sclerotic lesions concerning for new malignancy in his T\n and L spine. Octreotide scan showed increasing carcinoid tumor burden\n in liver, pelvic bone, posterior musculature abd wall, but not in his\n spine. The CT was without contrast out of concern for harming his\n kidneys and making PD no longer an option. The patient refused MRI.\n There was no cord compression by exam and spine consult did not think\n his exam was consistent with cord compression.\n He is being transferred to the MICU now to increased need for PD\n dialysis. His PD schedule was increased to q 2 hrs by renal to\n encephalopathy with worsening asterixis and hyperreflexivity thought\n uremia. He is DNR/DNI though accepted pressors and CVL during this\n admission. He currently complains of back pain and pain in his sacral\n decube. He denies any other pain, CP, SOB.\n .\n Regarding his metastatic carcinoid, his outpatient oncologist, Dr. \n has been involved. He was started on octreotide 50mcg TID sq which was\n subsequently discontinued out of concern for hypotension. There is\n currently an ongoing discussion between Dr. and the patient and\n family regarding goals of care and his possible appropriateness for\n hospice.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n PD exchange,alternating solutions with heparin and potassium added by\n RN. No abdominal pain, +bowel sounds.\n Action:\n Had 2 exchanges with last drain @0400. Left dry overnight.\n Response:\n Tolerated well. PD output clear.\n Plan:\n Continue PD exchange q2hrs with 2hr dwell x6/24hrs. Resume this\n morning. Add meds as ordered.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stg on coccyx. No drainage.\n Action:\n Mepilex foam dressing applied.\n Response:\n Ongoing.\n Plan:\n Need reconsult with wound care for treatment reccomendations.\n Delirium / confusion\n Assessment:\n Alert and oriented x3, but delirious. Following commands. MAE but weak\n and uncomfortable mets.\n Action:\n Ongoing assessment.\n Response:\n No change.\n Plan:\n Continue to monitor MS.\n Hypoxemia\n Assessment:\n Arrived to floor on room air with sats 90% but extremities cool and\n pleth with poor waveform. Lung sounds clear with diminished bases. No\n cough. No c/o SOB. RR teens with some apneic periods.\n Action:\n Sats persistently low this morning. Added 50% face tent.\n Response:\n Sats improved to 100%.\n Plan:\n Monitor respiratory status, wean o2 as tolerated.\n HR 60-80\ns SR with rare ectopy. BP 86-137/42-67.\n Stool x2, brown but guiac +.\n Chronic back pain. Medicated x1 with 2mg dilaudid with\n effect. Has standing oxycontin and lidocaine patch.\n Afebrile. On po vanco for colitis. WBC wnl.\n DNR/DNI. No contact from wife. ?palliative care consult if\n not already done.\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 367911,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Planning family meeting at 3pm today. Had transient hypotension,\n resolved after 1L NS. Stopped oxycontin as seemed to cause AMS.\n Continued PD with q2h exchanges.\n BLOOD CULTURED - At 03:30 PM\n 1x unable to obtain 2nd\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:28 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36\nC (96.8\n HR: 81 (55 - 84) bpm\n BP: 140/60(79) {71/30(45) - 164/120(95)} mmHg\n RR: 10 (10 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,731 mL\n 83 mL\n PO:\n TF:\n IVF:\n 1,731 mL\n 83 mL\n Blood products:\n Total out:\n 5,500 mL\n -2,400 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,769 mL\n 2,483 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n L base)\n Abdominal: Soft, Bowel sounds present, Tender: RLQ with guarding\n Extremities: Right: 1+, Left: 1+, Cyanosis\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.8 g/dL\n 368 K/uL\n 108 mg/dL\n 6.5 mg/dL\n 30 mEq/L\n 4.4 mEq/L\n 29 mg/dL\n 101 mEq/L\n 139 mEq/L\n 27.6 %\n 7.0 K/uL\n [image002.jpg]\n 04:48 AM\n 03:44 AM\n WBC\n 6.7\n 7.0\n Hct\n 29.2\n 27.6\n Plt\n 388\n 368\n Cr\n 6.9\n 6.5\n Glucose\n 101\n 108\n Other labs: PT / PTT / INR:32.0/39.0/3.3, ALT / AST:26/18, Alk Phos / T\n Bili:106/0.2, Differential-Neuts:76.1 %, Lymph:15.8 %, Mono:5.7 %,\n Eos:1.9 %, Lactic Acid:1.7 mmol/L, Albumin:2.0 g/dL, LDH:236 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:6.3 mg/dL\n Assessment and Plan\n HYPOXEMIA\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n DELIRIUM / CONFUSION\n 78 y/o m with CAD, mx carcinoid, colitis with sepsis, ESRD on PD, here\n with AMS, slight hypotension, and abd pain.\n 1. AMS: Slightly related to oxycontin\n -avoid long acting meds, cont. standing tylenol and dilaudid prn\n 2. ESRD on PD:\n -discussing PD 4-6 times per day\n -calcitriol, epogen\n -goal positive 1L\n 3. Abd pain: ? C. Diff\n -cont. po vanco/flagyl until 6th\n -discuss pain regimen with palliative care\n -may be ischemic colitis, worsened with eating\n -PD fluid GS neg\n 4. Mx carcinoid: Interval progression of disease\n -readdress at family meeting\n 5. CAD: recent NSTEMI\n -cont. ASA, statin\n -start metoprolol 12.5 mg \n 6. sacral decub: wound care, turning\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 22 Gauge - 10:21 PM\n 18 Gauge - 12:12 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent:\n ------ Protected Section ------\n I have seen and examined the patient with the fellow, reviewed and\n agree with the assessment and plan as above with the following\n modifications and emphasis:\n 78 year old male with CAD, NSTEMI, carcinoid tumor, ESRD on PD admitted\n to the hospital with colitis and transferred to the ICU because of\n change in mental status.\n No episodes of hypotension since yesterday and mental status improved\n thus likely related to the oxycodone.\n On exam, temp 36.8 P 81 BP 123/66 RR 20 95%\n Awake, alert\n Chest: CTA bilaterally\n Heart: S1S2 reg\n Abd: soft, NT, ND\n Ext: warm\n A:\n 1) Mental Status Changes: improved since yesterday and likely the\n result of oxycodone (in part)\n 2) Hypotension\n no episodes since yesterday and therefore likely\n oxycodone\n 3) Carcinoid tumor\n 4) ESRD on PD\n 5) CAD\n 6) Venous thrombosus\n Plan:\n - Can transfer to the floor\n - Continue PD\n - Family meeting today\n Time: 15 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 18:55 ------\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 367899,
"text": "Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n PD exchange,alternating solutions with heparin and potassium added by\n RN. No abdominal pain, +bowel sounds.\n Action:\n Had 2 exchanges with instillation at 1700. PD exchanges changed to\n q4h, using 1.5% only for 2hr dwell time.\n Response:\n Tolerated well. PD output clear yellow. -100-400cc balance.\n Plan:\n Continue PD exchange q2hrs with 2hr dwell x4/24hrs. Will drain last PD\n exchange at 1900. Resume tonight. Add meds as ordered. F/u on\n cytology/cultures. Renal following.\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stg on coccyx. Sm amounts of purulent/bldy drainage noted. Pt\n stooling x2 liquid GUIAIC + stool, noted to dirty dressing\n Action:\n Cleansed with wound cleanser. Mepilex foam dressing changed x2,\n mushroom cath. Inserted for stool management. Frequent turning\n q2-3hrs.\n Response:\n Ongoing.\n Plan:\n Reconsult with wound care for treatment reccomendations. Cont.\n frequent skin care and turning.\n Delirium / confusion\n Assessment:\n Alert and oriented x2-3, but delirious. Following commands. MAE but\n weak and uncomfortable mets. C/o back pain.\n Action:\n Ongoing assessment. Treated pain with Lidocaine patch and 2mg PO\n dilaudid x1.\n Response:\n No change. Pt noted to be more lethargic s/p pain medication.\n Plan:\n Continue to monitor MS.\n Hypoxemia\n Assessment:\n Received patient on nasal prongs 4L. Lung sounds clear with diminished\n bases. No cough. No c/o SOB. RR 13-28. Sating 98%\n Action:\n Encouraged to cough and deep breathe. Supplemental 02 removed.\n Response:\n Sats 100% on ra. Issue resolved.\n Plan:\n Monitor respiratory status.\n Afebrile. On po vanco for colitis. WBC wnl.\n DNR/DNI. Wife in this PM. Family mtg today involving\n Heme-Onc, Palliative care MD, and this RN regarding POC and code\n status. Discussed at length with pt\ns wife about poor prognosis of pt,\n and also discussed the option of being discharged to home with\n palliative services. Wife is interested in this, and would like to\n discuss this tomorrow with palliative care MD and pt when pt is more\n alert and oriented.\n Pt is c/o to floor, awaiting bed assignment.\n"
},
{
"category": "Social Work",
"chartdate": "2145-03-23 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 367896,
"text": "SOCIAL WORK:\n SW referred for coping support for wife after family meeting to discuss\n goals of care. Wife is hoping pt will be more alert tomorrow, and that\n she, pt, and team will be able to re-discuss treatment options. Mrs.\n is upset, relates to roller coaster ride of his medical care\n (and hers\n she is s/p CABG and CVA), references his multiple medical\n problems, and focuses on choice about central line placement. She\n recognizes the impact of pt\ns pain on his quality of life, and sees the\n joys in his life, e.g. clock building and dancing, being taken away by\n illness. States he used to be\nfull of hell.\n They met dancing eleven\n years ago. He has three children from his first marriage; she has four\n from hers (some local, some out west). Wife conveys difficulty\n sleeping. She does not want pt to see her crying. She states she is\n well supported by her children. Provided empathic support. Pt is\n being called out to floor with plan of revisiting goals of care with\n him tomorrow should he be more alert. SW available for support in MICU\n or on floor. Please page me at with any questions/concerns.\n -, LICSW\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-22 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 367793,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 78 y/o m with CAD, recent NSTEMI with POBA, CRF on PD, mx carcinoid p/w\n abd pain and hct drop. CT abd at OSH showed colitis. Developed sepsis,\n finished 10d zosyn, vanco 2 weeks, po vanco for empiric C. Fiff\n coverage. Initially in MICU organge, went to floor , course c/b UE\n DVT, had some hypotension on that responded to IVF, had some\n diffuse weakness, imaging of spine showed no cord compression but\n advancing mx disease. Had increasing PD requirements for volume\n overload as well as uremia, so transferred to ICU for q2h PD.\n Overnight had slight hypoxia while sleeping.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n See resident note\n See resident note\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: see resident note\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, Weight loss\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: Dialysis\n Integumentary (skin): No(t) Rash\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: Anemia, Coagulopathy\n Neurologic: back pain, confusion\n Psychiatric / Sleep: Delirious\n Pain: Mild\n Pain location: back\n Flowsheet Data as of 09:47 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 35.4\nC (95.8\n HR: 74 (62 - 84) bpm\n BP: 104/89(93) {85/42(51) - 137/89(93)} mmHg\n RR: 23 (9 - 41) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 100 mL\n 4,000 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n -4,000 mL\n Respiratory\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///29/\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Rhonchorous: bases)\n Abdominal: Soft, Tender: diffuse with guarding\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person/place/date, Movement: Not assessed,\n Tone: Not assessed, +asterixis\n Labs / Radiology\n 388 K/uL\n 29.2 %\n 9.1 g/dL\n 101 mg/dL\n 6.9 mg/dL\n 36 mg/dL\n 29 mEq/L\n 100 mEq/L\n 4.4 mEq/L\n 138 mEq/L\n 6.7 K/uL\n [image002.jpg]\n 04:48 AM\n WBC\n 6.7\n Hct\n 29.2\n Plt\n 388\n Cr\n 6.9\n Glucose\n 101\n Other labs: ALT / AST:28/18, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:76.1 %, Lymph:15.8 %, Mono:5.7 %, Eos:1.9 %,\n Albumin:2.0 g/dL, LDH:236 IU/L, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL, PO4:5.9\n mg/dL\n Assessment and Plan\n HYPOXEMIA\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n DELIRIUM / CONFUSION\n 78 y/o m with CAD, carcinoid, with recent sepsis colitis.\n 1. AMS: Suspect delirium\n -currently fully oriented\n -cont PD\n -avoid sedation, avoid heavy narcotics\n 2. ESRD on PD\n -f/u renal recs\n 3. LE weakness: be critical illness myopathy\n -consider neuro eval\n 4. carcinoid: Worsening mx disease\n -cont. pain control\n 5. RUE thrombus: On coumadin\n -in setting of CVL\n -check INR\n 6. colitis: ? ischemic vs. infectious\n -cont. renal diet\n -avoid persistent hypotension\n 7. GOC: Dr. planning a family meeting\n 8. CAD, recent NSTEMI: cont. ASA\n -start statin\n -consider BB when BP stable\n 9. sacral decub: wound care c/s\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 22 Gauge - 10:21 PM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n ------ Protected Section ------\n I have seen and examined the patient with the fellow, reviewed and\n agree with the assessment and plan as above with the following\n modifications and emphasis:\n 78 year old male with CAD, NSTEMI, carcinoid tumor, ESRD on PD admitted\n to the hospital with colitis and transferred to the ICU because of\n change in mental status.\n On exam, temp 36.8 P 74 BP 104/66 RR 23 99%\n On the initial exam as documented by the fellow above, the patient was\n alert and conversant, however on my exam (which was subsequent to a\n dose of oxycodone), the patient was confused/decrease MS \nive (80/60)\n responsive to minimal fluid\n Chest: CTA bilaterally\n Heart: S1S2 reg\n Abd: soft, NT, ND\n Ext: cool, clammy\n Lactate: 1.9\n A:\n 1) Mental Status Changes: this morning the MS change seemed to be\n directly related to dose of oxycodone which was likely also responsible\n for transient hypotension\n 2) Hypotension\n resolved with minimal fluid and likely result of\n oxycodone\n 3) Carcinoid tumor\n 4) ESRD on PD\n 5) CAD\n 6) Venous thrombosus\n Plan:\n - pan-culture and CXR\n - If BP drops again, will give empiric antibiotics\n - Goals of care meeting planned for tomorrow\n Critical Care time: 30 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 11:20 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 367872,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Planning family meeting at 3pm today. Had transient hypotension,\n resolved after 1L NS. Stopped oxycontin as seemed to cause AMS.\n Continued PD with q2h exchanges.\n BLOOD CULTURED - At 03:30 PM\n 1x unable to obtain 2nd\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:28 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36\nC (96.8\n HR: 81 (55 - 84) bpm\n BP: 140/60(79) {71/30(45) - 164/120(95)} mmHg\n RR: 10 (10 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,731 mL\n 83 mL\n PO:\n TF:\n IVF:\n 1,731 mL\n 83 mL\n Blood products:\n Total out:\n 5,500 mL\n -2,400 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,769 mL\n 2,483 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n L base)\n Abdominal: Soft, Bowel sounds present, Tender: RLQ with guarding\n Extremities: Right: 1+, Left: 1+, Cyanosis\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.8 g/dL\n 368 K/uL\n 108 mg/dL\n 6.5 mg/dL\n 30 mEq/L\n 4.4 mEq/L\n 29 mg/dL\n 101 mEq/L\n 139 mEq/L\n 27.6 %\n 7.0 K/uL\n [image002.jpg]\n 04:48 AM\n 03:44 AM\n WBC\n 6.7\n 7.0\n Hct\n 29.2\n 27.6\n Plt\n 388\n 368\n Cr\n 6.9\n 6.5\n Glucose\n 101\n 108\n Other labs: PT / PTT / INR:32.0/39.0/3.3, ALT / AST:26/18, Alk Phos / T\n Bili:106/0.2, Differential-Neuts:76.1 %, Lymph:15.8 %, Mono:5.7 %,\n Eos:1.9 %, Lactic Acid:1.7 mmol/L, Albumin:2.0 g/dL, LDH:236 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:6.3 mg/dL\n Assessment and Plan\n HYPOXEMIA\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n DELIRIUM / CONFUSION\n 78 y/o m with CAD, mx carcinoid, colitis with sepsis, ESRD on PD, here\n with AMS, slight hypotension, and abd pain.\n 1. AMS: Slightly related to oxycontin\n -avoid long acting meds, cont. standing tylenol and dilaudid prn\n 2. ESRD on PD:\n -discussing PD 4-6 times per day\n -calcitriol, epogen\n -goal positive 1L\n 3. Abd pain: ? C. Diff\n -cont. po vanco/flagyl until 6th\n -discuss pain regimen with palliative care\n -may be ischemic colitis, worsened with eating\n -PD fluid GS neg\n 4. Mx carcinoid: Interval progression of disease\n -readdress at family meeting\n 5. CAD: recent NSTEMI\n -cont. ASA, statin\n -start metoprolol 12.5 mg \n 6. sacral decub: wound care, turning\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 22 Gauge - 10:21 PM\n 18 Gauge - 12:12 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 367669,
"text": "TITLE:\n Chief Complaint: q 2 hr PD\n HPI:\n Mr. is a 78 yo male with PMh of CAD s/p CABG, metastatic\n carcinoid, ESRD on PD, chronic abd/back pain, and AAA who originally\n came in on with abdominal pain and has undergone a complicated\n course since. He presented to with hypotension and a\n hct drop, where a CT scan showed stable AAA and colitis dj to the\n hepatic flexure, and worsening metastatic disease. he was transferred\n to where surgery did not feel there were any acute surgical\n issues. Because of pressor dependent hypotension, he was admitted to\n the MICU where he was treated with po vanco and IV flagyl for\n presumptive cdiff (stool cultures were negative x 2). he was given\n zosyn empirically for colitis/diverticulitis and IV vancomycin for\n peritonitis. Peritoneal fluid had > 3500 WBCs, but culture was\n negative. He had an initial three pressor requirment. his PD was\n continued. He improved and was weaned off pressors by . He has\n since finished a 10 day course of zosyn for diverticulitis/colitis and\n a 2 week course IV vanc (completed ) for culture negative\n peritonitis. His PO vanc is planned for 2 weeks after cessation of his\n zosyn, to be completed on .\n .\n His recovery has been complicated by SBO vs ileus, requiring TPN over\n TF, which resolved on with successful advancment of diet. He has\n had significant pain requirments for severe back pain, ventually\n managed on gabapentin 100mg qhs, oxycontin 20 , standing tylenol,\n and dilaudid 2mg q 4 hours prn. He had elevated LFTs peak and\n 3222 ALT/AST respectively on , thought shock, now trending\n down. He had an HCT drop to 23 from BL low 30s. He had one\n transfusion of pRBCs on and his HCT has been stable since. He was\n guaiac negative. He was transferred to the floor on .\n .\n On , UE swelling was noted and dopplers showed RIJ occlusive\n thrombus, left subclavian nonocclusive thrombus, and left basilic vein\n occlusive thrombus. He had a RIJ CVL had already been removed. His\n right PICC was removed at that time. He never had a line on the left.\n He was started on coumadin with subsequent supertherapeutic INR\n requiring vit K (peak INR 7.1 on , currently 3.5).\n .\n He had recently been discharged on after admission for NSTEMI\n adn PNA. he recieved angioplasty to SVG-OM2 during that stay and\n finished a 10 day course of CTX/Levo. He triggered during this\n admission on 2/ for hypotension. This was responsive to 250cc fluid\n and CEs were negative with trop still trending down from recent\n admission. He denied CP during his stay.\n .\n He is s/p renal stent with multiple revisions over the last couple\n years. Urology was consulted re: hyperdense finding on CT exam. They\n feltthere was no intervention needed at this time.\n .\n In addition to pain, he has had progressive generalized weakness.\n There was a concern for cord compression. A CT of his C-T-L spine on\n showed sclerotic lesions concerning for new malignancy in his T\n and L spine. Octreotide scan showed increasing carcinoid tumor burden\n in liver, pelvic bone, posterior musculature abd wall, but not in his\n spine. The CT was without contrast out of concern for harming his\n kidneys and making PD no longer an option. The patient refused MRI.\n There was no cord compression by exam and spine consult did not think\n his exam was consistent with cord compression.\n .\n He is being transferred to the MICU now to increased need for PD\n dialysis being the reasonable capabilities of a floor nurse. His PD\n schedule was increased to q 2 hrs by renal to encephalopathy with\n worsening asterixis and hyperreflexivity thought uremia. He is\n DNR/DNI though accepted pressors and CVL during this admission. He\n currently complains of back pain and pain in his sacral decube. He\n denies any other pain, CP, SOB.\n .\n Regarding his metastatic carcinoid, his outpatient oncologist, Dr. \n has been involved. He was started on octreotide 50mcg TID sq which was\n subsequently discontinued out of concern for hypotension. There is\n currently an ongoing discussion between Dr. and the patient and\n family regarding goals of care and his possible appropriateness for\n hospice.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home:\n Aspirin 325 mg daily\n Clopidogrel 75 mg daily\n Metoprolol Tartrate 50 mg \n Simvastatin 40mg daily\n Lisinopril 5mg\n Imdur 30mg\n Terazosin 5mg\n Finasteride 5mg\n Amlodipine 10mg\n Protonix 40mg\n Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H\n Multivitamin daily\n Colace 100mg \n .\n Transfer Meds:\n Acetaminophen 650 mg PO Q8\n Aspirin 325 mg PO DAILY\n Ondansetron 4 mg IV Q8H:PRN nausea\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Ondansetron ODT 4 mg PO Q8H:PRN\n Docusate Sodium (Liquid) 100 mg PO BID\n Oxycodone SR (OxyconTIN) 20 mg PO Q12H\n Epoetin Alfa 10,000 UNIT SC QMOWEFR\n Pantoprazole 40 mg PO Q24H\n Gabapentin 100 mg PO HS\n Potassium Chloride 2 mEq IP 2 MEQ PER 1 L PD SOLUTION for hypokalemia\n HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN\n Senna 1 TAB PO BID:PRN\n Sertraline 25 mg PO DAILY\n Vancomycin Oral Liquid 250 mg PO Q6H\n sevelamer HYDROCHLORIDE 800 mg PO TID\n Past medical history:\n Family history:\n Social History:\n - Carcinoid tumor with mets to liver\n - Hypertension\n - Hyperlipidemia\n - CAD s/p CABG x 4 in , Cath -> severe native three vessel\n disease with 90% lesion in SVG-OM2, which was successfully\n angioplastied. Also with atretic SVG-OM1, and ?obstruction of LAD.\n Given subclavian stenoses, central pressures noted to be 60mmHg higher\n than peripheral pressures.\n - ESRD, on PD since , s/p HD tunneled cath placement\n - CAD s/p bilateral carotid endarterectomies in , c/b post-op\n seizure\n - Bilateral RAS & left common iliac artery aneurysm, s/p bilateral\n endarterectomies and aortobifemoral bypass graft with renal artery\n reimplantation to aortic graft in , left renal artery stenting in\n , s/p right ureteral stenting in c/b right mid-ureteral\n stricture with multiple stent exchanges in 07 & 08\n - AAA measuring 5 cm on CT\n - Sigmoid diverticulitis\n - Pancreatitis w/ ileus post AAA\n - BPH\n - H/o ruptured disk\n - S/p vasectomy, eye surgey, tonsillectomy\n brother with CAD s/p CABG, mother with CVA in 90s.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt is married, lives with his wife. Social history is\n significant for current tobacco use. Pt quit smoking in but\n resumed smoking last summer, about 6 cigarettes daily. Previously, he\n smoked one-and-a-half pack per day for 35 years. There is no history\n of alcohol abuse.\n Review of systems:\n Flowsheet Data as of 09:36 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n Vitals: T: 97 BP: 131/67 P: 91 RR: 12 O2: Sats 95% 2L\n General: NAD, comfortable\n HEENT: Sclera anicteric, MMM\n Neck: supple, no JVD\n Lungs: Scant crackles bilaterally at bases, otherwise clear, though\n exam limited by cooperation\n CV: RRR, distant no m/r/g\n Abdomen: soft, diffusely TTP inconsistently, non-distended, NABS, no\n guarding or rebound\n Ext: + LE edema\n Neuro: AOx2, + asterixis. UE 5/5 strength. LE hip flexors\n bilaterally, hamstring/quads bilaterally limited by cooperation.\n LE hyperreflexive. UE 2+ reflexes.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Chem 7:\n 138 99 41 93\n 4.8 29 7.4\n Ca: 8.0 Mg: 1.8 P: 6.3\n WBC: 7.8\n N:88.2 L:6.5 M:3.8 E:1.1 Bas:0.4\n HCT 28.3\n Plt 389\n PT: 33.7 PTT: 39.7 INR: 3.5\n Imaging: CT Abd/Pelvis \n IMPRESSION:\n 1. New wall thickening and inflammatory change around a short\n segment of right colon near the hepatic flexure. While this could\n represent inflammation related to diverticular disease, or other\n infectious or inflammatory causes, this loop of colon is situated close\n to multiple metastatic foci within the liver, and metastatic disease,\n or direct extent of tumor should also be considered.\n 2. Increased size of multiple hepatic metastases.\n 3. Free intraperitoneal air, presumably related to peritoneal\n dialysis.\n 4. Moderate right hydronephrosis, with dense material now seen in the\n right renal collecting system and bladder. This appearance is\n concerning for hemorrhage, unless there has been recent radiographic\n procedure with injection of contrast directly into the collecting\n system.\n 5. Cholelithiasis, without evidence of cholecystitis.\n 6. Grossly unchanged appearance of 5.5 cm descending thoracic and\n suprarenal abdominal aortic aneurysm.\n 7. Stable soft tissue density anterior to the right ureter, with tiny\n central punctate calcification.\n .\n KUB:\n IMPRESSION: Dilated loops of small bowel with residual air in the\n colon, this could be an ileus and less likely a new or incomplete SBO.\n Recommend followup.\n .\n CXR \n FINDINGS: The NG tube tip is in the proximal stomach. There continue to\n be dilated small bowel loops measuring up to 4.6 cm consistent with\n patient's known small-bowel obstruction. Right IJ line is unchanged\n with tip in the SVC/RA. There is some increased opacity at the right\n base and right mid lung consistent with infiltrate that is slightly\n improved compared to the prior exam.\n .\n CXR \n IMPRESSION: 5 French double-lumen Vaxcel PICC line placed via right\n basilic vein with tip in the SVC. The catheter is ready to use.\n .\n U/S \n IMPRESSION:\n 1) Occlusive thrombus in the right internal jugular vein and\n non-occlusive thrombus at the left subclavian vein.\n 2) Occlusive thrombus in the left basilic vein.\n .\n CT L-spine \n IMPRESSION:\n 1. Multilevel degenerative changes, with neural foraminal narrowing and\n spinal stenosis, most pronounced at L4-5 level. MR is more ideal\n for assessemnt of intrathecal structures, unless there is a\n contra-indication.\n 2. Faint foci of sclerosis in several vertebral bodies, unchanged from\n the most recent prior study; however, not present in and while\n these can represent bone islands, given the history, also concerning\n for metastatic foci. Correlation with radionuclide studies can be\n considered.\n 3. Large suprarenal abdominal aortic aneurysm, given limitation in lack\n of IV contrast, incompletely assessed.\n 4. Right hydronephrosis, double-J stent in place.\n 5. Upper abdominal ascites.\n Impressions- 3,4 &5- not compleely assessed.\n .\n CT T-spine .\n IMPRESSION:\n 1. Multiple, at least seven sclerotic foci, in the thoracic vertebrae\n and one involving the left eighth rib, mildly increased in size, and\n more conspicuous on today's study compared to the CT torso done in\n . Given the increase in size, these may represent metastatic\n lesions, though the appearance is nonspecific and resembles bone\n islands. No cortical discontinuity noted.\n 2. Lung, pleural and vascular changes as described above, incompletely\n imaged and characterized on the present study. CT\n Chest can be considered.\n 3. Distended bowel loops on the scout image with mildly increased\n diameter since the prior study scout- to correlate clinically to\n exclude obstructive etiology. These are not included on the other\n images.\n .\n CT C-spine .\n IMPRESSION:\n 1. Multilevel degenerative changes in the cervical spine as described\n above, causing moderate-to-severe neural foraminal narrowing as\n described above, and mild canal stenosis.\n 2. No definite sclerotic foci in the cervical spine to suggest\n metastases.\n Correlate with radionuclide studies.\n 3. Partially imaged T3 sclerotic focus, better assessed on the\n concurrent CT T spine study.\n 4. Significant atherosclerotic vascular calcifications as above.\n .\n CT Head .\n IMPRESSION:\n 1. No intracranial hemorrhage. Limited evaluation for intracranial\n metastases, though no obvious mass or edema is identified.\n 2. Chronic left posterior parietal infarct.\n .\n Octreotide scan. .\n IMPRESSION: 1. Octreotide-avid disease in a right pubic bone\n sclerotic lesion and increased uptake in the musculature\n posterior to the left greater trochanter, compatible with\n carcinoid. 2. Innumerable heterogeneous hepatic lesions in both\n lobes, some of which are subcapsular, warrant follow-up.\n .\n Echo : The left atrium is elongated. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. There is mild to\n moderate regional left ventricular systolic dysfunction with\n hypokinesis of the inferolateral and basal inferior walls. The\n remaining segments contract normally (LVEF = 45-50 %). Right\n ventricular chamber size and free wall motion are normal. The\n descending thoracic aorta is mildly dilated. The aortic valve leaflets\n (3) are mildly thickened with good leaflet excursion and no aortic\n regurgitation. The mitral valve leaflets are mildly thickened. At least\n mild (1+) mitral regurgitation is seen. There is moderate pulmonary\n artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n Microbiology: Urine/blood Cx: No grwoth\n Peritoneal Fluid: Cx: No growth, WBC:3150, poly 93%\n C. diff: negative x 2\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Now with\n ileus/SBO.\n .\n # AMS: variable course over his stay. likely multifactorial including\n narcotics, toxic/metabolic related to renal failure. It appears to be\n most consistent with delirium. Had CT head with contrast on , but\n this does not definitively r/o brain metastases. Neuro exam is\n nonfocal. BUN has improved over the last 10 days.\n - PD as per renal recs\n - cont pain management as is for now, but wean if possible\n - avoid any other sedating medications\n - consider head imaging, but presentation unlikely from stroke. ?\n relation to brain mets. None on CT head with contrast, but this is\n inferior to MRI.\n .\n # ESRD on PD: renal following. Sent to ICU for increased PD care per\n renal.\n - appreciate renal recs\n - continue Calcitriol, epo per renal recs\n .\n # LE weakness: underwent workup for cord compression, including spine\n consult. Not felt to be related to cord compression. Likely related\n to decondition, pain, lethargy from ? toxic/metabolic. ? myopathy.\n - PT\n - pain control\n - consider neuro consult, EMG, though goals of care should be addressed\n first.\n .\n #Back Pain: Chronic. Sclerotic lesions in T and L spine by CT and\n lesion on iliac by octreotide scan. Also contribution of degenerative\n changes and deconditioning. followed by P&P Care.\n - f/u PT recs\n - cont pain regimen\n .\n #. RIJ and L subclavian thrombus: Pt INR 3.5 today. Pt with difficult\n access and difficult lab draws. Sensitivity to coumadin likely \n nutrition deficiencies.\n - holding coumadin goal INR . Will need minimum of 3 months.\n - cont to monitor for bleeding\n .\n # Abdominal Pain/Colitis\n s/p 10 day course of zosyn. On PO vanco for\n presumptive c. diff until . Finished IV Vancomycin for peritonitis.\n Has continued diffuse TTP.\n - po Vanc until \n - trend exam, image for worsening.\n .\n #. Ileus/partial SBO: Resolved. tolerating regular diet. Pt clear by\n S&W.\n - cont to monitor\n .\n # Metastatic Carcinoid: Pt followed by Hem/Onc. Pt had octreotide scan\n that showed increase in disease.\n - palliative care recs\n - pain control\n - f/u with Dr. re: long term care goals\n .\n # Anemia: Baseline hct in low 30s, stable in upper 20s after 1 unit\n transfused. Guaiac was negative per resident report, but positive per\n nursing report.\n - goal Hct >25\n - guaiac all stools\n - PPI & trend hct\n .\n # Tranaminitis\n LFTs trending down. Previously thought to be from\n shocked liver. Likely combination of malignancy and shocked liver.\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat . Plavix was discontinued given therapeutic to\n supertherapeutic INR and no stent in last year.\n - continue Aspirin 325mg\n - metoprolol held for hypotension. Restart as BP tolerates.\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Decubitus Ulcer: wound care\n .\n # FEN: Cont regular diet with shakes\n .\n # Prophylaxis: Coumadin, PPI\n .\n # Access: PIV\n .\n # Code: DNR/DNI, but pressors/CVL okay as per last ICU stay. Needs to\n be readdressed with pt/family and goals of with Dr. .\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for PD. be able to go straight from ICU to\n rehab.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 367674,
"text": "Mr. is a 78 yo male with PMh of CAD s/p CABG, metastatic\n carcinoid, ESRD on PD, chronic abd/back pain, and AAA who originally\n came in on with abdominal pain and has undergone a complicated\n course since. He presented to with hypotension and a\n hct drop, CT scan showed stable AAA and colitis, and worsening\n metastatic disease. Transferred to where surgery did not feel\n there were any acute surgical issues. Because of pressor dependent\n hypotension, he was admitted to the MICU where he was treated with po\n vanco and IV flagyl for presumptive cdiff (stool cultures were negative\n x 2). He was given zosyn empirically for colitis/diverticulitis and IV\n vancomycin for peritonitis. Peritoneal fluid had > 3500 WBCs, but\n culture was negative. He had an initial three pressor requirment. His\n PD was continued. He improved and was weaned off pressors by . He\n has since finished a 10 day course of zosyn for diverticulitis/colitis\n and a 2 week course IV vanc (completed ) for culture negative\n peritonitis. His PO vanc is planned for 2 weeks after cessation of his\n zosyn, to be completed on .\n .\n His recovery has been complicated by SBO vs ileus, requiring TPN over\n TF, which resolved on with successful advancment of diet. He has\n had significant pain requirments for severe back pain, eventually\n managed on gabapentin 100mg qhs, oxycontin 20 , standing tylenol,\n and dilaudid 2mg q 4 hours prn. Elevated LFTs thought shock He\n had an HCT drop to 23 from BL low 30s. He had one transfusion of pRBCs\n on and his HCT has been stable since. He was guaiac negative. He\n was transferred to the floor on .\n .\n On , UE showed RIJ occlusive thrombus, left subclavian nonocclusive\n thrombus, and left basilic vein occlusive thrombus. He had a RIJ CVL\n had already been removed. His right PICC was removed at that time. He\n was started on coumadin.\n In addition to pain, he has had progressive generalized weakness.\n There was a concern for cord compression. A CT of his C-T-L spine on\n showed sclerotic lesions concerning for new malignancy in his T\n and L spine. Octreotide scan showed increasing carcinoid tumor burden\n in liver, pelvic bone, posterior musculature abd wall, but not in his\n spine. The CT was without contrast out of concern for harming his\n kidneys and making PD no longer an option. The patient refused MRI.\n There was no cord compression by exam and spine consult did not think\n his exam was consistent with cord compression.\n He is being transferred to the MICU now to increased need for PD\n dialysis. His PD schedule was increased to q 2 hrs by renal to\n encephalopathy with worsening asterixis and hyperreflexivity thought\n uremia. He is DNR/DNI though accepted pressors and CVL during this\n admission. He currently complains of back pain and pain in his sacral\n decube. He denies any other pain, CP, SOB.\n .\n Regarding his metastatic carcinoid, his outpatient oncologist, Dr. \n has been involved. He was started on octreotide 50mcg TID sq which was\n subsequently discontinued out of concern for hypotension. There is\n currently an ongoing discussion between Dr. and the patient and\n family regarding goals of care and his possible appropriateness for\n hospice.\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 367664,
"text": "TITLE:\n Chief Complaint: q 2 hr PD\n HPI:\n Mr. is a 78 yo male with PMh of CAD s/p CABG, metastatic\n carcinoid, ESRD on PD, chronic abd/back pain, and AAA who originally\n came in on with abdominal pain and has undergone a complicated\n course since. He presented to with hypotension and a\n hct drop, where a CT scan showed stable AAA and colitis dj to the\n hepatic flexure, and worsening metastatic disease. he was transferred\n to where surgery did not feel there were any acute surgical\n issues. Because of pressor dependent hypotension, he was admitted to\n the MICU where he was treated with po vanco and IV flagyl for\n presumptive cdiff (stool cultures were negative x 2). he was given\n zosyn empirically for colitis/diverticulitis and IV vancomycin for\n peritonitis. Peritoneal fluid had > 3500 WBCs, but culture was\n negative. He had an initial three pressor requirment. his PD was\n continued. He improved and was weaned off pressors by . He has\n since finished a 10 day course of zosyn for diverticulitis/colitis and\n a 2 week course IV vanc (completed ) for culture negative\n peritonitis. His PO vanc is planned for 2 weeks after cessation of his\n zosyn, to be completed on .\n .\n His recovery has been complicated by SBO vs ileus, requiring TPN over\n TF, which resolved on with successful advancment of diet. He has\n had significant pain requirments for severe back pain, ventually\n managed on gabapentin 100mg qhs, oxycontin 20 , standing tylenol,\n and dilaudid 2mg q 4 hours prn. He had elevated LFTs peak and\n 3222 ALT/AST respectively on , thought shock, now trending\n down. He had an HCT drop to 23 from BL low 30s. He had one\n transfusion of pRBCs on and his HCT has been stable since. He was\n guaiac negative. He was transferred to the floor on .\n .\n On , UE swelling was noted and dopplers showed RIJ occlusive\n thrombus, left subclavian nonocclusive thrombus, and left basilic vein\n occlusive thrombus. He had a RIJ CVL had already been removed. His\n right PICC was removed at that time. He never had a line on the left.\n He was started on coumadin with subsequent supertherapeutic INR\n requiring vit K (peak INR 7.1 on , currently 3.5).\n .\n He had recently been discharged on after admission for NSTEMI\n adn PNA. he recieved angioplasty to SVG-OM2 during that stay and\n finished a 10 day course of CTX/Levo. He triggered during this\n admission on 2/ for hypotension. This was responsive to 250cc fluid\n and CEs were negative with trop still trending down from recent\n admission. He denied CP during his stay.\n .\n In addition to pain, he has had progressive generalized weakness.\n There was a concern for cord compression. A CT of his C-T-L spine on\n showed sclerotic lesions concerning for new malignancy in his T\n and L spine. Octreotide scan showed increasing carcinoid tumor burden\n in liver, pelvic bone, posterior musculature abd wall, but not in his\n spine. The CT was without contrast out of concern for harming his\n kidneys and making PD no longer an option. The patient refused MRI.\n There was no cord compression by exam and spine consult did not think\n his exam was consistent with cord compression.\n .\n He is being transferred to the MICU now to increased need for PD\n dialysis being the reasonable capabilities of a floor nurse. His PD\n schedule was increased to q 2 hrs by renal to encephalopathy with\n worsening asterixis and hyperreflexivity thought uremia. He is\n DNR/DNI though accepted pressors and CVL during this admission.\n .\n Regarding his metastatic carcinoid, his outpatient oncologist, Dr. \n has been involved. He was started on octreotide 50mcg TID sq which was\n subsequently discontinued out of concern for hypotension. There is\n currently an ongoing discussion between Dr. and the patient and\n family regarding goals of care and his possible appropriateness for\n hospice.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home:\n Aspirin 325 mg daily\n Clopidogrel 75 mg daily\n Metoprolol Tartrate 50 mg \n Simvastatin 40mg daily\n Lisinopril 5mg\n Imdur 30mg\n Terazosin 5mg\n Finasteride 5mg\n Amlodipine 10mg\n Protonix 40mg\n Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H\n Multivitamin daily\n Colace 100mg \n .\n Transfer Meds:\n Acetaminophen 650 mg PO Q8\n Aspirin 325 mg PO DAILY\n Ondansetron 4 mg IV Q8H:PRN nausea\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Ondansetron ODT 4 mg PO Q8H:PRN\n Docusate Sodium (Liquid) 100 mg PO BID\n Oxycodone SR (OxyconTIN) 20 mg PO Q12H\n Epoetin Alfa 10,000 UNIT SC QMOWEFR\n Pantoprazole 40 mg PO Q24H\n Gabapentin 100 mg PO HS\n Potassium Chloride 2 mEq IP 2 MEQ PER 1 L PD SOLUTION for hypokalemia\n HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN\n Senna 1 TAB PO BID:PRN\n Sertraline 25 mg PO DAILY\n Vancomycin Oral Liquid 250 mg PO Q6H\n sevelamer HYDROCHLORIDE 800 mg PO TID\n Past medical history:\n Family history:\n Social History:\n - Carcinoid tumor with mets to liver\n - Hypertension\n - Hyperlipidemia\n - CAD s/p CABG x 4 in , Cath -> severe native three vessel\n disease with 90% lesion in SVG-OM2, which was successfully\n angioplastied. Also with atretic SVG-OM1, and ?obstruction of LAD.\n Given subclavian stenoses, central pressures noted to be 60mmHg higher\n than peripheral pressures.\n - ESRD, on PD since , s/p HD tunneled cath placement\n - CAD s/p bilateral carotid endarterectomies in , c/b post-op\n seizure\n - Bilateral RAS & left common iliac artery aneurysm, s/p bilateral\n endarterectomies and aortobifemoral bypass graft with renal artery\n reimplantation to aortic graft in , left renal artery stenting in\n , s/p right ureteral stenting in c/b right mid-ureteral\n stricture with multiple stent exchanges in 07 & 08\n - AAA measuring 5 cm on CT\n - Sigmoid diverticulitis\n - Pancreatitis w/ ileus post AAA\n - BPH\n - H/o ruptured disk\n - S/p vasectomy, eye surgey, tonsillectomy\n brother with CAD s/p CABG, mother with CVA in 90s.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt is married, lives with his wife. Social history is\n significant for current tobacco use. Pt quit smoking in but\n resumed smoking last summer, about 6 cigarettes daily. Previously, he\n smoked one-and-a-half pack per day for 35 years. There is no history\n of alcohol abuse.\n Review of systems:\n Flowsheet Data as of 09:36 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Chem 7:\n 138 99 41 93\n 4.8 29 7.4\n Ca: 8.0 Mg: 1.8 P: 6.3\n WBC: 7.8\n N:88.2 L:6.5 M:3.8 E:1.1 Bas:0.4\n HCT 28.3\n Plt 389\n PT: 33.7 PTT: 39.7 INR: 3.5\n Imaging: CT Abd/Pelvis \n IMPRESSION:\n 1. New wall thickening and inflammatory change around a short\n segment of right colon near the hepatic flexure. While this could\n represent inflammation related to diverticular disease, or other\n infectious or inflammatory causes, this loop of colon is situated close\n to multiple metastatic foci within the liver, and metastatic disease,\n or direct extent of tumor should also be considered.\n 2. Increased size of multiple hepatic metastases.\n 3. Free intraperitoneal air, presumably related to peritoneal\n dialysis.\n 4. Moderate right hydronephrosis, with dense material now seen in the\n right renal collecting system and bladder. This appearance is\n concerning for hemorrhage, unless there has been recent radiographic\n procedure with injection of contrast directly into the collecting\n system.\n 5. Cholelithiasis, without evidence of cholecystitis.\n 6. Grossly unchanged appearance of 5.5 cm descending thoracic and\n suprarenal abdominal aortic aneurysm.\n 7. Stable soft tissue density anterior to the right ureter, with tiny\n central punctate calcification.\n .\n KUB:\n IMPRESSION: Dilated loops of small bowel with residual air in the\n colon, this could be an ileus and less likely a new or incomplete SBO.\n Recommend followup.\n .\n CXR \n FINDINGS: The NG tube tip is in the proximal stomach. There continue to\n be dilated small bowel loops measuring up to 4.6 cm consistent with\n patient's known small-bowel obstruction. Right IJ line is unchanged\n with tip in the SVC/RA. There is some increased opacity at the right\n base and right mid lung consistent with infiltrate that is slightly\n improved compared to the prior exam.\n .\n CXR \n IMPRESSION: 5 French double-lumen Vaxcel PICC line placed via right\n basilic vein with tip in the SVC. The catheter is ready to use.\n .\n U/S \n IMPRESSION:\n 1) Occlusive thrombus in the right internal jugular vein and\n non-occlusive thrombus at the left subclavian vein.\n 2) Occlusive thrombus in the left basilic vein.\n .\n CT L-spine \n IMPRESSION:\n 1. Multilevel degenerative changes, with neural foraminal narrowing and\n spinal stenosis, most pronounced at L4-5 level. MR is more ideal\n for assessemnt of intrathecal structures, unless there is a\n contra-indication.\n 2. Faint foci of sclerosis in several vertebral bodies, unchanged from\n the most recent prior study; however, not present in and while\n these can represent bone islands, given the history, also concerning\n for metastatic foci. Correlation with radionuclide studies can be\n considered.\n 3. Large suprarenal abdominal aortic aneurysm, given limitation in lack\n of IV contrast, incompletely assessed.\n 4. Right hydronephrosis, double-J stent in place.\n 5. Upper abdominal ascites.\n Impressions- 3,4 &5- not compleely assessed.\n .\n CT T-spine .\n IMPRESSION:\n 1. Multiple, at least seven sclerotic foci, in the thoracic vertebrae\n and one involving the left eighth rib, mildly increased in size, and\n more conspicuous on today's study compared to the CT torso done in\n . Given the increase in size, these may represent metastatic\n lesions, though the appearance is nonspecific and resembles bone\n islands. No cortical discontinuity noted.\n 2. Lung, pleural and vascular changes as described above, incompletely\n imaged and characterized on the present study. CT\n Chest can be considered.\n 3. Distended bowel loops on the scout image with mildly increased\n diameter since the prior study scout- to correlate clinically to\n exclude obstructive etiology. These are not included on the other\n images.\n .\n CT C-spine .\n IMPRESSION:\n 1. Multilevel degenerative changes in the cervical spine as described\n above, causing moderate-to-severe neural foraminal narrowing as\n described above, and mild canal stenosis.\n 2. No definite sclerotic foci in the cervical spine to suggest\n metastases.\n Correlate with radionuclide studies.\n 3. Partially imaged T3 sclerotic focus, better assessed on the\n concurrent CT T spine study.\n 4. Significant atherosclerotic vascular calcifications as above.\n .\n CT Head .\n IMPRESSION:\n 1. No intracranial hemorrhage. Limited evaluation for intracranial\n metastases, though no obvious mass or edema is identified.\n 2. Chronic left posterior parietal infarct.\n .\n Octreotide scan. .\n IMPRESSION: 1. Octreotide-avid disease in a right pubic bone\n sclerotic lesion and increased uptake in the musculature\n posterior to the left greater trochanter, compatible with\n carcinoid. 2. Innumerable heterogeneous hepatic lesions in both\n lobes, some of which are subcapsular, warrant follow-up.\n .\n Echo : The left atrium is elongated. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. There is mild to\n moderate regional left ventricular systolic dysfunction with\n hypokinesis of the inferolateral and basal inferior walls. The\n remaining segments contract normally (LVEF = 45-50 %). Right\n ventricular chamber size and free wall motion are normal. The\n descending thoracic aorta is mildly dilated. The aortic valve leaflets\n (3) are mildly thickened with good leaflet excursion and no aortic\n regurgitation. The mitral valve leaflets are mildly thickened. At least\n mild (1+) mitral regurgitation is seen. There is moderate pulmonary\n artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n Microbiology: Urine/blood Cx: No grwoth\n Peritoneal Fluid: Cx: No growth, WBC:3150, poly 93%\n C. diff: negative x 2\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Now with\n ileus/SBO.\n .\n #Back Pain: Pain improved today. Pt showed areas of sclerotic\n lesions new since in T and L spine. Octreotide scan shows lesion\n on iliac. Also contribution of degenerative changes and deconditioning.\n Currently pain is being managed by oxycontin 20mg , restarted\n gabapentin and standing tylenol. Pt followed by P&P Care.\n - f/u PT recs\n - cont pain regimen\n .\n #. RIJ and L subclavian thrombus: Pt INR 3.5 today. Pt with difficult\n access and difficult lab draws.\n - hold coumadin goalINR . Will need minimum of 3 months.\n - cont to monitor for bleeding\n .\n # Abdominal Pain/Colitis\n Pt improved and abdominal pain controlled. Pt\n finished 10 day course of zosyn. Cont po vanco for presumptive c. diff\n and discontinued IV flagyl. Finished IV Vancomycin for peritonitis.\n - po Vanc C Diff colitis, will continue for 2 weeks after patient\n finishes 10day course of Zosyn ()\n .\n #. Ileus/partial SBO: Resolved. tolerating regular diet. Pt clear by\n S&W.\n - cont to monitor\n .\n # Peritonitis\n Per renal will plan on vancomycin for full two week\n course (day1: ). Finsidhed IV vanco\n - continue PD per renal\n .\n # Metastatic Carcinoid: Pt followed by Hem/Onc. Pt had octreotide scan\n that showed increase in disease.\n - will f/u Hem/Onc regarding octreotide scan results\n - Appreciate palliative care recs\n - oxycontin 20mg Q12 for long acting pain control. PO dilaudid for\n break through pain and IV dilaudid prn\n - cont gabapentin and standing tylenol\n - stopped octreotide yesterday over concern for hypotension and\n lethargy\n .\n # Anemia: Baseline hct in low 30s, 28.2 today. Guaiac was negative.\n - goal Hct >25\n - continue to guiac stools\n - PPI & trend hct\n .\n # Tranaminitis\n LFTs trending down. Previously thought to be from\n shocked liver. Likely combination of malignancy and shocked liver.\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat\n - continue Aspirin 325mg\n - d/c plavix given pt is now on anticoagulation and no recent stent in\n last year\n - held metoprolol for hypotension.\n # ESRD on PD: renal following, cont PD\n - appreciate renal recs\n - continue Calcitriol, epo per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # FEN: Cont regular diet with shakes\n .\n # Prophylaxis: Coumadin, PPI\n .\n # Access: PIV, lost access will attempt new PIV\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: pending above, likley d/c to rehab after discussion with\n Hem/Onc for further management.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 367665,
"text": "TITLE:\n Chief Complaint: q 2 hr PD\n HPI:\n Mr. is a 78 yo male with PMh of CAD s/p CABG, metastatic\n carcinoid, ESRD on PD, chronic abd/back pain, and AAA who originally\n came in on with abdominal pain and has undergone a complicated\n course since. He presented to with hypotension and a\n hct drop, where a CT scan showed stable AAA and colitis dj to the\n hepatic flexure, and worsening metastatic disease. he was transferred\n to where surgery did not feel there were any acute surgical\n issues. Because of pressor dependent hypotension, he was admitted to\n the MICU where he was treated with po vanco and IV flagyl for\n presumptive cdiff (stool cultures were negative x 2). he was given\n zosyn empirically for colitis/diverticulitis and IV vancomycin for\n peritonitis. Peritoneal fluid had > 3500 WBCs, but culture was\n negative. He had an initial three pressor requirment. his PD was\n continued. He improved and was weaned off pressors by . He has\n since finished a 10 day course of zosyn for diverticulitis/colitis and\n a 2 week course IV vanc (completed ) for culture negative\n peritonitis. His PO vanc is planned for 2 weeks after cessation of his\n zosyn, to be completed on .\n .\n His recovery has been complicated by SBO vs ileus, requiring TPN over\n TF, which resolved on with successful advancment of diet. He has\n had significant pain requirments for severe back pain, ventually\n managed on gabapentin 100mg qhs, oxycontin 20 , standing tylenol,\n and dilaudid 2mg q 4 hours prn. He had elevated LFTs peak and\n 3222 ALT/AST respectively on , thought shock, now trending\n down. He had an HCT drop to 23 from BL low 30s. He had one\n transfusion of pRBCs on and his HCT has been stable since. He was\n guaiac negative. He was transferred to the floor on .\n .\n On , UE swelling was noted and dopplers showed RIJ occlusive\n thrombus, left subclavian nonocclusive thrombus, and left basilic vein\n occlusive thrombus. He had a RIJ CVL had already been removed. His\n right PICC was removed at that time. He never had a line on the left.\n He was started on coumadin with subsequent supertherapeutic INR\n requiring vit K (peak INR 7.1 on , currently 3.5).\n .\n He had recently been discharged on after admission for NSTEMI\n adn PNA. he recieved angioplasty to SVG-OM2 during that stay and\n finished a 10 day course of CTX/Levo. He triggered during this\n admission on 2/ for hypotension. This was responsive to 250cc fluid\n and CEs were negative with trop still trending down from recent\n admission. He denied CP during his stay.\n .\n In addition to pain, he has had progressive generalized weakness.\n There was a concern for cord compression. A CT of his C-T-L spine on\n showed sclerotic lesions concerning for new malignancy in his T\n and L spine. Octreotide scan showed increasing carcinoid tumor burden\n in liver, pelvic bone, posterior musculature abd wall, but not in his\n spine. The CT was without contrast out of concern for harming his\n kidneys and making PD no longer an option. The patient refused MRI.\n There was no cord compression by exam and spine consult did not think\n his exam was consistent with cord compression.\n .\n He is being transferred to the MICU now to increased need for PD\n dialysis being the reasonable capabilities of a floor nurse. His PD\n schedule was increased to q 2 hrs by renal to encephalopathy with\n worsening asterixis and hyperreflexivity thought uremia. He is\n DNR/DNI though accepted pressors and CVL during this admission.\n .\n Regarding his metastatic carcinoid, his outpatient oncologist, Dr. \n has been involved. He was started on octreotide 50mcg TID sq which was\n subsequently discontinued out of concern for hypotension. There is\n currently an ongoing discussion between Dr. and the patient and\n family regarding goals of care and his possible appropriateness for\n hospice.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home:\n Aspirin 325 mg daily\n Clopidogrel 75 mg daily\n Metoprolol Tartrate 50 mg \n Simvastatin 40mg daily\n Lisinopril 5mg\n Imdur 30mg\n Terazosin 5mg\n Finasteride 5mg\n Amlodipine 10mg\n Protonix 40mg\n Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H\n Multivitamin daily\n Colace 100mg \n .\n Transfer Meds:\n Acetaminophen 650 mg PO Q8\n Aspirin 325 mg PO DAILY\n Ondansetron 4 mg IV Q8H:PRN nausea\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Ondansetron ODT 4 mg PO Q8H:PRN\n Docusate Sodium (Liquid) 100 mg PO BID\n Oxycodone SR (OxyconTIN) 20 mg PO Q12H\n Epoetin Alfa 10,000 UNIT SC QMOWEFR\n Pantoprazole 40 mg PO Q24H\n Gabapentin 100 mg PO HS\n Potassium Chloride 2 mEq IP 2 MEQ PER 1 L PD SOLUTION for hypokalemia\n HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN\n Senna 1 TAB PO BID:PRN\n Sertraline 25 mg PO DAILY\n Vancomycin Oral Liquid 250 mg PO Q6H\n sevelamer HYDROCHLORIDE 800 mg PO TID\n Past medical history:\n Family history:\n Social History:\n - Carcinoid tumor with mets to liver\n - Hypertension\n - Hyperlipidemia\n - CAD s/p CABG x 4 in , Cath -> severe native three vessel\n disease with 90% lesion in SVG-OM2, which was successfully\n angioplastied. Also with atretic SVG-OM1, and ?obstruction of LAD.\n Given subclavian stenoses, central pressures noted to be 60mmHg higher\n than peripheral pressures.\n - ESRD, on PD since , s/p HD tunneled cath placement\n - CAD s/p bilateral carotid endarterectomies in , c/b post-op\n seizure\n - Bilateral RAS & left common iliac artery aneurysm, s/p bilateral\n endarterectomies and aortobifemoral bypass graft with renal artery\n reimplantation to aortic graft in , left renal artery stenting in\n , s/p right ureteral stenting in c/b right mid-ureteral\n stricture with multiple stent exchanges in 07 & 08\n - AAA measuring 5 cm on CT\n - Sigmoid diverticulitis\n - Pancreatitis w/ ileus post AAA\n - BPH\n - H/o ruptured disk\n - S/p vasectomy, eye surgey, tonsillectomy\n brother with CAD s/p CABG, mother with CVA in 90s.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt is married, lives with his wife. Social history is\n significant for current tobacco use. Pt quit smoking in but\n resumed smoking last summer, about 6 cigarettes daily. Previously, he\n smoked one-and-a-half pack per day for 35 years. There is no history\n of alcohol abuse.\n Review of systems:\n Flowsheet Data as of 09:36 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n Vitals: T: 97 BP: 131/67 P: 91 RR: 12 O2: Sats 95% 2L\n General: NAD, comfortable\n HEENT: Sclera anicteric, MMM\n Neck: supple, no JVD\n Lungs: Scant crackles bilaterally at bases, otherwise clear, though\n exam limited by cooperation\n CV: RRR, distant no m/r/g\n Abdomen: soft, diffusely TTP inconsistently, non-distended, NABS, no\n guarding or rebound\n Ext: + LE edema\n Neuro: AOx2, + asterixis. UE 5/5 strength. LE hip flexors\n bilaterally, hamstring/quads bilaterally limited by cooperation.\n LE hyperreflexive. UE 2+ reflexes.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Chem 7:\n 138 99 41 93\n 4.8 29 7.4\n Ca: 8.0 Mg: 1.8 P: 6.3\n WBC: 7.8\n N:88.2 L:6.5 M:3.8 E:1.1 Bas:0.4\n HCT 28.3\n Plt 389\n PT: 33.7 PTT: 39.7 INR: 3.5\n Imaging: CT Abd/Pelvis \n IMPRESSION:\n 1. New wall thickening and inflammatory change around a short\n segment of right colon near the hepatic flexure. While this could\n represent inflammation related to diverticular disease, or other\n infectious or inflammatory causes, this loop of colon is situated close\n to multiple metastatic foci within the liver, and metastatic disease,\n or direct extent of tumor should also be considered.\n 2. Increased size of multiple hepatic metastases.\n 3. Free intraperitoneal air, presumably related to peritoneal\n dialysis.\n 4. Moderate right hydronephrosis, with dense material now seen in the\n right renal collecting system and bladder. This appearance is\n concerning for hemorrhage, unless there has been recent radiographic\n procedure with injection of contrast directly into the collecting\n system.\n 5. Cholelithiasis, without evidence of cholecystitis.\n 6. Grossly unchanged appearance of 5.5 cm descending thoracic and\n suprarenal abdominal aortic aneurysm.\n 7. Stable soft tissue density anterior to the right ureter, with tiny\n central punctate calcification.\n .\n KUB:\n IMPRESSION: Dilated loops of small bowel with residual air in the\n colon, this could be an ileus and less likely a new or incomplete SBO.\n Recommend followup.\n .\n CXR \n FINDINGS: The NG tube tip is in the proximal stomach. There continue to\n be dilated small bowel loops measuring up to 4.6 cm consistent with\n patient's known small-bowel obstruction. Right IJ line is unchanged\n with tip in the SVC/RA. There is some increased opacity at the right\n base and right mid lung consistent with infiltrate that is slightly\n improved compared to the prior exam.\n .\n CXR \n IMPRESSION: 5 French double-lumen Vaxcel PICC line placed via right\n basilic vein with tip in the SVC. The catheter is ready to use.\n .\n U/S \n IMPRESSION:\n 1) Occlusive thrombus in the right internal jugular vein and\n non-occlusive thrombus at the left subclavian vein.\n 2) Occlusive thrombus in the left basilic vein.\n .\n CT L-spine \n IMPRESSION:\n 1. Multilevel degenerative changes, with neural foraminal narrowing and\n spinal stenosis, most pronounced at L4-5 level. MR is more ideal\n for assessemnt of intrathecal structures, unless there is a\n contra-indication.\n 2. Faint foci of sclerosis in several vertebral bodies, unchanged from\n the most recent prior study; however, not present in and while\n these can represent bone islands, given the history, also concerning\n for metastatic foci. Correlation with radionuclide studies can be\n considered.\n 3. Large suprarenal abdominal aortic aneurysm, given limitation in lack\n of IV contrast, incompletely assessed.\n 4. Right hydronephrosis, double-J stent in place.\n 5. Upper abdominal ascites.\n Impressions- 3,4 &5- not compleely assessed.\n .\n CT T-spine .\n IMPRESSION:\n 1. Multiple, at least seven sclerotic foci, in the thoracic vertebrae\n and one involving the left eighth rib, mildly increased in size, and\n more conspicuous on today's study compared to the CT torso done in\n . Given the increase in size, these may represent metastatic\n lesions, though the appearance is nonspecific and resembles bone\n islands. No cortical discontinuity noted.\n 2. Lung, pleural and vascular changes as described above, incompletely\n imaged and characterized on the present study. CT\n Chest can be considered.\n 3. Distended bowel loops on the scout image with mildly increased\n diameter since the prior study scout- to correlate clinically to\n exclude obstructive etiology. These are not included on the other\n images.\n .\n CT C-spine .\n IMPRESSION:\n 1. Multilevel degenerative changes in the cervical spine as described\n above, causing moderate-to-severe neural foraminal narrowing as\n described above, and mild canal stenosis.\n 2. No definite sclerotic foci in the cervical spine to suggest\n metastases.\n Correlate with radionuclide studies.\n 3. Partially imaged T3 sclerotic focus, better assessed on the\n concurrent CT T spine study.\n 4. Significant atherosclerotic vascular calcifications as above.\n .\n CT Head .\n IMPRESSION:\n 1. No intracranial hemorrhage. Limited evaluation for intracranial\n metastases, though no obvious mass or edema is identified.\n 2. Chronic left posterior parietal infarct.\n .\n Octreotide scan. .\n IMPRESSION: 1. Octreotide-avid disease in a right pubic bone\n sclerotic lesion and increased uptake in the musculature\n posterior to the left greater trochanter, compatible with\n carcinoid. 2. Innumerable heterogeneous hepatic lesions in both\n lobes, some of which are subcapsular, warrant follow-up.\n .\n Echo : The left atrium is elongated. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. There is mild to\n moderate regional left ventricular systolic dysfunction with\n hypokinesis of the inferolateral and basal inferior walls. The\n remaining segments contract normally (LVEF = 45-50 %). Right\n ventricular chamber size and free wall motion are normal. The\n descending thoracic aorta is mildly dilated. The aortic valve leaflets\n (3) are mildly thickened with good leaflet excursion and no aortic\n regurgitation. The mitral valve leaflets are mildly thickened. At least\n mild (1+) mitral regurgitation is seen. There is moderate pulmonary\n artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n Microbiology: Urine/blood Cx: No grwoth\n Peritoneal Fluid: Cx: No growth, WBC:3150, poly 93%\n C. diff: negative x 2\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Now with\n ileus/SBO.\n .\n #Back Pain: Pain improved today. Pt showed areas of sclerotic\n lesions new since in T and L spine. Octreotide scan shows lesion\n on iliac. Also contribution of degenerative changes and deconditioning.\n Currently pain is being managed by oxycontin 20mg , restarted\n gabapentin and standing tylenol. Pt followed by P&P Care.\n - f/u PT recs\n - cont pain regimen\n .\n #. RIJ and L subclavian thrombus: Pt INR 3.5 today. Pt with difficult\n access and difficult lab draws.\n - hold coumadin goalINR . Will need minimum of 3 months.\n - cont to monitor for bleeding\n .\n # Abdominal Pain/Colitis\n Pt improved and abdominal pain controlled. Pt\n finished 10 day course of zosyn. Cont po vanco for presumptive c. diff\n and discontinued IV flagyl. Finished IV Vancomycin for peritonitis.\n - po Vanc C Diff colitis, will continue for 2 weeks after patient\n finishes 10day course of Zosyn ()\n .\n #. Ileus/partial SBO: Resolved. tolerating regular diet. Pt clear by\n S&W.\n - cont to monitor\n .\n # Peritonitis\n Per renal will plan on vancomycin for full two week\n course (day1: ). Finsidhed IV vanco\n - continue PD per renal\n .\n # Metastatic Carcinoid: Pt followed by Hem/Onc. Pt had octreotide scan\n that showed increase in disease.\n - will f/u Hem/Onc regarding octreotide scan results\n - Appreciate palliative care recs\n - oxycontin 20mg Q12 for long acting pain control. PO dilaudid for\n break through pain and IV dilaudid prn\n - cont gabapentin and standing tylenol\n - stopped octreotide yesterday over concern for hypotension and\n lethargy\n .\n # Anemia: Baseline hct in low 30s, 28.2 today. Guaiac was negative.\n - goal Hct >25\n - continue to guiac stools\n - PPI & trend hct\n .\n # Tranaminitis\n LFTs trending down. Previously thought to be from\n shocked liver. Likely combination of malignancy and shocked liver.\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat\n - continue Aspirin 325mg\n - d/c plavix given pt is now on anticoagulation and no recent stent in\n last year\n - held metoprolol for hypotension.\n # ESRD on PD: renal following, cont PD\n - appreciate renal recs\n - continue Calcitriol, epo per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # FEN: Cont regular diet with shakes\n .\n # Prophylaxis: Coumadin, PPI\n .\n # Access: PIV, lost access will attempt new PIV\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: pending above, likley d/c to rehab after discussion with\n Hem/Onc for further management.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 367668,
"text": "TITLE:\n Chief Complaint: q 2 hr PD\n HPI:\n Mr. is a 78 yo male with PMh of CAD s/p CABG, metastatic\n carcinoid, ESRD on PD, chronic abd/back pain, and AAA who originally\n came in on with abdominal pain and has undergone a complicated\n course since. He presented to with hypotension and a\n hct drop, where a CT scan showed stable AAA and colitis dj to the\n hepatic flexure, and worsening metastatic disease. he was transferred\n to where surgery did not feel there were any acute surgical\n issues. Because of pressor dependent hypotension, he was admitted to\n the MICU where he was treated with po vanco and IV flagyl for\n presumptive cdiff (stool cultures were negative x 2). he was given\n zosyn empirically for colitis/diverticulitis and IV vancomycin for\n peritonitis. Peritoneal fluid had > 3500 WBCs, but culture was\n negative. He had an initial three pressor requirment. his PD was\n continued. He improved and was weaned off pressors by . He has\n since finished a 10 day course of zosyn for diverticulitis/colitis and\n a 2 week course IV vanc (completed ) for culture negative\n peritonitis. His PO vanc is planned for 2 weeks after cessation of his\n zosyn, to be completed on .\n .\n His recovery has been complicated by SBO vs ileus, requiring TPN over\n TF, which resolved on with successful advancment of diet. He has\n had significant pain requirments for severe back pain, ventually\n managed on gabapentin 100mg qhs, oxycontin 20 , standing tylenol,\n and dilaudid 2mg q 4 hours prn. He had elevated LFTs peak and\n 3222 ALT/AST respectively on , thought shock, now trending\n down. He had an HCT drop to 23 from BL low 30s. He had one\n transfusion of pRBCs on and his HCT has been stable since. He was\n guaiac negative. He was transferred to the floor on .\n .\n On , UE swelling was noted and dopplers showed RIJ occlusive\n thrombus, left subclavian nonocclusive thrombus, and left basilic vein\n occlusive thrombus. He had a RIJ CVL had already been removed. His\n right PICC was removed at that time. He never had a line on the left.\n He was started on coumadin with subsequent supertherapeutic INR\n requiring vit K (peak INR 7.1 on , currently 3.5).\n .\n He had recently been discharged on after admission for NSTEMI\n adn PNA. he recieved angioplasty to SVG-OM2 during that stay and\n finished a 10 day course of CTX/Levo. He triggered during this\n admission on 2/ for hypotension. This was responsive to 250cc fluid\n and CEs were negative with trop still trending down from recent\n admission. He denied CP during his stay.\n .\n In addition to pain, he has had progressive generalized weakness.\n There was a concern for cord compression. A CT of his C-T-L spine on\n showed sclerotic lesions concerning for new malignancy in his T\n and L spine. Octreotide scan showed increasing carcinoid tumor burden\n in liver, pelvic bone, posterior musculature abd wall, but not in his\n spine. The CT was without contrast out of concern for harming his\n kidneys and making PD no longer an option. The patient refused MRI.\n There was no cord compression by exam and spine consult did not think\n his exam was consistent with cord compression.\n .\n He is being transferred to the MICU now to increased need for PD\n dialysis being the reasonable capabilities of a floor nurse. His PD\n schedule was increased to q 2 hrs by renal to encephalopathy with\n worsening asterixis and hyperreflexivity thought uremia. He is\n DNR/DNI though accepted pressors and CVL during this admission.\n .\n Regarding his metastatic carcinoid, his outpatient oncologist, Dr. \n has been involved. He was started on octreotide 50mcg TID sq which was\n subsequently discontinued out of concern for hypotension. There is\n currently an ongoing discussion between Dr. and the patient and\n family regarding goals of care and his possible appropriateness for\n hospice.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home:\n Aspirin 325 mg daily\n Clopidogrel 75 mg daily\n Metoprolol Tartrate 50 mg \n Simvastatin 40mg daily\n Lisinopril 5mg\n Imdur 30mg\n Terazosin 5mg\n Finasteride 5mg\n Amlodipine 10mg\n Protonix 40mg\n Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H\n Multivitamin daily\n Colace 100mg \n .\n Transfer Meds:\n Acetaminophen 650 mg PO Q8\n Aspirin 325 mg PO DAILY\n Ondansetron 4 mg IV Q8H:PRN nausea\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Ondansetron ODT 4 mg PO Q8H:PRN\n Docusate Sodium (Liquid) 100 mg PO BID\n Oxycodone SR (OxyconTIN) 20 mg PO Q12H\n Epoetin Alfa 10,000 UNIT SC QMOWEFR\n Pantoprazole 40 mg PO Q24H\n Gabapentin 100 mg PO HS\n Potassium Chloride 2 mEq IP 2 MEQ PER 1 L PD SOLUTION for hypokalemia\n HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN\n Senna 1 TAB PO BID:PRN\n Sertraline 25 mg PO DAILY\n Vancomycin Oral Liquid 250 mg PO Q6H\n sevelamer HYDROCHLORIDE 800 mg PO TID\n Past medical history:\n Family history:\n Social History:\n - Carcinoid tumor with mets to liver\n - Hypertension\n - Hyperlipidemia\n - CAD s/p CABG x 4 in , Cath -> severe native three vessel\n disease with 90% lesion in SVG-OM2, which was successfully\n angioplastied. Also with atretic SVG-OM1, and ?obstruction of LAD.\n Given subclavian stenoses, central pressures noted to be 60mmHg higher\n than peripheral pressures.\n - ESRD, on PD since , s/p HD tunneled cath placement\n - CAD s/p bilateral carotid endarterectomies in , c/b post-op\n seizure\n - Bilateral RAS & left common iliac artery aneurysm, s/p bilateral\n endarterectomies and aortobifemoral bypass graft with renal artery\n reimplantation to aortic graft in , left renal artery stenting in\n , s/p right ureteral stenting in c/b right mid-ureteral\n stricture with multiple stent exchanges in 07 & 08\n - AAA measuring 5 cm on CT\n - Sigmoid diverticulitis\n - Pancreatitis w/ ileus post AAA\n - BPH\n - H/o ruptured disk\n - S/p vasectomy, eye surgey, tonsillectomy\n brother with CAD s/p CABG, mother with CVA in 90s.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt is married, lives with his wife. Social history is\n significant for current tobacco use. Pt quit smoking in but\n resumed smoking last summer, about 6 cigarettes daily. Previously, he\n smoked one-and-a-half pack per day for 35 years. There is no history\n of alcohol abuse.\n Review of systems:\n Flowsheet Data as of 09:36 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n Physical Examination\n Vitals: T: 97 BP: 131/67 P: 91 RR: 12 O2: Sats 95% 2L\n General: NAD, comfortable\n HEENT: Sclera anicteric, MMM\n Neck: supple, no JVD\n Lungs: Scant crackles bilaterally at bases, otherwise clear, though\n exam limited by cooperation\n CV: RRR, distant no m/r/g\n Abdomen: soft, diffusely TTP inconsistently, non-distended, NABS, no\n guarding or rebound\n Ext: + LE edema\n Neuro: AOx2, + asterixis. UE 5/5 strength. LE hip flexors\n bilaterally, hamstring/quads bilaterally limited by cooperation.\n LE hyperreflexive. UE 2+ reflexes.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Chem 7:\n 138 99 41 93\n 4.8 29 7.4\n Ca: 8.0 Mg: 1.8 P: 6.3\n WBC: 7.8\n N:88.2 L:6.5 M:3.8 E:1.1 Bas:0.4\n HCT 28.3\n Plt 389\n PT: 33.7 PTT: 39.7 INR: 3.5\n Imaging: CT Abd/Pelvis \n IMPRESSION:\n 1. New wall thickening and inflammatory change around a short\n segment of right colon near the hepatic flexure. While this could\n represent inflammation related to diverticular disease, or other\n infectious or inflammatory causes, this loop of colon is situated close\n to multiple metastatic foci within the liver, and metastatic disease,\n or direct extent of tumor should also be considered.\n 2. Increased size of multiple hepatic metastases.\n 3. Free intraperitoneal air, presumably related to peritoneal\n dialysis.\n 4. Moderate right hydronephrosis, with dense material now seen in the\n right renal collecting system and bladder. This appearance is\n concerning for hemorrhage, unless there has been recent radiographic\n procedure with injection of contrast directly into the collecting\n system.\n 5. Cholelithiasis, without evidence of cholecystitis.\n 6. Grossly unchanged appearance of 5.5 cm descending thoracic and\n suprarenal abdominal aortic aneurysm.\n 7. Stable soft tissue density anterior to the right ureter, with tiny\n central punctate calcification.\n .\n KUB:\n IMPRESSION: Dilated loops of small bowel with residual air in the\n colon, this could be an ileus and less likely a new or incomplete SBO.\n Recommend followup.\n .\n CXR \n FINDINGS: The NG tube tip is in the proximal stomach. There continue to\n be dilated small bowel loops measuring up to 4.6 cm consistent with\n patient's known small-bowel obstruction. Right IJ line is unchanged\n with tip in the SVC/RA. There is some increased opacity at the right\n base and right mid lung consistent with infiltrate that is slightly\n improved compared to the prior exam.\n .\n CXR \n IMPRESSION: 5 French double-lumen Vaxcel PICC line placed via right\n basilic vein with tip in the SVC. The catheter is ready to use.\n .\n U/S \n IMPRESSION:\n 1) Occlusive thrombus in the right internal jugular vein and\n non-occlusive thrombus at the left subclavian vein.\n 2) Occlusive thrombus in the left basilic vein.\n .\n CT L-spine \n IMPRESSION:\n 1. Multilevel degenerative changes, with neural foraminal narrowing and\n spinal stenosis, most pronounced at L4-5 level. MR is more ideal\n for assessemnt of intrathecal structures, unless there is a\n contra-indication.\n 2. Faint foci of sclerosis in several vertebral bodies, unchanged from\n the most recent prior study; however, not present in and while\n these can represent bone islands, given the history, also concerning\n for metastatic foci. Correlation with radionuclide studies can be\n considered.\n 3. Large suprarenal abdominal aortic aneurysm, given limitation in lack\n of IV contrast, incompletely assessed.\n 4. Right hydronephrosis, double-J stent in place.\n 5. Upper abdominal ascites.\n Impressions- 3,4 &5- not compleely assessed.\n .\n CT T-spine .\n IMPRESSION:\n 1. Multiple, at least seven sclerotic foci, in the thoracic vertebrae\n and one involving the left eighth rib, mildly increased in size, and\n more conspicuous on today's study compared to the CT torso done in\n . Given the increase in size, these may represent metastatic\n lesions, though the appearance is nonspecific and resembles bone\n islands. No cortical discontinuity noted.\n 2. Lung, pleural and vascular changes as described above, incompletely\n imaged and characterized on the present study. CT\n Chest can be considered.\n 3. Distended bowel loops on the scout image with mildly increased\n diameter since the prior study scout- to correlate clinically to\n exclude obstructive etiology. These are not included on the other\n images.\n .\n CT C-spine .\n IMPRESSION:\n 1. Multilevel degenerative changes in the cervical spine as described\n above, causing moderate-to-severe neural foraminal narrowing as\n described above, and mild canal stenosis.\n 2. No definite sclerotic foci in the cervical spine to suggest\n metastases.\n Correlate with radionuclide studies.\n 3. Partially imaged T3 sclerotic focus, better assessed on the\n concurrent CT T spine study.\n 4. Significant atherosclerotic vascular calcifications as above.\n .\n CT Head .\n IMPRESSION:\n 1. No intracranial hemorrhage. Limited evaluation for intracranial\n metastases, though no obvious mass or edema is identified.\n 2. Chronic left posterior parietal infarct.\n .\n Octreotide scan. .\n IMPRESSION: 1. Octreotide-avid disease in a right pubic bone\n sclerotic lesion and increased uptake in the musculature\n posterior to the left greater trochanter, compatible with\n carcinoid. 2. Innumerable heterogeneous hepatic lesions in both\n lobes, some of which are subcapsular, warrant follow-up.\n .\n Echo : The left atrium is elongated. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. There is mild to\n moderate regional left ventricular systolic dysfunction with\n hypokinesis of the inferolateral and basal inferior walls. The\n remaining segments contract normally (LVEF = 45-50 %). Right\n ventricular chamber size and free wall motion are normal. The\n descending thoracic aorta is mildly dilated. The aortic valve leaflets\n (3) are mildly thickened with good leaflet excursion and no aortic\n regurgitation. The mitral valve leaflets are mildly thickened. At least\n mild (1+) mitral regurgitation is seen. There is moderate pulmonary\n artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n Microbiology: Urine/blood Cx: No grwoth\n Peritoneal Fluid: Cx: No growth, WBC:3150, poly 93%\n C. diff: negative x 2\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Now with\n ileus/SBO.\n .\n # AMS: variable course over his stay. likely multifactorial including\n narcotics, toxic/metabolic related to renal failure. Had CT head with\n contrast on , but this does not definitively r/o brain metastases.\n # ESRD on PD: renal following, cont PD\n - appreciate renal recs\n - continue Calcitriol, epo per renal recs\n .\n #Back Pain: Chronic. CT-scan showed areas of sclerotic lesions new\n since in T and L spine. Octreotide scan shows lesion on iliac.\n Also contribution of degenerative changes and deconditioning. Currently\n pain is being managed by oxycontin 20mg , gabapentin and standing\n tylenol. Pt followed by P&P Care.\n - f/u PT recs\n - cont pain regimen\n .\n #. RIJ and L subclavian thrombus: Pt INR 3.5 today. Pt with difficult\n access and difficult lab draws.\n - hold coumadin goalINR . Will need minimum of 3 months.\n - cont to monitor for bleeding\n .\n # Abdominal Pain/Colitis\n Pt improved and abdominal pain controlled. Pt\n finished 10 day course of zosyn. Cont po vanco for presumptive c. diff\n and discontinued IV flagyl. Finished IV Vancomycin for peritonitis.\n - po Vanc C Diff colitis, will continue for 2 weeks after patient\n finishes 10day course of Zosyn ()\n .\n #. Ileus/partial SBO: Resolved. tolerating regular diet. Pt clear by\n S&W.\n - cont to monitor\n .\n # Peritonitis\n Per renal will plan on vancomycin for full two week\n course (day1: ). Finsidhed IV vanco\n - continue PD per renal\n .\n # Metastatic Carcinoid: Pt followed by Hem/Onc. Pt had octreotide scan\n that showed increase in disease.\n - will f/u Hem/Onc regarding octreotide scan results\n - Appreciate palliative care recs\n - oxycontin 20mg Q12 for long acting pain control. PO dilaudid for\n break through pain and IV dilaudid prn\n - cont gabapentin and standing tylenol\n - stopped octreotide yesterday over concern for hypotension and\n lethargy\n .\n # Anemia: Baseline hct in low 30s, 28.2 today. Guaiac was negative.\n - goal Hct >25\n - continue to guiac stools\n - PPI & trend hct\n .\n # Tranaminitis\n LFTs trending down. Previously thought to be from\n shocked liver. Likely combination of malignancy and shocked liver.\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat\n - continue Aspirin 325mg\n - d/c plavix given pt is now on anticoagulation and no recent stent in\n last year\n - held metoprolol for hypotension.\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Decubitus Ulcer:\n .\n # FEN: Cont regular diet with shakes\n .\n # Prophylaxis: Coumadin, PPI\n .\n # Access: PIV, lost access will attempt new PIV\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: pending above, likley d/c to rehab after discussion with\n Hem/Onc for further management.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 367772,
"text": "Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Anuric, Received pt PD status cap dry for noc. c/o back and abd pain\n @ rest . Abd soft tender to palpation + BS. PD resumed with q2hr dwell\n exchanges with altermating solution. Dwell 2hrs and drain negative\n 100-200cc/exchange. Drainage clear pale yellow effluent sent for\n cytology and Culture. @ 12n Episode hypotension SBP 70\ns MAPS 50\n Fluid bolus 1.5L NS lactate sent.\n Action:\n Received Oxycodone for pain @ 0800 progrssive somulence and pain\n control. Hypotensive ? med related. Received FB 1.5 L NS with\n responding ^ BP. Had 3 PD exchanges thus far.\n Response:\n Tolerated PD clear effluent drainage. Lactate 1.8\n Plan:\n Continue PD exchange q2hrs with 2hr dwell x6/24hrs.\n Ok to keep dry overnight.\n Goal Fluid bal even\n Decubitus ulcer (Present At Admission)\n Assessment:\n Stg on coccyx. No drainage.\n Action:\n Mepilex foam dressing changed and evaluated by wound team\n Response:\n Painful wound\n Plan:\n Refer to wound care recommendations . Dsg changes q72hrs/PRN.\n Delirium / confusion\n Assessment:\n Alert and oriented x2, but delirious. Slow to respond will follow\n commands. MAE random but weak and uncomfortable mets.\n Action:\n PT eval brief due to hypotensive episode.\n Response:\n No change.\n Plan:\n Continue to monitor MS.\n Hypoxemia\n Assessment:\n Received pt on O2 FT50% and NC 3L. sats difficult to obtain due to poor\n peripheral perfusion. Sat cclip on Earlobe sats 98-100% on 3L/min NC.\n Lungs clear dim bases. Occassioal congested cough swallows secretions.\n Resp pattern irreg w periods of apnea.\n Action:\n 02 wean throughout shift to NC 3L/min\n Response:\n Sats improved to 100%.\n Plan:\n Monitor respiratory status, wean o2 as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-22 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 367779,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 78 y/o m with CAD, recent NSTEMI with POBA, CRF on PD, mx carcinoid p/w\n abd pain and hct drop. CT abd at OSH showed colitis. Developed sepsis,\n finished 10d zosyn, vanco 2 weeks, po vanco for empiric C. Fiff\n coverage. Initially in MICU organge, went to floor , course c/b UE\n DVT, had some hypotension on that responded to IVF, had some\n diffuse weakness, imaging of spine showed no cord compression but\n advancing mx disease. Had increasing PD requirements for volume\n overload as well as uremia, so transferred to ICU for q2h PD.\n Overnight had slight hypoxia while sleeping.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n See resident note\n See resident note\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: see resident note\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, Weight loss\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: Dialysis\n Integumentary (skin): No(t) Rash\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: Anemia, Coagulopathy\n Neurologic: back pain, confusion\n Psychiatric / Sleep: Delirious\n Pain: Mild\n Pain location: back\n Flowsheet Data as of 09:47 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 35.4\nC (95.8\n HR: 74 (62 - 84) bpm\n BP: 104/89(93) {85/42(51) - 137/89(93)} mmHg\n RR: 23 (9 - 41) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 100 mL\n 4,000 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -100 mL\n -4,000 mL\n Respiratory\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///29/\n Physical Examination\n General Appearance: Thin, Anxious\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Rhonchorous: bases)\n Abdominal: Soft, Tender: diffuse with guarding\n Extremities: Right: 2+, Left: 2+\n Musculoskeletal: Muscle wasting\n Skin: Cool\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person/place/date, Movement: Not assessed,\n Tone: Not assessed, +asterixis\n Labs / Radiology\n 388 K/uL\n 29.2 %\n 9.1 g/dL\n 101 mg/dL\n 6.9 mg/dL\n 36 mg/dL\n 29 mEq/L\n 100 mEq/L\n 4.4 mEq/L\n 138 mEq/L\n 6.7 K/uL\n [image002.jpg]\n 04:48 AM\n WBC\n 6.7\n Hct\n 29.2\n Plt\n 388\n Cr\n 6.9\n Glucose\n 101\n Other labs: ALT / AST:28/18, Alk Phos / T Bili:102/0.2,\n Differential-Neuts:76.1 %, Lymph:15.8 %, Mono:5.7 %, Eos:1.9 %,\n Albumin:2.0 g/dL, LDH:236 IU/L, Ca++:7.8 mg/dL, Mg++:1.8 mg/dL, PO4:5.9\n mg/dL\n Assessment and Plan\n HYPOXEMIA\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n DECUBITUS ULCER (PRESENT AT ADMISSION)\n DELIRIUM / CONFUSION\n 78 y/o m with CAD, carcinoid, with recent sepsis colitis.\n 1. AMS: Suspect delirium\n -currently fully oriented\n -cont PD\n -avoid sedation, avoid heavy narcotics\n 2. ESRD on PD\n -f/u renal recs\n 3. LE weakness: be critical illness myopathy\n -consider neuro eval\n 4. carcinoid: Worsening mx disease\n -cont. pain control\n 5. RUE thrombus: On coumadin\n -in setting of CVL\n -check INR\n 6. colitis: ? ischemic vs. infectious\n -cont. renal diet\n -avoid persistent hypotension\n 7. GOC: Dr. planning a family meeting\n 8. CAD, recent NSTEMI: cont. ASA\n -start statin\n -consider BB when BP stable\n 9. sacral decub: wound care c/s\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 22 Gauge - 10:21 PM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n"
},
{
"category": "Nutrition",
"chartdate": "2145-03-08 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 365725,
"text": "Subjective\n Unable to speak w/ pt\n Objective\n \n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 56 kg\n 19.3\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n Diagnosis:\n PMH :\n Food allergies and intolerances:\n Pertinent medications:\n Labs:\n Value\n Date\n Glucose\n 91 mg/dL\n 05:00 AM\n Glucose Finger Stick\n 160\n 10:00 PM\n BUN\n 50 mg/dL\n 05:00 AM\n Creatinine\n 8.1 mg/dL\n 05:00 AM\n Sodium\n 137 mEq/L\n 05:00 AM\n Potassium\n 3.0 mEq/L\n 05:00 AM\n Chloride\n 101 mEq/L\n 05:00 AM\n TCO2\n 23 mEq/L\n 05:00 AM\n Albumin\n 2.1 g/dL\n 05:00 AM\n Calcium non-ionized\n 7.5 mg/dL\n 05:00 AM\n Phosphorus\n 6.9 mg/dL\n 05:00 AM\n Magnesium\n 1.9 mg/dL\n 05:00 AM\n ALT\n 1127 IU/L\n 05:00 AM\n Alkaline Phosphate\n 125 IU/L\n 05:00 AM\n AST\n 544 IU/L\n 05:00 AM\n Amylase\n 197 IU/L\n 09:25 PM\n Total Bilirubin\n 0.3 mg/dL\n 05:00 AM\n WBC\n 9.8 K/uL\n 05:00 AM\n Hgb\n 7.6 g/dL\n 05:00 AM\n Hematocrit\n 23.5 %\n 05:00 AM\n Current diet order / nutrition support: PPN: 1L(50g dex, 35g aa),\n Regular- soft(dysphagia) w/ nectar thick lix\n GI:\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: Low po intake, Low protein stores, Needs nutrition\n support\n Estimated Nutritional Needs\n Calories: (BEE x or / cal/kg)\n Protein: ( g/kg)\n Fluid:\n Estimation of previous intake:\n Estimation of current intake:\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TPN\n Tube feeding / TPN recommendations:\n Comments:\n"
},
{
"category": "Nutrition",
"chartdate": "2145-03-08 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 365726,
"text": "Subjective\n Unable to speak w/ pt\n Objective\n \n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 56 kg\n 19.3\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 83\n n/a\n Diagnosis: Sepsis\n PMH :\n -Carcinoid tumor with mets to liver\n - Hypertension & Hyperlipidemia\n - CAD s/p CABG x 4 in , Cath -> severe native three vessel\n disease with 90% lesion in SVG-OM2 s/p PTCA\n - ESRD, on PD since , s/p HD tunneled cath placement\n - CAD s/p bilateral carotid endarterectomies in , c/b post-op\n seizure\n - Bilateral RAS & left common iliac artery aneurysm, s/p bilateral\n endarterectomies and aortobifemoral bypass graft with renal artery\n reimplantation to aortic graft in , left renal artery stenting in\n , s/p right ureteral stenting in c/b right mid-ureteral\n stricture with multiple stent exchanges in 07 & 08\n - AAA measuring 5 cm on CT\n - Sigmoid diverticulitis\n - Pancreatitis w/ ileus post AAA\n - BPH\n - H/o ruptured disk\n Food allergies and intolerances: n/a\n Pertinent medications: Vancomycin, Heparin, Protonix, Flagyl,asa,\n others noted\n Labs:\n Value\n Date\n Glucose\n 91 mg/dL\n 05:00 AM\n Glucose Finger Stick\n 160\n 10:00 PM\n BUN\n 50 mg/dL\n 05:00 AM\n Creatinine\n 8.1 mg/dL\n 05:00 AM\n Sodium\n 137 mEq/L\n 05:00 AM\n Potassium\n 3.0 mEq/L\n 05:00 AM\n Chloride\n 101 mEq/L\n 05:00 AM\n TCO2\n 23 mEq/L\n 05:00 AM\n Albumin\n 2.1 g/dL\n 05:00 AM\n Calcium non-ionized\n 7.5 mg/dL\n 05:00 AM\n Phosphorus\n 6.9 mg/dL\n 05:00 AM\n Magnesium\n 1.9 mg/dL\n 05:00 AM\n ALT\n 1127 IU/L\n 05:00 AM\n Alkaline Phosphate\n 125 IU/L\n 05:00 AM\n AST\n 544 IU/L\n 05:00 AM\n Amylase\n 197 IU/L\n 09:25 PM\n Total Bilirubin\n 0.3 mg/dL\n 05:00 AM\n WBC\n 9.8 K/uL\n 05:00 AM\n Hgb\n 7.6 g/dL\n 05:00 AM\n Hematocrit\n 23.5 %\n 05:00 AM\n Current diet order / nutrition support: PPN: 1L(50g dex, 35g aa),\n Regular- soft(dysphagia) w/ nectar thick lix\n GI: Abd soft/diffusely tender/ND/(+)BS/ (+) BM\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: Low po intake, Low protein stores, Needs nutrition\n support\n Estimated Nutritional Needs\n Calories: (BEE x or / cal/kg)\n Protein: ( g/kg)\n Fluid: per team\n Estimation of previous and current intake: Inadequate\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TPN\n Tube feeding / TPN recommendations:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365729,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - did not give PO narcan since patient had large bowel movement\n - KUB showed SBO vs ileus, pt has episode of vomitting, tube feeds\n stopped, NG placed on intermittent suction\n - renal wants IV vanc, they will give via HD protocol\n - wants patient on bowel rest since SBO vs ileus, no surgical\n intervention\n - trying to reduce the amount of narcotics by giving some anxitolytics\n for pain since both are causing pt discomfort\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:18 PM\n Piperacillin - 06:00 PM\n Metronidazole - 12:39 AM\n Piperacillin/Tazobactam (Zosyn) - 06:15 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.2\nC (99\n HR: 81 (63 - 88) bpm\n BP: 110/42(58) {96/42(53) - 140/67(84)} mmHg\n RR: 8 (8 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 7 (2 - 10)mmHg\n Total In:\n 684 mL\n 217 mL\n PO:\n TF:\n 144 mL\n IVF:\n 441 mL\n 217 mL\n Blood products:\n Total out:\n -4,000 mL\n -6,000 mL\n Urine:\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 4,684 mL\n 6,217 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 231 K/uL\n 7.6 g/dL\n 91 mg/dL\n 8.1 mg/dL\n 23 mEq/L\n 3.0 mEq/L\n 50 mg/dL\n 101 mEq/L\n 137 mEq/L\n 23.5 %\n 9.8 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n 04:22 PM\n 03:23 AM\n 05:00 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n 14.3\n 9.8\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n 23.7\n 25.5\n 23.5\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n 237\n 231\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n 8.0\n 8.1\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n 112\n 91\n Other labs: PT / PTT / INR:17.2/45.4/1.6, ALT / AST:1127/544, Alk Phos\n / T Bili:125/0.3, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.1 g/dL, LDH:750 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Now with\n ileus/SBO.\n .\n # presumptive Cdiff\n Presenation was 2-3 days of dark loose stools and\n poor po intake after completing a course of Abx for PNA. Per family, no\n fevers at home but pt reports subjective chills. WBC ct of 20 and CT\n with colitis. Concern for C Diff colitis vs ischemic colitis,\n complicated by sepsis\n requiring pressor support. SBP also possible,\n had high WBC count but no organisms grew. Pt was seen by gen and\n vasc surgery in ED, no plan for OR. Pt expressed goals of care to\n avoid heroic measures, confirmed by HCP. on contact\n precautions. C.diff has been complicated by what appears to be ileus,\n although SBO is still a possibility.\n - Zozyn for possible diverticulitis, will complete a 10 day course, no\n day \n - Flagyl and po Vanc and IV vanco for possible CDiff colitis\n - c.diff toxin negative, but still is likely the cause\n - pt with likely ileus, but had bowel movement yesterday\n gen \n reconsulted and following again. Will keep NGT on intermittent wall\n suction, remains NPO for bowel rest, continue bowel regimen and\n consider PO narcan as needed\n - holding narcotics, seems comfortable\n # peritonitis\n spoke to renal today, should give vanc for the full two\n week course, and will check peritoneal fluid again, they will continue\n PD through this infection.\n - vanc dosing should be 750 mg when daily vanco level is below 15\n # Shock liver\n LFTs peaked now trending down, patient continues to\n have coagulopathy, both improving\n .\n # altered Mental status\n waxing and , maybe baseline, maybe\n uremia v. narcotic usage\n - giving slight ativan since anxiety playing element in pain\n - stopping dilaudid for now, patient remains comfortable\n .\n # Hypotension: Resolved, patient is severe vasculopath and pressures\n are difficult to determine. Patient was initially started on levo and\n then moved to three pressors. He has bilateral subclavian stenosis with\n difficult time to determine blood pressure, weaned to mental status as\n well as blood pressures from legs. CT ruled out ruptured AAA and stool\n guaic was negative. Differential includes sepsis, hypovolemic, GI\n bleed, ischemic colitis, less likely to be MI or adrenal\n insufficiency. Most likely is sepsis in setting of colitis and\n peritonitis. Pressors off \n - hemodynamics stable\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission, continue to follow\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: renal following, plan for PD, peritonitis, see above\n - PD cath Cx\n no organisms seen on gram stain\n - f/u renal recs, did stop renagel due to its constipating effects\n - continue Calcitriol\n - will reculture fluid\n - added epo per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross; continue to guiac stools\n - CVL and PIV for access\n - PPI & trend hct, keep > 21\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: on bowel rest, today will do PPN and tomorrow plan for TPN as\n LFTs start to improve\n .\n # Prophylaxis: Heparin sc tid, PPI IV\n .\n # Access: PIV, RIJ; PICC attempted at bedside and could not be done,\n plan for IR guided PICC and removal of RIJ\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now, call out to floor today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-04 00:00:00.000",
"description": "Attending Note",
"row_id": 364982,
"text": "TITLE: Attending note\n 78 yo man with severe vasculopathy, COPD, recent MI, metastatic\n carcinoid presented with abdominal pain, vomiting and diarrhea at home.\n ESRD - will discuss whether she can continue to use PD with renal\n Exam sig for pt awake, interactive, appropriate. No resp distress. Very\n uncomfortable with chronic right flank pain and nausea/vomiting. Mucosa\n moist. Crackles at bases and clear at apices with moderate air\n movement. Distant heart sounds. Abdomen hypoactive bowel sounds, soft,\n ND. Diffusely tender. No tenderness to percussion but clearly\n uncomfortable with palpation. No rebound/guarding. No edema. No rashes.\n Recent chest CT shows severe emphysema,\n Abd CT from : Right colon wall thickening.\n Inflamm/civertic/extension of tumor which is contiguous. Increase in\n hepatic mets, moderate right hydronephrosis which was present on CT\n . Right renal collecting system with new hemorrhage. Lung windows\n show tiny right pleural effusion, mild bibasilar atelectasis.\n CXR shows PVC and atypical pattern of pulmonary edema with underlying\n emphysema.\n septic shock: 3 pressors. Most likely source CDiff. Other\n ddx: diverticulitis vs ischemic, on vanc/zosyn/flagyl/PO vanc. Large\n volume resuscitation. Now on levophed, vasopressin, neosynephrine.\n Surgery felt no intervention necessary. Ischemia less likely\n considering lactate 1.4, stool guaiac neg, but he is at risk.\n o avoid further volume if possible considering depressed\n systolic and diastolic cardiac function and crackles on exam\n Pain: Can be attributable to blood in right\n kidney/collecting system around ureteral stent. Chronic component as\n well. Percocet if taking POs.\n Nausea: try zofran.\n 40 minutes critical care time.\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365150,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - renal wants to go through with peritoneal dialysis\n - will discuss with them re peritonitis and general recs\n - vasc surgery not involved in peritoneal dialysis\n - around 5 pm, patient had five second pause after vasovagal episode\n - vanc level theraputic\n - hem/onc aware\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Metronidazole - 04:23 AM\n Vancomycin - 06:07 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.3 mcg/Kg/min\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:23 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.6\nC (97.8\n HR: 68 (59 - 131) bpm\n BP: 143/44(68) {84/39(60) - 152/78(89)} mmHg\n RR: 19 (8 - 20) insp/min\n SpO2: 100%\n Heart rhythm: Idioventricular\n CVP: 11 (8 - 18)mmHg\n Total In:\n 3,944 mL\n 612 mL\n PO:\n 100 mL\n TF:\n IVF:\n 3,844 mL\n 612 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 3,944 mL\n 612 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///16/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 285 K/uL\n 7.6 g/dL\n 130 mg/dL\n 8.9 mg/dL\n 16 mEq/L\n 5.3 mEq/L\n 42 mg/dL\n 103 mEq/L\n 137 mEq/L\n 24.7 %\n 22.6 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n Plt\n 241\n 285\n 259\n 285\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n Glucose\n 114\n 140\n 126\n 130\n Other labs: PT / PTT / INR:17.0/36.8/1.5, ALT / AST:67/92, Alk Phos / T\n Bili:73/0.2, Amylase / Lipase:95/38, Lactic Acid:1.5 mmol/L,\n Albumin:2.6 g/dL, LDH:323 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:9.6\n mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365151,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - renal wants to go through with peritoneal dialysis\n - will discuss with them re peritonitis and general recs\n - vasc surgery not involved in peritoneal dialysis\n - around 5 pm, patient had five second pause after vasovagal episode\n - vanc level theraputic\n - hem/onc aware\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Metronidazole - 04:23 AM\n Vancomycin - 06:07 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.3 mcg/Kg/min\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:23 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.6\nC (97.8\n HR: 68 (59 - 131) bpm\n BP: 143/44(68) {84/39(60) - 152/78(89)} mmHg\n RR: 19 (8 - 20) insp/min\n SpO2: 100%\n Heart rhythm: Idioventricular\n CVP: 11 (8 - 18)mmHg\n Total In:\n 3,944 mL\n 612 mL\n PO:\n 100 mL\n TF:\n IVF:\n 3,844 mL\n 612 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 3,944 mL\n 612 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///16/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 285 K/uL\n 7.6 g/dL\n 130 mg/dL\n 8.9 mg/dL\n 16 mEq/L\n 5.3 mEq/L\n 42 mg/dL\n 103 mEq/L\n 137 mEq/L\n 24.7 %\n 22.6 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n Plt\n 241\n 285\n 259\n 285\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n Glucose\n 114\n 140\n 126\n 130\n Other labs: PT / PTT / INR:17.0/36.8/1.5, ALT / AST:67/92, Alk Phos / T\n Bili:73/0.2, Amylase / Lipase:95/38, Lactic Acid:1.5 mmol/L,\n Albumin:2.6 g/dL, LDH:323 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:9.6\n mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n .\n # Hypotension: Pt with lethargy, hypotension that has transiently\n responded to IV boluses but continues to require low dose levophed. Pt\n is a vasculopath with complex arterial anatomy, recently discharged\n after NSTEMI. CT ruled out ruptured AAA and stool guaic was\n negative. Differential includes sepsis, hypovolemic, GI bleed,\n ischemic colitis, less likely to be MI or adrenal insufficiency.\n - bolus IVF prn to goal CVP>12\n - levophed prn for MAPs>65\n - Vanc/Zosyn for possible diverticulitis/colitis\n - start empiric Flagyl and po Vanc for possible CDiff colitis\n - f/u blood/urine/stool cx\n .\n # Abd pain/diarrhea: Pt is a known vasculopath who p/w 2-3 days of dark\n loose stools and poor po intake after completing a course of Abx for\n PNA. Per family, no fevers at home but pt reports subjective chills.\n WBC ct of 20 and CT with colitis. Concern for C Diff colitis vs\n ischemic colitis, though may be less likely given normal lactate. SBP\n also possible, will send fluid from peritoneal cath. Pt was seen by\n gen and vasc surgery in ED, no plan for OR. Pt expressed goals of\n care to avoid heroic measures, confirmed by HCP.\n - bolus IVF\n - type & cross\n - stool guaic & send for C diff\n - start empiric Flagyl & Po Vanc\n - Morphine prn pain\n - continue Vanc/Zosyn for possible diverticulitis\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: Lytes stable but given concern for sbp, would prefer to\n avoid using PD catheter. Plan to touch base with Renal in am.\n - send fluid from PD cath for Cx\n - t/b renal in am\n - continue Calcitriol\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross\n - CVL and PIV\n - PPI & trend hct\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: NPO for now with IVF boluses\n - replete electrolytes aggressively\n .\n # Prophylaxis: Heparin sc tid, PPI\n .\n # Access: RIJ, PIV\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365152,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - renal wants to go through with peritoneal dialysis\n - will discuss with them re peritonitis and general recs\n - vasc surgery not involved in peritoneal dialysis\n - around 5 pm, patient had five second pause after vasovagal episode\n - vanc level theraputic\n - hem/onc aware\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Metronidazole - 04:23 AM\n Vancomycin - 06:07 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.3 mcg/Kg/min\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:23 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.6\nC (97.8\n HR: 68 (59 - 131) bpm\n BP: 143/44(68) {84/39(60) - 152/78(89)} mmHg\n RR: 19 (8 - 20) insp/min\n SpO2: 100%\n Heart rhythm: Idioventricular\n CVP: 11 (8 - 18)mmHg\n Total In:\n 3,944 mL\n 612 mL\n PO:\n 100 mL\n TF:\n IVF:\n 3,844 mL\n 612 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 3,944 mL\n 612 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///16/\n Physical Examination\n Vitals: T: 98.2 BP: 123/59 repeat 88/42 P: 95 R: 18 O2: Sats 94% 2L\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 285 K/uL\n 7.6 g/dL\n 130 mg/dL\n 8.9 mg/dL\n 16 mEq/L\n 5.3 mEq/L\n 42 mg/dL\n 103 mEq/L\n 137 mEq/L\n 24.7 %\n 22.6 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n Plt\n 241\n 285\n 259\n 285\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n Glucose\n 114\n 140\n 126\n 130\n Other labs: PT / PTT / INR:17.0/36.8/1.5, ALT / AST:67/92, Alk Phos / T\n Bili:73/0.2, Amylase / Lipase:95/38, Lactic Acid:1.5 mmol/L,\n Albumin:2.6 g/dL, LDH:323 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:9.6\n mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n .\n # Hypotension: Pt with lethargy, hypotension that has transiently\n responded to IV boluses but continues to require low dose levophed. Pt\n is a vasculopath with complex arterial anatomy, recently discharged\n after NSTEMI. CT ruled out ruptured AAA and stool guaic was\n negative. Differential includes sepsis, hypovolemic, GI bleed,\n ischemic colitis, less likely to be MI or adrenal insufficiency.\n - bolus IVF prn to goal CVP>12\n - levophed prn for MAPs>65\n - Vanc/Zosyn for possible diverticulitis/colitis\n - start empiric Flagyl and po Vanc for possible CDiff colitis\n - f/u blood/urine/stool cx\n .\n # Abd pain/diarrhea: Pt is a known vasculopath who p/w 2-3 days of dark\n loose stools and poor po intake after completing a course of Abx for\n PNA. Per family, no fevers at home but pt reports subjective chills.\n WBC ct of 20 and CT with colitis. Concern for C Diff colitis vs\n ischemic colitis, though may be less likely given normal lactate. SBP\n also possible, will send fluid from peritoneal cath. Pt was seen by\n gen and vasc surgery in ED, no plan for OR. Pt expressed goals of\n care to avoid heroic measures, confirmed by HCP.\n - bolus IVF\n - type & cross\n - stool guaic & send for C diff\n - start empiric Flagyl & Po Vanc\n - Morphine prn pain\n - continue Vanc/Zosyn for possible diverticulitis\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: Lytes stable but given concern for sbp, would prefer to\n avoid using PD catheter. Plan to touch base with Renal in am.\n - send fluid from PD cath for Cx\n - t/b renal in am\n - continue Calcitriol\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross\n - CVL and PIV\n - PPI & trend hct\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: NPO for now with IVF boluses\n - replete electrolytes aggressively\n .\n # Prophylaxis: Heparin sc tid, PPI\n .\n # Access: RIJ, PIV\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365301,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Hypotension (not Shock)\n Assessment:\n SBP 90- 130\ns with a MAP 50-70\ns, off pressors since yesterday\n afternoon. The most accurate BP with rt thigh , HR 56 to 70\n slow afib w/ occasional PVC\ns CVP 10-13\n Action:\n Off Pressors, pm labs sent\n Response:\n SBP 90\ns- 130\ns off pressors w/ MAP remaining 50-70, CVP\n Plan:\n Monitor lactate, continues to rise reconsult gen r/t ? ischemic\n bowel.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Patient is ESRD on PD baseline creat \n Action:\n PD restarted a/o 1.5% dextrose , 1.5 L in and 1.5 L dwell time,\n ordered for 5 exchanges /day\n Response:\n PM labs when starting PD K+5.8, Po4 10.9, lactate 4, w/ anion gap 26.\n Plan:\n Continue PD a/o as tol, f/u labs at 18:00\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain and back pain , decreased some to w/\n repositioning\n Action:\n Dilaudid 0.5mg x3 and percocet x1 given\n Response:\n Pt states p[ain improved, now following last dose of dilaudid\n and percocet\n Plan:\n Prn percocet and dilaudid and repositioning for pain\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365302,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Hypotension (not Shock)\n Assessment:\n SBP 90- 130\ns with a MAP 50-70\ns, off pressors since yesterday\n afternoon. The most accurate BP with rt thigh , HR 56 to 70\n slow afib w/ occasional PVC\ns CVP 10-13\n Action:\n Off Pressors, pm labs sent\n Response:\n SBP 90\ns- 130\ns off pressors w/ MAP remaining 50-70, CVP\n Plan:\n Monitor lactate, continues to rise reconsult gen r/t ? Ischemic\n bowel.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Patient is ESRD on PD baseline creat \n Action:\n PD restarted a/o 1.5% dextrose , 1.5 L in and 1.5 L dwell time,\n ordered for 5 exchanges /day\n Response:\n Plan:\n Continue PD a/o as tol, f/u labs\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain and back pain ,\n Action:\n Dilaudid 0.5mg given\n Response:\n Pt states p[ain improved, now following last dose of dilaudid\n and percocet\n Plan:\n Prn percocet and dilaudid and repositioning for pain\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-07 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 365598,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - PICC request placed (did not get today)\n - NGT placed and TFs started\n - continued PD\n - PT c/s placed\n - cont PO, flagyl/zosyn IV\n - some vomiting this morning, got KUB\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Vancomycin - 08:18 PM\n Piperacillin - 06:00 PM\n Metronidazole - 11:59 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:34 PM\n Hydromorphone (Dilaudid) - 10:06 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.2\n HR: 68 (68 - 87) bpm\n BP: 121/51(67) {102/45(60) - 137/92(99)} mmHg\n RR: 8 (7 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 4 (2 - 12)mmHg\n Total In:\n 1,109 mL\n 215 mL\n PO:\n 100 mL\n TF:\n 79 mL\n 144 mL\n IVF:\n 890 mL\n 72 mL\n Blood products:\n Total out:\n 1,530 mL\n -1,800 mL\n Urine:\n NG:\n 30 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -421 mL\n 2,015 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///19/\n Physical Examination\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 237 K/uL\n 7.9 g/dL\n 112 mg/dL\n 8.0 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 53 mg/dL\n 101 mEq/L\n 136 mEq/L\n 25.5 %\n 14.3 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n 04:22 PM\n 03:23 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n 14.3\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n 23.7\n 25.5\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n 237\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n 8.0\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n 112\n Other labs: PT / PTT / INR:19.3/36.5/1.8, ALT / AST:1777/1426, Alk Phos\n / T Bili:139/0.2, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.3 g/dL, LDH:750 IU/L, Ca++:7.1 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.1 mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Now with\n ileus/SBO.\n .\n # presumptive Cdiff\n improving, now appears complicated by ileus/SBO.\n 2-3 days of dark loose stools and poor po intake after completing a\n course of Abx for PNA. Per family, no fevers at home but pt reports\n subjective chills. WBC ct of 20 and CT with colitis. Concern for C\n Diff colitis vs ischemic colitis, though may be less likely given\n normal lactate. SBP also possible, will send fluid from peritoneal\n cath. Pt was seen by gen and vasc surgery in ED, no plan for OR.\n Pt expressed goals of care to avoid heroic measures, confirmed by HCP.\n on contact precautions.\n - /Zosyn for possible diverticulitis/colitis\n - Flagyl and po for possible CDiff colitis\n - f/u blood/urine/stool cx\n no obvious source yet\n bisacodyl PR\n - reconsulting surgery today re: ileus/SBO\n - was tolerating some tube feeds, now stopped and placing NG\n on intermittent suction\n - d/c renogel since this is constipating\n - giving PO narcan for one day to stimulate , not\n want to do enema because of pain\n # peritonitis\n spoke to renal today, should give for the full two\n week course, and will check peritoneal fluid again today\n # Shock liver\n LFTs peaked now trending down, patient continues to\n have coagulopathy\n .\n # altered Mental status\n waxing and , maybe baseline, maybe\n uremia, patient on dilaudid\n - giving slight ativan since anxiety playing element in pain\n .\n # Hypotension: Resolved, patient is severe vasculopath and pressures\n are difficult to determine. Patient was initially started on levo and\n then moved to three pressors. He has bilateral subclavian stenosis with\n difficult time to determine blood pressure, weaned to mental status as\n well as blood pressures from legs. CT ruled out ruptured AAA and stool\n guaic was negative. Differential includes sepsis, hypovolemic, GI\n bleed, ischemic colitis, less likely to be MI or adrenal\n insufficiency. Most likely is sepsis in setting of colitis and\n peritonitis. Pressors off ;\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission, continue to follow\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: renal following, plan for PD, peritonitis, see above\n - PD cath Cx\n no organisms seen on gram stain\n - f/u renal recs\n - continue Calcitriol\n - will reculture fluid\n - added epo per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross\n - CVL and \n - PPI & trend hct, keep > 21\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: will need to place NG tube for TFs today\n .\n # Prophylaxis: Heparin sc tid, PPI\n .\n # Access: , d/c RIJ today and have PICC placed for long-term\n ABX and possible TPN\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 78M CAD, met carcinoid, ESRD, abd pain and\n colitis on CT. Started on PD, off pressors, liver function remains\n poor. Unable to tolerate POs, so NGT was placed.\n Exam notable for Tm 97.3 BP 120/50 HR 50-70 RR 18 with sat 100 on 2L\n NC. Frail man, responsive but confused. RRR s1s2. Soft tender abd, PD\n cath c/d/i. 2+ edema. Labs notable for WBC 14K, HCT 25, ALT / AST\n decreasing.\n Agree with plan to treat sepsis / likely c. diff with triple abx,\n including PO vanco while awaitning culture data. For ESRD, continue PD\n per renal team. Anemia is stable. He needs aggressive nutritional\n support, but appears to have an ileus. Will continue NGT in ILWS and\n start PPN and narcan PNGT following surgical evaluation. Not clear if\n this is from c. diff, meds, or met carcinoid. Will d/c CVL, continue\n PIVs and place PICC for long term access. Remainder of plan as outlined\n above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:14 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365606,
"text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365670,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - did not give PO narcan since patient had large bowel movement\n - KUB showed SBO vs ileus, pt has episode of vomitting, tube feeds\n stopped, NG placed on intermittent suction\n - renal wants IV vanc, they will give via HD protocol\n - wants patient on bowel rest since SBO vs ileus, no surgical\n intervention\n - trying to reduce the amount of narcotics by giving some anxitolytics\n for pain since both are causing pt discomfort\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:18 PM\n Piperacillin - 06:00 PM\n Metronidazole - 12:39 AM\n Piperacillin/Tazobactam (Zosyn) - 06:15 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.2\nC (99\n HR: 81 (63 - 88) bpm\n BP: 110/42(58) {96/42(53) - 140/67(84)} mmHg\n RR: 8 (8 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 7 (2 - 10)mmHg\n Total In:\n 684 mL\n 217 mL\n PO:\n TF:\n 144 mL\n IVF:\n 441 mL\n 217 mL\n Blood products:\n Total out:\n -4,000 mL\n -6,000 mL\n Urine:\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 4,684 mL\n 6,217 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 231 K/uL\n 7.6 g/dL\n 91 mg/dL\n 8.1 mg/dL\n 23 mEq/L\n 3.0 mEq/L\n 50 mg/dL\n 101 mEq/L\n 137 mEq/L\n 23.5 %\n 9.8 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n 04:22 PM\n 03:23 AM\n 05:00 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n 14.3\n 9.8\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n 23.7\n 25.5\n 23.5\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n 237\n 231\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n 8.0\n 8.1\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n 112\n 91\n Other labs: PT / PTT / INR:17.2/45.4/1.6, ALT / AST:1127/544, Alk Phos\n / T Bili:125/0.3, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.1 g/dL, LDH:750 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n HYPOTHERMIA\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365671,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - did not give PO narcan since patient had large bowel movement\n - KUB showed SBO vs ileus, pt has episode of vomitting, tube feeds\n stopped, NG placed on intermittent suction\n - renal wants IV vanc, they will give via HD protocol\n - wants patient on bowel rest since SBO vs ileus, no surgical\n intervention\n - trying to reduce the amount of narcotics by giving some anxitolytics\n for pain since both are causing pt discomfort\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:18 PM\n Piperacillin - 06:00 PM\n Metronidazole - 12:39 AM\n Piperacillin/Tazobactam (Zosyn) - 06:15 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.2\nC (99\n HR: 81 (63 - 88) bpm\n BP: 110/42(58) {96/42(53) - 140/67(84)} mmHg\n RR: 8 (8 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 7 (2 - 10)mmHg\n Total In:\n 684 mL\n 217 mL\n PO:\n TF:\n 144 mL\n IVF:\n 441 mL\n 217 mL\n Blood products:\n Total out:\n -4,000 mL\n -6,000 mL\n Urine:\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 4,684 mL\n 6,217 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 231 K/uL\n 7.6 g/dL\n 91 mg/dL\n 8.1 mg/dL\n 23 mEq/L\n 3.0 mEq/L\n 50 mg/dL\n 101 mEq/L\n 137 mEq/L\n 23.5 %\n 9.8 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n 04:22 PM\n 03:23 AM\n 05:00 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n 14.3\n 9.8\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n 23.7\n 25.5\n 23.5\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n 237\n 231\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n 8.0\n 8.1\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n 112\n 91\n Other labs: PT / PTT / INR:17.2/45.4/1.6, ALT / AST:1127/544, Alk Phos\n / T Bili:125/0.3, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.1 g/dL, LDH:750 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n HYPOTHERMIA\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365673,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - did not give PO narcan since patient had large bowel movement\n - KUB showed SBO vs ileus, pt has episode of vomitting, tube feeds\n stopped, NG placed on intermittent suction\n - renal wants IV , they will give via HD protocol\n - wants patient on bowel rest since SBO vs ileus, no surgical\n intervention\n - trying to reduce the amount of narcotics by giving some anxitolytics\n for pain since both are causing pt discomfort\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:18 PM\n Piperacillin - 06:00 PM\n Metronidazole - 12:39 AM\n Piperacillin/Tazobactam (Zosyn) - 06:15 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.2\nC (99\n HR: 81 (63 - 88) bpm\n BP: 110/42(58) {96/42(53) - 140/67(84)} mmHg\n RR: 8 (8 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 7 (2 - 10)mmHg\n Total In:\n 684 mL\n 217 mL\n PO:\n TF:\n 144 mL\n IVF:\n 441 mL\n 217 mL\n Blood products:\n Total out:\n -4,000 mL\n -6,000 mL\n Urine:\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 4,684 mL\n 6,217 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 231 K/uL\n 7.6 g/dL\n 91 mg/dL\n 8.1 mg/dL\n 23 mEq/L\n 3.0 mEq/L\n 50 mg/dL\n 101 mEq/L\n 137 mEq/L\n 23.5 %\n 9.8 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n 04:22 PM\n 03:23 AM\n 05:00 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n 14.3\n 9.8\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n 23.7\n 25.5\n 23.5\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n 237\n 231\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n 8.0\n 8.1\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n 112\n 91\n Other labs: PT / PTT / INR:17.2/45.4/1.6, ALT / AST:1127/544, Alk Phos\n / T Bili:125/0.3, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.1 g/dL, LDH:750 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Now with\n ileus/SBO.\n .\n # presumptive Cdiff\n improving, now appears complicated by ileus/SBO.\n 2-3 days of dark loose stools and poor po intake after completing a\n course of Abx for PNA. Per family, no fevers at home but pt reports\n subjective chills. WBC ct of 20 and CT with colitis. Concern for C\n Diff colitis vs ischemic colitis, though may be less likely given\n normal lactate. SBP also possible, will send fluid from peritoneal\n cath. Pt was seen by gen and vasc surgery in ED, no plan for OR.\n Pt expressed goals of care to avoid heroic measures, confirmed by HCP.\n on contact precautions.\n - /Zosyn for possible diverticulitis/colitis\n - Flagyl and po for possible CDiff colitis\n - f/u blood/urine/stool cx\n no obvious source yet\n bisacodyl PR\n - reconsulting surgery today re: ileus/SBO\n - was tolerating some tube feeds, now stopped and placing NG\n on intermittent suction\n - d/c renogel since this is constipating\n - giving PO narcan for one day to stimulate , not\n want to do enema because of pain\n # peritonitis\n spoke to renal today, should give for the full two\n week course, and will check peritoneal fluid again today\n # Shock liver\n LFTs peaked now trending down, patient continues to\n have coagulopathy\n .\n # altered Mental status\n waxing and , maybe baseline, maybe\n uremia, patient on dilaudid\n - giving slight ativan since anxiety playing element in pain\n .\n # Hypotension: Resolved, patient is severe vasculopath and pressures\n are difficult to determine. Patient was initially started on levo and\n then moved to three pressors. He has bilateral subclavian stenosis with\n difficult time to determine blood pressure, weaned to mental status as\n well as blood pressures from legs. CT ruled out ruptured AAA and stool\n guaic was negative. Differential includes sepsis, hypovolemic, GI\n bleed, ischemic colitis, less likely to be MI or adrenal\n insufficiency. Most likely is sepsis in setting of colitis and\n peritonitis. Pressors off ;\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission, continue to follow\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: renal following, plan for PD, peritonitis, see above\n - PD cath Cx\n no organisms seen on gram stain\n - f/u renal recs\n - continue Calcitriol\n - will reculture fluid\n - added epo per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross\n - CVL and \n - PPI & trend hct, keep > 21\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: will need to place NG tube for TFs today\n .\n # Prophylaxis: Heparin sc tid, PPI\n .\n # Access: , d/c RIJ today and have PICC placed for long-term\n ABX and possible TPN\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-05 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 365285,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - renal wants to go through with peritoneal dialysis\n - will discuss with them re peritonitis and general recs\n - vasc surgery not involved in peritoneal dialysis\n - around 5 pm, patient had five second pause after vasovagal episode\n - vanc level theraputic\n - hem/onc aware\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Metronidazole - 04:23 AM\n Vancomycin - 06:07 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.3 mcg/Kg/min\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:23 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.6\nC (97.8\n HR: 68 (59 - 131) bpm\n BP: 143/44(68) {84/39(60) - 152/78(89)} mmHg\n RR: 19 (8 - 20) insp/min\n SpO2: 100%\n Heart rhythm: Idioventricular\n CVP: 11 (8 - 18)mmHg\n Total In:\n 3,944 mL\n 612 mL\n PO:\n 100 mL\n TF:\n IVF:\n 3,844 mL\n 612 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 3,944 mL\n 612 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///16/\n Physical Examination\n Vitals: T: 98.2 BP: 123/59 repeat 88/42 P: 95 R: 18 O2: Sats 94% 2L\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 285 K/uL\n 7.6 g/dL\n 130 mg/dL\n 8.9 mg/dL\n 16 mEq/L\n 5.3 mEq/L\n 42 mg/dL\n 103 mEq/L\n 137 mEq/L\n 24.7 %\n 22.6 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n Plt\n 241\n 285\n 259\n 285\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n Glucose\n 114\n 140\n 126\n 130\n Other labs: PT / PTT / INR:17.0/36.8/1.5, ALT / AST:67/92, Alk Phos / T\n Bili:73/0.2, Amylase / Lipase:95/38, Lactic Acid:1.5 mmol/L,\n Albumin:2.6 g/dL, LDH:323 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:9.6\n mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n .\n # Hypotension: Pt with lethargy, hypotension that has transiently\n responded to IV boluses but continues to require low dose levophed,\n then requiring three pressors. Pt is a vasculopath with complex\n arterial anatomy, recently discharged after NSTEMI. CT ruled out\n ruptured AAA and stool guaic was negative. Differential includes\n sepsis, hypovolemic, GI bleed, ischemic colitis, less likely to be MI\n or adrenal insufficiency. Most likely is sepsis in setting of colitis\n and peritonitis.\n - bolus IVF prn to goal CVP>12\n - wean pressors today as tolerated; has subclavian stenosis with\n difficult time to determine blood pressure, are weaning to mental\n status as well as blood pressures from legs\n - Vanc/Zosyn for possible diverticulitis/colitis\n - start empiric Flagyl and po Vanc for possible CDiff colitis\n - f/u blood/urine/stool cx\n no obvious source yet\n .\n # Abd pain/diarrhea: Pt is a known vasculopath who p/w 2-3 days of dark\n loose stools and poor po intake after completing a course of Abx for\n PNA. Per family, no fevers at home but pt reports subjective chills.\n WBC ct of 20 and CT with colitis. Concern for C Diff colitis vs\n ischemic colitis, though may be less likely given normal lactate. SBP\n also possible, will send fluid from peritoneal cath. Pt was seen by\n gen and vasc surgery in ED, no plan for OR. Pt expressed goals of\n care to avoid heroic measures, confirmed by HCP.\n - following lactates, does have increasing gap acidosis today, unclear\n etiology, possibly from ischemia\n - bolus IVF\n - type & cross\n - started empiric Flagyl & Po Vanc for c.diff, results pending\n - dilaudid prn for pain, improved today\n - continue Vanc/Zosyn for possible diverticulitis and peritonitis\n - per , can start to advance diet slowly with serial abd exams as\n long as making stool\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission, continue to follow\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: renal following, plan for PD today\n - send fluid from PD cath for Cx\n no organisms seen on gram stain\n - continue Calcitriol\n - added epo and phos binder per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross\n - CVL and PIV\n - PPI & trend hct, hct has been stable\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: can start with clears\n - replete electrolytes aggressively, PD today for hyperkalemia\n .\n # Prophylaxis: Heparin sc tid, PPI\n .\n # Access: RIJ, PIV\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ------ Protected Section ------\n Attending Addendum\n 78 yo man, severe vasculopath, recent NSTEMI, COPD, metastatic\n carcinoid, on PD with peritonitis (though abd exam benign) and colitis,\n on 3 pressors and broad abx.\n This morning on 3 pressors, but now off.\n colitis and peritonitis, on vanc/zosyn/flagyl/PO vanc\n respiratory status stable\n WBC 26-->23, hct stable\n bicarb 29--> 16, AG 18, diarrhea but improving\n PD today\n discuss starting TF or trial of monitored Pos\n critically ill, 35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 18:57 ------\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365663,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain as well as nausea, vomiting and tarry diarrhea. Pt initially\n presented to with hypotension and mild hct drop. Pt\n underwent a CT Abd/Pelvis scan which revealed stable AAA and he was\n transferred to for further care. Of note, pt was discharged on\n after admission for NSTEMI & PNA. During that admission, pt was\n taken to cath and given co morbidities only the SVG-OM2 was\n angioplastied. He was treated with a 10day course of Ceftriaxone/Levo\n for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea.\n Code: DNR/DNI\n Events: back pain still present but better, continues on PD.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt is on 5cycles/day of PD.PD catheter has been clotting with fibrin\n clot for the last couple of days.\n Action:\n 1000 units of Heparin ordered for each bag of PD solution.\n Response:\n PD fluid running free, no sign of clots.\n Plan:\n Continue on scheduled PD runs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt continues to c/ and back pain.\n Action:\n Repositioned numerous times for pain relief.Hasnt needed any\n medication.Trying to avoid pain meds if possible but can have prn if\n needed.\n Response:\n Pain easily relieved after repositioning.Pain meds thought to have\n contributed to SBO.No BM this shift.\n Plan:\n Given pain meds when needed but assess carefully.\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365848,
"text": "78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n Hypotension resolved, off pressors. Pt on PD.\n Now with SBO (KUB), no surgical interventions, surgery recs. bowel\n rest. TF were started- FS Novasource Renal upto 30cc/hr and held. NGT\n to intermittent suction. Bowel sounds present, no bowel movements\n Consulted for TPN recs, start TPN via R IJ\n Tylenol x1 for pain with good effect\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt is on 5cycles/day of PD. 2L x1.5hr dwell time per cycle. PD fluid\n wasn\nt available for next cycle. Abd firm distended, patient anuric.\n Action:\n 1000 units of Heparin ordered for each bag of PD solution. Continued\n PD as ordered\n Response:\n PD fluid running free, no sign of clots. TPN tol well. AM labs\n Plan:\n Continue on scheduled PD runs. Monitor labs.\n Call out to floor awaiting bed\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365849,
"text": "78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n Hypotension resolved, off pressors. Pt on PD.\n Now with SBO (KUB), no surgical interventions, surgery recs. bowel\n rest. TF were started- FS Novasource Renal upto 30cc/hr and held. NGT\n to intermittent suction. Bowel sounds present, no bowel movements\n Consulted for TPN recs, start TPN via R IJ\n Tylenol x1 for pain with good effect\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt is on 5cycles/day of PD. 2L x1.5hr dwell time per cycle. PD fluid\n wasn\nt available for next cycle. Abd firm distended, patient anuric.\n Action:\n 1000 units of Heparin ordered for each bag of PD solution. Continued\n PD as ordered\n Response:\n PD fluid running free, no sign of clots. TPN tol well.\n Plan:\n Continue on scheduled PD runs. Monitor labs.\n Call out to floor awaiting bed\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365134,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n .\n In the ED, initial vs were: T 98.8 P 85 BP 91/37 RR 21 Sats 100% on 2L.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Hypotension (not Shock)\n Assessment:\n SBP 120-150\ns with triple pressors levo, neo and vasopressin gtt, the\n most accurate BP with rt thigh , and patient has left\n subclavian stenosis, his central pressure noted to be 60mmhg higher\n than peripheral pressures. Seen by cardiology, HR 110-140\n Action:\n Continued on triple pressors. Fluid bolus 250ml was given for new A fib\n Response:\n SBP 120-150\ns, continued pressors, HR a fib to idioventricular hr\n 60-130\n Plan:\n Wean pressors as tolerated\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Patient is ESRD on PD, ? baseline creat \n Action:\n Continue monitor labs, no PD for tonight\n Response:\n AM labs bun/creat 42/ 8.9, K 5.3.\n Plan:\n F/U with renal for plan with dialysis today, monitor labs,\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain and back pain, but patient able to sleep comfortably\n Action:\n Dilaudid 0.5mg x1 and percocet x1 given\n Response:\n Plan:\n Prn percocet and dilaudid for pain\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 365399,
"text": "Chief Complaint:\n 24 Hour Events:\n - pt pain better controlled with dilaudid\n - started PD per renal recs\n - weaned off all pressors in the early PM\n - new AG acidosis with lactate of 4.0, received IVF bolus\n - worsening transaminitis, likely shock liver\n - tried feeding, pt not hungry and ate almost nothing\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Vancomycin - 08:18 PM\n Metronidazole - 04:32 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:18 PM\n Heparin Sodium (Prophylaxis) - 12:41 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.6\nC (96.1\n HR: 64 (59 - 72) bpm\n BP: 93/48(58) {92/37(51) - 151/82(89)} mmHg\n RR: 8 (8 - 18) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 67 Inch\n CVP: 8 (8 - 21)mmHg\n Total In:\n 1,265 mL\n 236 mL\n PO:\n TF:\n IVF:\n 1,265 mL\n 236 mL\n Blood products:\n Total out:\n 1,300 mL\n 800 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -35 mL\n -564 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///19/\n Physical Examination\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 230 K/uL\n 7.2 g/dL\n 124 mg/dL\n 8.5 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 50 mg/dL\n 103 mEq/L\n 137 mEq/L\n 22.8 %\n 15.4 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n Other labs: PT / PTT / INR:21.2/42.9/2.0, ALT / AST:2271/3566, Alk Phos\n / T Bili:122/0.3, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.3 g/dL, LDH:3488 IU/L, Ca++:7.0\n mg/dL, Mg++:2.1 mg/dL, PO4:8.2 mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n .\n # Hypotension: Pt with lethargy, hypotension that has transiently\n responded to IV boluses but continues to require low dose levophed,\n then requiring three pressors. Pt is a vasculopath with complex\n arterial anatomy, recently discharged after NSTEMI. CT ruled out\n ruptured AAA and stool guaic was negative. Differential includes\n sepsis, hypovolemic, GI bleed, ischemic colitis, less likely to be MI\n or adrenal insufficiency. Most likely is sepsis in setting of colitis\n and peritonitis.\n - bolus IVF prn for hypotension, titrate to MS\n - pressors off ; has subclavian stenosis with difficult time to\n determine blood pressure, weaned to mental status as well as blood\n pressures from legs\n - Vanc/Zosyn for possible diverticulitis/colitis\n - Flagyl and po Vanc for possible CDiff colitis\n - f/u blood/urine/stool cx\n no obvious source yet\n .\n # Abd pain/diarrhea: Pt is a known vasculopath who p/w 2-3 days of dark\n loose stools and poor po intake after completing a course of Abx for\n PNA. Per family, no fevers at home but pt reports subjective chills.\n WBC ct of 20 and CT with colitis. Concern for C Diff colitis vs\n ischemic colitis, though may be less likely given normal lactate. SBP\n also possible, will send fluid from peritoneal cath. Pt was seen by\n gen and vasc surgery in ED, no plan for OR. Pt expressed goals of\n care to avoid heroic measures, confirmed by HCP.\n - following lactates\n - started empiric Flagyl & Po Vanc for c.diff, results pending\n - continue Vanc/Zosyn for possible diverticulitis and peritonitis\n - bisacodyl PR\n - per , can start to advance diet slowly with serial abd exams as\n long as making stool\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission, continue to follow\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: renal following, plan for PD\n - PD cath Cx\n no organisms seen on gram stain\n - f/u renal recs\n - continue Calcitriol\n - added epo and phos binder per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross\n - CVL and \n - PPI & trend hct, keep > 21\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: will need to place NG tube for TFs today\n .\n # Prophylaxis: Heparin sc tid, PPI\n .\n # Access: , d/c RIJ today and have PICC placed for long-term\n ABX and possible TPN\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 78M CAD, met carcinoid, abd pain and colitis\n on CT. Started on PD, off pressors, liver function remains poor. Unable\n to tolerate POs.\n Exam notable for Tm 97.3 BP 100/40 HR 50-70 RR 18 with sat 98 on 2L NC.\n Frail man, responsive but confused. RRR s1s2. Soft tender abd, PD cath\n c/d/i. 2+ edema. Labs notable for WBC 15K, HCT 23, K+ 3.9, Cr 8.5,\n lactate 2.2, ALT 2271, AST 3566.\n Agree with plan to treat sepsis / likely c. diff with triple abx,\n including PO vanco. For ESRD, continue PD per renal team. Will continue\n cardiac regimen and check PM HCT for progressive anemia. He needs\n aggressive nutritional support - will place NGT today. Will d/c CVL,\n continue PIVs and place PICC for long term access. Remainder of plan as\n outlined above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:41 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365265,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n .\n In the ED, initial vs were: T 98.8 P 85 BP 91/37 RR 21 Sats 100% on 2L.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Hypotension (not Shock)\n Assessment:\n SBP 130\ns-150\ns w/ MAP 65-75 with triple pressors levo, neo and\n vasopressin gtt, the most accurate BP with rt thigh , HR\n 60\ns-70\ns afib w/ occasional PVC\ns CVP 10-13\n Action:\n Pressors weaned off, 500ml IV N/S bolus r/t to lactate of 4.0\n Response:\n SBP 110\ns- 130\ns off pressors w/ MAP remaining 65-75, CVP 11 at this\n time following fliud bolus\n Plan:\n Wean pressors as tolerated f/u lactate at 1800 if lactate continues to\n rise reconsult gen r/t ? ischemic bowel.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Patient is ESRD on PD baseline creat \n Action:\n PD restarted a/o 1.5% dextrose , 1.5 L in and 1.5 L dwell time,\n ordered for 5 exchanges /day\n Response:\n PM labs when starting PD K+5.8, Po4 10.9, lactate 4, w/ anion gap 26.\n Plan:\n Continue PD a/o as tol, f/u labs at 18:00\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain and back pain , decreased some to w/\n repositioning\n Action:\n Dilaudid 0.5mg x3 and percocet x1 given\n Response:\n Pt states p[ain improved, now following last dose of dilaudid\n and percocet\n Plan:\n Prn percocet and dilaudid and repositioning for pain\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365119,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n .\n In the ED, initial vs were: T 98.8 P 85 BP 91/37 RR 21 Sats 100% on 2L.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Hypotension (not Shock)\n Assessment:\n SBP 120-150\ns with triple pressors levo, neo and vasopressin gtt, the\n most accurate BP with rt thigh , and patient has left\n subclavian stenosis, his central pressure noted to be 60mmhg higher\n than peripheral pressures. Seen by cardiology, Fluid bolus 250ml was\n given for new A fib, HR 110-140\n Action:\n Continued on triple pressors.\n Response:\n SBP 120-150\ns, continued pressors\n Plan:\n Wean pressors as tolerated,\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Patient is ESRD on PD, ? baseline creat \n Action:\n Continue monitor labs, no PD for tonight\n Response:\n AM labs\n Plan:\n F/U with renal, monitor labs\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain and back pain, but patient able to sleep comfortably\n Action:\n Response:\n Plan:\n Prn percocet and dilaudid for pain\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365387,
"text": "Chief Complaint:\n 24 Hour Events:\n - pt pain better controlled with dilaudid\n - started PD per renal recs\n - weaned off all pressors in the early PM\n - new AG acidosis with lactate of 4.0, received IVF bolus\n - worsening transaminitis, likely shock liver\n - tried feeding, pt not hungry and ate almost nothing\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Vancomycin - 08:18 PM\n Metronidazole - 04:32 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:18 PM\n Heparin Sodium (Prophylaxis) - 12:41 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.6\nC (96.1\n HR: 64 (59 - 72) bpm\n BP: 93/48(58) {92/37(51) - 151/82(89)} mmHg\n RR: 8 (8 - 18) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 67 Inch\n CVP: 8 (8 - 21)mmHg\n Total In:\n 1,265 mL\n 236 mL\n PO:\n TF:\n IVF:\n 1,265 mL\n 236 mL\n Blood products:\n Total out:\n 1,300 mL\n 800 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -35 mL\n -564 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///19/\n Physical Examination\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 230 K/uL\n 7.2 g/dL\n 124 mg/dL\n 8.5 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 50 mg/dL\n 103 mEq/L\n 137 mEq/L\n 22.8 %\n 15.4 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n Other labs: PT / PTT / INR:21.2/42.9/2.0, ALT / AST:2271/3566, Alk Phos\n / T Bili:122/0.3, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.3 g/dL, LDH:3488 IU/L, Ca++:7.0\n mg/dL, Mg++:2.1 mg/dL, PO4:8.2 mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n .\n # Hypotension: Pt with lethargy, hypotension that has transiently\n responded to IV boluses but continues to require low dose levophed,\n then requiring three pressors. Pt is a vasculopath with complex\n arterial anatomy, recently discharged after NSTEMI. CT ruled out\n ruptured AAA and stool guaic was negative. Differential includes\n sepsis, hypovolemic, GI bleed, ischemic colitis, less likely to be MI\n or adrenal insufficiency. Most likely is sepsis in setting of colitis\n and peritonitis.\n - bolus IVF prn for hypotension, titrate to MS\n - pressors off ; has subclavian stenosis with difficult time to\n determine blood pressure, weaned to mental status as well as blood\n pressures from legs\n - Vanc/Zosyn for possible diverticulitis/colitis\n - Flagyl and po Vanc for possible CDiff colitis\n - f/u blood/urine/stool cx\n no obvious source yet\n .\n # Abd pain/diarrhea: Pt is a known vasculopath who p/w 2-3 days of dark\n loose stools and poor po intake after completing a course of Abx for\n PNA. Per family, no fevers at home but pt reports subjective chills.\n WBC ct of 20 and CT with colitis. Concern for C Diff colitis vs\n ischemic colitis, though may be less likely given normal lactate. SBP\n also possible, will send fluid from peritoneal cath. Pt was seen by\n gen and vasc surgery in ED, no plan for OR. Pt expressed goals of\n care to avoid heroic measures, confirmed by HCP.\n - following lactates\n - started empiric Flagyl & Po Vanc for c.diff, results pending\n - continue Vanc/Zosyn for possible diverticulitis and peritonitis\n - bisacodyl PR\n - per , can start to advance diet slowly with serial abd exams as\n long as making stool\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission, continue to follow\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: renal following, plan for PD\n - PD cath Cx\n no organisms seen on gram stain\n - f/u renal recs\n - continue Calcitriol\n - added epo and phos binder per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross\n - CVL and \n - PPI & trend hct, keep > 21\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: will need to place NG tube for TFs today\n .\n # Prophylaxis: Heparin sc tid, PPI\n .\n # Access: , d/c RIJ today and have PICC placed for long-term\n ABX and possible TPN\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365345,
"text": "Chief Complaint:\n 24 Hour Events:\n - pt pain better controlled with dilaudid\n - started PD per renal recs\n - weaned off all pressors in the early PM\n - new AG acidosis with lactate of 4.0, received IVF bolus\n - worsening transaminitis, likely shock liver\n - tried feeding, pt not hungry and ate almost nothing\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Vancomycin - 08:18 PM\n Metronidazole - 04:32 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:18 PM\n Heparin Sodium (Prophylaxis) - 12:41 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.6\nC (96.1\n HR: 64 (59 - 72) bpm\n BP: 93/48(58) {92/37(51) - 151/82(89)} mmHg\n RR: 8 (8 - 18) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 67 Inch\n CVP: 8 (8 - 21)mmHg\n Total In:\n 1,265 mL\n 236 mL\n PO:\n TF:\n IVF:\n 1,265 mL\n 236 mL\n Blood products:\n Total out:\n 1,300 mL\n 800 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -35 mL\n -564 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///19/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 230 K/uL\n 7.2 g/dL\n 124 mg/dL\n 8.5 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 50 mg/dL\n 103 mEq/L\n 137 mEq/L\n 22.8 %\n 15.4 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n Other labs: PT / PTT / INR:21.2/42.9/2.0, ALT / AST:2271/3566, Alk Phos\n / T Bili:122/0.3, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.3 g/dL, LDH:3488 IU/L, Ca++:7.0\n mg/dL, Mg++:2.1 mg/dL, PO4:8.2 mg/dL\n Assessment and Plan\n HYPOTHERMIA\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365347,
"text": "Chief Complaint:\n 24 Hour Events:\n - pt pain better controlled with dilaudid\n - started PD per renal recs\n - weaned off all pressors in the early PM\n - new AG acidosis with lactate of 4.0, received IVF bolus\n - worsening transaminitis, likely shock liver\n - tried feeding, pt not hungry and ate almost nothing\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Vancomycin - 08:18 PM\n Metronidazole - 04:32 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:18 PM\n Heparin Sodium (Prophylaxis) - 12:41 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.6\nC (96.1\n HR: 64 (59 - 72) bpm\n BP: 93/48(58) {92/37(51) - 151/82(89)} mmHg\n RR: 8 (8 - 18) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 67 Inch\n CVP: 8 (8 - 21)mmHg\n Total In:\n 1,265 mL\n 236 mL\n PO:\n TF:\n IVF:\n 1,265 mL\n 236 mL\n Blood products:\n Total out:\n 1,300 mL\n 800 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -35 mL\n -564 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///19/\n Physical Examination\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 230 K/uL\n 7.2 g/dL\n 124 mg/dL\n 8.5 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 50 mg/dL\n 103 mEq/L\n 137 mEq/L\n 22.8 %\n 15.4 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n Other labs: PT / PTT / INR:21.2/42.9/2.0, ALT / AST:2271/3566, Alk Phos\n / T Bili:122/0.3, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.3 g/dL, LDH:3488 IU/L, Ca++:7.0\n mg/dL, Mg++:2.1 mg/dL, PO4:8.2 mg/dL\n Assessment and Plan\n HYPOTHERMIA\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365350,
"text": "Chief Complaint:\n 24 Hour Events:\n - pt pain better controlled with dilaudid\n - started PD per renal recs\n - weaned off all pressors in the early PM\n - new AG acidosis with lactate of 4.0, received IVF bolus\n - worsening transaminitis, likely shock liver\n - tried feeding, pt not hungry and ate almost nothing\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Vancomycin - 08:18 PM\n Metronidazole - 04:32 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:18 PM\n Heparin Sodium (Prophylaxis) - 12:41 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.6\nC (96.1\n HR: 64 (59 - 72) bpm\n BP: 93/48(58) {92/37(51) - 151/82(89)} mmHg\n RR: 8 (8 - 18) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 67 Inch\n CVP: 8 (8 - 21)mmHg\n Total In:\n 1,265 mL\n 236 mL\n PO:\n TF:\n IVF:\n 1,265 mL\n 236 mL\n Blood products:\n Total out:\n 1,300 mL\n 800 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -35 mL\n -564 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///19/\n Physical Examination\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 230 K/uL\n 7.2 g/dL\n 124 mg/dL\n 8.5 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 50 mg/dL\n 103 mEq/L\n 137 mEq/L\n 22.8 %\n 15.4 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n Other labs: PT / PTT / INR:21.2/42.9/2.0, ALT / AST:2271/3566, Alk Phos\n / T Bili:122/0.3, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.3 g/dL, LDH:3488 IU/L, Ca++:7.0\n mg/dL, Mg++:2.1 mg/dL, PO4:8.2 mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n .\n # Hypotension: Pt with lethargy, hypotension that has transiently\n responded to IV boluses but continues to require low dose levophed,\n then requiring three pressors. Pt is a vasculopath with complex\n arterial anatomy, recently discharged after NSTEMI. CT ruled out\n ruptured AAA and stool guaic was negative. Differential includes\n sepsis, hypovolemic, GI bleed, ischemic colitis, less likely to be MI\n or adrenal insufficiency. Most likely is sepsis in setting of colitis\n and peritonitis.\n - bolus IVF prn to goal CVP>12\n - pressors off ; has subclavian stenosis with difficult time to\n determine blood pressure, weaned to mental status as well as blood\n pressures from legs\n - Vanc/Zosyn for possible diverticulitis/colitis\n - Flagyl and po Vanc for possible CDiff colitis\n - f/u blood/urine/stool cx\n no obvious source yet\n .\n # Abd pain/diarrhea: Pt is a known vasculopath who p/w 2-3 days of dark\n loose stools and poor po intake after completing a course of Abx for\n PNA. Per family, no fevers at home but pt reports subjective chills.\n WBC ct of 20 and CT with colitis. Concern for C Diff colitis vs\n ischemic colitis, though may be less likely given normal lactate. SBP\n also possible, will send fluid from peritoneal cath. Pt was seen by\n gen and vasc surgery in ED, no plan for OR. Pt expressed goals of\n care to avoid heroic measures, confirmed by HCP.\n - following lactates, does have gap acidosis today, unclear etiology,\n possibly from ischemia\n - bolus IVF\n - started empiric Flagyl & Po Vanc for c.diff, results pending\n - dilaudid prn for pain, improved today\n - continue Vanc/Zosyn for possible diverticulitis and peritonitis\n - per , can start to advance diet slowly with serial abd exams as\n long as making stool\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission, continue to follow\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: renal following, plan for PD\n - PD cath Cx\n no organisms seen on gram stain\n - continue Calcitriol\n - added epo and phos binder per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross\n - CVL and PIV\n - PPI & trend hct, hct has been stable\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: can start with clears\n - replete electrolytes aggressively, PD today for hyperkalemia\n .\n # Prophylaxis: Heparin sc tid, PPI\n .\n # Access: RIJ, PIV\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365351,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Hypotension (not Shock)\n Assessment:\n SBP 90- 130\ns with a MAP 50-70\ns, off pressors since yesterday\n afternoon. The most accurate BP with rt thigh , h/o lt\n subclavian stenosis, HR 56 to 70\ns slow afib w/ occasional PVC\ns CVP\n 8-14\n Action:\n Off Pressors, pm labs sent\n Response:\n SBP 90\ns- 130\ns off pressors w/ MAP remaining 50-70, CVP 8-14, wbc is\n 15.4, lactate trending down to 2.2,a gap 19\n Plan:\n Monitor lactate/WBC, F/U culture results,continues to rise reconsult\n gen r/t ? Ischemic bowel.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Patient is ESRD on PD baseline creat \n Action:\n PD restarted a/o 1.5% dextrose , 1.5 L in and 1.5 L dwell time,\n ordered for 5 exchanges /day\n Response:\n BUN 50, creat 8.5, other lytes within acceptable limits, PD continued\n Plan:\n Continue PD a/o as tol, f/u labs\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain and back pain ,\n Action:\n Dilaudid 0.5mg given\n Response:\n Pt states p[ain improved, slept most of the night, without c/o pain,now\n / slightly confused easily oriented back, ?hallucinating, very\n sleepy\n Plan:\n Prn percocet and dilaudid and repositioning for pain\n Hypothermia\n Assessment:\n Temp to 94.0 axillary\n Action:\n Bair hugger is on, warm fluid used for PD\n Response:\n Temp up to 96.1, patient is taking off his blanket, encouraged not to\n take off the blanket and bair hugger\n Plan:\n Continue monitor temp, bair hugger and warm PD fluid\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365445,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Events: remains off pressors, back pain still present but better,\n continues on PD.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Anuric, PD ordered for 5 exchanges with a dwell time of 1.5hours.\n Action:\n Foley catheter removed, with small amounts of blood draining, Pt has\n periods of time when she is empty. Run scheduled at 1600 had trouble\n infusing. After consulting with Dr , the catheter was flushed with\n 60cc of sterile NS.\n Response:\n 2 very long fibrogen clots were removed then fluid infused easily. PD\n runs today did not remove any fluid.\n Plan:\n Continue with the scheduled PD runs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt was C/O severe back pain this am. He was inconsistent with his\n description of the pain. Weak pulses in all limbs.\n Action:\n Given dilaudid .5mg IVP with eventual relief. He C/O further pain\n around 1300 with good relief from his back pain.\n Response:\n Amount of meds needed to relieve his pain is decreasing.\n Plan:\n Continue to assess pain and try to transition to his usual percocet.\n Hypothermia\n Assessment:\n Temp this am was 97.1, skin was cool to the touch.\n Action:\n Bair hugger blanket kept on his lower body to help warm pt.\n Response:\n When temp was 98.2 The blanker was turned off at 1600. He turned back\n on when he C/O being cold at 1800 at a low temp. Remains on Flagyl,\n vanco PO, vanco IV (level sent) and pipercillin.\n Plan:\n Continued to monitor temp and adjust bair hugger as needed. Maintain\n antibotics as ordered\n NGT inserted in right nare, confirmed placement with CXR and tube\n feedings started of novasource renal at 10cc/hr. Will get nutrition\n consult in am for goal rate.\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365461,
"text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt is anuric on PD for 5 exchanges/day\n Action:\n PD done as per orders.PD cath blocked x1,flushed with NS, got out one\n long fibrinogen clot.\n Response:\n PD cath infusing easily after the flush.\n Plan:\n Continue with the scheduled PD runs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain to back not exactly describing the kind and type of pain.\n Action:\n Given 0.5 mg IV dilaudid and po percocet.Repositioned and backrub as\n needed.\n Response:\n Pt slept after the dilaudid, no more c/o pain after.\n Plan:\n Monitor pain,administer pain meds as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365568,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - PICC request placed (did not get today)\n - NGT placed and TFs started\n - continued PD\n - PT c/s placed\n - cont PO, flagyl/zosyn IV\n - some vomiting this morning, got KUB\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Vancomycin - 08:18 PM\n Piperacillin - 06:00 PM\n Metronidazole - 11:59 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:34 PM\n Hydromorphone (Dilaudid) - 10:06 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.2\nC (97.2\n HR: 68 (68 - 87) bpm\n BP: 121/51(67) {102/45(60) - 137/92(99)} mmHg\n RR: 8 (7 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 4 (2 - 12)mmHg\n Total In:\n 1,109 mL\n 215 mL\n PO:\n 100 mL\n TF:\n 79 mL\n 144 mL\n IVF:\n 890 mL\n 72 mL\n Blood products:\n Total out:\n 1,530 mL\n -1,800 mL\n Urine:\n NG:\n 30 mL\n 100 mL\n Stool:\n Drains:\n Balance:\n -421 mL\n 2,015 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///19/\n Physical Examination\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 237 K/uL\n 7.9 g/dL\n 112 mg/dL\n 8.0 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 53 mg/dL\n 101 mEq/L\n 136 mEq/L\n 25.5 %\n 14.3 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n 04:22 PM\n 03:23 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n 14.3\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n 23.7\n 25.5\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n 237\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n 8.0\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n 112\n Other labs: PT / PTT / INR:19.3/36.5/1.8, ALT / AST:1777/1426, Alk Phos\n / T Bili:139/0.2, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.3 g/dL, LDH:750 IU/L, Ca++:7.1 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.1 mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Now with\n ileus/SBO.\n .\n # presumptive Cdiff\n improving, now appears complicated by ileus/SBO.\n 2-3 days of dark loose stools and poor po intake after completing a\n course of Abx for PNA. Per family, no fevers at home but pt reports\n subjective chills. WBC ct of 20 and CT with colitis. Concern for C\n Diff colitis vs ischemic colitis, though may be less likely given\n normal lactate. SBP also possible, will send fluid from peritoneal\n cath. Pt was seen by gen and vasc surgery in ED, no plan for OR.\n Pt expressed goals of care to avoid heroic measures, confirmed by HCP.\n on contact precautions.\n - /Zosyn for possible diverticulitis/colitis\n - Flagyl and po for possible CDiff colitis\n - f/u blood/urine/stool cx\n no obvious source yet\n bisacodyl PR\n - reconsulting surgery today re: ileus/SBO\n - was tolerating some tube feeds, now stopped and placing NG\n on intermittent suction\n - d/c renogel since this is constipating\n - giving PO narcan for one day to stimulate , not\n want to do enema because of pain\n # peritonitis\n spoke to renal today, should give for the full two\n week course, and will check peritoneal fluid again today\n # Shock liver\n LFTs peaked now trending down, patient continues to\n have coagulopathy\n .\n # altered Mental status\n waxing and , maybe baseline, maybe\n uremia, patient on dilaudid\n - giving slight ativan since anxiety playing element in pain\n .\n # Hypotension: Resolved, patient is severe vasculopath and pressures\n are difficult to determine. Patient was initially started on levo and\n then moved to three pressors. He has bilateral subclavian stenosis with\n difficult time to determine blood pressure, weaned to mental status as\n well as blood pressures from legs. CT ruled out ruptured AAA and stool\n guaic was negative. Differential includes sepsis, hypovolemic, GI\n bleed, ischemic colitis, less likely to be MI or adrenal\n insufficiency. Most likely is sepsis in setting of colitis and\n peritonitis. Pressors off ;\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission, continue to follow\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: renal following, plan for PD, peritonitis, see above\n - PD cath Cx\n no organisms seen on gram stain\n - f/u renal recs\n - continue Calcitriol\n - will reculture fluid\n - added epo per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross\n - CVL and \n - PPI & trend hct, keep > 21\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: will need to place NG tube for TFs today\n .\n # Prophylaxis: Heparin sc tid, PPI\n .\n # Access: , d/c RIJ today and have PICC placed for long-term\n ABX and possible TPN\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365783,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain as well as nausea, vomiting and tarry diarrhea. Pt initially\n presented to with hypotension and mild hct drop. Pt\n underwent a CT Abd/Pelvis scan which revealed stable AAA and he was\n transferred to for further care. Of note, pt was discharged on\n after admission for NSTEMI & PNA. During that admission, pt was\n taken to cath and given co morbidities only the SVG-OM2 was\n angioplastied. He was treated with a 10day course of Ceftriaxone/Levo\n for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea.\n Initially pt was on pressors x3, started on abx, w/ improvement in\n hypotension after ~48hrs. pt now off pressors, cont on IV Zosyn,\n Flagyl, and Vanco as well as Vanco PO. At baseline pt is on PD which\n has been restarted ( problem list for specifics). Pt was seen by\n surgery r/t abd pain and plan was to medically manage as pt is not a\n surgical candidate.\n Pt initially presented w/ diarrhea r/t to colitis, now w/ ilieus.\n Code: DNR/DNI\n Events: back pain still present but better, continues on PD. Remains\n on bowel rest, started on TPN. Sm BM x1.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt is on 5cycles/day of PD. 2L x1.5hr dwell time per cycle. PD\n catheter had been clotting with fibrin clot for the last couple of\n days. K+ this am 3.0\n Action:\n 1000 units of Heparin ordered for each bag of PD solution. K+ repleted\n w/ 20 meq KCL pt started on TPN.\n Response:\n PD fluid running free, no sign of clots. TPN tol well.\n Plan:\n Continue on scheduled PD runs. Monitor labs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt continues to c/ and back pain. .\n Action:\n Repositioned numerous times for pain relief. Tylenol x1. Trying to\n avoid pain meds if possible but can have prn if needed.\n Response:\n Pain improved w/ repositioning and Tylenol to and tolerable.\n Narcotic pain med\ns discontinued r/t pain meds thought to have\n contributed to ileus. Sm BM x1 this shift.\n Plan:\n Given pain meds when needed but assess carefully.\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 364927,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given comorbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n .\n In the ED, initial vs were: T 98.8 P 85 BP 91/37 RR 21 Sats 100% on 2L.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Continue on O2 4L simple face mask\n Hypotension (not Shock)\n Assessment:\n Hypotension to SBP 70-80\ns, patient felt light headed, CVP 8-9,\n Action:\n Started initially with levophed and max to 0.3 mcg/kg/min and 2.25L\n fluid bolus and later started on vasopressin and neo gtt and titrated\n for MAP >65.\n Response:\n SBp 100-110 on triple pressors, CVP 8-9 initially and to 14-16 ,\n afebrile, WBC to 26.3, stool guaic\n Plan:\n Triple pressors to keep MAP>65, antibiotics vanco/zosyn/ for possible\n colitis and po vanco and flagyl for C diff colitis. F/U culture\n results,\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n ESRD on PD, Patient is anuric since admission, foleys cath in place.BUN\n 30 and creat 7.8\n Action:\n Fluid from PD catheter sent for culture,\n Response:\n Am labs\n Plan:\n Consult renal this am, monitor fluid balance and AM labs.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abdominal pain and back pain, level , ? progression of hepatic\n mets, or colitis\n Action:\n Morphine 1-2mg iv PRN given, fluid sent from PD cath for cx\n Response:\n Some improvement with pain but still continues to have back and\n abdominal pain. Guaic\n Plan:\n F/U culture results, Morphine PRN, empiric flagyl and PO vanc\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 364934,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given comorbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n .\n In the ED, initial vs were: T 98.8 P 85 BP 91/37 RR 21 Sats 100% on 2L.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Continue on O2 6L simple face mask\n Hypotension (not Shock)\n Assessment:\n Hypotension to SBP 70-80\ns, patient felt light headed, CVP 8-9,\n Action:\n Started initially with levophed and max to 0.3 mcg/kg/min and 2.25L\n fluid bolus and later started on vasopressin and neo gtt and titrated\n for MAP >65.\n Response:\n SBp 100-110 on triple pressors, CVP 8-9 initially and to 14-16 ,\n afebrile, WBC to 26.3, stool guaic\n Plan:\n Triple pressors to keep MAP>65, antibiotics vanco/zosyn/ for possible\n colitis and po vanco and flagyl for C diff colitis. F/U culture\n results,\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n ESRD on PD, Patient is anuric since admission, foleys cath in place.BUN\n 30 and creat 7.8\n Action:\n Fluid from PD catheter sent for culture,\n Response:\n Am labs BUN 32/creat 7.5\n Plan:\n Consult renal this am, monitor fluid balance and AM labs ,? To remove\n the foley\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abdominal pain and back pain, level , ? progression of hepatic\n mets, or colitis\n Action:\n Morphine 1-2mg iv PRN given, fluid sent from PD cath for cx\n Response:\n Some improvement with pain but still continues to have back and\n abdominal pain. Guaic\n Plan:\n F/U culture results, Morphine PRN, empiric flagyl and PO vanc\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365227,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - renal wants to go through with peritoneal dialysis\n - will discuss with them re peritonitis and general recs\n - vasc surgery not involved in peritoneal dialysis\n - around 5 pm, patient had five second pause after vasovagal episode\n - vanc level theraputic\n - hem/onc aware\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:46 PM\n Metronidazole - 04:23 AM\n Vancomycin - 06:07 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.3 mcg/Kg/min\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:23 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.6\nC (97.8\n HR: 68 (59 - 131) bpm\n BP: 143/44(68) {84/39(60) - 152/78(89)} mmHg\n RR: 19 (8 - 20) insp/min\n SpO2: 100%\n Heart rhythm: Idioventricular\n CVP: 11 (8 - 18)mmHg\n Total In:\n 3,944 mL\n 612 mL\n PO:\n 100 mL\n TF:\n IVF:\n 3,844 mL\n 612 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 3,944 mL\n 612 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///16/\n Physical Examination\n Vitals: T: 98.2 BP: 123/59 repeat 88/42 P: 95 R: 18 O2: Sats 94% 2L\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 285 K/uL\n 7.6 g/dL\n 130 mg/dL\n 8.9 mg/dL\n 16 mEq/L\n 5.3 mEq/L\n 42 mg/dL\n 103 mEq/L\n 137 mEq/L\n 24.7 %\n 22.6 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n Plt\n 241\n 285\n 259\n 285\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n Glucose\n 114\n 140\n 126\n 130\n Other labs: PT / PTT / INR:17.0/36.8/1.5, ALT / AST:67/92, Alk Phos / T\n Bili:73/0.2, Amylase / Lipase:95/38, Lactic Acid:1.5 mmol/L,\n Albumin:2.6 g/dL, LDH:323 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:9.6\n mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n .\n # Hypotension: Pt with lethargy, hypotension that has transiently\n responded to IV boluses but continues to require low dose levophed,\n then requiring three pressors. Pt is a vasculopath with complex\n arterial anatomy, recently discharged after NSTEMI. CT ruled out\n ruptured AAA and stool guaic was negative. Differential includes\n sepsis, hypovolemic, GI bleed, ischemic colitis, less likely to be MI\n or adrenal insufficiency. Most likely is sepsis in setting of colitis\n and peritonitis.\n - bolus IVF prn to goal CVP>12\n - wean pressors today as tolerated; has subclavian stenosis with\n difficult time to determine blood pressure, are weaning to mental\n status as well as blood pressures from legs\n - Vanc/Zosyn for possible diverticulitis/colitis\n - start empiric Flagyl and po Vanc for possible CDiff colitis\n - f/u blood/urine/stool cx\n no obvious source yet\n .\n # Abd pain/diarrhea: Pt is a known vasculopath who p/w 2-3 days of dark\n loose stools and poor po intake after completing a course of Abx for\n PNA. Per family, no fevers at home but pt reports subjective chills.\n WBC ct of 20 and CT with colitis. Concern for C Diff colitis vs\n ischemic colitis, though may be less likely given normal lactate. SBP\n also possible, will send fluid from peritoneal cath. Pt was seen by\n gen and vasc surgery in ED, no plan for OR. Pt expressed goals of\n care to avoid heroic measures, confirmed by HCP.\n - following lactates, does have increasing gap acidosis today, unclear\n etiology, possibly from ischemia\n - bolus IVF\n - type & cross\n - started empiric Flagyl & Po Vanc for c.diff, results pending\n - dilaudid prn for pain, improved today\n - continue Vanc/Zosyn for possible diverticulitis and peritonitis\n - per , can start to advance diet slowly with serial abd exams as\n long as making stool\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission, continue to follow\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: renal following, plan for PD today\n - send fluid from PD cath for Cx\n no organisms seen on gram stain\n - continue Calcitriol\n - added epo and phos binder per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross\n - CVL and PIV\n - PPI & trend hct, hct has been stable\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: can start with clears\n - replete electrolytes aggressively, PD today for hyperkalemia\n .\n # Prophylaxis: Heparin sc tid, PPI\n .\n # Access: RIJ, PIV\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365031,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who went to with worsening\n abdominal pain over the last 3 days as well as nausea, vomiting and\n tarry diarrhea, he was hypotensive and had a mild hct drop. He was\n transferred to for further care.\n .\n In the ED, initial vs were: T 98.8 P 85 BP 91/37 RR 21 Sats 100% on 2L.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n Hypotension (not Shock)\n Assessment:\n Pt remains hypotensive and tachy in the 1teens, afebrile\n Action:\n He conts on levophed, neo, and vasopressin, zosyn, vanco and Flagyl\n Response:\n Able to wean the neo but unable to stop it\n Plan:\n Wean the pressors as able, cont antibiotics, f/u on clx\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt is a PD patient, his lytes are stable, he is pressor dependant as\n above\n Action:\n There is talk about doing PD today even though he is on triple pressors\n but our team decided to hold off until he is more stable\n Response:\n Plan:\n f/u with PD tomorrow\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain mainly on his R side, states that he has been in pain since\n he has been here but is also confused telling me is pain free and a\n moment later saying that he\nhurts terribly\n Action:\n He was given 2 percocetts and an hour later he said that he was still\n in pain, then given 2 mg of IV morphine\n Response:\n He was able to fall asleep after the morphine, when he woke he was more\n confused but also said that he was comfortable\n Plan:\n The morphine was d/ced due to the confusion and dilaudid was added.\n"
},
{
"category": "Nutrition",
"chartdate": "2145-03-05 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 365212,
"text": "Patient has been NPO and/or on unsupplemented clear liquid diet for 1\n days. If patient's diet is not able to be advanced and tolerated,\n for nutrition support\n Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n DDx C.diff colitis, ischemic colitis, SBP. Checking for C.diff\n No plan for OR, pt wishes no heroic measures.\n If pt w/ ischemic colitis would need TPN if within goals of care.\n Recs:\n 1. Please discuss w/ family re. TPN, indicated for nutrition\n support if within goals of care.\n 2. If pt/family wishes to initiate nutrition support, please\n consult for recs.\n 3. c/w lyte mngt as you are\n 4. Monitor hydration status.\n Please page with questions #\n 12:02\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365437,
"text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hypothermia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365103,
"text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365104,
"text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365106,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n .\n In the ED, initial vs were: T 98.8 P 85 BP 91/37 RR 21 Sats 100% on 2L.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Hypotension (not Shock)\n Assessment:\n SBP 120-150\ns with triple pressors levo, neo and vasopressin gtt, the\n most accurate BP with rt thigh as per cardiology. Fluid bolus\n 250ml was infusing for new A fib, HR 110-140\n Action:\n Continued on triple pressors.\n Response:\n Plan:\n Wean pressors as tolerated,\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Patient is ESRD on PD, ?\n Action:\n Continue monitor labs, no PD for tonight\n Response:\n AM labs\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain and back pain, but patient able to sleep comfortably\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365321,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Hypotension (not Shock)\n Assessment:\n SBP 90- 130\ns with a MAP 50-70\ns, off pressors since yesterday\n afternoon. The most accurate BP with rt thigh , h/o lt\n subclavian stenosis, HR 56 to 70\ns slow afib w/ occasional PVC\ns CVP\n 8-14\n Action:\n Off Pressors, pm labs sent\n Response:\n SBP 90\ns- 130\ns off pressors w/ MAP remaining 50-70, CVP 8-14, wbc is\n 15.4, lactate trending down to 2.2,a gap 19\n Plan:\n Monitor lactate/WBC, F/U culture results,continues to rise reconsult\n gen r/t ? Ischemic bowel.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Patient is ESRD on PD baseline creat \n Action:\n PD restarted a/o 1.5% dextrose , 1.5 L in and 1.5 L dwell time,\n ordered for 5 exchanges /day\n Response:\n BUN 50, creat 8.5, other lytes within acceptable limits, PD continued\n Plan:\n Continue PD a/o as tol, f/u labs\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain and back pain ,\n Action:\n Dilaudid 0.5mg given\n Response:\n Pt states p[ain improved, slept most of the night, without c/o pain,now\n /\n Plan:\n Prn percocet and dilaudid and repositioning for pain\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365322,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Hypotension (not Shock)\n Assessment:\n SBP 90- 130\ns with a MAP 50-70\ns, off pressors since yesterday\n afternoon. The most accurate BP with rt thigh , h/o lt\n subclavian stenosis, HR 56 to 70\ns slow afib w/ occasional PVC\ns CVP\n 8-14\n Action:\n Off Pressors, pm labs sent\n Response:\n SBP 90\ns- 130\ns off pressors w/ MAP remaining 50-70, CVP 8-14, wbc is\n 15.4, lactate trending down to 2.2,a gap 19\n Plan:\n Monitor lactate/WBC, F/U culture results,continues to rise reconsult\n gen r/t ? Ischemic bowel.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Patient is ESRD on PD baseline creat \n Action:\n PD restarted a/o 1.5% dextrose , 1.5 L in and 1.5 L dwell time,\n ordered for 5 exchanges /day\n Response:\n BUN 50, creat 8.5, other lytes within acceptable limits, PD continued\n Plan:\n Continue PD a/o as tol, f/u labs\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain and back pain ,\n Action:\n Dilaudid 0.5mg given\n Response:\n Pt states p[ain improved, slept most of the night, without c/o pain,now\n /\n Plan:\n Prn percocet and dilaudid and repositioning for pain\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365324,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Hypotension (not Shock)\n Assessment:\n SBP 90- 130\ns with a MAP 50-70\ns, off pressors since yesterday\n afternoon. The most accurate BP with rt thigh , h/o lt\n subclavian stenosis, HR 56 to 70\ns slow afib w/ occasional PVC\ns CVP\n 8-14\n Action:\n Off Pressors, pm labs sent\n Response:\n SBP 90\ns- 130\ns off pressors w/ MAP remaining 50-70, CVP 8-14, wbc is\n 15.4, lactate trending down to 2.2,a gap 19\n Plan:\n Monitor lactate/WBC, F/U culture results,continues to rise reconsult\n gen r/t ? Ischemic bowel.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Patient is ESRD on PD baseline creat \n Action:\n PD restarted a/o 1.5% dextrose , 1.5 L in and 1.5 L dwell time,\n ordered for 5 exchanges /day\n Response:\n BUN 50, creat 8.5, other lytes within acceptable limits, PD continued\n Plan:\n Continue PD a/o as tol, f/u labs\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain and back pain ,\n Action:\n Dilaudid 0.5mg given\n Response:\n Pt states p[ain improved, slept most of the night, without c/o pain,now\n /\n Plan:\n Prn percocet and dilaudid and repositioning for pain\n Hypothermia\n Assessment:\n Temp to 94.4 axillary\n Action:\n Bair hugger is on, warm fluid used for PD\n Response:\n Temp up to 96. ., patient is taking off his blanket, encouraged not to\n take off the blanket and bair hugger\n Plan:\n Continue monitor temp, bair hugger and warm PD fluid\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365325,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Hypotension (not Shock)\n Assessment:\n SBP 90- 130\ns with a MAP 50-70\ns, off pressors since yesterday\n afternoon. The most accurate BP with rt thigh , h/o lt\n subclavian stenosis, HR 56 to 70\ns slow afib w/ occasional PVC\ns CVP\n 8-14\n Action:\n Off Pressors, pm labs sent\n Response:\n SBP 90\ns- 130\ns off pressors w/ MAP remaining 50-70, CVP 8-14, wbc is\n 15.4, lactate trending down to 2.2,a gap 19\n Plan:\n Monitor lactate/WBC, F/U culture results,continues to rise reconsult\n gen r/t ? Ischemic bowel.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Patient is ESRD on PD baseline creat \n Action:\n PD restarted a/o 1.5% dextrose , 1.5 L in and 1.5 L dwell time,\n ordered for 5 exchanges /day\n Response:\n BUN 50, creat 8.5, other lytes within acceptable limits, PD continued\n Plan:\n Continue PD a/o as tol, f/u labs\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain and back pain ,\n Action:\n Dilaudid 0.5mg given\n Response:\n Pt states p[ain improved, slept most of the night, without c/o pain,now\n /\n Plan:\n Prn percocet and dilaudid and repositioning for pain\n Hypothermia\n Assessment:\n Temp to 94.0 axillary\n Action:\n Bair hugger is on, warm fluid used for PD\n Response:\n Temp up to 96.1, patient is taking off his blanket, encouraged not to\n take off the blanket and bair hugger\n Plan:\n Continue monitor temp, bair hugger and warm PD fluid\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365434,
"text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hypothermia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365820,
"text": "78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n Hypotension resolved, off pressors. Pt on PD.\n Now with SBO (KUB), no surgical interventions, surgery recs. bowel\n rest. TF were started- FS Novasource Renal upto 30cc/hr and held. NGT\n to intermittent suction.\n Consulted for TPN recs, start TPN via R IJ\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt is on 5cycles/day of PD. 2L x1.5hr dwell time per cycle. PD fluid\n wasn\nt available for next cycle. Abd firm distended, patient anuric.\n Action:\n 1000 units of Heparin ordered for each bag of PD solution. Continued\n PD as ordered\n Response:\n PD fluid running free, no sign of clots. TPN tol well. AM labs\n Plan:\n Continue on scheduled PD runs. Monitor labs.\n Call out to floor awaiting bed\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 364914,
"text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-08 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 365747,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - did not give PO narcan since patient had large bowel movement\n - KUB showed SBO vs ileus, pt has episode of vomitting, tube feeds\n stopped, NG placed on intermittent suction\n - renal wants IV vanc, they will give via HD protocol\n - wants patient on bowel rest since SBO vs ileus, no surgical\n intervention\n - trying to reduce the amount of narcotics by giving some anxitolytics\n for pain since both are causing pt discomfort\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:18 PM\n Piperacillin - 06:00 PM\n Metronidazole - 12:39 AM\n Piperacillin/Tazobactam (Zosyn) - 06:15 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.2\nC (99\n HR: 81 (63 - 88) bpm\n BP: 110/42(58) {96/42(53) - 140/67(84)} mmHg\n RR: 8 (8 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 7 (2 - 10)mmHg\n Total In:\n 684 mL\n 217 mL\n PO:\n TF:\n 144 mL\n IVF:\n 441 mL\n 217 mL\n Blood products:\n Total out:\n -4,000 mL\n -6,000 mL\n Urine:\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 4,684 mL\n 6,217 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 231 K/uL\n 7.6 g/dL\n 91 mg/dL\n 8.1 mg/dL\n 23 mEq/L\n 3.0 mEq/L\n 50 mg/dL\n 101 mEq/L\n 137 mEq/L\n 23.5 %\n 9.8 K/uL\n [image002.jpg]\n 11:00 PM\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n 04:22 PM\n 03:23 AM\n 05:00 AM\n WBC\n 20.4\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n 14.3\n 9.8\n Hct\n 23.1\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n 23.7\n 25.5\n 23.5\n Plt\n 241\n 285\n 259\n 285\n 243\n 230\n 237\n 231\n Cr\n 7.8\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n 8.0\n 8.1\n Glucose\n 114\n 140\n 126\n 130\n 101\n 181\n 124\n 112\n 91\n Other labs: PT / PTT / INR:17.2/45.4/1.6, ALT / AST:1127/544, Alk Phos\n / T Bili:125/0.3, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.1 g/dL, LDH:750 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Now with\n ileus/SBO.\n .\n # presumptive Cdiff\n Presenation was 2-3 days of dark loose stools and\n poor po intake after completing a course of Abx for PNA. Per family, no\n fevers at home but pt reports subjective chills. WBC ct of 20 and CT\n with colitis. Concern for C Diff colitis vs ischemic colitis,\n complicated by sepsis\n requiring pressor support. SBP also possible,\n had high WBC count but no organisms grew. Pt was seen by gen and\n vasc surgery in ED, no plan for OR. Pt expressed goals of care to\n avoid heroic measures, confirmed by HCP. on contact\n precautions. C.diff has been complicated by what appears to be ileus,\n although SBO is still a possibility.\n - Zozyn for possible diverticulitis, will complete a 10 day course, no\n day \n - Flagyl and po Vanc and IV vanco for possible CDiff colitis\n - c.diff toxin negative, but still is likely the cause\n - pt with likely ileus, but had bowel movement yesterday\n gen \n reconsulted and following again. Will keep NGT on intermittent wall\n suction, remains NPO for bowel rest, continue bowel regimen and\n consider PO narcan as needed\n - holding narcotics, seems comfortable\n # peritonitis\n spoke to renal today, should give vanc for the full two\n week course, and will check peritoneal fluid again, they will continue\n PD through this infection.\n - vanc dosing should be 750 mg when daily vanco level is below 15\n # Shock liver\n LFTs peaked now trending down, patient continues to\n have coagulopathy, both improving\n .\n # altered Mental status\n waxing and , maybe baseline, maybe\n uremia v. narcotic usage\n - giving slight ativan since anxiety playing element in pain\n - stopping dilaudid for now, patient remains comfortable\n .\n # Hypotension: Resolved, patient is severe vasculopath and pressures\n are difficult to determine. Patient was initially started on levo and\n then moved to three pressors. He has bilateral subclavian stenosis with\n difficult time to determine blood pressure, weaned to mental status as\n well as blood pressures from legs. CT ruled out ruptured AAA and stool\n guaic was negative. Differential includes sepsis, hypovolemic, GI\n bleed, ischemic colitis, less likely to be MI or adrenal\n insufficiency. Most likely is sepsis in setting of colitis and\n peritonitis. Pressors off \n - hemodynamics stable\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission, continue to follow\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: renal following, plan for PD, peritonitis, see above\n - PD cath Cx\n no organisms seen on gram stain\n - f/u renal recs, did stop renagel due to its constipating effects\n - continue Calcitriol\n - will reculture fluid\n - added epo per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross; continue to guiac stools\n - CVL and PIV for access\n - PPI & trend hct, keep > 21\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: on bowel rest, today will do PPN and tomorrow plan for TPN as\n LFTs start to improve\n .\n # Prophylaxis: Heparin sc tid, PPI IV\n .\n # Access: PIV, RIJ; PICC attempted at bedside and could not be done,\n plan for IR guided PICC and removal of RIJ\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now, call out to floor today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 78M CAD, met carcinoid, ESRD, abd pain and\n colitis on CT. Started on PD, off pressors, liver function remains\n poor. Mental status slowly improving, +BM x1 with decreased pain.\n Exam notable for Tm 99.1 BP 130/60 HR 77 RR 18 with sat 100 on 2L NC.\n Frail man, responsive but confused. RRR s1s2. Soft tender abd, PD cath\n c/d/i. 2+ edema. Labs notable for WBC 9K, HCT 23, ALT / AST decreasing.\n Agree with plan to treat likely c. diff with PO vanco / IV flagyl while\n awaiting culture data. Will stop zosyn after 10 days and continue c.\n diff rx for a further 14 days after that. For ESRD, continue PD per\n renal team. Anemia is stable. He needs aggressive nutritional support,\n but appears to have an ileus. Will continue NGT in ILWS and start PPN\n with transition to TPN if ileus persists in AM, d/c narcotics. Not\n clear if this ileus is from c. diff, meds, or met carcinoid, surgery\n following. Will d/c CVL, continue PIVs and place PICC for long term\n access, including possible need for TPN. DNR/I. Remainder of plan as\n outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 12:58 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365818,
"text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt is on 5cycles/day of PD. 2L x1.5hr dwell time per cycle. PD fluid\n wasn\nt available for next cycle. Abd firm distended, patient anuric.\n Action:\n 1000 units of Heparin ordered for each bag of PD solution. Continued\n PD as ordered\n Response:\n PD fluid running free, no sign of clots. TPN tol well. AM labs\n Plan:\n Continue on scheduled PD runs. Monitor labs.\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365819,
"text": "78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n Hypotension resolved, off pressors. Pt on PD.\n Now with SBO (KUB), no surgical interventions, surgery recs. bowel\n rest. TF were started- FS Novasource Renal upto 30cc/hr and held. NGT\n to intermittent suction.\n Consulted for TPN recs, start TPN via R IJ\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt is on 5cycles/day of PD. 2L x1.5hr dwell time per cycle. PD fluid\n wasn\nt available for next cycle. Abd firm distended, patient anuric.\n Action:\n 1000 units of Heparin ordered for each bag of PD solution. Continued\n PD as ordered\n Response:\n PD fluid running free, no sign of clots. TPN tol well. AM labs\n Plan:\n Continue on scheduled PD runs. Monitor labs.\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365890,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain as well as nausea, vomiting and tarry diarrhea. Pt initially\n presented to with hypotension and mild hct drop. Pt\n underwent a CT Abd/Pelvis scan which revealed stable AAA and he was\n transferred to for further care. Of note, pt was discharged on\n after admission for NSTEMI & PNA. During that admission, pt was\n taken to cath and given co morbidities only the SVG-OM2 was\n angioplastied. He was treated with a 10day course of Ceftriaxone/Levo\n for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea.\n Initially pt was on pressors x3, started on abx, w/ improvement in\n hypotension after ~48hrs. pt now off pressors, cont on IV Zosyn,\n Flagyl, and Vanco as well as Vanco PO. At baseline pt is on PD which\n has been restarted ( problem list for specifics). Pt was seen by\n surgery r/t abd pain and plan was to medically manage as pt is not a\n surgical candidate.\n Pt initially presented w/ diarrhea r/t to colitis, now w/ ilieus.\n Code: DNR/DNI\n Events: back pain still present but better, continues on PD. Remains\n on bowel rest, started on TPN. Sm BM x1.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt is on 5cycles/day of PD. 2L x1.5hr dwell time per cycle. PD\n catheter had been clotting with fibrin clot for the last couple of\n days. K+ this am 3.0\n Action:\n 1000 units of Heparin ordered for each bag of PD solution. K+ repleted\n w/ 20 meq KCL pt started on TPN.\n Response:\n PD fluid running free, no sign of clots. TPN tol well.\n Plan:\n Continue on scheduled PD runs. Monitor labs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt continues to c/ and back pain. .\n Action:\n Repositioned numerous times for pain relief. Tylenol x1. Trying to\n avoid pain meds if possible but can have prn if needed.\n Response:\n Pain improved w/ repositioning and Tylenol to and tolerable.\n Narcotic pain med\ns discontinued r/t pain meds thought to have\n contributed to ileus. Sm BM x1 this shift.\n Plan:\n Given pain meds when needed but assess carefully.\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 365893,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain as well as nausea, vomiting and tarry diarrhea. Pt initially\n presented to with hypotension and mild hct drop. Pt\n underwent a CT Abd/Pelvis scan which revealed stable AAA and he was\n transferred to for further care. Of note, pt was discharged on\n after admission for NSTEMI & PNA. During that admission, pt was\n taken to cath and given co morbidities only the SVG-OM2 was\n angioplastied. He was treated with a 10day course of Ceftriaxone/Levo\n for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea.\n Initially pt was on pressors x3, started on abx, w/ improvement in\n hypotension after ~48hrs. pt now off pressors, cont on IV Zosyn,\n Flagyl, and Vanco as well as Vanco PO. At baseline pt is on PD which\n has been restarted ( problem list for specifics). Pt was seen by\n surgery r/t abd pain and plan was to medically manage as pt is not a\n surgical candidate.\n Pt initially presented w/ diarrhea r/t to colitis, now w/ ilieus.\n Code: DNR/DNI\n Events: back pain still present but better, continues on PD. Remains\n on bowel rest, started on TPN. Sm BM x1.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt is on 5cycles/day of PD. 2L x1.5hr dwell time per cycle. PD\n catheter had been clotting with fibrin clot for the last couple of\n days.\n Action:\n 1000 units of Heparin ordered for each bag of PD solution, pt started\n on TPN \n Response:\n PD fluid running free, no sign of clots. TPN tol well. Last cycle\n completed at 10:00, peritoneum left empty at this time.\n Plan:\n Continue on scheduled PD runs, next cycle due at 16:00. Monitor labs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt continues to c/ and back pain. .\n Action:\n Repositioned numerous times for pain relief. Tylenol x1. Trying to\n avoid pain meds if possible but can have prn if needed.\n Response:\n Pain improved w/ repositioning and Tylenol to and tolerable.\n Narcotic pain med\ns discontinued r/t pain meds thought to have\n contributed to ileus. Sm BM x1 this shift.\n Plan:\n Given pain meds when needed but assess carefully.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n SEPSIS\n Code status:\n DNR / DNI\n Height:\n 67 Inch\n Admission weight:\n 56 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: CAD, Hypertension\n Additional history: Carcinoid tumor with mets to liver, hyperlipidemia\n , CAD s/p CABG x4 in , s/p bilateral carotid endarterectomies,\n AAA measuring 5 cm on \n ESRD on PD since , s/p HD tunneled cath placement, sigmoid\n diverticulitis, BPH , H/o ruptured disk, s/p vasectomy, eye surgery,\n tonsillectomy.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:148\n D:52\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 11 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 666 mL\n 24h total out:\n 100 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 05:53 AM\n Potassium:\n 3.9 mEq/L\n 05:53 AM\n Chloride:\n 102 mEq/L\n 05:53 AM\n CO2:\n 25 mEq/L\n 05:53 AM\n BUN:\n 54 mg/dL\n 05:53 AM\n Creatinine:\n 7.8 mg/dL\n 05:53 AM\n Glucose:\n 163 mg/dL\n 05:53 AM\n Hematocrit:\n 23.0 %\n 05:53 AM\n Finger Stick Glucose:\n 157\n 04:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 683\n Transferred to: CC722\n Date & time of Transfer: 1000\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365896,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - continued on bowel rest\n - had several small BMs during day\n - replaced K+ per renal recs\n - pain tolerated without narcotics\n - called out but did not receive a bed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:00 PM\n Metronidazole - 12:30 AM\n Piperacillin/Tazobactam (Zosyn) - 05:40 AM\n Vancomycin - 05:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:03 PM\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98.1\n HR: 81 (66 - 88) bpm\n BP: 124/50(67) {100/40(54) - 149/95(100)} mmHg\n RR: 8 (8 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 3 (3 - 7)mmHg\n Total In:\n 844 mL\n 503 mL\n PO:\n TF:\n IVF:\n 550 mL\n 218 mL\n Blood products:\n Total out:\n -5,200 mL\n 100 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 6,044 mL\n 403 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ////\n Physical Examination\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 219 K/uL\n 7.5 g/dL\n 91 mg/dL\n 8.1 mg/dL\n 23 mEq/L\n 3.0 mEq/L\n 50 mg/dL\n 101 mEq/L\n 137 mEq/L\n 23.0 %\n 9.5 K/uL\n [image002.jpg]\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n 04:22 PM\n 03:23 AM\n 05:00 AM\n 05:53 AM\n WBC\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n 14.3\n 9.8\n 9.5\n Hct\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n 23.7\n 25.5\n 23.5\n 23.0\n Plt\n 285\n 259\n 285\n 243\n 230\n 237\n 231\n 219\n Cr\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n 8.0\n 8.1\n Glucose\n 140\n 126\n 130\n 101\n 181\n 124\n 112\n 91\n Other labs: PT / PTT / INR:17.2/45.4/1.6, ALT / AST:1127/544, Alk Phos\n / T Bili:125/0.3, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.1 g/dL, LDH:750 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Now with\n ileus/SBO.\n .\n # presumptive Cdiff\n Presenation was 2-3 days of dark loose stools and\n poor po intake after completing a course of Abx for PNA. Per family, no\n fevers at home but pt reports subjective chills. WBC ct of 20 and CT\n with colitis. Concern for C Diff colitis vs ischemic colitis,\n complicated by sepsis\n requiring pressor support. SBP also possible,\n had high WBC count but no organisms grew. Pt was seen by gen and\n vasc surgery in ED, no plan for OR. Pt expressed goals of care to\n avoid heroic measures, confirmed by HCP. on contact\n precautions. C.diff has been complicated by what appears to be ileus,\n probably not SBO as pt is having bowel movements, has normal bowel\n sounds and no severe belly pain.\n - IV vanco for peritonitis (see below)\n - Zozyn for possible diverticulitis, will complete a 10 day course, no\n day \n - Flagyl and po Vanc for possible CDiff colitis, plan to treat for 2\n weeks after course of vanco/zosyn completed\n - c.diff toxin negative, but still is likely the cause\n - pt with likely ileus, continuing to have bowel movements; keep on\n bowel rest for now, continue to monitor with occasional KUBs, follow up\n with surgery about plans for advancing diet\n - holding narcotics, seems comfortable\n # peritonitis\n spoke to renal today, should give vanc for the full two\n week course, and will check peritoneal fluid again, they will continue\n PD through this infection.\n - vanc dosing should be 750 mg when daily vanco level is below 15; cont\n checking daily vanc levels\n -todays level 17, likely will be redosed tomorrow.\n # Shock liver\n LFTs peaked now trending down, patient continues to\n have coagulopathy, both improving\n .\n # altered Mental status\n waxing and , maybe baseline, maybe\n uremia v. narcotic usage\n - avoiding all deleriogenic drugs\n - stopped narcotics, Tylenol helping pain\n .\n # Hypotension: Resolved, patient is severe vasculopath and pressures\n are difficult to determine. Patient was initially started on levo and\n then moved to three pressors. He has bilateral subclavian stenosis with\n difficult time to determine blood pressure, weaned to mental status as\n well as blood pressures from legs. CT ruled out ruptured AAA and stool\n guaic was negative. Differential includes sepsis, hypovolemic, GI\n bleed, ischemic colitis, less likely to be MI or adrenal\n insufficiency. Most likely is sepsis in setting of colitis and\n peritonitis. Pressors off \n - hemodynamics stable\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission, continue to follow\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: renal following, plan for PD, peritonitis, see above\n - continue PD\n - follow renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n - hydro not likely a nidus of infection as is a chronic problem\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross; continue to guiac stools\n - CVL and PIV for access\n - PPI & trend hct, keep > 21\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: on bowel rest, TPN started \n .\n # Prophylaxis: Heparin sc tid, PPI IV\n .\n # Access: plan for IR guided PICC today, can then pull RIJ\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now, call out to floor today.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:00 PM 42 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 364915,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given comorbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n .\n In the ED, initial vs were: T 98.8 P 85 BP 91/37 RR 21 Sats 100% on 2L.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Hypotension (not Shock)\n Assessment:\n Hypotension to SBP 70-80\ns, patient felt light headed,\n Action:\n Started initially with levophed and max to 0.3 mcg/kg/min and 2.25L\n fluid bolus and later started on vasopressin and neo gtt.\n Response:\n SBp 100-110 on triple pressors, CVP 8-9 initially and to 14-16\n Plan:\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365092,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who went to with worsening\n abdominal pain over the last 3 days as well as nausea, vomiting and\n tarry diarrhea, he was hypotensive and had a mild hct drop. He was\n transferred to for further care.\n .\n In the ED, initial vs were: T 98.8 P 85 BP 91/37 RR 21 Sats 100% on 2L.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n Hypotension (not Shock)\n Assessment:\n Pt remains hypotensive and tachy in the 1teens, afebrile\n Action:\n He conts on levophed, neo, and vasopressin, zosyn, vanco and Flagyl\n Response:\n Able to wean the neo but unable to stop it\n Plan:\n Wean the pressors as able, cont antibiotics, f/u on clx\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt is a PD patient, his lytes are stable, he is pressor dependant as\n above\n Action:\n There is talk about doing PD today even though he is on triple pressors\n but our team decided to hold off until he is more stable\n Response:\n Plan:\n f/u with PD tomorrow\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain mainly on his R side, states that he has been in pain since\n he has been here but is also confused telling me is pain free and a\n moment later saying that he\nhurts terribly\n Action:\n He was given 2 percocetts and an hour later he said that he was still\n in pain, then given 2 mg of IV morphine\n Response:\n He was able to fall asleep after the morphine, when he woke he was more\n confused but also said that he was comfortable\n Plan:\n The morphine was d/ced due to the confusion and dilaudid was added.\n ------ Protected Section ------\n This afternoon pt had a pause and then his rate decreased to 60, he\n felt faint but did not have LOC. His HR soon went back to his rate in\n the 1teens. Later he went into afib in the 130s-140s, given a 250cc NS\n bolus but he did not have any change in his HR.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:12 ------\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-09 00:00:00.000",
"description": "ICU attending addendum",
"row_id": 365888,
"text": "CRITICAL CARE STAFF ADDENDUM\n 8:40a\n I saw and examined Mr. with the ICU team, whose note from today\n reflects my input. I would add/emphasize that he began TPN yesterday.\n Was called out but no beds available. TM 99, WBC 9.5 (peak 22.6).\n Exam generally comfortable. Has mild right flank discomfort with deep\n palpation.\n Meds: PPI, Plavix, ASA, SQH, colace, vanco PO, epo, Flagyl 500 q12,\n Zosyn IV, vanco IV\n Assessment and Plan\n 78 year old man with metastatic carcinoid, CAD s/p CABG who presented\n with colitis, peritonitis, and shock. Shock and clinical peritonitis\n has resolved. Agree with plan to continue vanco/zosyn (now day ),\n then continue c diff therapy for 14 days afterwards. For ESRD, will\n continue PD per renal. For his ileus -- although he is beginning to\n have some bowel activity, his malnutrition argues for aggressive\n nutritional support, and we will continue TPN until his oral caloric\n intake has improved. Anemia is essentially stable. We will consult IR\n for PICC today; when PICC in place, d/c CVL. DNR/DNI. To floor today.\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365163,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n .\n In the ED, initial vs were: T 98.8 P 85 BP 91/37 RR 21 Sats 100% on 2L.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Hypotension (not Shock)\n Assessment:\n SBP 120-150\ns with triple pressors levo, neo and vasopressin gtt, the\n most accurate BP with rt thigh , and patient has left\n subclavian stenosis, his central pressure noted to be 60mmhg higher\n than peripheral pressures. Seen by cardiology, HR 110-140\n Action:\n Continued on triple pressors. Fluid bolus 250ml was given for new A fib\n Response:\n SBP 120-150\ns, continued pressors, HR a fib to idioventricular to slow\n a fib hr 60-130\n Plan:\n Wean pressors as tolerated\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Patient is ESRD on PD, ? baseline creat \n Action:\n Continue monitor labs, no PD for tonight\n Response:\n AM labs bun/creat 42/ 8.9, K 5.3.\n Plan:\n F/U with renal for plan with dialysis today, monitor labs,\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o abd pain and back pain, but patient able to sleep comfortably\n Action:\n Dilaudid 0.5mg x1 and percocet x1 given\n Response:\n No response to dilaudid and 1percoecet, repeated another percoect and\n 0.5 dilaudid\n Plan:\n Prn percocet and dilaudid for pain\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365496,
"text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt is anuric on PD for 5 exchanges/day\n Action:\n PD done as per orders.PD cath blocked x1,flushed with NS, got out one\n long fibrinogen clot.\n Response:\n PD cath infusing easily after the flush.\n Plan:\n Continue with the scheduled PD runs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain to back not exactly describing the kind and type of pain.\n Action:\n Given 0.5 mg IV dilaudid and po percocet.Repositioned and backrub as\n needed.\n Response:\n Pt slept after the dilaudid, no more c/o pain after.\n Plan:\n Monitor pain,administer pain meds as needed.\n TF advanced to 30cc/hr.Pt vomited this am at 5:30 am.Aspirated 100cc of\n bilious liq from the NGT and NGT to LCS for decompression of stomach.Pt\n had 4mg of ondansetron wih effect.\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365614,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Events: back pain still present but better, continues on PD.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n PD continues fibrogen clots seen but did not clot the catheter. Renal\n fellow notified.\n Action:\n 1000 units of Heparin ordered for each bag of PD solution. PD dwell\n increased to 2000cc\n Response:\n PD fluid running free, no sign of clots. No fluid being removed from\n dialysis. He remains even\n Plan:\n Continue on scheduled PD runs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt continues to C/O back/abd pain off and on. He was c/o severe back\n pain this am so was getting peroceccd 1 tab PO\n Action:\n Before the meds could be given to him. He fell asleep. KUB showed\n grossely enlarged colon.\n Response:\n Pain meds contributing to partial SBO. Pain Meds D/C\ned, (can get PRN\n MEDS when needed) Assess need for meds closely. He occasionally seems\n to asks then falls asleep.\n Plan:\n Given pain meds when needed but assess carefully.\n Hypotension (not Shock)\n Assessment:\n B/P has been 120-130\ns/60-70\nsHR in 80\n Action:\n Response:\n Stable hemodynamics.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2145-03-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 365617,
"text": "78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given co morbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.08mcg on transfer from the\n ED.\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Code: DNR/DNI\n Events: back pain still present but better, continues on PD.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n PD continues fibrogen clots seen but did not clot the catheter. Renal\n fellow notified.\n Action:\n 1000 units of Heparin ordered for each bag of PD solution. PD dwell\n increased to 2000cc\n Response:\n PD fluid running free, no sign of clots. No fluid being removed from\n dialysis. He remains even\n Plan:\n Continue on scheduled PD runs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt continues to C/O back/abd pain off and on. He was c/o severe back\n pain this am so was getting peroceccd 1 tab PO\n Action:\n Before the meds could be given to him. He fell asleep. KUB showed\n grossely enlarged colon.\n Response:\n Pain meds contributing to partial SBO. Pain Meds D/C\ned, (can get PRN\n MEDS when needed) Assess need for meds closely. He occasionally seems\n to asks then falls asleep.\n Plan:\n Given pain meds when needed but assess carefully.\n Hypotension (not Shock)\n Assessment:\n B/P has been 120-130\ns/60-70\nsHR in 80\n Action:\n None needed\n Response:\n Stable hemodynamics.\n Plan:\n Continue to monitor\n He was OOB to the chair, while in the chair he had a mod amount of\n loose brown stool. Specimen sent for C. diff.\n"
},
{
"category": "Nutrition",
"chartdate": "2145-03-08 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 365737,
"text": "Subjective\n Unable to speak w/ pt\n Objective\n \n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 56 kg\n 19.3\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 83\n n/a\n Diagnosis: Sepsis\n PMH :\n -Carcinoid tumor with mets to liver\n - Hypertension & Hyperlipidemia\n - CAD s/p CABG x 4 in , Cath -> severe native three vessel\n disease with 90% lesion in SVG-OM2 s/p PTCA\n - ESRD, on PD since , s/p HD tunneled cath placement\n - CAD s/p bilateral carotid endarterectomies in , c/b post-op\n seizure\n - Bilateral RAS & left common iliac artery aneurysm, s/p bilateral\n endarterectomies and aortobifemoral bypass graft with renal artery\n reimplantation to aortic graft in , left renal artery stenting in\n , s/p right ureteral stenting in c/b right mid-ureteral\n stricture with multiple stent exchanges in 07 & 08\n - AAA measuring 5 cm on CT\n - Sigmoid diverticulitis\n - Pancreatitis w/ ileus post AAA\n - BPH\n - H/o ruptured disk\n Food allergies and intolerances: n/a\n Pertinent medications: Vancomycin, Heparin, Protonix, Flagyl,asa,\n others noted\n Labs:\n Value\n Date\n Glucose\n 91 mg/dL\n 05:00 AM\n Glucose Finger Stick\n 160\n 10:00 PM\n BUN\n 50 mg/dL\n 05:00 AM\n Creatinine\n 8.1 mg/dL\n 05:00 AM\n Sodium\n 137 mEq/L\n 05:00 AM\n Potassium\n 3.0 mEq/L\n 05:00 AM\n Chloride\n 101 mEq/L\n 05:00 AM\n TCO2\n 23 mEq/L\n 05:00 AM\n Albumin\n 2.1 g/dL\n 05:00 AM\n Calcium non-ionized\n 7.5 mg/dL\n 05:00 AM\n Phosphorus\n 6.9 mg/dL\n 05:00 AM\n Magnesium\n 1.9 mg/dL\n 05:00 AM\n ALT\n 1127 IU/L\n 05:00 AM\n Alkaline Phosphate\n 125 IU/L\n 05:00 AM\n AST\n 544 IU/L\n 05:00 AM\n Amylase\n 197 IU/L\n 09:25 PM\n Total Bilirubin\n 0.3 mg/dL\n 05:00 AM\n WBC\n 9.8 K/uL\n 05:00 AM\n Hgb\n 7.6 g/dL\n 05:00 AM\n Hematocrit\n 23.5 %\n 05:00 AM\n Current diet order / nutrition support: PPN: 1L(50g dex, 35g aa),\n Regular- soft(dysphagia) w/ nectar thick lix\n GI: Abd soft/diffusely tender/ND/(+)BS/ (+) BM\n Assessment of Nutritional Status\n Malnourished\n Pt at risk due to: Low po intake, Low protein stores, Needs nutrition\n support, low % IBW\n Estimated Nutritional Needs based on IBW\n Calories: 1675-2010kcals/day (25-30kcal/kg)\n Protein: 80- 94g/day (1.2-1.4 g/kg)\n Fluid: per team\n Estimation of previous and current intake: Inadequate\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n HoTN resolved, off pressors. Pt on PD.\n Now with SBO (KUB), no surgical interventions, surgery recs. bowel\n rest. TF were started- FS Novasource Renal upto 30cc/hr and held. NGT\n to intermittent suction.\n Consulted for TPN recs, start TPN via R IJ\n PPN ordered for today to provide 310kcals/day\n .\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. DC PPN, as pt w/ central access start TPN to meet nutrition\n needs and prevent further nutritional decline.\n 2. Initiate w/ day 1 TPN :1L (150g dex, 70g aa) w/ non-std lytes\n to provide 800kcals/day\n 3. Adv to goal as BG allow to 1.8L(300gdex, 90g aa, 40g lipid) to\n provide 1797kcals/day\n 4. Check trig w/ am labs, hold lipid if >400\n 5. c/w lyte mngt as you are.\n 6. Multivitamin / Mineral supplement: via TPN\n Following closely, will change TPN Rx prn based on LFTs/progress\n Please pge w/ questions #\n 11:47\n"
},
{
"category": "Nutrition",
"chartdate": "2145-03-08 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 365745,
"text": "Subjective\n Unable to speak w/ pt\n Objective\n \n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 56 kg\n 19.3\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 83\n n/a\n Diagnosis: Sepsis\n PMH :\n -Carcinoid tumor with mets to liver\n - Hypertension & Hyperlipidemia\n - CAD s/p CABG x 4 in , Cath -> severe native three vessel\n disease with 90% lesion in SVG-OM2 s/p PTCA\n - ESRD, on PD since , s/p HD tunneled cath placement\n - CAD s/p bilateral carotid endarterectomies in , c/b post-op\n seizure\n - Bilateral RAS & left common iliac artery aneurysm, s/p bilateral\n endarterectomies and aortobifemoral bypass graft with renal artery\n reimplantation to aortic graft in , left renal artery stenting in\n , s/p right ureteral stenting in c/b right mid-ureteral\n stricture with multiple stent exchanges in 07 & 08\n - AAA measuring 5 cm on CT\n - Sigmoid diverticulitis\n - Pancreatitis w/ ileus post AAA\n - BPH\n - H/o ruptured disk\n Food allergies and intolerances: n/a\n Pertinent medications: Vancomycin, Heparin, Protonix, Flagyl,asa,\n others noted\n Labs:\n Value\n Date\n Glucose\n 91 mg/dL\n 05:00 AM\n Glucose Finger Stick\n 160\n 10:00 PM\n BUN\n 50 mg/dL\n 05:00 AM\n Creatinine\n 8.1 mg/dL\n 05:00 AM\n Sodium\n 137 mEq/L\n 05:00 AM\n Potassium\n 3.0 mEq/L\n 05:00 AM\n Chloride\n 101 mEq/L\n 05:00 AM\n TCO2\n 23 mEq/L\n 05:00 AM\n Albumin\n 2.1 g/dL\n 05:00 AM\n Calcium non-ionized\n 7.5 mg/dL\n 05:00 AM\n Phosphorus\n 6.9 mg/dL\n 05:00 AM\n Magnesium\n 1.9 mg/dL\n 05:00 AM\n ALT\n 1127 IU/L\n 05:00 AM\n Alkaline Phosphate\n 125 IU/L\n 05:00 AM\n AST\n 544 IU/L\n 05:00 AM\n Amylase\n 197 IU/L\n 09:25 PM\n Total Bilirubin\n 0.3 mg/dL\n 05:00 AM\n WBC\n 9.8 K/uL\n 05:00 AM\n Hgb\n 7.6 g/dL\n 05:00 AM\n Hematocrit\n 23.5 %\n 05:00 AM\n Current diet order / nutrition support: PPN: 1L(50g dex, 35g aa),\n Regular- soft(dysphagia) w/ nectar thick lix\n GI: Abd soft/diffusely tender/ND/(+)BS/ (+) BM\n Assessment of Nutritional Status\n Malnourished\n Pt at risk due to: Low po intake, Low protein stores, Needs nutrition\n support, low % IBW\n Estimated Nutritional Needs based on IBW\n Calories: 1675-2010kcals/day (25-30kcal/kg)\n Protein: 80- 94g/day (1.2-1.4 g/kg)\n Fluid: per team\n Estimation of previous and current intake: Inadequate\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n HoTN resolved, off pressors. Pt on PD.\n Now with SBO (KUB), no surgical interventions, surgery recs. bowel\n rest. TF were started- FS Novasource Renal upto 30cc/hr and held. NGT\n to intermittent suction.\n Consulted for TPN recs, start TPN via R IJ\n PPN ordered for today to provide 310kcals/day\n .\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. DC PPN, as pt w/ central access start TPN to meet nutrition\n needs and prevent further nutritional decline.\n 2. Initiate w/ day 1 TPN :1L (150g dex, 70g aa) w/ non-std lytes\n to provide 800kcals/day\n 3. Adv to goal as BG allow to 1.8L(300gdex, 90g aa, 40g lipid) to\n provide 1797kcals/day\n 4. Check trig w/ am labs, hold lipid if >400\n 5. c/w lyte mngt as you are.\n 6. Multivitamin / Mineral supplement: via TPN\n Following closely, will change TPN Rx prn based on LFTs/progress\n Please pge w/ questions #\n 11:47\n ------ Protected Section ------\n Consider Phosbinders for high Phos.\n ------ Protected Section Addendum Entered By: , MS, RD,\n , CNSD on: 12:16 ------\n 12:16\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365866,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - continued on bowel rest\n - had several small BMs during day\n - replaced K+ per renal recs\n - pain tolerated without narcotics\n - called out but did not receive a bed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:00 PM\n Metronidazole - 12:30 AM\n Piperacillin/Tazobactam (Zosyn) - 05:40 AM\n Vancomycin - 05:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:03 PM\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98.1\n HR: 81 (66 - 88) bpm\n BP: 124/50(67) {100/40(54) - 149/95(100)} mmHg\n RR: 8 (8 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 3 (3 - 7)mmHg\n Total In:\n 844 mL\n 503 mL\n PO:\n TF:\n IVF:\n 550 mL\n 218 mL\n Blood products:\n Total out:\n -5,200 mL\n 100 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 6,044 mL\n 403 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 219 K/uL\n 7.5 g/dL\n 91 mg/dL\n 8.1 mg/dL\n 23 mEq/L\n 3.0 mEq/L\n 50 mg/dL\n 101 mEq/L\n 137 mEq/L\n 23.0 %\n 9.5 K/uL\n [image002.jpg]\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n 04:22 PM\n 03:23 AM\n 05:00 AM\n 05:53 AM\n WBC\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n 14.3\n 9.8\n 9.5\n Hct\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n 23.7\n 25.5\n 23.5\n 23.0\n Plt\n 285\n 259\n 285\n 243\n 230\n 237\n 231\n 219\n Cr\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n 8.0\n 8.1\n Glucose\n 140\n 126\n 130\n 101\n 181\n 124\n 112\n 91\n Other labs: PT / PTT / INR:17.2/45.4/1.6, ALT / AST:1127/544, Alk Phos\n / T Bili:125/0.3, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.1 g/dL, LDH:750 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n HYPOTHERMIA\n HYPOTENSION (NOT SHOCK)\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n TPN without Lipids - 05:00 PM 42 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365867,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - continued on bowel rest\n - had several small BMs during day\n - replaced K+ per renal recs\n - pain tolerated without narcotics\n - called out but did not receive a bed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:00 PM\n Metronidazole - 12:30 AM\n Piperacillin/Tazobactam (Zosyn) - 05:40 AM\n Vancomycin - 05:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:03 PM\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98.1\n HR: 81 (66 - 88) bpm\n BP: 124/50(67) {100/40(54) - 149/95(100)} mmHg\n RR: 8 (8 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 3 (3 - 7)mmHg\n Total In:\n 844 mL\n 503 mL\n PO:\n TF:\n IVF:\n 550 mL\n 218 mL\n Blood products:\n Total out:\n -5,200 mL\n 100 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 6,044 mL\n 403 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 219 K/uL\n 7.5 g/dL\n 91 mg/dL\n 8.1 mg/dL\n 23 mEq/L\n 3.0 mEq/L\n 50 mg/dL\n 101 mEq/L\n 137 mEq/L\n 23.0 %\n 9.5 K/uL\n [image002.jpg]\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n 04:22 PM\n 03:23 AM\n 05:00 AM\n 05:53 AM\n WBC\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n 14.3\n 9.8\n 9.5\n Hct\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n 23.7\n 25.5\n 23.5\n 23.0\n Plt\n 285\n 259\n 285\n 243\n 230\n 237\n 231\n 219\n Cr\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n 8.0\n 8.1\n Glucose\n 140\n 126\n 130\n 101\n 181\n 124\n 112\n 91\n Other labs: PT / PTT / INR:17.2/45.4/1.6, ALT / AST:1127/544, Alk Phos\n / T Bili:125/0.3, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.1 g/dL, LDH:750 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Now with\n ileus/SBO.\n .\n # presumptive Cdiff\n Presenation was 2-3 days of dark loose stools and\n poor po intake after completing a course of Abx for PNA. Per family, no\n fevers at home but pt reports subjective chills. WBC ct of 20 and CT\n with colitis. Concern for C Diff colitis vs ischemic colitis,\n complicated by sepsis\n requiring pressor support. SBP also possible,\n had high WBC count but no organisms grew. Pt was seen by gen and\n vasc surgery in ED, no plan for OR. Pt expressed goals of care to\n avoid heroic measures, confirmed by HCP. on contact\n precautions. C.diff has been complicated by what appears to be ileus,\n although SBO is still a possibility.\n - Zozyn for possible diverticulitis, will complete a 10 day course, no\n day \n - Flagyl and po Vanc and IV vanco for possible CDiff colitis\n - c.diff toxin negative, but still is likely the cause\n - pt with likely ileus, but had bowel movement yesterday\n gen \n reconsulted and following again. Will keep NGT on intermittent wall\n suction, remains NPO for bowel rest, continue bowel regimen and\n consider PO narcan as needed\n - holding narcotics, seems comfortable\n # peritonitis\n spoke to renal today, should give vanc for the full two\n week course, and will check peritoneal fluid again, they will continue\n PD through this infection.\n - vanc dosing should be 750 mg when daily vanco level is below 15\n # Shock liver\n LFTs peaked now trending down, patient continues to\n have coagulopathy, both improving\n .\n # altered Mental status\n waxing and , maybe baseline, maybe\n uremia v. narcotic usage\n - giving slight ativan since anxiety playing element in pain\n - stopping dilaudid for now, patient remains comfortable\n .\n # Hypotension: Resolved, patient is severe vasculopath and pressures\n are difficult to determine. Patient was initially started on levo and\n then moved to three pressors. He has bilateral subclavian stenosis with\n difficult time to determine blood pressure, weaned to mental status as\n well as blood pressures from legs. CT ruled out ruptured AAA and stool\n guaic was negative. Differential includes sepsis, hypovolemic, GI\n bleed, ischemic colitis, less likely to be MI or adrenal\n insufficiency. Most likely is sepsis in setting of colitis and\n peritonitis. Pressors off \n - hemodynamics stable\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission, continue to follow\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: renal following, plan for PD, peritonitis, see above\n - PD cath Cx\n no organisms seen on gram stain\n - f/u renal recs, did stop renagel due to its constipating effects\n - continue Calcitriol\n - will reculture fluid\n - added epo per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross; continue to guiac stools\n - CVL and PIV for access\n - PPI & trend hct, keep > 21\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: on bowel rest, today will do PPN and tomorrow plan for TPN as\n LFTs start to improve\n .\n # Prophylaxis: Heparin sc tid, PPI IV\n .\n # Access: PIV, RIJ; PICC attempted at bedside and could not be done,\n plan for IR guided PICC and removal of RIJ\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now, call out to floor today.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:00 PM 42 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 365868,
"text": "Chief Complaint:\n 24 Hour Events:\n Events:\n - continued on bowel rest\n - had several small BMs during day\n - replaced K+ per renal recs\n - pain tolerated without narcotics\n - called out but did not receive a bed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:00 PM\n Metronidazole - 12:30 AM\n Piperacillin/Tazobactam (Zosyn) - 05:40 AM\n Vancomycin - 05:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:03 PM\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.7\nC (98.1\n HR: 81 (66 - 88) bpm\n BP: 124/50(67) {100/40(54) - 149/95(100)} mmHg\n RR: 8 (8 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n CVP: 3 (3 - 7)mmHg\n Total In:\n 844 mL\n 503 mL\n PO:\n TF:\n IVF:\n 550 mL\n 218 mL\n Blood products:\n Total out:\n -5,200 mL\n 100 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 6,044 mL\n 403 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ////\n Physical Examination\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 219 K/uL\n 7.5 g/dL\n 91 mg/dL\n 8.1 mg/dL\n 23 mEq/L\n 3.0 mEq/L\n 50 mg/dL\n 101 mEq/L\n 137 mEq/L\n 23.0 %\n 9.5 K/uL\n [image002.jpg]\n 04:19 AM\n 04:18 PM\n 03:23 AM\n 02:45 PM\n 09:25 PM\n 03:48 AM\n 04:22 PM\n 03:23 AM\n 05:00 AM\n 05:53 AM\n WBC\n 26.3\n 22.2\n 22.6\n 17.5\n 15.4\n 14.3\n 9.8\n 9.5\n Hct\n 25.4\n 25.8\n 24.7\n 24.0\n 22.8\n 23.7\n 25.5\n 23.5\n 23.0\n Plt\n 285\n 259\n 285\n 243\n 230\n 237\n 231\n 219\n Cr\n 7.5\n 8.4\n 8.9\n 9.4\n 8.8\n 8.5\n 8.0\n 8.1\n Glucose\n 140\n 126\n 130\n 101\n 181\n 124\n 112\n 91\n Other labs: PT / PTT / INR:17.2/45.4/1.6, ALT / AST:1127/544, Alk Phos\n / T Bili:125/0.3, Amylase / Lipase:197/160, Fibrinogen:611 mg/dL,\n Lactic Acid:2.2 mmol/L, Albumin:2.1 g/dL, LDH:750 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT. Now with\n ileus/SBO.\n .\n # presumptive Cdiff\n Presenation was 2-3 days of dark loose stools and\n poor po intake after completing a course of Abx for PNA. Per family, no\n fevers at home but pt reports subjective chills. WBC ct of 20 and CT\n with colitis. Concern for C Diff colitis vs ischemic colitis,\n complicated by sepsis\n requiring pressor support. SBP also possible,\n had high WBC count but no organisms grew. Pt was seen by gen and\n vasc surgery in ED, no plan for OR. Pt expressed goals of care to\n avoid heroic measures, confirmed by HCP. on contact\n precautions. C.diff has been complicated by what appears to be ileus,\n although SBO is still a possibility.\n - Zozyn for possible diverticulitis, will complete a 10 day course, no\n day \n - Flagyl and po Vanc and IV vanco for possible CDiff colitis\n - c.diff toxin negative, but still is likely the cause\n - pt with likely ileus, but had bowel movement yesterday\n gen \n reconsulted and following again. Will keep NGT on intermittent wall\n suction, remains NPO for bowel rest, continue bowel regimen and\n consider PO narcan as needed\n - holding narcotics, seems comfortable\n # peritonitis\n spoke to renal today, should give vanc for the full two\n week course, and will check peritoneal fluid again, they will continue\n PD through this infection.\n - vanc dosing should be 750 mg when daily vanco level is below 15\n # Shock liver\n LFTs peaked now trending down, patient continues to\n have coagulopathy, both improving\n .\n # altered Mental status\n waxing and , maybe baseline, maybe\n uremia v. narcotic usage\n - giving slight ativan since anxiety playing element in pain\n - stopping dilaudid for now, patient remains comfortable\n .\n # Hypotension: Resolved, patient is severe vasculopath and pressures\n are difficult to determine. Patient was initially started on levo and\n then moved to three pressors. He has bilateral subclavian stenosis with\n difficult time to determine blood pressure, weaned to mental status as\n well as blood pressures from legs. CT ruled out ruptured AAA and stool\n guaic was negative. Differential includes sepsis, hypovolemic, GI\n bleed, ischemic colitis, less likely to be MI or adrenal\n insufficiency. Most likely is sepsis in setting of colitis and\n peritonitis. Pressors off \n - hemodynamics stable\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission, continue to follow\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: renal following, plan for PD, peritonitis, see above\n - PD cath Cx\n no organisms seen on gram stain\n - f/u renal recs, did stop renagel due to its constipating effects\n - continue Calcitriol\n - will reculture fluid\n - added epo per renal recs\n .\n # Ureteral stent\n urology consulted for hyperdense finding in CT scan,\n thought to possibly be blood. Urology reviewed scan and did not think\n any intervention at this time was needed, especially in setting of this\n infection.\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross; continue to guiac stools\n - CVL and PIV for access\n - PPI & trend hct, keep > 21\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: on bowel rest, today will do PPN and tomorrow plan for TPN as\n LFTs start to improve\n .\n # Prophylaxis: Heparin sc tid, PPI IV\n .\n # Access: PIV, RIJ; PICC attempted at bedside and could not be done,\n plan for IR guided PICC and removal of RIJ\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now, call out to floor today.\n ICU Care\n Nutrition:\n TPN without Lipids - 05:00 PM 42 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 11:05 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-04 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 364908,
"text": "Chief Complaint: abd pain, hypotension\n HPI:\n 78M with PMHx of CAD s/p CABG, Metastatic carcinoid, ESRD on PD,\n Chronic abd/back pain and AAA who presents with worsening abdominal\n pain over the last 3 days as well as nausea, vomiting and tarry\n diarrhea. Pt initially presented to with hypotension and\n mild hct drop. Pt underwent a CT Abd/Pelvis scan which revealed stable\n AAA and he was transferred to for further care. Of note, pt was\n discharged on after admission for NSTEMI & PNA. During that\n admission, pt was taken to cath and given comorbidities only the\n SVG-OM2 was angioplastied. He was treated with a 10day course of\n Ceftriaxone/Levo for PNA and discharged to home.\n .\n In the ED, initial vs were: T 98.8 P 85 BP 91/37 RR 21 Sats 100% on 2L.\n CT abd was reviewed by radiology and revealed colitis adjacent to the\n hepatic flexure and worsening metastatic disease. Surgery and Vascular\n were consulted and felt there were no surgical issues. Pt had a RIJ\n placed and was given approx 4L of NS IVF, Vanc, Zosyn, Zofran and\n Morphine for abd pain. He was on Levophed 0.8mcg on transfer from the\n ED.\n .\n On arrival to the ICU, pt was complaining of diffuse abd and back\n pain. He denies CP/SOB but reports intermittent nausea, poor po intake\n and dark brown diarrhea for the last 2-3days.\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 11:40 PM\n Vancomycin - 12:30 AM\n Infusions:\n Norepinephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:11 AM\n Heparin Sodium (Prophylaxis) - 12:12 AM\n Other medications:\n recent discharge meds\n Aspirin 325 mg daily\n Clopidogrel 75 mg daily\n Metoprolol Tartrate 50 mg \n Simvastatin 40mg daily\n Lisinopril 5mg\n Imdur 30mg\n Terazosin 5mg\n Finasteride 5mg\n Amlodipine 10mg\n Protonix 40mg\n Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H\n Multivitamin daily\n Colace 100mg \n Past medical history:\n Family history:\n Social History:\n - Carcinoid tumor with mets to liver\n - Hypertension & Hyperlipidemia\n - CAD s/p CABG x 4 in , Cath -> severe native three vessel\n disease with 90% lesion in SVG-OM2 s/p PTCA\n - ESRD, on PD since , s/p HD tunneled cath placement\n - CAD s/p bilateral carotid endarterectomies\n in , c/b post-op seizure\n - Bilateral RAS & left common iliac artery aneurysm, s/p bilateral\n endarterectomies and aortobifemoral bypass graft with renal artery\n reimplantation to aortic graft in , left renal artery stenting in\n , s/p right ureteral stenting in c/b right mid-ureteral\n stricture with multiple stent exchanges in 07 & 08\n - AAA measuring 5 cm on CT\n - Sigmoid diverticulitis\n - Pancreatitis w/ ileus post AAA\n - BPH\n - H/o ruptured disk\n - S/p vasectomy, eye surgey, tonsillectomy\n NC\n Pt is married, lives with his wife. Social history is\n significant for current tobacco use. Pt quit smoking in but\n resumed smoking last summer, about 6 cigarettes daily. Previously, he\n smoked one-and-a-half pack per day for 35 years. There is no history of\n alcohol abuse.\n Flowsheet Data as of 01:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.7\nC (96.2\n HR: 92 (92 - 95) bpm\n BP: 99/44(56) {68/37(44) - 123/59(72)} mmHg\n RR: 12 (11 - 18) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 13 (9 - 13)mmHg\n Total In:\n 3,135 mL\n 1,070 mL\n PO:\n TF:\n IVF:\n 1,135 mL\n 1,070 mL\n Blood products:\n Total out:\n 45 mL\n 0 mL\n Urine:\n 45 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,090 mL\n 1,070 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n Vitals: T: 98.2 BP: 123/59 repeat 88/42 P: 95 R: 18 O2: Sats 94% 2L\n General: Mildly lethargic but responsive, oriented to place\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: supple, no LAD\n Lungs: Scant crackles bilaterally at bases, otherwise clear\n CV: RRR, soft SEM gr over RUSB, no gallop\n Abdomen: soft, diffusely tender to place, non-distended, bowel sounds\n present, no guarding, PD cath site non-tender\n Ext: Warm, palpable DP pulses, no edema\n Labs / Radiology\n 241 K/uL\n 7.2 g/dL\n 114 mg/dL\n 7.8 mg/dL\n 30 mg/dL\n 23 mEq/L\n 104 mEq/L\n 3.9 mEq/L\n 140 mEq/L\n 23.1 %\n 20.4 K/uL\n [image002.jpg]\n \n 2:33 A2/11/ 11:00 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 20.4\n Hct\n 23.1\n Plt\n 241\n Cr\n 7.8\n Glucose\n 114\n Other labs: PT / PTT / INR:15.3/30.1/1.3, Lactic Acid:1.4 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:6.2 mg/dL\n Fluid analysis / Other labs: Trop-T: 2.91 (trending down from peak of\n 31)\n .\n 139 97 31 108 AGap=17\n 3.9 29 8.2\n .\n CK: 69 MB: Notdone\n .\n ALT: 9 AP: 64 Tbili: 0.2 Alb:\n AST: 17 Lip: 38\n .\n WBC 20.3 HCT 27.2 PLT 251\n .\n PT: 14.5 PTT: 28.3 INR: 1.3\n Imaging: Images: CT Abd/Pelvis prelim\n -unchanged 4.5 cm AAA\n -new thickening and inflammatory stranding around hepatic flexure of\n colon, could be diverticular, infectious or inflammatory, but spread of\n metastatic disease should also be considered.\n -progression of hepatic mets\n -R ureteral stent remains in place, but is surrounded by dense material\n concerning for hemorrhage within the right renal collecting system.\n -free air is presumably related to peritoneal dialysis catheter.\n .\n CXR : Single AP upright portable chest radiograph is obtained.\n Midline sternotomy wires and mediastinal clips are again noted. There\n is interval placement of a right IJ central venous catheter with its\n tip in the approximate location of the superior vena cava. There is\n persistent cardiomegaly with pulmonary vascular congestion which is\n stable. Left pleural effusion is unchanged. Cardiomediastinal contour\n is stable with cardiomegaly again noted.\n .\n Echo : The left atrium is elongated. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. There is mild to\n moderate regional left ventricular systolic dysfunction with\n hypokinesis of the inferolateral and basal inferior walls. The\n remaining segments contract normally (LVEF = 45-50 %). Right\n ventricular chamber size and free wall motion are normal. The\n descending thoracic aorta is mildly dilated. The aortic valve leaflets\n (3) are mildly thickened with good leaflet excursion and no aortic\n regurgitation. The mitral valve leaflets are mildly thickened. At least\n mild (1+) mitral regurgitation is seen. There is moderate pulmonary\n artery systolic hypertension. There is a trivial/physiologic\n pericardial effusion.\n Microbiology: Urine/blood Cx pending\n EKG: NSR with IVCD, LVH and inverted TW in V4-V6, essentially unchanged\n from prior tracings.\n Assessment and Plan\n 78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and\n chronic abd/back pain who presents with decreased po intake, diarrhea,\n lethargy and hypotension found to have colitis on CT.\n .\n # Hypotension: Pt with lethargy, hypotension that has transiently\n responded to IV boluses but continues to require low dose levophed. Pt\n is a vasculopath with complex arterial anatomy, recently discharged\n after NSTEMI. CT ruled out ruptured AAA and stool guaic was\n negative. Differential includes sepsis, hypovolemic, GI bleed,\n ischemic colitis, less likely to be MI or adrenal insufficiency.\n - bolus IVF prn to goal CVP>12\n - levophed prn for MAPs>65\n - Vanc/Zosyn for possible diverticulitis/colitis\n - start empiric Flagyl and po Vanc for possible CDiff colitis\n - f/u blood/urine/stool cx\n .\n # Abd pain/diarrhea: Pt is a known vasculopath who p/w 2-3 days of dark\n loose stools and poor po intake after completing a course of Abx for\n PNA. Per family, no fevers at home but pt reports subjective chills.\n WBC ct of 20 and CT with colitis. Concern for C Diff colitis vs\n ischemic colitis, though may be less likely given normal lactate. SBP\n also possible, will send fluid from peritoneal cath. Pt was seen by\n gen and vasc surgery in ED, no plan for OR. Pt expressed goals of\n care to avoid heroic measures, confirmed by HCP.\n - bolus IVF\n - type & cross\n - stool guaic & send for C diff\n - start empiric Flagyl & Po Vanc\n - Morphine prn pain\n - continue Vanc/Zosyn for possible diverticulitis\n .\n # CAD s/p CABG/NSTEMI: pt is currently denying CP, EKGs at baseline.\n CK/MB flat and troponin continues to trend down from max of 30 during\n prior admission\n - continue Aspirin 325mg & Plavix 75mg daily\n - hold BB given hypotension\n .\n # ESRD on PD: Lytes stable but given concern for sbp, would prefer to\n avoid using PD catheter. Plan to touch base with Renal in am.\n - send fluid from PD cath for Cx\n - t/b renal in am\n - continue Calcitriol\n .\n # Anemia: Baseline hct in low 30s, down to 23 with IVF. Now concern\n for lower GI bleed given colitis and dark stool, though guaic negative\n on exam.\n - type & cross\n - CVL and PIV\n - PPI & trend hct\n .\n # Metastatic Carcinoid: Pt with known liver mets followed by hem/onc\n with apparent worsening disease on CT\n - f/u hem/onc as outpt\n .\n # FEN: NPO for now with IVF boluses\n - replete electrolytes aggressively\n .\n # Prophylaxis: Heparin sc tid, PPI\n .\n # Access: RIJ, PIV\n .\n # Code: DNR/DNI, but pressors/CVL okay\n .\n # Communication: Patient & wife \n .\n # Disposition: ICU for now\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: none for now\n Lines:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-04 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 364904,
"text": "Chief Complaint: hypotension, colitis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 78M recently discharged after stenting for NSTEMI, also pneumonia. At\n home diarrhea, abdominal and back pain. Abdominal CT shows new liver\n mets and colitis. Right IJ placed and started on levophed and\n antibiotics.\n Now complaining of abdominal pain and loose stools.\n Patient admitted from: ER\n History obtained from Patient, HO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n CABG\n PVD\n metastatic carcinoid\n AAA\n ESRD on PD\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fatigue\n Gastrointestinal: Abdominal pain, Diarrhea\n Flowsheet Data as of 01:15 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 35.7\nC (96.2\n HR: 94 (93 - 95) bpm\n BP: 90/43(59) {68/37(44) - 123/59(72)} mmHg\n RR: 12 (11 - 18) insp/min\n SpO2: 95%\n CVP: 9 (9 - 9)mmHg\n Total In:\n 3,035 mL\n 1,038 mL\n PO:\n TF:\n IVF:\n 1,035 mL\n 1,038 mL\n Blood products:\n Total out:\n 45 mL\n 0 mL\n Urine:\n 45 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,990 mL\n 1,038 mL\n Respiratory\n SpO2: 95%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bases)\n Abdominal: Soft, No(t) Distended, Tender: , PD cath\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 241 K/uL\n 23.1 %\n 7.2 g/dL\n 114 mg/dL\n 7.8 mg/dL\n 30 mg/dL\n 23 mEq/L\n 104 mEq/L\n 3.9 mEq/L\n 140 mEq/L\n 20.4 K/uL\n [image002.jpg]\n 11:00 PM\n WBC\n 20.4\n Hct\n 23.1\n Plt\n 241\n Cr\n 7.8\n Glucose\n 114\n Other labs: PT / PTT / INR:15.3/30.1/1.3, Lactic Acid:1.4 mmol/L,\n Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:6.2 mg/dL\n Imaging: Abd CT inflammation hepatic flexure of colon, new liver mets,\n ureteral stent\n CXR pulm vascular congestion\n ECG: IVCD, LVH, unchanged\n Assessment and Plan\n Abdominal pain, colitis - ? CDiff versus diverticulitis versus\n ischemic, continue antibiotics, IVF, surgery has seen him\n hypotension - has received 5L IVF, on levophed - wean as tol\n Recent MI - continue outpatient regimen\n metastatic carcinoid - progressing though no active issues\n ESRD - will discuss whether she can continue to use PD with renal\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 11:05 PM\n 20 Gauge - 11:06 PM\n Multi Lumen - 11:07 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n Total time spent: 36 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2145-03-04 00:00:00.000",
"description": "Attending Note",
"row_id": 365080,
"text": "TITLE: Attending note\n Please see Dr and Dr \ns notes from today for details.\n Briefly,\n 78 yo man with severe vasculopathy, COPD, recent MI, metastatic\n carcinoid presented with abdominal pain, vomiting and diarrhea at home.\n Chronic PD and possible colonic perforation possible sources of\n peritonitis.\n Exam sig for pt awake, interactive, appropriate. No resp distress. Very\n uncomfortable with chronic right flank pain and nausea/vomiting. Mucosa\n moist. Crackles at bases and clear at apices with moderate air\n movement. Distant heart sounds. Abdomen hypoactive bowel sounds, soft,\n ND. Diffusely tender. No tenderness to percussion but clearly\n uncomfortable with palpation. No rebound/guarding. No edema. No rashes.\n Recent chest CT shows severe emphysema.\n Abd CT from : Right colon wall thickening.\n Inflamm/civertic/extension of tumor which is contiguous. Increase in\n hepatic mets, moderate right hydronephrosis which was present on CT\n . Right renal collecting system with new hemorrhage. Lung windows\n show tiny right pleural effusion, mild bibasilar atelectasis.\n CXR shows PVC and atypical pattern of pulmonary edema with underlying\n emphysema.\n septic shock: 3 pressors. Colitis. Peritoneal fluid c/w\n acute infection. Other ddx: CDiff, diverticulitis vs ischemic, on\n vanc/zosyn/flagyl/PO vanc. Large volume resuscitation. Now on levophed,\n vasopressin, neosynephrine. Surgery felt no intervention necessary.\n Ischemia less likely considering lactate 1.4, stool guaiac neg, but he\n is at risk.\n o avoid further volume if possible considering depressed\n systolic and diastolic cardiac function and crackles on exam\n Pain: Can be attributable to blood in right\n kidney/collecting system around ureteral stent. Chronic component as\n well. Percocet if taking POs.\n Nausea: try zofran.\n ESRD - will discuss whether she can continue to use PD with\n renal- at the moment hypotensive on 3 pressors and no urgent\n indication.\n 40 minutes critical care time.\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-12 00:00:00.000",
"description": "BILAT UP EXT VEINS US",
"row_id": 1063780,
"text": " 9:22 AM\n BILAT UP EXT VEINS US Clip # \n Reason: pt with swelling in his ext R>L, please eval for clot (pt ha\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with CAD s/p CABG, ESRD on PD and metastatic carcinoid presents\n with upper ext R>L\n REASON FOR THIS EXAMINATION:\n pt with swelling in his ext R>L, please eval for clot (pt had RIJ and currently\n with R PICC)\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc FRI 11:41 AM\n Occlusive thrombus at right internal jugular vein and non-occlusive thrombus\n in left subclavian vein. Also seen is occlusive non-compressible thrombus at\n the left basilic vein.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right greater than left upper extremity swelling in a patient with\n previous right internal jugular catheter and current right PIC catheter.\n\n COMPARISON: Comparison is made to ultrasound study done on .\n\n FINDINGS:\n On the right, the subclavian, axillary, brachial, basilic and cephalic veins\n are patent with normal flow on Doppler analysis and compressibility where\n appropriate. The right internal jugular vein is notable for echogenic\n endoluminal material, no flow on Doppler analysis and failure to compress, all\n indicating occlusive thrombus. Note is made of a right PICC coursing from the\n basilic vein through the axillary and subclavian veins.\n\n On the left, the internal jugular, axillary, brachial and cephalic veins are\n all patent with normal color Doppler flow and normal response to compression.\n The left subclavian vein is notable for eccentric isoechoic material with lack\n of wall-to-wall flow, overall suggestive of non-occlusive thrombus.\n Additionally, on the left, basilic vein shows no flow on color Doppler\n analysis and is non- compressible.\n\n IMPRESSION:\n 1) Occlusive thrombus in the right internal jugular vein and non-occlusive\n thrombus at the left subclavian vein.\n 2) Occlusive thrombus in the left basilic vein.\n\n These findings were discussed with Dr. from the medicine service at\n ~11AM on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-12 00:00:00.000",
"description": "BILAT UP EXT VEINS US",
"row_id": 1063781,
"text": ", P. MED CC7A 9:22 AM\n BILAT UP EXT VEINS US Clip # \n Reason: pt with swelling in his ext R>L, please eval for clot (pt ha\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with CAD s/p CABG, ESRD on PD and metastatic carcinoid presents\n with upper ext R>L\n REASON FOR THIS EXAMINATION:\n pt with swelling in his ext R>L, please eval for clot (pt had RIJ and currently\n with R PICC)\n ______________________________________________________________________________\n PFI REPORT\n Occlusive thrombus at right internal jugular vein and non-occlusive thrombus\n in left subclavian vein. Also seen is occlusive non-compressible thrombus at\n the left basilic vein.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1062818,
"text": " 5:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?assess location of NGT\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p NGT placement\n REASON FOR THIS EXAMINATION:\n ?assess location of NGT\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: NG tube placement.\n\n FINDINGS: The NG tube is in the stomach. Right upper abdomen catheter seen\n with dilated loops of bowel in the abdomen measuring up to 4.3 cm and presumed\n small bowel. Both hemidiaphragms are obscured likely secondary to effusion,\n although small infiltrates cannot be excluded. Right IJ line is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1063004,
"text": " 12:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: NG tube placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with NG tube placement\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW, ON \n\n HISTORY: NG tube placement.\n\n FINDINGS: The NG tube tip is in the proximal stomach. There continue to be\n dilated small bowel loops measuring up to 4.6 cm consistent with patient's\n known small-bowel obstruction. Right IJ line is unchanged with tip in the\n SVC/RA. There is some increased opacity at the right base and right mid lung\n consistent with infiltrate that is slightly improved compared to the prior\n exam.\n\n"
},
{
"category": "ECG",
"chartdate": "2145-03-20 00:00:00.000",
"description": "Report",
"row_id": 144555,
"text": "Sinus rhythm. T wave inversion in leads V2-V6. Compared to the previous\ntracing of the rate has slowed. The ST segment depression is less\nprominent in leads I, aVL and V4-V6. The T waves are now inverted in these\nleads. Rule out active ischemic process. Followup and clinical correlation\nare suggested. Sinus rhythm has appeared.\n\n"
},
{
"category": "ECG",
"chartdate": "2145-03-04 00:00:00.000",
"description": "Report",
"row_id": 144556,
"text": "Atrial fibrillation with a mean ventricular rate, 131. Non-specific\nQRS complex widening. Diffuse non-diagnostic repolarization abnormalities.\nCompared to the previous tracing of cardiac rhythm is now atrial\nfibrillation.\n\n"
},
{
"category": "ECG",
"chartdate": "2145-03-03 00:00:00.000",
"description": "Report",
"row_id": 144557,
"text": "Sinus rhythm. Non-specific intraventricular conduction delay. Downsloping\nST segments with T wave inversions in leads V4-V6. Cannot exclude ischemia.\nCompared to tracing #1 no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2145-03-03 00:00:00.000",
"description": "Report",
"row_id": 144558,
"text": "Sinus rhythm. Non-specific intraventricular conduction delay. Downsloping\nST segments with T wave inversions in leads V4-V6. Cannot exclude ischemia.\nCompared to the previous tracing of ST segment depression is slightly\nless pronounced.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-15 00:00:00.000",
"description": "CT L-SPINE W/O CONTRAST",
"row_id": 1064375,
"text": " 5:38 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: please eval for mets, stenosis, disc or other pathology. Pt\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with CAD, ESRD on PD and met carcinoid with chronic back pain\n and weakness\n REASON FOR THIS EXAMINATION:\n please eval for mets, stenosis, disc or other pathology. Pt refusing MRI\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD on PD\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf MON 7:48 PM\n PFI:\n\n 1. Multilevel degenerative changes, most pronounced at L4-5 level, with\n bilateral neural foraminal narrowing and spinal canal stenosis.\n\n 2. Several foci of faintly increased sclerosis in the vertebral bodies were\n present on the most recent prior study; however, new since , and therefore\n raise concern for metastatic involvement.\n\n 3. Stable appearance of a large suprarenal abdominal aortic aneurysm.\n\n 4. Redemonstration of right hydronephrosis and double-J stent.\n ______________________________________________________________________________\n FINAL REPORT\n CT LUMBAR SPINE WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: 78-year-old man with metastatic carcinoid and chronic back pain\n and weakness. Evaluate for metastatic disease, stenosis or other pathology.\n\n COMPARISON: CT abdomen and pelvis dated .\n\n TECHNIQUE: MDCT axial images of the lumbar spine were obtained without\n administration of intravenous contrast. Coronal and sagittal reformatted\n images were obtained.\n\n FINDINGS: Vertebral body heights are maintained. Intervertebral disc spaces\n are relatively preserved. A small sclerotic focus in the T12 vertebral body\n is unchanged compared to the prior study; however, was not present in \n , and could potentially represent a focus of metastatic disease.\n\n At T12-L1 through L2-L3 level, there is no significant central canal stenosis\n or neural foraminal narrowing. Mild disc bulges are noted.\n\n At L3-4 level, there is mild central canal stenosis secondary to facet joint\n hypertrophy and ligamentum flavum hypertrophy and disc bulge; mild right sided\n neural foraminal narrowing.\n\n At L4-5 level, there is most pronounced moderate narrowing of the central\n canal, due to disc protrusion, ligamentum flavum hypertrophy and bilateral\n (Over)\n\n 5:38 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: please eval for mets, stenosis, disc or other pathology. Pt\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n facet joint hypertrophy, which also causes mild bilateral neural foraminal\n narrowing at this level.\n\n At L5-S1 level, there is bilateral facet joint hypertrophy, and uncovertebral\n joint hypertrophy, leading to moderate left neural foraminal narrowing and\n mild canal stenosis. End plate changes and sclerosis are noted.\n\n Additionally, within L5 vertebral body and L3 vertebral body, there are faint\n foci of increased sclerosis.\n\n As noted on the previous CT of the abdomen, there is a large incompletely\n imaged abdominal aortic aneurysm, with calcified wall, as well as partially\n thrombosed lumen. Renal artery stent is noted on the left.\n\n No hydronephrosis is noted in the left kidney. The right kidney continues to\n demonstrate hydronephrosis. Double-J stent is in place on the right. Again\n noted is an abdominal ascites. Peritoneal dialysis catheter ends in the\n pelvis.\n\n IMPRESSION:\n\n 1. Multilevel degenerative changes, with neural foraminal narrowing and\n spinal stenosis, most pronounced at L4-5 level. MR is more ideal for\n assessemnt of intrathecal structures, unless there is a contra-indication.\n\n 2. Faint foci of sclerosis in several vertebral bodies, unchanged from the\n most recent prior study; however, not present in and while these can\n represent bone islands, given the history, also concerning for metastatic\n foci. Correlation with radionuclide studies can be considered.\n\n 3. Large suprarenal abdominal aortic aneurysm, given limitation in lack of IV\n contrast, incompletely assessed.\n\n 4. Right hydronephrosis, double-J stent in place.\n\n 5. Upper abdominal ascites.\n\n Impressions- 3,4 &5- not compleely assessed.\n\n\n\n (Over)\n\n 5:38 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: please eval for mets, stenosis, disc or other pathology. Pt\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-15 00:00:00.000",
"description": "CT L-SPINE W/O CONTRAST",
"row_id": 1064376,
"text": ", L. MED CC7A 5:38 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: please eval for mets, stenosis, disc or other pathology. Pt\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with CAD, ESRD on PD and met carcinoid with chronic back pain\n and weakness\n REASON FOR THIS EXAMINATION:\n please eval for mets, stenosis, disc or other pathology. Pt refusing MRI\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD on PD\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. Multilevel degenerative changes, most pronounced at L4-5 level, with\n bilateral neural foraminal narrowing and spinal canal stenosis.\n\n 2. Several foci of faintly increased sclerosis in the vertebral bodies were\n present on the most recent prior study; however, new since , and therefore\n raise concern for metastatic involvement.\n\n 3. Stable appearance of a large suprarenal abdominal aortic aneurysm.\n\n 4. Redemonstration of right hydronephrosis and double-J stent.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-07 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1062890,
"text": " 8:02 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for SBO\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL ADDENDUM\n Correlation with radionuclide studies can be considered for confirmation of\n the nature of the sclerotic foci.\n\n\n 8:02 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for SBO\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL ADDENDUM\n Pl. note that the previously added addendum was done in error on this clip- it\n belongs to the CT T spine study done on .\n\n\n\n 8:02 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for SBO\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with new vomitting after tube feeds, known carcinamatosis and\n resolving c diff\n REASON FOR THIS EXAMINATION:\n eval for SBO\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN ON \n\n HISTORY: New vomiting after tube feeds, known carcinomatosis, and resolving\n C. diff, question small bowel obstruction.\n\n FINDINGS: Dilated loops of bowel are seen in the mid abdomen. The small\n bowel measuring up to 4.4 cm. However, gas is seen in the transverse colon.\n There is no upright or lateral decubitus film to assess for free air, but the\n overall impression is that of an ileus given the amount of air in the colon.\n The right ureteral stent is again visualized. A densely calcified aorta\n aneurysmally dilated up to 5.5 cm, similar to what was seen on the CT from\n . The dilated small bowel loops are new compared to the prior CT scan.\n\n IMPRESSION: Dilated loops of small bowel with residual air in the colon, this\n could be an ileus and less likely a new or incomplete SBO. Recommend\n followup.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-03 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1062237,
"text": " 4:37 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ?AA change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with known AAA, carcinioid with met to Liver, hypotension,\n anemia\n REASON FOR THIS EXAMINATION:\n ?AA change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd WED 5:03 PM\n unchanged 4.5 cm AAA\n\n new thickening and inflammatory stranding around hepatic flexure of colon,\n could be diverticular, infectious or inflammatory, but spread of metastatic\n disease should also be considered.\n\n progression of hepatic mets\n\n R ureteral stent remains in place, but is surrounded by dense material\n concerning for hemorrhage within the right renal collecting system.\n\n free air is presumably related to peritoneal dialysis catheter.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Known abdominal aortic aneurysm, and metastatic carcinoid. Now\n with hypotension and anemia. Please evaluate for change in AAA.\n\n COMPARISON: Multiple prior CT studies, most recently referenced images from\n . Comparison also made to the CT obtained at from .\n\n TECHNIQUE: Axial CT images from Hospital obtained at \n at 13:18 hours were submitted for interpretation at following patient\n transfer. A formal report of the study is not provided. If there is clinical\n concern for change in known abdominal aortic aneurysm, metastatic carcinoid\n disease, and the patient is also anemic and hypotensive.\n\n FINDINGS: Evaluation is slightly limited, as multiplanar reformatted images\n are printout provided for interpretation.\n\n There is moderate dependent bibasilar atelectasis at the visualized lung\n bases.\n\n Pneumoperitoneum is not significantly changed from multiple prior studies,\n presumably related to peritoneal dialysis catheter, which is unchanged in\n position in the lower pelvis.\n\n Multiple heterogeneously enhancing metastatic foci in the liver have increased\n in size. The largest is situated in the posterior right lobe of the liver,\n near the free edge, now measuring nearly 5.0 cm in size (2, 50). There is no\n biliary ductal dilatation. There is no ascites. Multiple gallstones are\n unchanged, but the gallbladder is not distended, and there is no wall\n (Over)\n\n 4:37 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ?AA change\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n thickening or pericholecystic fluid. Pancreas, spleen, and adrenal glands are\n unremarkable.\n\n Extensive atherosclerotic calcification of the abdominal aorta is not\n significantly changed. Suprarenal fusiform aneurysm measuring up to 5.5 cm is\n not significantly changed since . The eccentric thrombus within this\n aneurysm is also stable.\n\n Atrophic and slightly hypoenhancing left kidney is unchanged. There is no\n left hydronephrosis. Double-J ureteral stent remains in place within the\n right kidney, but there persists moderate right hydronephrosis, and there is\n now dense material within the right renal collecting system, concerning for\n hemorrhage. A large amount of dense material is also seen within the bladder.\n\n There is a large amount of free intraperitoneal air as described above.\n\n There is new wall thickening and inflammatory stranding centered around a\n short segment of colon near the hepatic flexure. Intra-abdominal loops of\n large and small bowel are otherwise unremarkable.\n\n CT PELVIS: Aortobifemoral bypass graft is unchanged in position, and remains\n patent. Mild thickening in the wall of the sigmoid colon is stable, and may\n relate to muscular hypertrophy from prior episodes of diverticulitis. There\n is no surrounding inflammatory stranding. Multiple diverticuli are again\n noted. Distal end of the double-J stent terminates within the bladder.\n Prostatic calcifications are unchanged. Small amount of free pelvic fluid is\n presumably related to peritoneal dialysis. There is no abnormal pelvic or\n inguinal lymphadenopathy.\n\n There is no osseous lesion suspicious for malignancy. Degenerative changes in\n the lower lumbar spine are grossly unchanged.\n\n IMPRESSION:\n 1. New wall thickening and inflammatory change around a short segment of\n right colon near the hepatic flexure. While this could represent inflammation\n related to diverticular disease, or other infectious or inflammatory causes,\n this loop of colon is situated close to multiple metastatic foci within the\n liver, and metastatic disease, or direct extent of tumor should also be\n considered.\n\n 2. Increased size of multiple hepatic metastases.\n\n 3. Free intraperitoneal air, presumably related to peritoneal dialysis.\n\n 4. Moderate right hydronephrosis, with dense material now seen in the right\n renal collecting system and bladder. This appearance is concerning for\n hemorrhage, unless there has been recent radiographic procedure with injection\n (Over)\n\n 4:37 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ?AA change\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of contrast directly into the collecting system.\n\n 5. Cholelithiasis, without evidence of cholecystitis.\n\n 6. Grossly unchanged appearance of 5.5 cm descending thoracic and suprarenal\n abdominal aortic aneurysm.\n\n 7. Stable soft tissue density anterior to the right ureter, with tiny central\n punctate calcification.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-09 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1063332,
"text": " 5:47 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: pls place picc\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with colitis, ESRD on PD now on several abx\n REASON FOR THIS EXAMINATION:\n pls place picc\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 78-year-old man with coronary artery disease, colitis,\n and peritonitis. Request is made for PICC line placement for long-term\n antibiotics.\n\n FELLOW: Dr. .\n\n STAFF RADIOLOGISTS: Dr. who supervised the procedure.\n\n ANESTHESIA: 1% lidocaine for local anesthesia.\n\n PROCEDURE AND FINDINGS: The patient was brought to the angiography suite and\n placed supine on the imaging table. The right upper arm was prepped and\n draped in the usual sterile fashion. Access was obtained into the right\n basilic vein under ultrasound guidance with a micropuncture needle through\n which an 0.18 wire was passed and advanced into the SVC under flouroscopic\n guidance. Hard copy ultrasound images were obtained before and after access.\n The needle was replaced with a 5 French peel-away sheath. A new 38-cm double-\n lumen Vaxcel 5 French PICC line was advanced over the wire into the SVC. The\n wire was removed and the sheath was peeled away. Both ports were flushed with\n saline. A sterile dressing was applied. There were no immediate\n complications.\n\n IMPRESSION: 5 French double-lumen Vaxcel PICC line placed via right basilic\n vein with tip in the SVC. The catheter is ready to use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-09 00:00:00.000",
"description": "PICC LINE PLACMENT SCH",
"row_id": 1063331,
"text": " 5:46 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC for antibiotics\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n PRELIMINARY REPORT\n CLINICAL INFORMATION: 78-year-old man with coronary artery disease, colitis,\n and peritonitis. Request is made for PICC line placement for long-term\n antibiotics.\n\n FELLOW: Dr. .\n\n STAFF RADIOLOGISTS: Dr. who supervised the procedure.\n\n ANESTHESIA: 1% lidocaine for local anesthesia.\n\n PROCEDURE AND FINDINGS: The patient was brought to the angiography suite and\n placed supine on the imaging table. The right upper arm was prepped and\n draped in the usual sterile fashion. Access was obtained into the right\n basilic vein under ultrasound guidance with a micropuncture needle through\n which an 0.18 wire was passed and advanced into the SVC. Hard copy ultrasound\n images were obtained before and after access. The needle was replaced with a\n 5 French peel-away sheath. A new 38-cm double-lumen Vaxcel 5 French PICC line\n was advanced over the wire into the SVC. The wire was removed and the sheath\n was peeled away. Both ports were flushed with saline. A sterile dressing was\n applied. There were no immediate complications.\n\n IMPRESSION: 5 French double-lumen Vaxcel PICC line placed via right basilic\n vein with tip in the SVC. The catheter is ready to use.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2145-03-18 00:00:00.000",
"description": "OCTREOTIDE SCAN (SOMATOSTATIN)",
"row_id": 1064741,
"text": "OCTREOTIDE SCAN (SOMATOSTATIN) Clip # \n Reason: ESRD ON HD METASTAIC CARCINOID EVAL FOR SPREAD OF CARCINOID\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 6.0 mCi In-111 Octreotide ();\n HISTORY: 78-YEAR-OLD MAN WITH METASTATIC CARCINOID, END STAGE RENAL DISEASE ON\n HEMO DIALYSIS. EVALUATE FOR SPREAD OF CARCINOID.\n\n INTERPRETATION: Whole body images obtained at at 6 hours and 24 hours, and\n SPECT images of the abdomen and pelvis were obtained at 24 hours.\n\n Planar images show focal abnormal tracer uptake in the left inguinal region.\n\n SPECT/CT demonstrates increased octreotide avidity projecting over a sclerotic\n lesion in the right pubic bone. There is increased uptake in the musculature\n posterior to the left greater trochanter. Prominent octreotide avidity in the\n duodenum and jejunum precludes optimal evaluation of the retroperitoneum.\n\n Physiologic tracer uptake is present in the liver, spleen, gastrointestinal and\n genitourinary tracts.\n\n CT images show innumerable heterogeneous hepatic lesions in both lobes, some of\n which are subcapsular, without definite octreotide avidity. A large amount of\n ascites is present. Dense atherosclerotic vascular calcifications are present in\n the aorta and its branches. A large suprarenal abdominal aortic aneurysm is\n identified.\n A double-J stent remains in place. There is some edema in the subcutaneou\n tissues of both thighs.\n\n IMPRESSION: 1. Octreotide-avid disease in a right pubic bone sclerotic lesion\n and increased uptake in the musculature posterior to the left greater\n trochanter, compatible with carcinoid. 2. Innumerable heterogeneous hepatic\n lesions in both lobes, some of which are subcapsular, warrant follow-up.\n\n\n , M.D.\n , M.D. Approved: MON 4:05 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-16 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1064546,
"text": " 2:33 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for mass, fracture, mets or other pathology\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with CAD, ESRD on PD, metastatic carcinoid presents with lower\n ext weakness and pain\n REASON FOR THIS EXAMINATION:\n eval for mass, fracture, mets or other pathology\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD on PD\n ______________________________________________________________________________\n WET READ: NPw TUE 3:49 PM\n Multilevel DJD in the cervical spine with mild canal stenosis and moderate-\n severe neuroa foramianl narrowing at C5/6 and C6/7 levels.\n No definite sclerotic foci in the c spine; partially imaged T3 sclerotic focus\n better assessed on the concurrent CT T spine study.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old male patient, with CAD, end-stage renal disease,\n metastatic carcinoid presents with lower extremity weakness and pain, to\n evaluate for metastatic lesions.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast CT of the cervical spine was performed with sagittal\n and coronal reformations.\n\n FINDINGS:\n\n There is evidence of spondylosis at multiple levels in the cervical spine,\n with anterior and posterior osteophytes, disc osteophyte complexes, and\n uncovertebral osteophytes. There is also diffuse osteopenia, with a slightly\n heterogeneous appearance of the dens. There is grade 1 retrolisthesis of C3\n over C4.\n\n At C2-3, there is a small disc osteophyte complex, causing minimal indentation\n on the ventral thecal sac.\n\n At C3-4, there is a broad-based disc osteophyte complex, causing mild\n indentation on the ventral thecal sac. Bilateral uncovertebral osteophytes\n are noted, causing moderate neural foraminal narrowing on the right side.\n\n At C4-5, there is mild narrowing of the disc space, endplate sclerosis, disc\n osteophyte complex, causing mild indentation on the ventral thecal sac.\n Uncovertebral osteophytes are again noted, right more than left, causing\n moderate narrowing on the right side.\n\n At C5-6, there is narrowing of the disc space, with posterior disc osteophyte\n complex, uncovertebral osteophytes, causing bilateral moderate neural\n foraminal narrowing and moderate indentation on the ventral thecal sac.\n (Over)\n\n 2:33 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for mass, fracture, mets or other pathology\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n At C6-7, there is narrowing of the disc space, disc osteophyte complex, along\n with uncovertebral osteophytes, causing moderate-to-severe neural foraminal\n narrowing.\n\n There are also facet degenerative changes noted at multiple levels.\n\n No pre- or para-vertebral soft tissue swelling or masses are noted.\n\n Significant atherosclerotic vascular calcifications are noted near the\n origins of the arch vessels, in the common carotid, subclavian arteries, as\n well as in the cervical internal carotid arteries and intracranial vertebral\n arteries, not adequately assessed on the present study.\n\n No definite sclerotic foci are noted in the cervical spine.\n\n There is a partially imaged sclerotic focus in the T3 vertebral body, which is\n better assessed on the dedicated CT of the T-spine, performed concurrently.\n\n IMPRESSION:\n 1. Multilevel degenerative changes in the cervical spine as described above,\n causing moderate-to-severe neural foraminal narrowing as described above, and\n mild canal stenosis.\n 2. No definite sclerotic foci in the cervical spine to suggest metastases.\n Correlate with radionuclide studies.\n\n 3. Partially imaged T3 sclerotic focus, better assessed on the concurrent CT T\n spine study.\n\n 4. Significant atherosclerotic vascular calcifications as above.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-16 00:00:00.000",
"description": "CT T-SPINE W/O CONTRAST",
"row_id": 1064547,
"text": " 2:33 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: eval for mass, fracture, mets or other pathology\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL ADDENDUM\n Correlation with radionuclide studies can be considered for confirmation of\n the nature of the lesions.\n\n\n\n 2:33 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: eval for mass, fracture, mets or other pathology\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with CAD, ESRD on PD, metastatic carcinoid presents with lower\n ext weakness and pain\n REASON FOR THIS EXAMINATION:\n eval for mass, fracture, mets or other pathology\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD on PD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old male patient, with metastatic carcinoid, to look for\n spinal mets.\n\n COMPARISON: Torso CT, done on .\n\n TECHNIQUE: Non-contrast CT of the thoracic spine was performed with sagittal\n and coronal reformations.\n\n FINDINGS:\n\n There are a few well-defined sclerotic lesions, noted in the thoracic spine,\n one in the anterior aspect of the T3, which measures 0.7 cm, and was barely\n visible on the prior torso CT sagittal reformations. Similarly, a lesion\n noted in the posteroinferior aspect of T8 vertebral body, with minimal\n convexity of the posterior contour, measuring 1.2 x 1.1 cm is also more\n conspicuous on the present study and may be mildly increased.\n On the prior CT torso, the lesion approximately measures 0.6 cm. and faintly\n visible. In the mid T9 vertebral body, there is a 0.5 cm sclerotic focus.\n Another two sclerotic foci were noted in the T12 vertebral body, are mildly\n increased in size and more conspicuous.\n The lesion, located in the T12 vertebral body, anteroinferiorly may relate to\n degenerative changes versus a neoplastic lesion.\n There is no cortical discontinuity.\n\n In addition, multilevel degenerative changes, were noted in the thoracic\n spine, with anterior and bridging osteophytes. Small sclerotic focus, noted\n at the left costovertebral junction and the in the left 8th rib(series 3,\n image 49) may relate to a similar etiology.\n\n Bilateral pleural effusions, moderate on the right and mild on the left along\n with associated changes in the lung parenchyma were partially imaged and\n better assessed, on CT Chest.\n\n On the scout image, there are distended bowel loops, which have mildly\n increased comapred to the prior CT Lumbar spine but not assessed on the\n present study.\n\n IMPRESSION:\n\n (Over)\n\n 2:33 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: eval for mass, fracture, mets or other pathology\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Multiple, at least seven sclerotic foci, in the thoracic vertebrae and one\n involving the left eighth rib, mildly increased in size, and more conspicuous\n on today's study compared to the CT torso done in . Given the\n increase in size, these may represent metastatic lesions, though the\n appearance is nonspecific and resembles bone islands. No cortical\n discontinuity noted.\n\n 2. Lung, pleural and vascular changes as described above, incompletely imaged\n and characterized on the present study. CT Chest can be considered.\n\n\n 3. Distended bowel loops on the scout image with mildly increased\n diameter since the prior study scout- to correlate clinically to exclude\n obstructive etiology. These are not included on the other images.\n\n\n (Please note that the intrathecal structures are not well evaluated on the\n present study.)\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1065672,
"text": " 5:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infection\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with hypotension\n REASON FOR THIS EXAMINATION:\n r/o infection\n ______________________________________________________________________________\n WET READ: AGLc MON 11:39 PM\n Opacity at the right base and right mid lung are as before. There apepars to\n be increased left retrocardiac opacity, possibly representing some atelectasis\n or aspiration; striated linear densities/lucencies projecting over this region\n may represent skin folds or material external to the patient.\n Cardiomediastianal contours not changed.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypotension, to evaluate for pneumonia.\n\n FINDINGS: In comparison with the study of , there is persistent patchy\n opacification at the right base and mid lung zone as on previous study. Some\n increasing left retrocardiac opacity could reflect aspiration or atelectasis.\n Indistinctness of pulmonary vessels is consistent with elevated pulmonary\n venous pressure in this patient with enlargement of the cardiac silhouette and\n intact midline sternal sutures.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1064777,
"text": " 5:16 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: change in mental status, please eval for mets or bleed\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with ESRD on PD, metastatic carcinoid presents with confusion\n and chenage in mental status\n REASON FOR THIS EXAMINATION:\n change in mental status, please eval for mets or bleed\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD on PD\n ______________________________________________________________________________\n WET READ: ARHb WED 5:53 PM\n No intracranial hemorrhage or edema. Old left parietal infarct.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old male with end-stage renal disease on peritoneal\n dialysis with metastatic carcinoid. Now presenting with mental status change.\n Evaluate for metastasis or intracranial hemorrhage.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the head are obtained at 5-mm section\n thickness.\n\n FINDINGS: There is no intracranial hemorrhage, shift of normally midline\n structures, or evidence of acute major vascular territorial infarct. A small\n focus of encephalomalacia in the posterior left parietal lobe is a sequela of\n a chronic infarct. While evaluation for intracranial metastases on non-\n contrast head CT is limited, no obvious intracranial mass or edema is\n observed. Ventricular and sulcal size appear age-appropriate. Atherosclerotic\n calcifications involve the cavernous carotid arteries bilaterally. The imaged\n portions of the paranasal sinuses and mastoid air cells appear well aerated.\n\n IMPRESSION:\n 1. No intracranial hemorrhage. Limited evaluation for intracranial\n metastases, though no obvious mass or edema is identified.\n 2. Chronic left posterior parietal infarct.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1062232,
"text": " 4:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with hypotension, pain\n REASON FOR THIS EXAMINATION:\n eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY DATED .\n\n HISTORY: 78-year-old male with hypertension and pain.\n\n COMPARISON: .\n\n FINDINGS: A single supine AP view of the chest was obtained. The\n cardiomediastinal silhouette is stable in appearance. There is\n atherosclerotic disease of the aorta. Again noted are median sternotomy\n wires, which are unchanged in appearance. There is central pulmonary vascular\n congestion. Also noted are hazy opacities noted in the right mid lung and\n left lung base. The left costophrenic angle is blunted, suggesting a small\n effusion. No pneumothorax is identified. There has been interval removal of\n a left-sided PICC line.\n\n IMPRESSION:\n\n Cardiomegaly and mild CHF with a small left pleural effusion. Hazy opacity\n within the right mid lung and retrocardiac region, which may represent\n residual pneumonia. Followup chest x-ray following diuresis and treatment is\n recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-03-03 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1062245,
"text": " 6:35 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval new R IJ, eval for PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with new R IJ\n REASON FOR THIS EXAMINATION:\n eval new R IJ, eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n Compared with a prior study from earlier today.\n\n INDICATION: 78-year-old man with new right IJ central line. Evaluate for\n line placement, pneumothorax.\n\n FINDINGS: Single AP upright portable chest radiograph is obtained. Midline\n sternotomy wires and mediastinal clips are again noted. There is interval\n placement of a right IJ central venous catheter with its tip in the\n approximate location of the superior vena cava. There is persistent\n cardiomegaly with pulmonary vascular congestion which is stable. Left pleural\n effusion is unchanged. Cardiomediastinal contour is stable with cardiomegaly\n again noted.\n\n IMPRESSION: New right IJ central venous catheter with tip in appropriate\n position. Otherwise, no change.\n SESHa\n\n"
}
] |
4,113 | 138,805 | Patient is a 45 y/o female with CAD s/p CABG, diastolic HF and kidney transplant presenting from OSH with shortness of breath. . # CORONARIES: Known CAD s/p CABG in . Was cathed on admission which showed no change from previous cath in . Report was as follows: Coronary angiography in this right dominant system revealed diffuse multivessel coronary artery disease. The LMCA had no significant stenosis. The LAD had a 70% mid-portion stenosis after the D1 branch with competitive flow from a patent LIMA that filled the distal vessel. The LCX had severe diffuse disease in the mid-portion extending into a distal branching OM that was unchanged compared with prior caths in and performed after known SVG-OM occlusion. The RCA was not injected. The SVG-->R-PDA was patent with filling of a diffusely diseased distal RCA. The LIMA-LAD was patent. Resting hemodynamics performed on intravenous nitroglycerine revealed slightly left and right filling pressures with mean RA pressure of 10 mmHg and mean PCWP of 15 mmHg. No intervention was performed at this time. Patient denied chest pain or anginal equivalent while in hospital. The patient underwent a repeat cardiac cath on with PTCA of the left circumflex artery, which was thought to be contributing to the patient's symptoms. Final angiography revealed 30% residual stenosis, no angiographically apparent dissection, and TIMI 3 flow. Patient was continued on telemetry without events. She was continued on aspirin, atorvastatin, plavix, and metoprolol was changed to 12.5 mg XL. . # PUMP: History of diastolic dysfunction now presented with CHF exacerbation. ECHO showed low normal LVEF (50-55%), Grade II (moderate) LV diastolic dysfunction, and Moderate (2+) mitral regurgitation. The patient also had an episode of flash pulmonary edema, which responded to lasix diuresis and temporary NRB mask. Patient was treated with metoprolol 12.5 XL, nifedipine was changed to Lisinopril and Lasix was increased to 40 mg daily. In addition, the patient was extensively counseled on self-monitoring fluid status with daily self weights and titration of lasix as needed to prevent further episodes of pulmonary edema. Weight at discharge was 59 kg. . # RHYTHM: Patient remained in NSR. Her metoprolol was changed from 50 mg to 12.5 mg extended release. . # Immune Suppression: Patient is s/p living donor kidney transplant. She was continued on sirolimus 3 mg daily and tacrolimus 2 mg twice daily, as per home regimen. Home dose of prednisone (4mg daily) and bactrim prophylaxis continued as well. . # Diabetes Mellitus Type I: Last A1C on was 8.7%. During admission, pt was continued on Lantus plus sliding scale insulin with good blood glucose control. She has a follow-up appt with her endocrinologist in 1 week. . # Chronic Renal Disease: Patient is s/p kidney transplant. Her creatinine over the last year has ranged from 0.8-1.1. During the course of her hospitalization, the patient had a Cr mildly from baseline, consistent with acute on chronic renal failure, likely secondary to contrast administration from multiple cardiac catheterizations. On discharge, Cr was 1.3. . # Hypertension: Patient was initially continued on home doses of metoprolol and nifedipine extended release. After diuresis, patient had an episode of hypotension and nifedipine was discontinued, and metoprolol 50 mg changed to 12.5 mg XR po daily. Lisinopril was added for afterload reduction and can be tapered up as needed to keep SBP in goal range of 120-140. . # Depression: continued on home medications of bupropion and citalopram. She has f/u with her ouptpt psychiatrist. . # Pain: Questionable allergy to codeine- patient reports nausea/vomiting but has been taking oxycodone recently for ankle fracture. Discharged on Ultram for left leg pain. Note that pt has tolerated oxycodone Po for treatment of her left leg pain. . # Insomnia: Continued on home dose of trazodone. . # Nausea: Continued on reglan and zofran. . # Osteoporosis: Continued vitamin D and calcium. | CARDIAC CATH: 1. CARDIAC CATH: 1. To IR, R brachial single lumen PICC placed. FS at 22:00- 32 symptomatic Action: Amp D50 given Response: Repeat FS 188 half dose glargine dose given. FS at 22:00- 32 symptomatic Action: Amp D50 given Response: Repeat FS 188 half dose glargine dose given. FS at 22:00- 32 symptomatic Action: Amp D50 given Response: Repeat FS 188 half dose glargine dose given. FS at 22:00- 32 symptomatic Action: Amp D50 given Response: Repeat FS 188 half dose glargine dose given. Mitral valve disease.Height: (in) 67Weight (lb): 120BSA (m2): 1.63 m2BP (mm Hg): 130/60HR (bpm): 84Status: InpatientDate/Time: at 14:51Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Disp:*30 Tablet(s)* Refills:*0* 19. Disp:*30 Tablet(s)* Refills:*0* 19. Disp:*30 Tablet(s)* Refills:*0* 19. Hypoglycemic w/ FS 32symptomatic. R brachial single lumen PICC placed. Moderate (2+) mitral regurgitation is seen. Moderate (2+) mitral regurgitation is seen. : Hypoglycemic w/ FS 32symptomatic. : Hypoglycemic w/ FS 32symptomatic. # CORONARIES: Known CAD s/p CABG in . # CORONARIES: Known CAD s/p CABG in . # CORONARIES: Known CAD s/p CABG in . # CORONARIES: Known CAD s/p CABG in . Mild Rt pedal edema. Mild Rt pedal edema. Mild Rt pedal edema. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. Action: AM po lasix dose held. R brachial single lumen PICC placed in IR. Rt fem cath puncture sites WNL w/ good perfusion distally. Rt fem cath puncture sites WNL w/ good perfusion distally. Rt fem cath puncture sites WNL w/ good perfusion distally. -continue PO oxycodone. -continue PO oxycodone. -continue PO oxycodone. -continue PO oxycodone. -continue PO oxycodone. -continue PO oxycodone. -continue PO oxycodone. # CORONARIES: Known CAD s/p CABG in . # CORONARIES: Known CAD s/p CABG in . # CORONARIES: Known CAD s/p CABG in . # CORONARIES: Known CAD s/p CABG in . # CORONARIES: Known CAD s/p CABG in . # CORONARIES: Known CAD s/p CABG in . # CORONARIES: Known CAD s/p CABG in . diuresing well Action: Cont o2 cool neb (as pt. R brachial single lumen PICC placed. Mild Rt pedal edema. Mild Rt pedal edema. Mild Rt pedal edema. Mild Rt pedal edema. Mild Rt pedal edema. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. Response: To recheck hs FS. Hypoglycemic w/ FS 32symptomatic. Hypoglycemic w/ FS 32symptomatic. Hypoglycemic w/ FS 32symptomatic. Hypoglycemic w/ FS 32symptomatic. Restart po dose in am. # PUMP: History of diastolic dysfunction now presented with CHF exacerbation. # PUMP: History of diastolic dysfunction now presented with CHF exacerbation. # PUMP: History of diastolic dysfunction now presented with CHF exacerbation. Action: AM po lasix dose held. Mild Rt pedal edema. Rt fem cath puncture sites WNL w/ good perfusion distally. -continue PO oxycodone. -continue PO oxycodone. -continue PO oxycodone. -continue PO oxycodone. -continue PO oxycodone. LS rhonchorous. # CORONARIES: Known CAD s/p CABG in . # CORONARIES: Known CAD s/p CABG in . # CORONARIES: Known CAD s/p CABG in . # CORONARIES: Known CAD s/p CABG in . # CORONARIES: Known CAD s/p CABG in . Restart po dose in am. Sclera anicteric. Sclera anicteric. Sclera anicteric. Sclera anicteric. Sclera anicteric. Delayedprecordial R wave progression; possibly normal variant. Blunting of the right costophrenic angle persists. Non-specific lateralrepolarization changes consistent with myocardial ischemia. Repeat sugar was 188. Repeat sugar was 188. Repeat sugar was 188. Repeat sugar was 188. Dopple pulses. PERRL, EOMI. PERRL, EOMI. PERRL, EOMI. PERRL, EOMI. PERRL, EOMI. +CSM. # RHYTHM: Patient in normal sinus rhythm. # RHYTHM: Patient in normal sinus rhythm. # RHYTHM: Patient in normal sinus rhythm. # RHYTHM: Patient in normal sinus rhythm. # RHYTHM: Patient in normal sinus rhythm. Hypoglycemic w/ FS 32symptomatic. + CMS, popliteal pulse. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. # Hypertension: -continue home doses of metoprolol and nifedipine extended release. pm dose of lasix as diuresis slows. More discrete opacifications bilaterally are consistent with atelectasis and probable pleural effusions. # Nausea: Continued reglan and zofran. # Nausea: Continued reglan and zofran. # Nausea: Continued reglan and zofran. # Nausea: Continued reglan and zofran. # Nausea: Continued reglan and zofran. # PUMP: History of diastolic dysfunction now presented with CHF exacerbation. # PUMP: History of diastolic dysfunction now presented with CHF exacerbation. | 50 | [
{
"category": "Echo",
"chartdate": "2148-09-25 00:00:00.000",
"description": "Report",
"row_id": 63629,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Mitral valve disease.\nHeight: (in) 67\nWeight (lb): 120\nBSA (m2): 1.63 m2\nBP (mm Hg): 130/60\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 14:51\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith >55% decrease during respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. Low normal LVEF. Estimated cardiac index is high\n(>4.0L/min/m2). Transmitral Doppler and TVI c/w Grade II (moderate) LV\ndiastolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; basal inferolateral - hypo; mid inferolateral - hypo; anterior apex -\nhypo; lateral apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate (2+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Mild PR. The end-diastolic PR velocity is\nincreased c/w PA diastolic hypertension.\n\nConclusions:\nThe left atrium is mildly dilated. The estimated right atrial pressure is 0-5\nmmHg. There is mild symmetric left ventricular hypertrophy with normal cavity\nsize. There is mild regional left ventricular systolic dysfunction with\ninferolateral hypokinesis and distal anterior hypokinesis. Overall left\nventricular systolic function is low normal (LVEF 50-55%). The estimated\ncardiac index is high (>4.0L/min/m2). Transmitral Doppler imaging is\nconsistent with Grade II (moderate) LV diastolic dysfunction. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThe end-diastolic pulmonic regurgitation velocity is increased suggesting\npulmonary artery diastolic hypertension.\n\nCompared with the prior study (images reviewed) of , the inferolateral\nwall systolic dysfunction is more evident and the severity of mitral\nregurgitation has decreased slightly.\n\n\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385715,
"text": "Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n L fem cath site w/ venous sheath\nWNL. + CMS, popliteal pulse. R fem\n puncture sites oozing. No CP\n Action:\n Team notified--pressure dsg applied to R groin\n Bed in reverse T-\nBedrest maintained\n Response:\n R groin stable. HCT\n Plan:\n Continue to monitor groins/VS/HCTs/PLTs\n DC venous sheath today\ndifficult stick, ? PICC\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Sats 96-99% on NRB. Adequate UOP. HR/BP WNL\n Action:\n Daily cardiac meds given last night as pt had not taken any\n meds per pt and per documentation.\n 02 weaned to NC\n Response:\n Currently on 4L NC w/ sats 92-96%. Denies SOB.\n Plan:\n Wean 02 as tolerated\n Diabetes Mellitus (DM), Type I\n Assessment:\n Did not eat supper-pt asleep. Given 2 custards w/ 20:00 meds. FS at\n 22:00- 32 symptomatic\n Action:\n Amp D50 given\n Response:\n Repeat FS 188\n half dose glargine dose given.\n Plan:\n Closely monitor FS, treat as indicated.\n Cardiac healthy/diabetic diet.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o L ankle pain\n Action:\n Oxycodone 5mg given\n Response:\n Good relief\n Plan:\n Continue present pain managment\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 385885,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Given another dose of Lasix 20mg IV at 1800 and has put out\n 140-200cc/hr of urine since. Still on non-rebreather. Myocardial\n viability study cancelled today because EF=55% so heart tissue must be\n viable. Patient will need cath on Monday. Plan is to increase home\n regimen of Lasix to 20mg PO BID once patient is completely diuresed and\n off of oxygen requirement.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:50 PM\n Ranitidine (Prophylaxis) - 10:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.6\nC (96\n HR: 79 (75 - 86) bpm\n BP: 143/75(87) {96/54(63) - 167/88(106)} mmHg\n RR: 12 (11 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55 kg (admission): 57.8 kg\n Height: 67 Inch\n Total In:\n 765 mL\n PO:\n 765 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,975 mL\n 800 mL\n Urine:\n 2,975 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,210 mL\n -800 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: ////\n Physical Examination\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with no elevated JVP\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: Crackles heard at bases. Good respiratory effort. No\n wheezes.\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged-\n no signs of hematoma, erythema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 410 K/uL\n 8.6 g/dL\n 90 mg/dL\n 1.4 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 30 mg/dL\n 105 mEq/L\n 138 mEq/L\n 27.3 %\n 6.0 K/uL\n [image002.jpg]\n 09:41 PM\n 05:30 AM\n 08:00 AM\n 10:47 PM\n 01:00 AM\n 04:50 AM\n WBC\n 6.6\n 6.3\n 6.0\n Hct\n 29.1\n 28.8\n 25.5\n 24.2\n 27.3\n Plt\n 454\n 415\n 410\n Cr\n 1.3\n 1.1\n 1.4\n Glucose\n 30\n 185\n 168\n 90\n Other labs: Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n Patient is a 45 yo female with CAD s/p CABG, diastolic HF and kidney\n transplant presenting from with shortness of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n -post-cath check showing small hematoma, bilateral buits\n - wean oxygen as tolerated\n -no enzymes ordered given lack of symptoms and cath results which\n showed no changes from previous cath\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO shows \"the inferolateral wall systolic dysfunction\n is more evident and the severity of mitral regurgitation has decreased\n slightly.\" Went into flash pulmonary edema overnight, and received\n 20mg IV lasix this AM.\n -consider 20 mg IV lasix again this AM\n -O2 wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her creatinine over\n the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n -currently slightly elevated, but suspect acute pulmonary edema as\n etiology, and suspect improvement with diuresis\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PICC line\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM: (mother)- \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 05:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385697,
"text": "45 yo female w/ known CAD s/p CABG \n pt recently admitted to OSH\n for CHF and was managed at and d/c\nd home. Redeveloped SOB\n this morning, took home dose lasix 20mg po\n but could not urinate. SOB\n worsened so called 911 and sent to OSH\n O2 sats 80% on room air w/\n rapid respirations. Started on CPAP with sats 100% - 20mg IV lasix\n given and Tx to for cath. In Cath no changes noted from old cath\n in \n no interventions done. Additional 20mg IV lasix given. Tx to\n CCU for further management on NRB.\n Diabetes Mellitus (DM), Type I\n Assessment:\n On admission FS 287.\n Action:\n Given 6units humalog s/c. ordered supper.\n Response:\n To recheck hs FS.\n Plan:\n Glargine ordered for hs. Check FS hs. Assist with supper tray this\n evening.\n Coronary artery disease + Congestive Heart Failure.\n Assessment:\n No c/o chest pain. s/p cath\n which showed no change from previous\n cath in \n no intervention. Accessed Lt groin, some Rt groin\n sticks. #24g PIV Lt inner wrist\n flushes poorly. Pt rec\nd 20mg IV\n lasix in cath lab.\n Action:\n Both Rt + Lt groin sites WNL\n DSD. Dopplerable pulses on Rt. Unable to\n check Lt due to cast on lwr leg/foot. +csm to Lt foot. Lt venous sheath\n #8 remains in place due to poor IV access. LS coarse crackles bilat.\n Remains on NRB 100% with sats 94-96%.\n Response:\n No change.\n Plan:\n Repeat post cath lytes this evening. ?more lasix this evening. Monitor\n u/o. monitor respiratory status.\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-25 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 385703,
"text": "TITLE:\n Chief Complaint: shortness of breath\n HPI: 45 y/o female with known CAD s/p CABG presenting to \n upon transfer from for shortness of breath. She was recently\n admitted to (discharged on ) with CHF and eventually\n transferred to for management. She was medically managed and\n discharged home. This most recent episode began two nights ago. She\n had some shortness of breath that resolved after she took her home dose\n of lasix (20mg). Denied any symptoms over the day yesterday but then\n woke up over night and felt quite short of breath. She took 20mg PO\n lasix but said she \"could not urinate\". Symptoms progressively\n worsened so she called 911 and was taken to . Upon arrival to ,\n O2 sat was 80% with rapid respirations. The patient was started on\n CPAP and sats increased to 100%. The patient was also given 20mg IV\n lasix at . Remained pain free. Then transferred for cardiac\n catheterization. Prior to transfer to the patient was changed to\n non rebreather and was satting 98-100%.\n .\n Upon arrival to , patient underwent cardiac cath, which showed no\n changes from her previous cath. No intervention performed given\n results. ECHO today: \"compared with the prior study (images reviewed)\n of , the inferolateral wall systolic dysfunction is more\n evident and the severity of mitral regurgitation has decreased\n slightly.\"\n .\n Upon arrival to CCU, patient was comfortable. Reported improvement of\n her symptoms but still was requiring non-rebreather. Satting 96%.\n Denies any chest pain, syncope, headaches or dizziness. VS: BP-\n 102/45, HR- 78, RR- 17, O2- 96% on NRB.\n .\n On review of systems, she denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n She denies recent fevers, chills or rigors. She denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, ankle edema, palpitations,\n syncope or presyncope. Reports orthopnea and shortness of breath.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n 1. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily):\n Please take at 5 PM everyday.\n 2. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every\n 12 hours).\n 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)\n Tablet PO MWF (Monday-Wednesday-Friday).\n 4. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)\n as needed for insomnia.\n 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2\n times a day).\n 6. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY\n (Daily).\n 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\n PO DAILY (Daily).\n 8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY\n (Daily).\n 9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY\n (Daily).\n 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID\n (2 times a day).\n 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)\n Tablet, Chewable PO BID (2 times a day).\n 13. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY\n (Daily).\n 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID\n (2 times a day).\n 15. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2)\n Tablet Sustained Release PO DAILY (Daily).\n 16. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)\n Tablet PO BID (2 times a day).\n 17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr\n Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).\n 18. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4\n hours) as needed for left ankle pain for 5 days.\n Disp:*30 Tablet(s)* Refills:*0*\n 19. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY\n (Daily).\n 20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)\n Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for\n constipation: Please take as needed for constipation while you\n are taking pain medications.\n 21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\n day) as needed for constipation: Please take if needed for\n constipation while you are taking pain medications.\n 22. Compazine 25 mg Suppository Sig: One (1) Rectal three times\n a day as needed for nausea.\n 23. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day\n as needed for nausea.\n 24. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)\n units Subcutaneous at bedtime.\n 25. Insulin Lispro 100 unit/mL Solution Sig: sliding scale\n Subcutaneous four times a day: Please use according to your\n sliding scale.\n 26. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO once a day.\n 27. Ergocalciferol (Vitamin D2) 400 unit Capsule Sig: One (1)\n Capsule PO twice a day.\n 28. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs\n Inhalation every six (6) hours as needed for cough.\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension\n 2. CARDIAC HISTORY:\n -CABG: \n -PERCUTANEOUS CORONARY INTERVENTIONS: None\n -PACING/ICD: None\n 3. OTHER PAST MEDICAL HISTORY:\n CAD\n s/p coronary bypass surgery - LIMA to LAD, SVG to\n OM, SVG to Diagonal, and SVG to PDA. SVG to the OM and diagonal\n occluded.\n Diastolic Heart Failure\n Diabetes Mellitus-type I\n s/p living-related kidney transplant (baseline Cr\n 0.8-1.1 over the last year)\n s/p MI\n tobacco use\n osteoporosis\n gastroparesis\n s/p right tibial fracture\n peripheral vascular disease: s/p right femoropopliteal bypass\n and left SFA drug-eluting , \n retinopathy- legally blind\n s/p left patella open reduction and fixation, \n s/p right leg fracture (cast), \n s/p left wrist fracture, \n s/p fall and intracranial bleed, \n s/p cholecystectomy\n sarcoid, reported lung nodule\n neuropathy\n depression\n hypertension\n blood group specific substance. Blood products (red cells and\n platelets) should be leukoreduced.\n chronic heel ulcers\n hyponatremia\n There is no history of diabetes or kidney disease. Her father\n had an MI at 74 and mother has hypertension. Grandfather had\n leukemia and hypertension.\n -Tobacco history: smokes half a pack per day\n -ETOH: none\n -Illicit drugs: smokes marijuana several times per week to help\n with nausea and appetite\n Review of systems:\n Reports shortness of breath, orthopnea, LE edema. Denies chest pain,\n fevers, chills, nausea, vomiting, dizziness, headaches\n Flowsheet Data as of 08:14 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 75 (73 - 80) bpm\n BP: 134/68(84) {102/45(59) - 134/68(84)} mmHg\n RR: 12 (12 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 327 mL\n PO:\n 45 mL\n TF:\n IVF:\n 282 mL\n Blood products:\n Total out:\n 0 mL\n 1,120 mL\n Urine:\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -793 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 98%\n Physical Examination\n VS: T=97.7 BP=130/60 HR=77 RR=17 O2 sat= 95% on NRB\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of *** cm.\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged-\n no signs of hematoma, erythema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n Patient is a 45yo female with PMHx significant for CAD s/p CABG,\n diastolic HF and kidney transplant presenting from with shortness\n of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n -post-cath check at 2100\n -o2- wean as tolerated\n -no enzymes ordered given lack of symptoms and cath results which\n showed no changes from previous cath\n -EKG in AM\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO today shows \"the inferolateral wall systolic\n dysfunction is more evident and the severity of mitral regurgitation\n has decreased slightly.\" Received 20mg IV lasix today.\n -f/u ECHO\n -lasix 20mg PO for diuresis\n -O2- wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her\n creatinine over the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM:\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:42 PM\n Cordis/Introducer - 04:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-25 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 385704,
"text": "TITLE:\n Chief Complaint: shortness of breath\n HPI: 45 y/o female with known CAD s/p CABG presenting to \n upon transfer from for shortness of breath. She was recently\n admitted to (discharged on ) with CHF and eventually\n transferred to for management. She was medically managed and\n discharged home. This most recent episode began two nights ago. She\n had some shortness of breath that resolved after she took her home dose\n of lasix (20mg). Denied any symptoms over the day yesterday but then\n woke up over night and felt quite short of breath. She took 20mg PO\n lasix but said she \"could not urinate\". Symptoms progressively\n worsened so she called 911 and was taken to . Upon arrival to ,\n O2 sat was 80% with rapid respirations. The patient was started on\n CPAP and sats increased to 100%. The patient was also given 20mg IV\n lasix at . Remained pain free. Then transferred for cardiac\n catheterization. Prior to transfer to the patient was changed to\n non rebreather and was satting 98-100%.\n .\n Upon arrival to , patient underwent cardiac cath, which showed no\n changes from her previous cath. No intervention performed given\n results. ECHO today: \"compared with the prior study (images reviewed)\n of , the inferolateral wall systolic dysfunction is more\n evident and the severity of mitral regurgitation has decreased\n slightly.\"\n .\n Upon arrival to CCU, patient was comfortable. Reported improvement of\n her symptoms but still was requiring non-rebreather. Satting 96%.\n Denies any chest pain, syncope, headaches or dizziness. VS: BP-\n 102/45, HR- 78, RR- 17, O2- 96% on NRB.\n .\n On review of systems, she denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n She denies recent fevers, chills or rigors. She denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, ankle edema, palpitations,\n syncope or presyncope. Reports orthopnea and shortness of breath.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n 1. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily):\n Please take at 5 PM everyday.\n 2. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every\n 12 hours).\n 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)\n Tablet PO MWF (Monday-Wednesday-Friday).\n 4. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)\n as needed for insomnia.\n 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2\n times a day).\n 6. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY\n (Daily).\n 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\n PO DAILY (Daily).\n 8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY\n (Daily).\n 9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY\n (Daily).\n 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID\n (2 times a day).\n 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)\n Tablet, Chewable PO BID (2 times a day).\n 13. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY\n (Daily).\n 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID\n (2 times a day).\n 15. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2)\n Tablet Sustained Release PO DAILY (Daily).\n 16. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)\n Tablet PO BID (2 times a day).\n 17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr\n Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).\n 18. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4\n hours) as needed for left ankle pain for 5 days.\n Disp:*30 Tablet(s)* Refills:*0*\n 19. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY\n (Daily).\n 20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)\n Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for\n constipation: Please take as needed for constipation while you\n are taking pain medications.\n 21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\n day) as needed for constipation: Please take if needed for\n constipation while you are taking pain medications.\n 22. Compazine 25 mg Suppository Sig: One (1) Rectal three times\n a day as needed for nausea.\n 23. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day\n as needed for nausea.\n 24. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)\n units Subcutaneous at bedtime.\n 25. Insulin Lispro 100 unit/mL Solution Sig: sliding scale\n Subcutaneous four times a day: Please use according to your\n sliding scale.\n 26. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO once a day.\n 27. Ergocalciferol (Vitamin D2) 400 unit Capsule Sig: One (1)\n Capsule PO twice a day.\n 28. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs\n Inhalation every six (6) hours as needed for cough.\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension\n 2. CARDIAC HISTORY:\n -CABG: \n -PERCUTANEOUS CORONARY INTERVENTIONS: None\n -PACING/ICD: None\n 3. OTHER PAST MEDICAL HISTORY:\n CAD\n s/p coronary bypass surgery - LIMA to LAD, SVG to\n OM, SVG to Diagonal, and SVG to PDA. SVG to the OM and diagonal\n occluded.\n Diastolic Heart Failure\n Diabetes Mellitus-type I\n s/p living-related kidney transplant (baseline Cr\n 0.8-1.1 over the last year)\n s/p MI\n tobacco use\n osteoporosis\n gastroparesis\n s/p right tibial fracture\n peripheral vascular disease: s/p right femoropopliteal bypass\n and left SFA drug-eluting , \n retinopathy- legally blind\n s/p left patella open reduction and fixation, \n s/p right leg fracture (cast), \n s/p left wrist fracture, \n s/p fall and intracranial bleed, \n s/p cholecystectomy\n sarcoid, reported lung nodule\n neuropathy\n depression\n hypertension\n blood group specific substance. Blood products (red cells and\n platelets) should be leukoreduced.\n chronic heel ulcers\n hyponatremia\n There is no history of diabetes or kidney disease. Her father\n had an MI at 74 and mother has hypertension. Grandfather had\n leukemia and hypertension.\n -Tobacco history: smokes half a pack per day\n -ETOH: none\n -Illicit drugs: smokes marijuana several times per week to help\n with nausea and appetite\n Review of systems:\n Reports shortness of breath, orthopnea, LE edema. Denies chest pain,\n fevers, chills, nausea, vomiting, dizziness, headaches\n Flowsheet Data as of 08:14 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 75 (73 - 80) bpm\n BP: 134/68(84) {102/45(59) - 134/68(84)} mmHg\n RR: 12 (12 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 327 mL\n PO:\n 45 mL\n TF:\n IVF:\n 282 mL\n Blood products:\n Total out:\n 0 mL\n 1,120 mL\n Urine:\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -793 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 98%\n Physical Examination\n VS: T=97.7 BP=130/60 HR=77 RR=17 O2 sat= 95% on NRB\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with no elevated JVP noted.\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged-\n no signs of hematoma, erythema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n EKG: sinus rhythm with previous septal infarct\n .\n 2D-ECHOCARDIOGRAM: The left atrium is mildly dilated. The estimated\n right atrial pressure is 0-5 mmHg. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. There is mild regional\n left ventricular systolic dysfunction with inferolateral hypokinesis\n and distal anterior hypokinesis. Overall left ventricular systolic\n function is low normal (LVEF 50-55%). The estimated cardiac index is\n high (>4.0L/min/m2). Transmitral Doppler imaging is consistent with\n Grade II (moderate) LV diastolic dysfunction. Right ventricular chamber\n size and free wall motion are normal. The aortic valve leaflets (3)\n appear structurally normal with good leaflet excursion and no aortic\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. There is no mitral valve prolapse. Moderate (2+)\n mitral regurgitation is seen. There is mild pulmonary artery systolic\n hypertension. The end-diastolic pulmonic regurgitation velocity is\n increased suggesting pulmonary artery diastolic hypertension.\n .\n CARDIAC CATH: 1. Coronary angiography in this right dominant system\n revealed diffuse multivessel coronary artery disease. The LMCA had no\n significant stenosis. The LAD had a 70% mid-portion stenosis after the\n D1 branch with competitive flow from a patent LIMA that filled the\n distal vessel.\n The LCX had severe diffuse disease in the mid-portion extending into a\n distal branching OM that was unchanged compared with prior caths in\n and performed after known SVG-OM occlusion. The RCA was not\n injected. The SVG-->R-PDA was patent with filling of a diffusely\n diseased distal RCA. The LIMA-LAD was patent.\n 2. Resting hemodynamics performed on intravenous nitroglycerine\n revealed slightly elevated left and right filling pressures with mean\n RA pressure of 10 mmHg and mean PCWP of 15 mmHg.\n FINAL DIAGNOSIS:\n 1. Diffuse coronary artery disease.\n 2. Slightly elevated left and right filling pressures on IV\n nitroglycerine.\n .\n HEMODYNAMICS: SBP in 130s with HR in 70s\n Assessment and Plan\n Patient is a 45yo female with PMHx significant for CAD s/p CABG,\n diastolic HF and kidney transplant presenting from with shortness\n of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n -post-cath check at 2100\n -o2- wean as tolerated\n -no enzymes ordered given lack of symptoms and cath results which\n showed no changes from previous cath\n -EKG in AM\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO today shows \"the inferolateral wall systolic\n dysfunction is more evident and the severity of mitral regurgitation\n has decreased slightly.\" Received 20mg IV lasix today.\n -f/u ECHO\n -lasix 20mg PO for diuresis\n -O2- wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her\n creatinine over the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM:\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:42 PM\n Cordis/Introducer - 04:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-25 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 385705,
"text": "TITLE:\n Chief Complaint: shortness of breath\n HPI: 45 y/o female with known CAD s/p CABG presenting to \n upon transfer from for shortness of breath. She was recently\n admitted to (discharged on ) with CHF and eventually\n transferred to for management. She was medically managed and\n discharged home. This most recent episode began two nights ago. She\n had some shortness of breath that resolved after she took her home dose\n of lasix (20mg). Denied any symptoms over the day yesterday but then\n woke up over night and felt quite short of breath. She took 20mg PO\n lasix but said she \"could not urinate\". Symptoms progressively\n worsened so she called 911 and was taken to . Upon arrival to ,\n O2 sat was 80% with rapid respirations. The patient was started on\n CPAP and sats increased to 100%. The patient was also given 20mg IV\n lasix at . Remained pain free. Then transferred for cardiac\n catheterization. Prior to transfer to the patient was changed to\n non rebreather and was satting 98-100%.\n .\n Upon arrival to , patient underwent cardiac cath, which showed no\n changes from her previous cath. No intervention performed given\n results. ECHO today: \"compared with the prior study (images reviewed)\n of , the inferolateral wall systolic dysfunction is more\n evident and the severity of mitral regurgitation has decreased\n slightly.\"\n .\n Upon arrival to CCU, patient was comfortable. Reported improvement of\n her symptoms but still was requiring non-rebreather. Satting 96%.\n Denies any chest pain, syncope, headaches or dizziness. VS: BP-\n 102/45, HR- 78, RR- 17, O2- 96% on NRB.\n .\n On review of systems, she denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, bleeding at the time of surgery,\n myalgias, joint pains, cough, hemoptysis, black stools or red stools.\n She denies recent fevers, chills or rigors. She denies exertional\n buttock or calf pain. All of the other review of systems were\n negative.\n .\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, ankle edema, palpitations,\n syncope or presyncope. Reports orthopnea and shortness of breath.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n 1. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily):\n Please take at 5 PM everyday.\n 2. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every\n 12 hours).\n 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)\n Tablet PO MWF (Monday-Wednesday-Friday).\n 4. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)\n as needed for insomnia.\n 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2\n times a day).\n 6. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY\n (Daily).\n 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable\n PO DAILY (Daily).\n 8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY\n (Daily).\n 9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).\n 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY\n (Daily).\n 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID\n (2 times a day).\n 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)\n Tablet, Chewable PO BID (2 times a day).\n 13. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY\n (Daily).\n 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID\n (2 times a day).\n 15. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2)\n Tablet Sustained Release PO DAILY (Daily).\n 16. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)\n Tablet PO BID (2 times a day).\n 17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr\n Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).\n 18. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4\n hours) as needed for left ankle pain for 5 days.\n Disp:*30 Tablet(s)* Refills:*0*\n 19. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY\n (Daily).\n 20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)\n Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for\n constipation: Please take as needed for constipation while you\n are taking pain medications.\n 21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a\n day) as needed for constipation: Please take if needed for\n constipation while you are taking pain medications.\n 22. Compazine 25 mg Suppository Sig: One (1) Rectal three times\n a day as needed for nausea.\n 23. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day\n as needed for nausea.\n 24. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)\n units Subcutaneous at bedtime.\n 25. Insulin Lispro 100 unit/mL Solution Sig: sliding scale\n Subcutaneous four times a day: Please use according to your\n sliding scale.\n 26. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO once a day.\n 27. Ergocalciferol (Vitamin D2) 400 unit Capsule Sig: One (1)\n Capsule PO twice a day.\n 28. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs\n Inhalation every six (6) hours as needed for cough.\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension\n 2. CARDIAC HISTORY:\n -CABG: \n -PERCUTANEOUS CORONARY INTERVENTIONS: None\n -PACING/ICD: None\n 3. OTHER PAST MEDICAL HISTORY:\n CAD\n s/p coronary bypass surgery - LIMA to LAD, SVG to\n OM, SVG to Diagonal, and SVG to PDA. SVG to the OM and diagonal\n occluded.\n Diastolic Heart Failure\n Diabetes Mellitus-type I\n s/p living-related kidney transplant (baseline Cr\n 0.8-1.1 over the last year)\n s/p MI\n tobacco use\n osteoporosis\n gastroparesis\n s/p right tibial fracture\n peripheral vascular disease: s/p right femoropopliteal bypass\n and left SFA drug-eluting , \n retinopathy- legally blind\n s/p left patella open reduction and fixation, \n s/p right leg fracture (cast), \n s/p left wrist fracture, \n s/p fall and intracranial bleed, \n s/p cholecystectomy\n sarcoid, reported lung nodule\n neuropathy\n depression\n hypertension\n blood group specific substance. Blood products (red cells and\n platelets) should be leukoreduced.\n chronic heel ulcers\n hyponatremia\n There is no history of diabetes or kidney disease. Her father\n had an MI at 74 and mother has hypertension. Grandfather had\n leukemia and hypertension.\n -Tobacco history: smokes half a pack per day\n -ETOH: none\n -Illicit drugs: smokes marijuana several times per week to help\n with nausea and appetite\n Review of systems:\n Reports shortness of breath, orthopnea, LE edema. Denies chest pain,\n fevers, chills, nausea, vomiting, dizziness, headaches\n Flowsheet Data as of 08:14 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 75 (73 - 80) bpm\n BP: 134/68(84) {102/45(59) - 134/68(84)} mmHg\n RR: 12 (12 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 327 mL\n PO:\n 45 mL\n TF:\n IVF:\n 282 mL\n Blood products:\n Total out:\n 0 mL\n 1,120 mL\n Urine:\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -793 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 98%\n Physical Examination\n VS: T=97.7 BP=130/60 HR=77 RR=17 O2 sat= 95% on NRB\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with no elevated JVP noted.\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged-\n no signs of hematoma, erythema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n EKG: sinus rhythm with previous septal infarct\n .\n 2D-ECHOCARDIOGRAM: The left atrium is mildly dilated. The estimated\n right atrial pressure is 0-5 mmHg. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. There is mild regional\n left ventricular systolic dysfunction with inferolateral hypokinesis\n and distal anterior hypokinesis. Overall left ventricular systolic\n function is low normal (LVEF 50-55%). The estimated cardiac index is\n high (>4.0L/min/m2). Transmitral Doppler imaging is consistent with\n Grade II (moderate) LV diastolic dysfunction. Right ventricular chamber\n size and free wall motion are normal. The aortic valve leaflets (3)\n appear structurally normal with good leaflet excursion and no aortic\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are mildly thickened. There is no mitral valve prolapse. Moderate (2+)\n mitral regurgitation is seen. There is mild pulmonary artery systolic\n hypertension. The end-diastolic pulmonic regurgitation velocity is\n increased suggesting pulmonary artery diastolic hypertension.\n .\n CARDIAC CATH: 1. Coronary angiography in this right dominant system\n revealed diffuse multivessel coronary artery disease. The LMCA had no\n significant stenosis. The LAD had a 70% mid-portion stenosis after the\n D1 branch with competitive flow from a patent LIMA that filled the\n distal vessel.\n The LCX had severe diffuse disease in the mid-portion extending into a\n distal branching OM that was unchanged compared with prior caths in\n and performed after known SVG-OM occlusion. The RCA was not\n injected. The SVG-->R-PDA was patent with filling of a diffusely\n diseased distal RCA. The LIMA-LAD was patent.\n 2. Resting hemodynamics performed on intravenous nitroglycerine\n revealed slightly elevated left and right filling pressures with mean\n RA pressure of 10 mmHg and mean PCWP of 15 mmHg.\n FINAL DIAGNOSIS:\n 1. Diffuse coronary artery disease.\n 2. Slightly elevated left and right filling pressures on IV\n nitroglycerine.\n .\n HEMODYNAMICS: SBP in 130s with HR in 70s\n Assessment and Plan\n Patient is a 45yo female with PMHx significant for CAD s/p CABG,\n diastolic HF and kidney transplant presenting from with shortness\n of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n -post-cath check at 2100\n -o2- wean as tolerated\n -no enzymes ordered given lack of symptoms and cath results which\n showed no changes from previous cath\n -EKG in AM\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO today shows \"the inferolateral wall systolic\n dysfunction is more evident and the severity of mitral regurgitation\n has decreased slightly.\" Received 20mg IV lasix today.\n -f/u ECHO\n -lasix 20mg PO for diuresis\n -O2- wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her\n creatinine over the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM: (mother)- \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:42 PM\n Cordis/Introducer - 04:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 385710,
"text": "Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n L fem cath site w/ venous sheath\nWNL. R fem puncture sites oozing. No\n CP\n Action:\n Team notified--pressure dsg applied to R groin\n Bed in reverse T-\nBedrest maintained\n Response:\n R groin stable. HCT\n Plan:\n Continue to monitor groins/VS/HCTs/PLTs\n DC venous sheath today\ndifficult stick, ? PICC\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Sats 96-99% on NRB. Adequate UOP. HR/BP WNL\n Action:\n Daily cardiac meds given last night as pt had not taken any\n meds per pt and per documentation.\n 02 weaned to NC\n Response:\n Currently on 4L NC w/ sats 92-96%. Denies SOB.\n Plan:\n Wean 02 as tolerated\n Diabetes Mellitus (DM), Type I\n Assessment:\n Did not eat supper-pt asleep. Given 2 custards w/ 20:00 meds. FS at\n 22:00- 32 symptomatic\n Action:\n Amp D50 given\n Response:\n Repeat FS 188\n half dose glargine dose given.\n Plan:\n Closely monitor FS, treat as indicated.\n Cardiac healthy/diabetic diet.\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385711,
"text": "Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n L fem cath site w/ venous sheath\nWNL. + CMS, popliteal pulse. R fem\n puncture sites oozing. No CP\n Action:\n Team notified--pressure dsg applied to R groin\n Bed in reverse T-\nBedrest maintained\n Response:\n R groin stable. HCT\n Plan:\n Continue to monitor groins/VS/HCTs/PLTs\n DC venous sheath today\ndifficult stick, ? PICC\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Sats 96-99% on NRB. Adequate UOP. HR/BP WNL\n Action:\n Daily cardiac meds given last night as pt had not taken any\n meds per pt and per documentation.\n 02 weaned to NC\n Response:\n Currently on 4L NC w/ sats 92-96%. Denies SOB.\n Plan:\n Wean 02 as tolerated\n Diabetes Mellitus (DM), Type I\n Assessment:\n Did not eat supper-pt asleep. Given 2 custards w/ 20:00 meds. FS at\n 22:00- 32 symptomatic\n Action:\n Amp D50 given\n Response:\n Repeat FS 188\n half dose glargine dose given.\n Plan:\n Closely monitor FS, treat as indicated.\n Cardiac healthy/diabetic diet.\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 385928,
"text": "HPI: 45 y/o female with known CAD s/p CABG presenting to \n upon transfer from for shortness of breath. She was recently\n admitted to (discharged on ) with CHF and eventually\n transferred to for management. She was medically managed and\n discharged home. This most recent episode began two nights ago. She\n had some shortness of breath that resolved after she took her home dose\n of lasix (20mg). Denied any symptoms over the day yesterday but then\n woke up over night and felt quite short of breath. She took 20mg PO\n lasix but said she \"could not urinate\". Symptoms progressively\n worsened so she called 911 and was taken to . Upon arrival to ,\n O2 sat was 80% with rapid respirations. The patient was started on\n CPAP and sats increased to 100%. The patient was also given 20mg IV\n lasix at . Remained pain free. Then transferred for cardiac\n catheterization. Prior to transfer to the patient was changed to\n non rebreather and was satting 98-100%.\n .\n Upon arrival to , patient underwent cardiac cath, which showed no\n changes from her previous cath. No intervention performed given\n results. ECHO today: \"compared with the prior study (images reviewed)\n of , the inferolateral wall systolic dysfunction is more\n evident and the severity of mitral regurgitation has decreased\n slightly.\"\n .\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain this am has pain in Lt leg and neuropathy on neurontin\n at baseline\n Action:\n Pt given oxycodone 10 mg po this am\n Response:\n No pain within the next hr\n Plan:\n Prn pain meds for leg and neuropathy pain\n Diabetes Mellitus (DM), Type I\n Assessment:\n Blood sugars remain ^ 463 at noon\n Action:\n Increase sliding scale m covered wih 14 units of humalog\n Response:\n Will recheck in the evening\n Plan:\n Increase sliding scale, pt taking ensure will change to glucerna\n because of increasing bs\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Pt denies cp or sob, off o2 sats 97% Lung clear bilaterally\n Action:\n Pt received 40 po lasix this am,\n Response:\n Putting out 300 cc of urine from lasix\n Plan:\n Follow urine output and lung exam\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt denies any cp\n Action:\n Pt stable on cardiac meds\n Response:\n stable\n Plan:\n Cath on monday\n Pt has rt picc placed on \n PMh cad s/p cabge , diastyolic disfunction, immune suppression\n s/p live kidney , dm, reanl disease, htn, depression, psin\n osetoporosis, depression.\n Team will need to speak with transplant service prior to cath and plan\n what to do in reguards to die load, prior to cath due to kidney\n transplant.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE CARDIAC CATHETERIZATION\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 57.8 kg\n Daily weight:\n 55 kg\n Allergies/Reactions:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin, HEMO or PD, Renal Failure, Smoker\n CV-PMH: CAD, CHF, Hypertension, MI, PVD\n Additional history: HTN, CABG , s/p MI, diastolic heart failure,\n IDDM, retinopathy - legally blind, neuropathy, s/p renal transplant\n (baseline Cr 0.8-1.1), SMOKER + marjuana use daily, gastroparesis,\n osteoporosis, s/p recent Rt tibial fracture - still wearing cast this\n admit, PVD s/p Rt femoropopliteal bypass and Lt SFA drug eluting stent\n , s/p Lt patella open reduction + fixation , s/p Rt leg\n fracture, s/p Lt wrist fracture, s/p fall and intracranial bleed ,\n s/p choley, sarcoid lung nodule, depression, hyponatremia.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:83\n D:48\n Temperature:\n 97.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 600 mL\n 24h total out:\n 1,040 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 05:01 AM\n Potassium:\n 4.4 mEq/L\n 05:01 AM\n Chloride:\n 104 mEq/L\n 05:01 AM\n CO2:\n 26 mEq/L\n 05:01 AM\n BUN:\n 28 mg/dL\n 05:01 AM\n Creatinine:\n 1.2 mg/dL\n 05:01 AM\n Glucose:\n 194 mg/dL\n 05:01 AM\n Hematocrit:\n 27.0 %\n 05:01 AM\n Finger Stick Glucose:\n 462\n 12:00 PM\n Valuables / Signature\n Patient valuables: clothes\n Other valuables:earing in\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: ccu\n Transferred to: 315\n Date & time of Transfer: 1230Pm\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 385929,
"text": "HPI: 45 y/o female with known CAD s/p CABG presenting to \n upon transfer from for shortness of breath. She was recently\n admitted to (discharged on ) with CHF and eventually\n transferred to for management. She was medically managed and\n discharged home. This most recent episode began two nights ago. She\n had some shortness of breath that resolved after she took her home dose\n of lasix (20mg). Denied any symptoms over the day yesterday but then\n woke up over night and felt quite short of breath. She took 20mg PO\n lasix but said she \"could not urinate\". Symptoms progressively\n worsened so she called 911 and was taken to . Upon arrival to ,\n O2 sat was 80% with rapid respirations. The patient was started on\n CPAP and sats increased to 100%. The patient was also given 20mg IV\n lasix at . Remained pain free. Then transferred for cardiac\n catheterization. Prior to transfer to the patient was changed to\n non rebreather and was satting 98-100%.\n .\n Upon arrival to , patient underwent cardiac cath, which showed no\n changes from her previous cath. No intervention performed given\n results. ECHO today: \"compared with the prior study (images reviewed)\n of , the inferolateral wall systolic dysfunction is more\n evident and the severity of mitral regurgitation has decreased\n slightly.\"\n .\n Rt picc placed on pt has fem sited both rt and lt dry and intact\n with clear dressing intact,\n Pt has cast on rt leg at this time unsure if she can weight bear\n resident to follow up with ortho about this. Cast was put on in osh\n 2 weeks ago\n Pmh mi, diastolic heart failer iddm,retinopathy, legally blind,\n neuropathy, s/p renal transplant , gastroporosis, rt tibial fx,\n pvd, s/p femoropoplitesl bypass, and lt sfa drug eliting stent ,s/p\n lt patella open reduction and fixation , s/p rt leg fx, s/p lt\n wrist fx, s/p fall and intracranial bleed08,sarcoid lung nodule\n depression, hyponatremia\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has pain in rt leg plus suffers from neuropathy, This am c/o pain\n \n Action:\n Pt given po 10 mg oxycodone and also is on neuroton standing\n Response:\n Within one he pain was gone\n Plan:\n Prn pain meds as reposition as needed\n Diabetes Mellitus (DM), Type I\n Assessment:\n Pt remains on a sliding scale insulin blood sugars ranging between\n 150-300, pt states our sliding scale is low for her she takes a larger\n doses\n Action:\n Will have team adjust insulin scale up to where she normal doses\n Response:\n Plan:\n Will repeat bs at noon and follow new scale\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Pt denies cp or sob\n Action:\n Pt continues on cardiac meds and lasix\n Response:\n Stable BP and hr\n Plan:\n Plan for cath on monday\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Lungs clear\n Action:\n Pt off o2 now, on room air, pt given 40 of po lasix this am\n Response:\n Pt states her breathing is much better, sats 97-99 %\n Plan:\n Follow urine output , follow lung exam\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385767,
"text": "Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n L fem cath site w/ venous sheath\nWNL. + CMS, popliteal pulse. R fem\n puncture with pressure dsg. Dopplerable pulses on Rt leg, unable to\n check pedal pulses on Lt foot due to knee to toe cast. +CSM.\n Action:\n Bandaid to Rt groin site. Dopple pulses. Bed in reverse T-\nBedrest\n maintained.\n Response:\n R groin stable. HCT 28.8 (29.1). To Interventional radiology for PICC\n line placement in Rt brachial. Placement comfirmed via fluoro.\n Plan:\n Viability study ordered\n needs venous access for study\n to start in\n am to nuclear med in am. Scan will be completed by Saturday am. Needs\n sheath pulled from Lt groin now that PICC line placed.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Sats 96-99% on 4L n/c. LS rhonchorous.\n Action:\n Tolerating cardiac meds today. Desaturated around noon to mid 80s\n stating nose stuffy and unable to breathe properly. Placed on simple\n facemask same 4L\n sats increased back to mid 90s. started on po lasix\n 40mg daily.\n Response:\n VSS. Sats >95% on 4L n/c this afternoon.\n Plan:\n Wean 02 as tolerated\n monitor resp status.\n Diabetes Mellitus (DM), Type I\n Assessment:\n FS qid w/ humalog sliding scale. glargine ordered for bedtime.\n Action/Response:\n Covered with HISS today. Taking meals well today.\n Plan:\n Closely monitor FS, treat as indicated. Cardiac healthy/diabetic diet.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o L ankle pain (recent fracture\n leg in cast)\n Action:\n PRN 10mg poOxycodone ordered for pain\n Response:\n Good relief of paint.\n Plan:\n Continue present pain managment\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 385709,
"text": "Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n L fem cath site w/ venous sheath\nWNL. R fem puncture sites oozing. No\n CP\n Action:\n Team notified--pressure dsg applied to R groin\n Response:\n R groin stable. HCT\n Plan:\n Continue to monitor groins/VS/HCTs/PLTs\n DC venous sheath today\ndifficult stick, ? PICC\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Sats 96-99% on NRB. Adequate UOP. HR/BP WNL\n Action:\n Daily cardiac meds given last night as pt had not taken any\n meds per pt and per documentation.\n 02 weaned to NC\n Response:\n Currently on 4L NC w/ sats 92-96%. Denies SOB.\n Plan:\n Wean 02 as tolerated\n Diabetes Mellitus (DM), Type I\n Assessment:\n Did not eat supper-pt asleep. Given 2 custards w/ 20:00 meds. FS at\n 22:00- 32 symptomatic\n Action:\n Amp D50 given\n Response:\n Repeat FS 188\n half dose glargine dose given.\n Plan:\n Closely monitor FS, treat as indicated.\n Cardiac healthy/diabetic diet.\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385775,
"text": "Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n L fem cath site w/ venous sheath\nWNL. + CMS, popliteal pulse. R fem\n puncture with pressure dsg. Dopplerable pulses on Rt leg, unable to\n check pedal pulses on Lt foot due to knee to toe cast. +CSM.\n Action:\n Bandaid to Rt groin site. Dopple pulses. Bed in reverse T-\nBedrest\n maintained.\n Response:\n R groin stable. HCT 28.8 (29.1). To Interventional radiology for PICC\n line placement in Rt brachial. Placement comfirmed via fluoro.\n Plan:\n Viability study ordered\n needs venous access for study\n to start in\n am to nuclear med in am. Scan will be completed by Saturday am. Needs\n sheath pulled from Lt groin now that PICC line placed.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Sats 96-99% on 4L n/c. LS rhonchorous.\n Action:\n Tolerating cardiac meds today. Desaturated around noon to mid 80s\n stating nose stuffy and unable to breathe properly. Placed on simple\n facemask same 4L\n sats increased back to mid 90s. started on po lasix\n 40mg daily.\n Response:\n VSS. Sats >95% on 4L n/c this afternoon.\n Plan:\n Wean 02 as tolerated\n monitor resp status.\n Diabetes Mellitus (DM), Type I\n Assessment:\n FS qid w/ humalog sliding scale. glargine ordered for bedtime.\n Action/Response:\n Covered with HISS today. Taking meals well today.\n Plan:\n Closely monitor FS, treat as indicated. Cardiac healthy/diabetic diet.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o L ankle pain (recent fracture\n leg in cast)\n Action:\n PRN 10mg poOxycodone ordered for pain\n Response:\n Good relief of paint.\n Plan:\n Continue present pain managment\n ------ Protected Section ------\n Lt groin sheath d/c\nd by fellow at bedside this evening. Monitor Lt\n groin site.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:33 ------\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385778,
"text": ": Hypoglycemic w/ FS 32\nsymptomatic.\n Difficult stick\n Lt fem venous sheath DCd at 18:00. R brachial\n single lumen PICC placed.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n PICC site oozing bleeding at 1900\ndsg re-inforced. Lt fem w/ small,\n non-expanding hematoma. No c/o abd/back pain. Rt fem cath puncture\n sites WNL. PM HCT 25.5 (28.8 yesterday AM).\n Action:\n HCTs checked\ngroin monitored\n Clot sent to blood bank\n Response:\n Hemodynamically stable, HR 80s SR and BPs 100-130s/60-70s. Stable\n groins. Adequate UOP. No further bleeding from PICC. AM HCT to be\n drawn\n Plan:\n Monitor s/sx bleeding- guiac stools.\n Serial HCTs--? Transfuse\n Change PICC dsg today\n Diabetes Mellitus (DM), Type I\n Assessment:\n Hyperglycemic FS 300-400s\n Action:\n HISS and glargine given accordingly\n Supper given\n Response:\n AM serum glucose\n Plan:\n Continue to monitor, treat as indicated.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n No SOB. LS rhonchorus-dim. 02 sats 100% on 5 L face mask. Mild Rt pedal\n edema. On lasix PO daily\n Action:\n 02 weaned\n Response:\n RA sats 96% when awake. Sats borderline 90-92% when asleep\n FM applied\n (dry nose to NC prior day\n Ocean spray ordered and given)\n Plan:\n Continue present mangement\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385779,
"text": ": Hypoglycemic w/ FS 32\nsymptomatic.\n Difficult stick\n Lt fem venous sheath DCd at 18:00. To IR, R\n brachial single lumen PICC placed.\n Viability study ordered\n needs venous access for study\n to start in\n am to nuclear med in am. Scan will be completed by Saturday am\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n PICC site oozing bleeding at 1900\ndsg re-inforced. Lt fem w/ small,\n non-expanding hematoma. + CSM, popliteal pulse (unable to check pedal\n pulses on Lt foot due to knee to toe cast). No c/o abd/back pain. Rt\n fem cath puncture sites WNL w/ good perfusion distally. PM HCT 25.5\n (28.8 yesterday AM).\n Action:\n HCTs checked\ngroin monitored\n Clot sent to blood bank\n Response:\n Hemodynamically stable, HR 80s SR and BPs 100-130s/60-70s. Stable\n groins. Adequate UOP. No further bleeding from PICC. AM HCT to be\n drawn\n Plan:\n Monitor s/sx bleeding- guiac stools.\n Serial HCTs--? Transfuse\n Change PICC dsg today\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n LS rhonchorus-dim. 02 sats 100% on 5 L face mask. Mild Rt pedal\n edema. On lasix PO daily\n Action:\n 02 weaned\n Response:\n RA sats 96% when awake. Sats borderline 90-92% when asleep\n FM applied\n (dry nose to NC prior day\n Ocean spray ordered and given). Denies\n SOB\n Plan:\n Continue present mangement\n Diabetes Mellitus (DM), Type I\n Assessment:\n Hyperglycemic FS 300-400s\n Action:\n HISS and glargine given accordingly\n Supper given\n Response:\n AM serum glucose\n Plan:\n Continue to monitor, treat as indicated.\n Cardiac heart healthy/diabetic diet\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o L ankle pain (recent fx\n leg in cast)\n Action:\n PRN 10mg PO Oxycodone ordered for pain\n Response:\n Good relief of pain\n Plan:\n Continue present pain management\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385780,
"text": "45 yo female w/ known CAD s/p CABG \n pt recently admitted to OSH\n for CHF and was managed at and d/c\nd home. Redeveloped SOB\n this morning, took home dose lasix 20mg po\n but could not urinate. SOB\n worsened so called 911 and sent to OSH\n O2 sats 80% on room air w/\n rapid respirations. Started on CPAP with sats 100% - 20mg IV lasix\n given and Tx to for cath. In Cath no changes noted from old cath\n in \n no interventions done. Additional 20mg IV lasix given. Tx to\n CCU for further management on NRB w/ Lt fem venous sheath in place.\n CCU course: 02 weaned. Rt groin oozing requiring pressure dsg.\n Hypoglycemic w/ FS 32\nsymptomatic.\n Difficult stick\n Lt fem venous sheath DCd @ 1800. R brachial\n single lumen PICC placed in IR\n Viability study ordered\n needs venous access for study\n to start in\n am to nuclear med in am. Scan will be completed by Saturday am\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n PICC site oozing bleeding at 1900\ndsg re-inforced. Lt fem w/ small,\n non-expanding hematoma. + CSM, popliteal pulse (unable to check pedal\n pulses on Lt foot due to knee to toe cast). No c/o abd/back pain. Rt\n fem cath puncture sites WNL w/ good perfusion distally. PM HCT 25.5\n (28.8 yesterday AM).\n Action:\n HCTs checked\ngroin monitored\n Clot sent to blood bank\n Response:\n Hemodynamically stable, HR 80s SR and BPs 100-130s/60-70s. Stable\n groins. Adequate UOP. No further bleeding from PICC. AM HCT to be\n drawn\n Plan:\n Monitor s/sx bleeding- guiac stools.\n Serial HCTs--? Transfuse\n Change PICC dsg today\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n LS rhonchorus-dim. 02 sats 100% on 5 L face mask. Mild Rt pedal\n edema. On lasix PO daily\n Action:\n 02 weaned\n Response:\n RA sats 96% when awake. Sats borderline 90-92% when asleep\n FM applied\n (dry nose to NC prior day\n Ocean spray ordered and given). Denies\n SOB\n Plan:\n Continue present mangement\n Diabetes Mellitus (DM), Type I\n Assessment:\n Hyperglycemic FS 300-400s\n Action:\n HISS and glargine given accordingly\n Supper given\n Response:\n AM serum glucose\n Plan:\n Continue to monitor, treat as indicated.\n Cardiac heart healthy/diabetic diet\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o L ankle pain (recent fx\n leg in cast)\n Action:\n PRN 10mg PO Oxycodone ordered for pain\n Response:\n Good relief of pain\n Plan:\n Continue present pain management\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385782,
"text": "45 yo F w/ CAD s/p CABG , diastolic HF w/ EF 55%, renal tx 2001and\n PVD, recently DCd from for CHF, admitted from OSH w/ SOB.\n Cath showed no changes from prior cath \nno interventions done.\n Diuresed w/ 20mg IV lasix and transferred to CCU for further management\n on NRB w/ Lt fem venous sheath in place. .\n CCU course: 02 weaned. Rt groin ooze requiring pressure dsg.\n Hypoglycemic w/ FS 32\nsymptomatic.\n Difficult stick\n Lt fem venous sheath DCd @ 1800. R brachial\n single lumen PICC placed in IR\n Viability study ordered\n needs venous access for study\n to start in\n am to nuclear med in am. Scan will be completed by Saturday am\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n PICC site oozing bleeding at 1900\ndsg re-inforced. Lt fem w/ small,\n non-expanding hematoma. + CSM, popliteal pulse (unable to check pedal\n pulses on Lt foot due to knee to toe cast). No c/o abd/back pain. Rt\n fem cath puncture sites WNL w/ good perfusion distally. PM HCT 25.5\n (28.8 yesterday AM).\n Action:\n HCTs checked\ngroin monitored\n Clot sent to blood bank\n Response:\n HD stable, HR 80s SR and BPs 100-130s/60-70s. (of note: BPs taken on R\n upper thigh R brachial PICC and L lower arm old\n fistula-thrombosed). Stable groins. Adequate UOP. No further bleeding\n from PICC. AM HCT to be drawn\n Plan:\n Monitor s/sx bleeding- guiac stools.\n Serial HCTs--? Transfuse\n Change PICC dsg today\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n LS course-dim. 02 sats 100% on 5 L face mask. Mild Rt pedal edema. On\n lasix PO daily\n Action:\n 02 weaned\n Response:\n RA sats 96% when awake. Sats borderline 90-92% when asleep\n FM applied\n (dry nose to NC prior day\n Ocean spray ordered and given). Denies\n SOB\n Plan:\n Continue present management\n Diabetes Mellitus (DM), Type I\n Assessment:\n Hyperglycemic FS 300-400s\n Action:\n HISS and glargine given accordingly\n Supper given\n Response:\n AM serum glucose\n Plan:\n Continue to monitor, treat as indicated.\n Cardiac heart healthy/diabetic diet\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o L ankle pain (recent fx\n leg in cast)\n Action:\n PRN 10mg PO Oxycodone ordered for pain\n Response:\n Good relief of pain. Last given at\n Plan:\n Continue present pain management\n Legally blind. Mult recent falls at home. HIGH FALL RISK. ADLs/Feeds\n self with set up and some assistance.\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385893,
"text": "45 yo F w/ CAD s/p CABG , diastolic HF w/ EF 55%, renal tx 2001and\n PVD, recently DCd from for fx l fibula f/b admit for CHF,\n admitted from OSH w/ SOB. Card cath showed no changes from prior\n cath \nno interventions done. Diuresed w/ 20mg IV lasix and\n transferred to CCU for further management\n Diabetes Mellitus (DM), Type I\n Assessment:\n Blood sugars > 200. Poor appetite.\n Action:\n Received glargine as ordered last eve, covering elevated blood glucose\n with ssri.\n Response:\n Blood glucose remains elevated despite coverage.\n Plan:\n Monitor fs, encourage po intake as tol.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n On 40% cool neb with o2 sats 95-97%. RR 22-24. crackles at bases,\n denies c/o sob. No further lasix given. diuresing well\n Action:\n Cont o2 cool neb (as pt. prefers).\n Response:\n Diuresing well, maintaining adequate o2 sats.\n Plan:\n Cath lab on Monday, possible PCI for lcx lesion. Monitor lytes,\n bun/creat, I/O\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385777,
"text": ": Hypoglycemic w/ FS 32\nsymptomatic.\n Difficult stick\n Lt fem venous sheath DCd at 18:00. R brachial\n single lumen PICC placed.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n PICC site oozing bleeding at 1900\ndsg re-inforced. Lt fem w/ small,\n non-expanding hematoma. No c/o abd/back pain. Rt fem cath puncture\n sites WNL. PM HCT 25.5 (28.8 yesterday AM).\n Action:\n HCTs checked\ngroin monitored\n Clot sent to blood bank\n Response:\n Hemodynamically stable, HR 80s SR and BPs 100-130s/60-70s. Stable\n groins. Adequate UOP. No further bleeding from PICC. AM HCT to be\n drawn\n Plan:\n Monitor s/sx bleeding- guiac stools.\n Serial HCTs--? Transfuse \\\n Change PICC dsg today\n Diabetes Mellitus (DM), Type I\n Assessment:\n Hyperglycemic FS 300-400s\n Action:\n HISS and glargine given accordingly\n Supper given\n Response:\n AM serum glucose\n Plan:\n Continue to monitor, treat as indicated.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n No SOB. LS rhonchorus-dim. 02 sats 100% on 5 L face mask. Mild Rt pedal\n edema. On lasix PO daily\n Action:\n 02 weaned\n Response:\n RA sats 96% when awake. Sats borderline 90-92% when asleep\n FM applied\n (dry nose to NC prior day\n Ocean spray ordered and given)\n Plan:\n Continue present mangement\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 385914,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Given another dose of Lasix 20mg IV at 1800 and has put out\n 140-200cc/hr of urine since. Still on non-rebreather. Myocardial\n viability study cancelled today because EF=55% so heart tissue must be\n viable. Patient will need cath (with intervention) on Monday. Plan is\n to increase home regimen of Lasix to 20mg PO BID once patient is\n completely diuresed and off of oxygen requirement.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:50 PM\n Ranitidine (Prophylaxis) - 10:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.6\nC (96\n HR: 79 (75 - 86) bpm\n BP: 143/75(87) {96/54(63) - 167/88(106)} mmHg\n RR: 12 (11 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55 kg (admission): 57.8 kg\n Height: 67 Inch\n Total In:\n 765 mL\n PO:\n 765 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,975 mL\n 800 mL\n Urine:\n 2,975 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,210 mL\n -800 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: ////\n Physical Examination\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with no elevated JVP\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: Scattered crackles heard at bases. Good respiratory effort.\n No wheezes.\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Cath sites- no erythema, no\n hematoma. Healing.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 410 K/uL\n 8.6 g/dL\n 90 mg/dL\n 1.4 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 30 mg/dL\n 105 mEq/L\n 138 mEq/L\n 27.3 %\n 6.0 K/uL\n [image002.jpg]\n 09:41 PM\n 05:30 AM\n 08:00 AM\n 10:47 PM\n 01:00 AM\n 04:50 AM\n WBC\n 6.6\n 6.3\n 6.0\n Hct\n 29.1\n 28.8\n 25.5\n 24.2\n 27.3\n Plt\n 454\n 415\n 410\n Cr\n 1.3\n 1.1\n 1.4\n Glucose\n 30\n 185\n 168\n 90\n Other labs: Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n Patient is a 45 yo female with CAD s/p CABG, diastolic HF and kidney\n transplant presenting from with shortness of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -cath on Monday with planned intervention\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n - wean oxygen as tolerated\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO shows \"the inferolateral wall systolic dysfunction\n is more evident and the severity of mitral regurgitation has decreased\n slightly.\" Went into flash pulmonary edema overnight, and received\n 20mg IV lasix this AM.\n -switch to 40mg PO lasix\n -O2 wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n -consider adding ACE or to regimen\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n -monitor levels of sirolimus and tacrlimus\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her creatinine over\n the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n -currently slightly elevated, but suspect acute pulmonary edema as\n etiology, and suspect improvement with diuresis\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PICC line\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM: (mother)- \n .\n DISPO: 3 today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 05:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 385916,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Given another dose of Lasix 20mg IV at 1800 and has put out\n 140-200cc/hr of urine since. Still on non-rebreather. Myocardial\n viability study cancelled today because EF=55% so heart tissue must be\n viable. Patient will need cath (with intervention) on Monday. Plan is\n to increase home regimen of Lasix to 20mg PO BID once patient is\n completely diuresed and off of oxygen requirement.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:50 PM\n Ranitidine (Prophylaxis) - 10:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 04:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.6\nC (96\n HR: 79 (75 - 86) bpm\n BP: 143/75(87) {96/54(63) - 167/88(106)} mmHg\n RR: 12 (11 - 31) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55 kg (admission): 57.8 kg\n Height: 67 Inch\n Total In:\n 765 mL\n PO:\n 765 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 2,975 mL\n 800 mL\n Urine:\n 2,975 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,210 mL\n -800 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 95%\n ABG: ////\n Physical Examination\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with no elevated JVP\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: Scattered crackles heard at bases. Good respiratory effort.\n No wheezes.\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Cath sites- no erythema, no\n hematoma. Healing.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 410 K/uL\n 8.6 g/dL\n 90 mg/dL\n 1.4 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 30 mg/dL\n 105 mEq/L\n 138 mEq/L\n 27.3 %\n 6.0 K/uL\n [image002.jpg]\n 09:41 PM\n 05:30 AM\n 08:00 AM\n 10:47 PM\n 01:00 AM\n 04:50 AM\n WBC\n 6.6\n 6.3\n 6.0\n Hct\n 29.1\n 28.8\n 25.5\n 24.2\n 27.3\n Plt\n 454\n 415\n 410\n Cr\n 1.3\n 1.1\n 1.4\n Glucose\n 30\n 185\n 168\n 90\n Other labs: Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n Patient is a 45 yo female with CAD s/p CABG, diastolic HF and kidney\n transplant presenting from with shortness of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -cath on Monday with planned intervention\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n - wean oxygen as tolerated\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO shows \"the inferolateral wall systolic dysfunction\n is more evident and the severity of mitral regurgitation has decreased\n slightly.\" Went into flash pulmonary edema overnight, and received\n 20mg IV lasix this AM.\n -switch to 40mg PO lasix\n -O2 wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n -consider adding ACE or to regimen\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n -monitor levels of sirolimus and tacrlimus\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her creatinine over\n the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n -currently slightly elevated, but suspect acute pulmonary edema as\n etiology, and suspect improvement with diuresis\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PICC line\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM: (mother)- \n .\n DISPO: 3 today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 05:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n Agree with above, nothing to add\n Physical Examination\n Agree with above, nothing to add\n Medical Decision Making\n Agree with above, nothing to add\n Total time spent on patient care: 60 minutes\n ------ Protected Section Addendum Entered By: ,MD\n on: 09:50 ------\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 385919,
"text": "HPI: 45 y/o female with known CAD s/p CABG presenting to \n upon transfer from for shortness of breath. She was recently\n admitted to (discharged on ) with CHF and eventually\n transferred to for management. She was medically managed and\n discharged home. This most recent episode began two nights ago. She\n had some shortness of breath that resolved after she took her home dose\n of lasix (20mg). Denied any symptoms over the day yesterday but then\n woke up over night and felt quite short of breath. She took 20mg PO\n lasix but said she \"could not urinate\". Symptoms progressively\n worsened so she called 911 and was taken to . Upon arrival to ,\n O2 sat was 80% with rapid respirations. The patient was started on\n CPAP and sats increased to 100%. The patient was also given 20mg IV\n lasix at . Remained pain free. Then transferred for cardiac\n catheterization. Prior to transfer to the patient was changed to\n non rebreather and was satting 98-100%.\n .\n Upon arrival to , patient underwent cardiac cath, which showed no\n changes from her previous cath. No intervention performed given\n results. ECHO today: \"compared with the prior study (images reviewed)\n of , the inferolateral wall systolic dysfunction is more\n evident and the severity of mitral regurgitation has decreased\n slightly.\"\n .\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385870,
"text": "45 yo F w/ CAD s/p CABG , diastolic HF w/ EF 55%, renal tx 2001and\n PVD, recently DCd from for fx l fibula f/b admit for CHF,\n admitted from OSH w/ SOB. Card cath showed no changes from prior\n cath \nno interventions done. Diuresed w/ 20mg IV lasix and\n transferred to CCU for further management on NRB w/ Lt fem venous\n sheath in place. R fem also w/ puncture.\n CCU course: 02 weaned. Rt groin ooze requiring pressure dsg.\n Hypoglycemic w/ FS 32\nsymptomatic.\n Difficult stick\n Lt fem venous sheath DCd @ 1800. R brachial\n single lumen PICC placed in IR.\n Vasc\n PICC, l fem site w/ small hematoma. Hct down to a low of 24.2\n 8/27 up to 27.3 8./28\n Viability study ordered , but discontinued . Plan for another\n cath w/ LCX intervention on Mon .\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Rec\nd pt on 100% NRB w/ sats 97-100%. Pt w/ crackles 1/3 up bilat.\n Mild Rt pedal edema.\n Action:\n AM po lasix dose held. 20mg IVP lasix given at 0800 at 1800\n Humidified face tent placed and weaned down to 40%. Lopressor 50mg\n given this am, then discontinued. Carvedilol 12.5mg to start at 8pm.\n Response:\n Sats maintained approx 96-98% throughout day. Rales cont 1/3 up.\n Diuresed over 1000cc with 8am lasix 20mg. Comfortable on current o2.\n Able to tolerate 2ln/p while eating w/ sats 97%.\n Plan:\n Monitor resp status, wean 02 as tol\n ? Restart po dose in am. Monitor renal fxn\n Diabetes Mellitus (DM), Type I\n Assessment:\n Fasting BS 90. Before breakfast fingerstick 148. Before lunch 208.\n Before dinner 452 w/ repeat 397.\n Action:\n HISS as ordered. 12 u h at 1800 for pre dinner fs. Encouraged po\n intake for solid food, as pt\ns preference is boost strawberry shake.\n Response:\n Poor po intake, cont w/ labile BS (pt states that this is baseline)\n Plan:\n Continue to monitor BS and treat as indicated. Cont encourage good\n nutritional intake.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o L ankle pain (recent fx\n leg in cast). Last oxycodone 15 hrs\n ago. Pt attempting to stretch out pain meds.\n Action:\n Oxycodone ii administered x2 during day.\n Response:\n Pain down to 2/10 post oxycodone.\n Plan:\n Continue present pain management encouraging pt to take meds when\n needed, Possibility of taking I oxycodone as to start to wean, turn and\n position for comfort.\n Legally blind. Mult recent falls at home. HIGH FALL RISK. ADLs/Feeds\n self with set up and some assistance.\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385731,
"text": "Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n L fem cath site w/ venous sheath\nWNL. + CMS, popliteal pulse. R fem\n puncture sites oozing. No CP\n Action:\n Team notified--pressure dsg applied to R groin\n Bed in reverse T-\nBedrest maintained\n Response:\n R groin stable. HCT 28.8 (29.1)\n Plan:\n Continue to monitor groins/VS/HCTs/PLTs\n DC venous sheath today\ndifficult stick, ? PICC\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Sats 96-99% on NRB. Adequate UOP. HR/BP WNL\n Action:\n Daily cardiac meds given last night as pt had not taken any\n meds per pt and per documentation.\n 02 weaned to NC\n Response:\n Currently on 4L NC w/ sats 92-96%. Denies SOB.\n Plan:\n Wean 02 as tolerated\n Diabetes Mellitus (DM), Type I\n Assessment:\n Did not eat supper-pt asleep. Given 2 custards w/ 20:00 meds. FS at\n 22:00- 32 symptomatic\n Action:\n Amp D50 given\n Response:\n Repeat FS 188\n half dose glargine dose given.\n Plan:\n Closely monitor FS, treat as indicated.\n Cardiac healthy/diabetic diet.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o L ankle pain\n Action:\n PRN Oxycodone ordered for pain\n Response:\n Good relief. Last dose given at 05:40\n Plan:\n Continue present pain managment\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 385826,
"text": "Chief Complaint:\n 24 Hour Events:\n - seen by IV access, who were unable to get access, IR placed PICC\n line.\n - femoral sheath removed, site checked @ 2153 - 1-2 cm hematoma noted\n on left femoral site, with bilateral femoral bruits auscultated,\n bilateral distal pulses 2+\n - checked HCT @ 10:47, dropped from 28.8 this AM to 25.5, patient is\n not tachycardiac, maintaining BP, Asx, will recheck at 1 AM and T&S 2\n units.\n - 1 am hct 24.2, decided against transfusion because of h/o flash\n pulmonary edema and patient hemodynamically stable and asx. Will follow\n up 5 am cbc. Returned at 27.\n - temporarily placed on NRB due to O2 sats 85%\n 93% with NRB. On\n exam, diffuse crackles\n gave 20 mg IV lasix (pt has been\n auto-diuresing well). Put out 110 mL in 15 mins after this.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:30 PM\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98.1\n HR: 82 (77 - 92) bpm\n BP: 121/69(80) {84/47(62) - 132/95(100)} mmHg\n RR: 14 (11 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55 kg (admission): 57.8 kg\n Height: 67 Inch\n Total In:\n 1,850 mL\n PO:\n 1,660 mL\n TF:\n IVF:\n 190 mL\n Blood products:\n Total out:\n 1,425 mL\n 490 mL\n Urine:\n 1,425 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 425 mL\n -490 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with no elevated JVP\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: Crackles heard at bases. Good respiratory effort. No\n wheezes.\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged-\n no signs of hematoma, erythema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 410 K/uL\n 8.6 g/dL\n 90\n 1.4 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 30 mg/dL\n 105 mEq/L\n 138 mEq/L\n 27.3 %\n 6.0 K/uL\n [image002.jpg]\n 09:41 PM\n 05:30 AM\n 08:00 AM\n 10:47 PM\n 01:00 AM\n WBC\n 6.6\n 6.3\n Hct\n 29.1\n 28.8\n 25.5\n 24.2\n Plt\n 454\n 415\n Cr\n 1.3\n 1.1\n Glucose\n 30\n 185\n 168\n Other labs: Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n DIABETES MELLITUS (DM), TYPE I\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n Patient is a 45 yo female with CAD s/p CABG, diastolic HF and kidney\n transplant presenting from with shortness of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n -post-cath check showing small hematoma, bilateral buits\n - wean oxygen as tolerated\n -no enzymes ordered given lack of symptoms and cath results which\n showed no changes from previous cath\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO shows \"the inferolateral wall systolic dysfunction\n is more evident and the severity of mitral regurgitation has decreased\n slightly.\" Went into flash pulmonary edema overnight, and received\n 20mg IV lasix this AM.\n -consider 20 mg IV lasix again this AM\n -O2 wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her creatinine over\n the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n -currently slightly elevated, but suspect acute pulmonary edema as\n etiology, and suspect improvement with diuresis\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PICC line\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM: (mother)- \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 05:07 PM\n Prophylaxis:\n DVT: HSQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: possible transfer to 3\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n Nothing to add\n Physical Examination\n Nothing to add\n Medical Decision Making\n Nothing to add\n Total time spent on patient care: 45 minutes.\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 385827,
"text": "Chief Complaint:\n 24 Hour Events:\n - seen by IV access, who were unable to get access, IR placed PICC\n line.\n - femoral sheath removed, site checked @ 2153 - 1-2 cm hematoma noted\n on left femoral site, with bilateral femoral bruits auscultated,\n bilateral distal pulses 2+\n - checked HCT @ 10:47, dropped from 28.8 this AM to 25.5, patient is\n not tachycardiac, maintaining BP, Asx, will recheck at 1 AM and T&S 2\n units.\n - 1 am hct 24.2, decided against transfusion because of h/o flash\n pulmonary edema and patient hemodynamically stable and asx. Will follow\n up 5 am cbc. Returned at 27.\n - temporarily placed on NRB due to O2 sats 85%\n 93% with NRB. On\n exam, diffuse crackles\n gave 20 mg IV lasix (pt has been\n auto-diuresing well). Put out 110 mL in 15 mins after this.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:30 PM\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98.1\n HR: 82 (77 - 92) bpm\n BP: 121/69(80) {84/47(62) - 132/95(100)} mmHg\n RR: 14 (11 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55 kg (admission): 57.8 kg\n Height: 67 Inch\n Total In:\n 1,850 mL\n PO:\n 1,660 mL\n TF:\n IVF:\n 190 mL\n Blood products:\n Total out:\n 1,425 mL\n 490 mL\n Urine:\n 1,425 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 425 mL\n -490 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with no elevated JVP\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: Crackles heard at bases. Good respiratory effort. No\n wheezes.\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged-\n no signs of hematoma, erythema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 410 K/uL\n 8.6 g/dL\n 90\n 1.4 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 30 mg/dL\n 105 mEq/L\n 138 mEq/L\n 27.3 %\n 6.0 K/uL\n [image002.jpg]\n 09:41 PM\n 05:30 AM\n 08:00 AM\n 10:47 PM\n 01:00 AM\n WBC\n 6.6\n 6.3\n Hct\n 29.1\n 28.8\n 25.5\n 24.2\n Plt\n 454\n 415\n Cr\n 1.3\n 1.1\n Glucose\n 30\n 185\n 168\n Other labs: Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n DIABETES MELLITUS (DM), TYPE I\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n Patient is a 45 yo female with CAD s/p CABG, diastolic HF and kidney\n transplant presenting from with shortness of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n -post-cath check showing small hematoma, bilateral buits\n - wean oxygen as tolerated\n -no enzymes ordered given lack of symptoms and cath results which\n showed no changes from previous cath\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO shows \"the inferolateral wall systolic dysfunction\n is more evident and the severity of mitral regurgitation has decreased\n slightly.\" Went into flash pulmonary edema overnight, and received\n 20mg IV lasix this AM.\n -consider 20 mg IV lasix again this AM\n -O2 wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her creatinine over\n the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n -currently slightly elevated, but suspect acute pulmonary edema as\n etiology, and suspect improvement with diuresis\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PICC line\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM: (mother)- \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 05:07 PM\n Prophylaxis:\n DVT: HSQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: possible transfer to 3\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385735,
"text": "45 yo female w/ known CAD s/p CABG \n pt recently admitted to OSH\n for CHF and was managed at and d/c\nd home. Redeveloped SOB\n this morning, took home dose lasix 20mg po\n but could not urinate. SOB\n worsened so called 911 and sent to OSH\n O2 sats 80% on room air w/\n rapid respirations. Started on CPAP with sats 100% - 20mg IV lasix\n given and Tx to for cath. In Cath no changes noted from old cath\n in \n no interventions done. Additional 20mg IV lasix given. Tx to\n CCU for further management on NRB.\n Diabetes Mellitus (DM), Type I\n Assessment:\n On admission FS 287.\n Action:\n Given 6units humalog s/c. ordered supper.\n Response:\n To recheck hs FS. Supper arrived at 7pm. Pt needs assist with tray\n blind.\n Plan:\n Glargine ordered for hs. Check FS hs. Assist with supper tray this\n evening.\n Coronary artery disease + Congestive Heart Failure.\n Assessment:\n No c/o chest pain. s/p cath\n which showed no change from previous\n cath in \n no intervention. Accessed Lt groin, some Rt groin\n sticks. #24g PIV Lt inner wrist\n flushes poorly. Pt rec\nd 20mg IV\n lasix in cath lab.\n Action:\n Both Rt + Lt groin sites WNL\n DSD. Dopplerable pulses on Rt. Unable to\n check Lt due to cast on lwr leg/foot. +csm to Lt foot. Lt venous sheath\n #8 remains in place due to poor IV access. LS coarse crackles bilat.\n Remains on NRB 100% with sats 94-96%.\n Response:\n No change.\n Plan:\n Repeat post cath lytes this evening. ?more lasix this evening. Monitor\n u/o. monitor respiratory status.\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 385725,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Last night- patient had low symptomatic FSBS (32). Was given 25mg of\n D50 and some juice. Repeat sugar was 188. Patient given half\n dose (9U) of lantus in evening. Felt much better. Says shortness of\n breath improving also.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:30 PM\n Heparin Sodium (Prophylaxis) - 09:45 PM\n Dextrose 50% - 10:02 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.3\nC (97.3\n HR: 79 (69 - 84) bpm\n BP: 123/54(70) {102/45(59) - 148/73(91)} mmHg\n RR: 15 (11 - 23) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 895 mL\n 181 mL\n PO:\n 525 mL\n 120 mL\n TF:\n IVF:\n 320 mL\n 61 mL\n Blood products:\n Total out:\n 1,505 mL\n 390 mL\n Urine:\n 505 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -610 mL\n -209 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of *** cm.\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged-\n no signs of hematoma, erythema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 454 K/uL\n 9.3 g/dL\n 30 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 137 mEq/L\n 29.1 %\n 6.6 K/uL\n [image002.jpg]\n 09:41 PM\n WBC\n 6.6\n Hct\n 29.1\n Plt\n 454\n Cr\n 1.3\n Glucose\n 30\n Other labs: Ca++:9.0 mg/dL, Mg++:1.9 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n Patient is a 45yo female with PMHx significant for CAD s/p CABG,\n diastolic HF and kidney transplant presenting from with shortness\n of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n -post-cath check at 2100\n -o2- wean as tolerated\n -no enzymes ordered given lack of symptoms and cath results which\n showed no changes from previous cath\n -EKG in AM\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO today shows \"the inferolateral wall systolic\n dysfunction is more evident and the severity of mitral regurgitation\n has decreased slightly.\" Received 20mg IV lasix today.\n -f/u ECHO\n -lasix 20mg PO for diuresis\n -O2- wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her\n creatinine over the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM: (mother)- \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:42 PM\n Cordis/Introducer - 04:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385722,
"text": "Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n L fem cath site w/ venous sheath\nWNL. + CMS, popliteal pulse. R fem\n puncture sites oozing. No CP\n Action:\n Team notified--pressure dsg applied to R groin\n Bed in reverse T-\nBedrest maintained\n Response:\n R groin stable. HCT\n Plan:\n Continue to monitor groins/VS/HCTs/PLTs\n DC venous sheath today\ndifficult stick, ? PICC\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Sats 96-99% on NRB. Adequate UOP. HR/BP WNL\n Action:\n Daily cardiac meds given last night as pt had not taken any\n meds per pt and per documentation.\n 02 weaned to NC\n Response:\n Currently on 4L NC w/ sats 92-96%. Denies SOB.\n Plan:\n Wean 02 as tolerated\n Diabetes Mellitus (DM), Type I\n Assessment:\n Did not eat supper-pt asleep. Given 2 custards w/ 20:00 meds. FS at\n 22:00- 32 symptomatic\n Action:\n Amp D50 given\n Response:\n Repeat FS 188\n half dose glargine dose given.\n Plan:\n Closely monitor FS, treat as indicated.\n Cardiac healthy/diabetic diet.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o L ankle pain\n Action:\n PRN Oxycodone ordered for pain\n Response:\n Good relief. Last dose given at 05:40\n Plan:\n Continue present pain managment\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385803,
"text": "45 yo F w/ CAD s/p CABG , diastolic HF w/ EF 55%, renal tx 2001and\n PVD, recently DCd from for CHF, admitted from OSH w/ SOB.\n Cath showed no changes from prior cath \nno interventions done.\n Diuresed w/ 20mg IV lasix and transferred to CCU for further management\n on NRB w/ Lt fem venous sheath in place. .\n CCU course: 02 weaned. Rt groin ooze requiring pressure dsg.\n Hypoglycemic w/ FS 32\nsymptomatic.\n Difficult stick\n Lt fem venous sheath DCd @ 1800. R brachial\n single lumen PICC placed in IR\n Viability study ordered\n to start in nuclear med in am. Scan will be\n completed by Saturday am\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n PICC site oozing bleeding at 1900\ndsg re-inforced. Lt fem cath site w/\n small, non-expanding hematoma. + CSM/opliteal pulse (unable to check\n pedal pulses on Lt foot due to knee to toe cast). No c/o abd/back pain.\n Rt fem cath puncture sites WNL w/ good perfusion distally. PM HCT 25.5\n (28.8 yesterday AM).\n Action:\n HCTs checked\ngroin monitored\n Clot sent to blood bank, type and cross for 2 units\n Response:\n HD stable, HR 80s SR and BPs 100-130s/60-70s. (of note: BPs taken on R\n upper thigh R brachial PICC and L lower arm old\n fistula-thrombosed). Stable groins. Adequate UOP. No further bleeding\n from PICC. AM HCT 27.3 (24.2)\n Plan:\n Monitor s/sx bleeding- guiac stools.\n Serial HCTs\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n LS course-dim. 02 sats 100% on 5L face mask. RA sats 96% when awake.\n Sats borderline 90-92% when asleep. Denies SOB. Mild Rt pedal edema.\n On 20mg lasix PO daily. Autodiuresing well\n Action:\n FM applied when asleep (dry nose to NC prior day\n Ocean\n spray ordered and given)\n Response:\n Sats 95% on 6L FM. ~0400, desat to 86% while sleeping. Lungs wet, +SOB,\n tachypneic\nplaced in high fowlers, NRB applied, atrovent puffs,f/b\n 20mg IV Lasix. Sats up to 100%. Diuresing. Less WOB noted. RR 15-17. AM\n Cr 1.4 (1.1)\n Plan:\n Monitor resp status, wean 02 as tol\n HOLD AM PO LASIX DOSE, discuss w/ HO re: need for more IV\n Lasix. Monitor renal fxn\n Diabetes Mellitus (DM), Type I\n Assessment:\n Hyperglycemic FS 300-400s\n Action:\n HISS and glargine given accordingly\n Supper given\n Response:\n AM serum glucose 90\n snack given at 06:00\n Plan:\n Continue to monitor, treat as indicated.\n Cardiac heart healthy/diabetic diet\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o L ankle pain (recent fx\n leg in cast)\n Action:\n PRN PO Oxycodone ordered for pain\n Response:\n Good relief of pain.\n Plan:\n Continue present pain management\n Legally blind. Mult recent falls at home. HIGH FALL RISK. ADLs/Feeds\n self with set up and some assistance.\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 385811,
"text": "Chief Complaint:\n 24 Hour Events:\n - seen by IV access, who were unable to get access, IR placed PICC\n line.\n - femoral sheath removed, site checked @ 2153 - 1-2 cm hematoma noted\n on left femoral site, with bilateral femoral bruits auscultated,\n bilateral distal pulses 2+\n - checked HCT @ 10:47, dropped from 28.8 this AM to 25.5, patient is\n not tachycardiac, maintaining BP, Asx, will recheck at 1 AM and T&S 2\n units.\n - 1 am hct 24.2, decided against transfusion because of h/o flash\n pulmonary edema and patient hemodynamically stable and asx. Will follow\n up 5 am cbc. Returned at 27.\n - temporarily placed on NRB due to O2 sats 85%\n 93% with NRB. On\n exam, diffuse crackles\n gave 20 mg IV lasix (pt has been\n auto-diuresing well). Put out 110 mL in 15 mins after this.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:30 PM\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98.1\n HR: 82 (77 - 92) bpm\n BP: 121/69(80) {84/47(62) - 132/95(100)} mmHg\n RR: 14 (11 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55 kg (admission): 57.8 kg\n Height: 67 Inch\n Total In:\n 1,850 mL\n PO:\n 1,660 mL\n TF:\n IVF:\n 190 mL\n Blood products:\n Total out:\n 1,425 mL\n 490 mL\n Urine:\n 1,425 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 425 mL\n -490 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with no elevated JVP\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: Crackles heard at bases. Good respiratory effort. No\n wheezes.\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged-\n no signs of hematoma, erythema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 410 K/uL\n 8.6 g/dL\n 90\n 1.4 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 30 mg/dL\n 105 mEq/L\n 138 mEq/L\n 27.3 %\n 6.0 K/uL\n [image002.jpg]\n 09:41 PM\n 05:30 AM\n 08:00 AM\n 10:47 PM\n 01:00 AM\n WBC\n 6.6\n 6.3\n Hct\n 29.1\n 28.8\n 25.5\n 24.2\n Plt\n 454\n 415\n Cr\n 1.3\n 1.1\n Glucose\n 30\n 185\n 168\n Other labs: Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n DIABETES MELLITUS (DM), TYPE I\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n Patient is a 45 yo female with CAD s/p CABG, diastolic HF and kidney\n transplant presenting from with shortness of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n -post-cath check showing small hematoma, bilateral buits\n - wean oxygen as tolerated\n -no enzymes ordered given lack of symptoms and cath results which\n showed no changes from previous cath\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO shows \"the inferolateral wall systolic dysfunction\n is more evident and the severity of mitral regurgitation has decreased\n slightly.\" Went into flash pulmonary edema overnight, and received\n 20mg IV lasix this AM.\n -consider 20 mg IV lasix again this AM\n -O2 wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her creatinine over\n the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n -currently slightly elevated, but suspect acute pulmonary edema as\n etiology, and suspect improvement with diuresis\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PICC line\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM: (mother)- \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 05:07 PM\n Prophylaxis:\n DVT: HSQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: possible transfer to 3\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 385797,
"text": "Chief Complaint:\n 24 Hour Events:\n - shortness of breath improved\n seen by IV access, who were unable to get access, IR placed PICC line.\n - femoral sheath removed, site checked @ 2153 - 1-2 cm hematoma noted\n on left femoral site, with bilateral femoral bruits auscultated,\n bilateral distal pulses 2+\n - checked HCT @ 10:47, dropped from 28.8 this AM to 25.5, patient is\n not tachycardiac, maintaining BP, Asx, will recheck at 1 AM and T&S 2\n units.\n - 1 am hct 24.2, decided against transfusion because of h/o flash\n pulmonary edema and patient hemodynamically stable and asx. Will follow\n up 5 am cbc.\n - temporarily placed on NRB due to O2 sats 85%\n 93% with NRB. On\n exam, diffuse crackles\n gave 20 mg IV lasix (pt has been\n auto-diuresing well)\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:30 PM\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98.1\n HR: 82 (77 - 92) bpm\n BP: 121/69(80) {84/47(62) - 132/95(100)} mmHg\n RR: 14 (11 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55 kg (admission): 57.8 kg\n Height: 67 Inch\n Total In:\n 1,850 mL\n PO:\n 1,660 mL\n TF:\n IVF:\n 190 mL\n Blood products:\n Total out:\n 1,425 mL\n 490 mL\n Urine:\n 1,425 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 425 mL\n -490 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with no elevated JVP\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: Occasional crackles heard at bases. Good respiratory effort.\n No wheezes. .\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged-\n no signs of hematoma, erythema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 415 K/uL\n 9.2 g/dL\n 168\n 1.1 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 24 mg/dL\n 105 mEq/L\n 138 mEq/L\n 24.2 %\n 6.3 K/uL\n [image002.jpg]\n 09:41 PM\n 05:30 AM\n 08:00 AM\n 10:47 PM\n 01:00 AM\n WBC\n 6.6\n 6.3\n Hct\n 29.1\n 28.8\n 25.5\n 24.2\n Plt\n 454\n 415\n Cr\n 1.3\n 1.1\n Glucose\n 30\n 185\n 168\n Other labs: Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n DIABETES MELLITUS (DM), TYPE I\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n Patient is a 45yo female with PMHx significant for CAD s/p CABG,\n diastolic HF and kidney transplant presenting from with shortness\n of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n -post-cath check at 2100\n -o2- wean as tolerated\n -no enzymes ordered given lack of symptoms and cath results which\n showed no changes from previous cath\n -EKG in AM\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO today shows \"the inferolateral wall systolic\n dysfunction is more evident and the severity of mitral regurgitation\n has decreased slightly.\" Received 20mg IV lasix today.\n -f/u ECHO\n -lasix 20mg PO for diuresis\n -O2- wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her\n creatinine over the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PICC line\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM: (mother)- \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 05:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385798,
"text": "45 yo F w/ CAD s/p CABG , diastolic HF w/ EF 55%, renal tx 2001and\n PVD, recently DCd from for CHF, admitted from OSH w/ SOB.\n Cath showed no changes from prior cath \nno interventions done.\n Diuresed w/ 20mg IV lasix and transferred to CCU for further management\n on NRB w/ Lt fem venous sheath in place. .\n CCU course: 02 weaned. Rt groin ooze requiring pressure dsg.\n Hypoglycemic w/ FS 32\nsymptomatic.\n Difficult stick\n Lt fem venous sheath DCd @ 1800. R brachial\n single lumen PICC placed in IR\n Viability study ordered\n needs venous access for study\n to start in\n am to nuclear med in am. Scan will be completed by Saturday am\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n PICC site oozing bleeding at 1900\ndsg re-inforced. Lt fem cath site w/\n small, non-expanding hematoma. + CSM/opliteal pulse (unable to check\n pedal pulses on Lt foot due to knee to toe cast). No c/o abd/back pain.\n Rt fem cath puncture sites WNL w/ good perfusion distally. PM HCT 25.5\n (28.8 yesterday AM).\n Action:\n HCTs checked\ngroin monitored\n Clot sent to blood bank, type and cross for 2 units\n Response:\n HD stable, HR 80s SR and BPs 100-130s/60-70s. (of note: BPs taken on R\n upper thigh R brachial PICC and L lower arm old\n fistula-thrombosed). Stable groins. Adequate UOP. No further bleeding\n from PICC. AM HCT to be drawn\n Plan:\n Monitor s/sx bleeding- guiac stools.\n Serial HCTs--? Transfuse\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n LS course-dim. 02 sats 100% on 5L face mask. RA sats 96% when awake.\n Sats borderline 90-92% when asleep. Denies SOB. Mild Rt pedal edema.\n On 20mg lasix PO daily. Autodiuresing well\n Action:\n FM applied when asleep (dry nose to NC prior day\n Ocean\n spray ordered and given)\n Response:\n Sats 95% on 6L FM. ~0400, desat to 86% while sleeping. Lungs wet, +SOB,\n tachypneic\nplaced in high fowlers, NRB applied, atrovent puffs,f/b\n 20mg IV Lasix. Sats currently 93-94%. Diuresing.\n Plan:\n Monitor resp status\n Diabetes Mellitus (DM), Type I\n Assessment:\n Hyperglycemic FS 300-400s\n Action:\n HISS and glargine given accordingly\n Supper given\n Response:\n AM serum glucose\n Plan:\n Continue to monitor, treat as indicated.\n Cardiac heart healthy/diabetic diet\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o L ankle pain (recent fx\n leg in cast)\n Action:\n PRN 10mg PO Oxycodone ordered for pain\n Response:\n Good relief of pain. Last given at\n Plan:\n Continue present pain management\n Legally blind. Mult recent falls at home. HIGH FALL RISK. ADLs/Feeds\n self with set up and some assistance.\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 385788,
"text": "Chief Complaint:\n 24 Hour Events:\n - shortness of breath improved\n seen by IV access, who were unable to get access, IR placed PICC line.\n - femoral sheath removed, site checked @ 2153 - 1-2 cm hematoma noted\n on left femoral site, with bilateral femoral bruits auscultated,\n bilateral distal pulses 2+\n - checked HCT @ 10:47, dropped from 28.8 this AM to 25.5, patient is\n not tachycardiac, maintaining BP, Asx, will recheck at 1 AM and T&S 2\n units.\n - 1 am hct 24.2, decided against transfusion because of h/o flash\n pulmonary edema and patient hemodynamically stable and asx. Will follow\n up 5 am cbc.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:30 PM\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98.1\n HR: 82 (77 - 92) bpm\n BP: 121/69(80) {84/47(62) - 132/95(100)} mmHg\n RR: 14 (11 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55 kg (admission): 57.8 kg\n Height: 67 Inch\n Total In:\n 1,850 mL\n PO:\n 1,660 mL\n TF:\n IVF:\n 190 mL\n Blood products:\n Total out:\n 1,425 mL\n 490 mL\n Urine:\n 1,425 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 425 mL\n -490 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n Labs / Radiology\n 415 K/uL\n 9.2 g/dL\n 168\n 1.1 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 24 mg/dL\n 105 mEq/L\n 138 mEq/L\n 24.2 %\n 6.3 K/uL\n [image002.jpg]\n 09:41 PM\n 05:30 AM\n 08:00 AM\n 10:47 PM\n 01:00 AM\n WBC\n 6.6\n 6.3\n Hct\n 29.1\n 28.8\n 25.5\n 24.2\n Plt\n 454\n 415\n Cr\n 1.3\n 1.1\n Glucose\n 30\n 185\n 168\n Other labs: Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n DIABETES MELLITUS (DM), TYPE I\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 05:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 385789,
"text": "Chief Complaint:\n 24 Hour Events:\n - shortness of breath improved\n seen by IV access, who were unable to get access, IR placed PICC line.\n - femoral sheath removed, site checked @ 2153 - 1-2 cm hematoma noted\n on left femoral site, with bilateral femoral bruits auscultated,\n bilateral distal pulses 2+\n - checked HCT @ 10:47, dropped from 28.8 this AM to 25.5, patient is\n not tachycardiac, maintaining BP, Asx, will recheck at 1 AM and T&S 2\n units.\n - 1 am hct 24.2, decided against transfusion because of h/o flash\n pulmonary edema and patient hemodynamically stable and asx. Will follow\n up 5 am cbc.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:30 PM\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 03:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98.1\n HR: 82 (77 - 92) bpm\n BP: 121/69(80) {84/47(62) - 132/95(100)} mmHg\n RR: 14 (11 - 33) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 55 kg (admission): 57.8 kg\n Height: 67 Inch\n Total In:\n 1,850 mL\n PO:\n 1,660 mL\n TF:\n IVF:\n 190 mL\n Blood products:\n Total out:\n 1,425 mL\n 490 mL\n Urine:\n 1,425 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 425 mL\n -490 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with no elevated JVP\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: Occasional crackles heard at bases. Good respiratory effort.\n No wheezes. .\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged-\n no signs of hematoma, erythema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 415 K/uL\n 9.2 g/dL\n 168\n 1.1 mg/dL\n 23 mEq/L\n 4.7 mEq/L\n 24 mg/dL\n 105 mEq/L\n 138 mEq/L\n 24.2 %\n 6.3 K/uL\n [image002.jpg]\n 09:41 PM\n 05:30 AM\n 08:00 AM\n 10:47 PM\n 01:00 AM\n WBC\n 6.6\n 6.3\n Hct\n 29.1\n 28.8\n 25.5\n 24.2\n Plt\n 454\n 415\n Cr\n 1.3\n 1.1\n Glucose\n 30\n 185\n 168\n Other labs: Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n DIABETES MELLITUS (DM), TYPE I\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n Patient is a 45yo female with PMHx significant for CAD s/p CABG,\n diastolic HF and kidney transplant presenting from with shortness\n of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n -post-cath check at 2100\n -o2- wean as tolerated\n -no enzymes ordered given lack of symptoms and cath results which\n showed no changes from previous cath\n -EKG in AM\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO today shows \"the inferolateral wall systolic\n dysfunction is more evident and the severity of mitral regurgitation\n has decreased slightly.\" Received 20mg IV lasix today.\n -f/u ECHO\n -lasix 20mg PO for diuresis\n -O2- wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her\n creatinine over the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PICC line\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM: (mother)- \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 05:07 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 385736,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Last night- patient had low symptomatic FSBS (32). Was given 25mg of\n D50 and some juice. Repeat sugar was 188. Patient given half\n dose (9U) of lantus in evening. Felt much better. Says shortness of\n breath improving also.\n Patient feels better this AM- denies any chest pain, dizziness,\n headaches. Improved shortness of breath.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:30 PM\n Heparin Sodium (Prophylaxis) - 09:45 PM\n Dextrose 50% - 10:02 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.3\nC (97.3\n HR: 79 (69 - 84) bpm\n BP: 123/54(70) {102/45(59) - 148/73(91)} mmHg\n RR: 15 (11 - 23) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 895 mL\n 181 mL\n PO:\n 525 mL\n 120 mL\n TF:\n IVF:\n 320 mL\n 61 mL\n Blood products:\n Total out:\n 1,505 mL\n 390 mL\n Urine:\n 505 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -610 mL\n -209 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with no elevated JVP\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged-\n no signs of hematoma, erythema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 454 K/uL\n 9.3 g/dL\n 30 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 137 mEq/L\n 29.1 %\n 6.6 K/uL\n [image002.jpg]\n 09:41 PM\n WBC\n 6.6\n Hct\n 29.1\n Plt\n 454\n Cr\n 1.3\n Glucose\n 30\n Other labs: Ca++:9.0 mg/dL, Mg++:1.9 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n Patient is a 45yo female with PMHx significant for CAD s/p CABG,\n diastolic HF and kidney transplant presenting from with shortness\n of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n -post-cath check at 2100\n -o2- wean as tolerated\n -no enzymes ordered given lack of symptoms and cath results which\n showed no changes from previous cath\n -EKG in AM\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO today shows \"the inferolateral wall systolic\n dysfunction is more evident and the severity of mitral regurgitation\n has decreased slightly.\" Received 20mg IV lasix today.\n -f/u ECHO\n -lasix 20mg PO for diuresis\n -O2- wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her\n creatinine over the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM: (mother)- \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:42 PM\n Cordis/Introducer - 04:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385762,
"text": "Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n L fem cath site w/ venous sheath\nWNL. + CMS, popliteal pulse. R fem\n puncture with pressure dsg. Dopplerable pulses on Rt leg, unable to\n check pedal pulses on Lt foot due to knee to toe cast. +CSM.\n Action:\n Bandaid to Rt groin site. Dopple pulses. Bed in reverse T-\nBedrest\n maintained.\n Response:\n R groin stable. HCT 28.8 (29.1).\n Plan:\n Viability study ordered\n needs venous access for study\n to start in\n am to nuclear med in am. Scan will be completed by Saturday am.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Sats 96-99% on 4L n/c. LS rhonchorous.\n Action:\n Tolerating cardiac meds today. Desaturated around noon to mid 80s\n stating nose stuffy and unable to breathe properly. Placed on simple\n facemask same 4L\n sats increased back to mid 90s. started on po lasix\n 40mg daily.\n Response:\n VSS. Sats >95% on 4L n/c this afternoon.\n Plan:\n Wean 02 as tolerated\n monitor resp status.\n Diabetes Mellitus (DM), Type I\n Assessment:\n FS qid w/ humalog sliding scale. glargine ordered for bedtime.\n Action/Response:\n Covered with HISS today. Taking meals well today.\n Plan:\n Closely monitor FS, treat as indicated. Cardiac healthy/diabetic diet.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o L ankle pain (recent fracture\n leg in cast)\n Action:\n PRN 10mg poOxycodone ordered for pain\n Response:\n Good relief of paint.\n Plan:\n Continue present pain managment\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 385738,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Last night- patient had low symptomatic FSBS (32). Was given 25mg of\n D50 and some juice. Repeat sugar was 188. Patient given half\n dose (9U) of lantus in evening. Felt much better. Says shortness of\n breath improving also.\n Patient feels better this AM- denies any chest pain, dizziness,\n headaches. Improved shortness of breath.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:30 PM\n Heparin Sodium (Prophylaxis) - 09:45 PM\n Dextrose 50% - 10:02 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.3\nC (97.3\n HR: 79 (69 - 84) bpm\n BP: 123/54(70) {102/45(59) - 148/73(91)} mmHg\n RR: 15 (11 - 23) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 895 mL\n 181 mL\n PO:\n 525 mL\n 120 mL\n TF:\n IVF:\n 320 mL\n 61 mL\n Blood products:\n Total out:\n 1,505 mL\n 390 mL\n Urine:\n 505 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -610 mL\n -209 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with no elevated JVP\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: Occasional crackles heard at bases. Good respiratory effort.\n No wheezes. .\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged-\n no signs of hematoma, erythema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 454 K/uL\n 9.3 g/dL\n 30 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 137 mEq/L\n 29.1 %\n 6.6 K/uL\n [image002.jpg]\n 09:41 PM\n WBC\n 6.6\n Hct\n 29.1\n Plt\n 454\n Cr\n 1.3\n Glucose\n 30\n Other labs: Ca++:9.0 mg/dL, Mg++:1.9 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n Patient is a 45yo female with PMHx significant for CAD s/p CABG,\n diastolic HF and kidney transplant presenting from with shortness\n of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n -post-cath check at 2100\n -o2- wean as tolerated\n -no enzymes ordered given lack of symptoms and cath results which\n showed no changes from previous cath\n -EKG in AM\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO today shows \"the inferolateral wall systolic\n dysfunction is more evident and the severity of mitral regurgitation\n has decreased slightly.\" Received 20mg IV lasix today.\n -f/u ECHO\n -lasix 20mg PO for diuresis\n -O2- wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her\n creatinine over the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM: (mother)- \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:42 PM\n Cordis/Introducer - 04:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 385739,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Last night- patient had low symptomatic FSBS (32). Was given 25mg of\n D50 and some juice. Repeat sugar was 188. Patient given half\n dose (9U) of lantus in evening. Felt much better. Says shortness of\n breath improving also.\n Patient feels better this AM- denies any chest pain, dizziness,\n headaches. Improved shortness of breath.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:30 PM\n Heparin Sodium (Prophylaxis) - 09:45 PM\n Dextrose 50% - 10:02 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.3\nC (97.3\n HR: 79 (69 - 84) bpm\n BP: 123/54(70) {102/45(59) - 148/73(91)} mmHg\n RR: 15 (11 - 23) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 895 mL\n 181 mL\n PO:\n 525 mL\n 120 mL\n TF:\n IVF:\n 320 mL\n 61 mL\n Blood products:\n Total out:\n 1,505 mL\n 390 mL\n Urine:\n 505 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -610 mL\n -209 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with no elevated JVP\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: Occasional crackles heard at bases. Good respiratory effort.\n No wheezes. .\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged-\n no signs of hematoma, erythema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 454 K/uL\n 9.3 g/dL\n 30 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 137 mEq/L\n 29.1 %\n 6.6 K/uL\n [image002.jpg]\n 09:41 PM\n WBC\n 6.6\n Hct\n 29.1\n Plt\n 454\n Cr\n 1.3\n Glucose\n 30\n Other labs: Ca++:9.0 mg/dL, Mg++:1.9 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n Patient is a 45yo female with PMHx significant for CAD s/p CABG,\n diastolic HF and kidney transplant presenting from with shortness\n of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n -post-cath check at 2100\n -o2- wean as tolerated\n -no enzymes ordered given lack of symptoms and cath results which\n showed no changes from previous cath\n -EKG in AM\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO today shows \"the inferolateral wall systolic\n dysfunction is more evident and the severity of mitral regurgitation\n has decreased slightly.\" Received 20mg IV lasix today.\n -f/u ECHO\n -lasix 20mg PO for diuresis\n -O2- wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her\n creatinine over the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM: (mother)- \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:42 PM\n Cordis/Introducer - 04:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2148-09-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 385748,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Last night- patient had low symptomatic FSBS (32). Was given 25mg of\n D50 and some juice. Repeat sugar was 188. Patient given half\n dose (9U) of lantus in evening. Felt much better. Says shortness of\n breath improving also.\n Patient feels better this AM- denies any chest pain, dizziness,\n headaches. Improved shortness of breath.\n Allergies:\n Codeine\n Nausea/Vomiting\n Amoxicillin\n Nausea/Vomiting\n Blood-Group Specific Substance\n Unknown;\n Adhesive Tape (Topical)\n \"tape absorbs i\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:30 PM\n Heparin Sodium (Prophylaxis) - 09:45 PM\n Dextrose 50% - 10:02 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.3\nC (97.3\n HR: 79 (69 - 84) bpm\n BP: 123/54(70) {102/45(59) - 148/73(91)} mmHg\n RR: 15 (11 - 23) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 895 mL\n 181 mL\n PO:\n 525 mL\n 120 mL\n TF:\n IVF:\n 320 mL\n 61 mL\n Blood products:\n Total out:\n 1,505 mL\n 390 mL\n Urine:\n 505 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n -610 mL\n -209 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///23/\n Physical Examination\n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with no elevated JVP\n CARDIAC: Regular rate and rhythm. holosystolic murmur heard best\n at apex. PMI located in 5th intercostal space, midclavicular line.\n Normal S1, S2. No rubs or gallops. No thrills, lifts.\n LUNGS: Occasional crackles heard at bases. Good respiratory effort.\n No wheezes. .\n ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.\n EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged-\n no signs of hematoma, erythema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 454 K/uL\n 9.3 g/dL\n 30 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 105 mEq/L\n 137 mEq/L\n 29.1 %\n 6.6 K/uL\n [image002.jpg]\n 09:41 PM\n WBC\n 6.6\n Hct\n 29.1\n Plt\n 454\n Cr\n 1.3\n Glucose\n 30\n Other labs: Ca++:9.0 mg/dL, Mg++:1.9 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n Patient is a 45yo female with PMHx significant for CAD s/p CABG,\n diastolic HF and kidney transplant presenting from with shortness\n of breath.\n .\n # CORONARIES: Known CAD s/p CABG in . Was cathed today which\n showed no change from previous cath in - no intervention was\n performed. Patient continues to deny chest pain.\n -tele\n -ASA 81mg daily\n -atorvastatin 40mg daily\n -plavix 75mg daily\n -Ezetimibe 10 mg daily\n -Isosorbide Mononitrate (Extended Release) 60 mg daily\n -post-cath check at 2100\n -o2- wean as tolerated\n -no enzymes ordered given lack of symptoms and cath results which\n showed no changes from previous cath\n -EKG in AM\n .\n # PUMP: History of diastolic dysfunction now presented with CHF\n exacerbation. ECHO today shows \"the inferolateral wall systolic\n dysfunction is more evident and the severity of mitral regurgitation\n has decreased slightly.\" Received 20mg IV lasix today.\n -f/u ECHO\n -lasix 20mg PO for diuresis\n -O2- wean as tolerated\n -metoprolol 50mg \n -nifedipine cr 60mg daily\n .\n # RHYTHM: Patient in normal sinus rhythm.\n -increase metoprolol dose if rate elevates for a sustained period of\n time\n .\n # Immune Suppression: Patient is s/p living donor kidney\n transplant.\n -continue on sirolimus 3 mg daily and tacrolimus 2 mg twice daily.\n -contact transplant regarding any dose changes needed\n -home dose of prednisone (4mg daily) continued\n .\n # Diabetes Mellitus Type I: Last A1C on was 8.7%.\n -Lantus plus sliding scale insulin.\n -monitor sugars\n .\n # Renal Disease: Patient is s/p kidney transplant. Her\n creatinine over the last year has ranged from 0.8-1.1.\n -monitor Cr given lasix administration\n .\n # Hypertension:\n -continue home doses of metoprolol and nifedipine extended release.\n .\n # Depression:\n -continue home medications of bupropion and citalopram.\n .\n # Pain: Questionable allergy to codiene- patient reports\n nausea/vomiting but has been taking oxycodone recently for ankle\n fracture.\n -continue PO oxycodone.\n .\n # Insomnia: Continue home dose of trazodone.\n .\n # Nausea: Continued reglan and zofran.\n .\n # Osteoporosis: Continued vitamin D and calcium.\n .\n FEN: replete lytes as needed. monitor closely given patient on lasix\n .\n ACCESS: PIV's\n .\n PROPHYLAXIS:\n -DVT ppx with heparin SC\n -Pain management with oxycodone PRN\n -Bowel regimen with senna, colace\n .\n CODE: Presumed full\n .\n COMM: (mother)- \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:42 PM\n Cordis/Introducer - 04:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n Nothing to add\n Physical Examination\n Nothing to add\n Medical Decision Making\n Nothing to add\n Total time spent on patient care: 70 minutes.\n ------ Protected Section Addendum Entered By: ,MD\n on: 09:59 ------\n"
},
{
"category": "Nursing",
"chartdate": "2148-09-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 385845,
"text": "45 yo F w/ CAD s/p CABG , diastolic HF w/ EF 55%, renal tx 2001and\n PVD, recently DCd from for fx l fibula f/b admit for CHF,\n admitted from OSH w/ SOB. Card cath showed no changes from prior\n cath \nno interventions done. Diuresed w/ 20mg IV lasix and\n transferred to CCU for further management on NRB w/ Lt fem venous\n sheath in place. R fem also w/ puncture.\n CCU course: 02 weaned. Rt groin ooze requiring pressure dsg.\n Hypoglycemic w/ FS 32\nsymptomatic.\n Difficult stick\n Lt fem venous sheath DCd @ 1800. R brachial\n single lumen PICC placed in IR\n Viability study ordered , but discontinued . Plan for another\n cath w/ LCX intervention on Mon .\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n PICC site oozing bleeding at 1900\ndsg re-inforced. Lt fem cath site w/\n small, non-expanding hematoma. + CSM/opliteal pulse (unable to check\n pedal pulses on Lt foot due to knee to toe cast). No c/o abd/back pain.\n Rt fem cath puncture sites WNL w/ good perfusion distally. PM HCT 25.5\n (28.8 yesterday AM).\n Action:\n HCTs checked\ngroin monitored\n Clot sent to blood bank, type and cross for 2 units\n Response:\n HD stable, HR 80s SR and BPs 100-130s/60-70s. (of note: BPs taken on R\n upper thigh R brachial PICC and L lower arm old\n fistula-thrombosed). Stable groins. Adequate UOP. No further bleeding\n from PICC. AM HCT 27.3 (24.2)\n Plan:\n Monitor s/sx bleeding- guiac stools.\n Serial HCTs\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Rec\nd pt on 100% NRB w/ sats 97-100%. Pt w/ crackles 1/3 up bilat.\n Mild Rt pedal edema.\n Action:\n AM po lasix dose held. 20mg IVP lasix given. Humidified face tent\n placed and weaned down to 40\n Response:\n Sats maintained approx 96-98% throughout day. Rales cont 1/3 up.\n Diuresed over 1000cc with 8am lasix 20mg. Comfortable on current o2.\n 1)\n Plan:\n Monitor resp status, wean 02 as tol\n ? pm dose of lasix as diuresis slows. Restart po dose in am. Monitor\n renal fxn\n Diabetes Mellitus (DM), Type I\n Assessment:\n Fasting BS 90. Before breakfast fingerstick 148. Before lunch 208.\n Action:\n HISS as ordered. Encouraged po intake for solid food, as pt\n preference is boost strawberry shake.\n Response:\n Poor po intake, but BS stable.\n Plan:\n Continue to monitor BS and treat as indicated. Cont encourage good\n nutritional intake.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o L ankle pain (recent fx\n leg in cast). Last oxycodone 15 hrs\n ago. Pt attempting to stretch out pain meds.\n Action:\n Oxycodone ii administered,\n Response:\n Good relief of pain.\n Plan:\n Continue present pain management encouraging pt to take meds when\n needed, Possibility of taking I oxycodone as to start to wean, turn and\n position for comfort.\n Legally blind. Mult recent falls at home. HIGH FALL RISK. ADLs/Feeds\n self with set up and some assistance.\n"
},
{
"category": "ECG",
"chartdate": "2148-10-01 00:00:00.000",
"description": "Report",
"row_id": 126918,
"text": "Sinus rhythm. Since the previous tracing the pattern of ST-T wave abnormalities\nin the precordial leads is different. T waves are not as prominent. Clinical\ncorrelation is suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2148-09-30 00:00:00.000",
"description": "Report",
"row_id": 126919,
"text": "Sinus rhythm. Since the previous tracing probably no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2148-09-30 00:00:00.000",
"description": "Report",
"row_id": 126920,
"text": "Sinus rhythm. Lateral T wave abnormalities. Baseline artifact. Since the\nprevious tracing of atrial premature beat not seen. ST-T wave\nabnormalities are less prominent.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2148-09-25 00:00:00.000",
"description": "Report",
"row_id": 126921,
"text": "Normal sinus rhythm, rate 84. Occasional ventricular premature beat. Delayed\nprecordial R wave progression; possibly normal variant. Non-specific lateral\nrepolarization changes consistent with myocardial ischemia. Compared to the\nprevious tracing of ventricular ectopy is new and lateral\nrepolarization changes are marginally more striking.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-09-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1095535,
"text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF vs. PNA\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CARDIAC CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman requiring non-rebreather despite diuresis\n REASON FOR THIS EXAMINATION:\n CHF vs. PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Requiring non-rebreather despite diuresis, to evaluate for pneumonia\n versus congestive failure.\n\n FINDINGS: In comparison with the study of , there is some decrease in the\n pulmonary interstitial prominence, consistent with some improvement in\n pulmonary vascular congestion. Blunting of the right costophrenic angle\n persists. Mild atelectatic changes are seen at the bases.\n\n No evidence of acute focal pneumonia.\n\n The right PICC line remains in place in this patient with intact midline\n sternal sutures.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1095366,
"text": " 7:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate, effusions, edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CARDIAC CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with shortness of breath, crackles on exam\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate, effusions, edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath with crackles on examination.\n\n FINDINGS: In comparison with the study of , there is increased prominence\n of ill-defined pulmonary vessels consistent with increasing pulmonary venous\n pressure. More discrete opacifications bilaterally are consistent with\n atelectasis and probable pleural effusions. The possibility of supervening\n consolidation cannot be unequivocally excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-09-26 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1095273,
"text": " 3:44 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: access\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CARDIAC CATHETERIZATION\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with PVD and history of poor access, currently had femoral\n sheath only from cath which needs to be removed before it gets infected. IV\n nurse and cannot place PICC.\n REASON FOR THIS EXAMINATION:\n access\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:40 PM\n PFI: Uncomplicated right brachial approach 27 cm internal length single-lumen\n PICC line placement.\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for antibiotics.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Drs. , , and performed the procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right brachial\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a single-lumen PICC line measuring 27 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided single-lumen\n PICC line placement via the right brachial venous approach. Final internal\n length is 27 cm, with the tip positioned in SVC. The line is ready to use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-09-26 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1095274,
"text": ", J. 3:44 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: access\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CARDIAC CATHETERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with PVD and history of poor access, currently had femoral\n sheath only from cath which needs to be removed before it gets infected. IV\n nurse and cannot place PICC.\n REASON FOR THIS EXAMINATION:\n access\n ______________________________________________________________________________\n PFI REPORT\n PFI: Uncomplicated right brachial approach 27 cm internal length single-lumen\n PICC line placement.\n\n\n"
}
] |
69,472 | 189,088 | This 57-year-old patient with recent syncopal attacks was investigated and was found to have a critical aortic stenosis, moderate mitral regurgitation with preserved left ventricular function. The patient was brought to the operating room on where the patient underwent an aortic valve replacement with size 23 St. Regent mechanical valve and mitral valve repair with size 26 annuloplasty band. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. The patient was diuresed on post operative day 1 and ventilator was weaned. Early POD 2 found the patient extubated, alert and oriented and breathing comfortably. She was weaned off her vasoactive medications on post operative day 2, including epinephrine and Neosynephrine. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. She went into a rapid atrial fibrillation and was loaded with Amiodarone in the CVICU. The patient was transferred to the telemetry floor for further recovery. Beta blockers were increased and Diltiazem was added for better heart rate control. Coumadin was started for atrial fibrillation and mechanical AVR. She was therapeutic with her INR at the time of discharge with a goal INR 2.5-3.5. Chest tubes and pacing wires were discontinued without complication. Cipro was started for a Klebsiella UTI (sensitive to Cipro). She was completing a 3 day course at the time of discharge and had a repeat urine culture prior to discharge which was pending. An echocardiogram was done on and results were pending at the time of this discharge summary. Upon discharge Zaroxyln was stopped and Lasix was changed to 40 mg po BID due to slight rise in BUN and creatinine. Her fluid status should be monitored closely and Lasix dosing is to be reevaluated in 2 weeks based on need for further diuresis. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 9 the patient was ambulating with assistance, she was tolerating a full oral diet, the wound was healing and pain was controlled with Ultram. The patient was discharged to House Rehab in in good condition with appropriate follow up appointment instructions and lab work instructions. | Mild (1+) aorticregurgitation is seen. Normal ascending aortadiameter. A right-sided PICC line is again seen, distal aspect not well appreciated, but likely unchanged in position, extending to the mid-to-lower portion of the SVC. Moderate retrocardiac atelectasis. There is mildpulmonary artery systolic hypertension. Theprosthetic aortic valve leaflets appear normal A mitral valve annuloplastyring is present. Small secundum ASD.LEFT VENTRICLE: Mild symmetric LVH. Unchanged moderate cardiomegaly with enlarged contour of the left heart border. The aortic valve isbicuspid. Normal descending aorta diameter.AORTIC VALVE: Bicuspid aortic valve. There is mild symmetric leftventricular hypertrophy. Mildly widened mediastinum, most likely of post-surgical origin. Right ventricular function. Minor ST-T waveabnormalities. A smallsecundum atrial septal defect is present. Trivialmitral regurgitation persists.Aorta is intact post decannulation. Suboptimal image quality as the patient wasdifficult to position. Moderate [2+] TR.Mild PA systolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Additional left retrocardiac atelectasis. FINDINGS: A right-sided chest tube has been removed. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. IMPRESSION: Right-sided chest tube removed. Moderate to severe (3+) MR.TRICUSPID VALVE: Moderate [2+] TR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Left ventricular function. To be leftalone for now.Annuloplasty ring seen in the mitral position. The patient has been extubated, the nasogastric tube has been removed, but the Swan-Ganz catheter and the pleural drains are still in place. Normal mitral valvesupporting structures. Normal AVR leaflets.MITRAL VALVE: Mitral valve annuloplasty ring. Cardiac and mediastinal silhouettes are stable. Moderate [2+] tricuspidregurgitation is seen. Double contour of the right heart border and hilus is unchanged. There iscritical aortic valve stenosis (valve area <0.8cm2). IMPRESSION: Unchanged postoperative appearance. Bilateral small pleural effusions and pulmonary vascular congestion are similar. The size of the cardiac silhouette has minimally decreased. Retrocardiac opacity likely atelectasis. Thepatient appears to be in sinus rhythm. Mediastinal drain and Swan-Ganz catheter remain in place. Small left pleural effusion is similar. On the left, the presence of a small pleural effusion cannot be excluded. Mild enlargement of the cardiac silhouette persists with some evidence of elevated pulmonary venous pressure. Aortic repair is visible. Probable sinus rhythm with low amplitude P waves. Biventricularsystolic function is unchanged. Unchanged right central venous access line, unchanged normal alignment of the sternal wires. Left-to-right shunt across the interatrial septumat rest. If clinicallyindicated, a transesophageal echocardiographic examination is recommended.Conclusions:The left atrium is dilated. If clinical concern CTA chest can be considered. Sternotomy wires and midline clips are intact. Sternotomy wires are intact. FINDINGS: Single AP upright portable view of the chest was obtained. FINAL REPORT INDICATION: Status post AVR and MVR. Since the previous tracing of the ventricular rate isfaster and further ST-T wave changes are present. Minimal overhydration. Inferolateral lead ST-T wave abnormalities arenon-specific. Aortic valve disease. Minimally improved ventilation of the right lung parenchyma with decrease of pulmonary edema. The left hemidiaphragm is still not well seen, consistent with atelectasis and probable small effusion. Right ventricular chamber size and free wallmotion are normal. COMPARISON: Preoperative chest radiograph from . Surgeon made aware offindings. PATIENT/TEST INFORMATION:Indication: Intraoperative TEE for AVR. Mitral valve disease. Mitral valve disease. Mitral regurgitation is present but cannot be quantified.Moderate [2+] tricuspid regurgitation is seen (may be significantlyunderestimated due to the suboptimal nature of this study). There is no pericardial effusion.IMPRESSION: Suboptimal image quality. Swan-Ganz catheter remains at the left main pulmonary artery. Dr made aware. Right IJ line is in unchanged position. Pulmonary hypertension. Normal regional LV systolic function.Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic arch diameter.AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). Suboptimalimage quality - poor parasternal views. Dr consulted. Critical AS (area <0.8cm2). Results were personally reviewed withthe MD caring for the patient.Conclusions:PrebypassA left-to-right shunt across the interatrial septum is seen at rest. Mechanical valve seen in the aortic position.The leaflets move well and the valve appears well seated. If clinically indicated, atransesophageal echocardiographic examination is recommended to betterquantitate the valvular regurgitation. Overall left ventricular systolicfunction is normal (LVEF>55%). The mitral valve leaflets are mildly thickened.Moderate to severe (3+) mitral regurgitation is seen. Widened mediastinum, could be post-surgical mediastinal hematoma. Suboptimal image quality - poor apicalviews. Bibasilar opacities are again seen, which may represent combination of effusion and atelectasis, although underlying consolidation due to pneumonia and/or aspiration cannot be excluded. Regional left ventricular wall motion is normal.Overall left ventricular systolic function is normal (LVEF>55%). The patient was undergeneral anesthesia throughout the procedure. Low lung volumes. Low lung volumes. Rightventricular chamber size and free wall motion are normal. Lung volumes are low. Valvular heart disease.Height: (in) 64Weight (lb): 277BSA (m2): 2.25 m2HR (bpm): 73Status: InpatientDate/Time: at 10:41Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA.LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded. Cardiomegaly is stable. LINE PLACEMENT Clip # Reason: CARDIAC SURGERY. Preoperative assessment. MR present but cannot bequantified.TRICUSPID VALVE: Tricuspid valve not well visualized. Suboptimal image quality - body habitus. A bileaflet aortic valve prosthesis is present. FINDINGS: As compared to the previous radiograph, there is no relevant change. Severely thickened/deformed aortic valveleaflets. PATIENT/TEST INFORMATION:Indication: Aortic valve disease. Cannot exclude accelerated junctional rhythm. On CPBto fix it.Despite third bypass run the jet extending from the aortic root to the leftatrium persists. Suboptimal image quality - poor subcostal views. Prosthetic valve function. Narrow complex tachycardia of uncertain mechanism but may be atrial tachycardiaor possible flutter. Since the previous tracing of the rate is slower.P waves have lesser magnitude. | 13 | [
{
"category": "Radiology",
"chartdate": "2144-02-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1176409,
"text": " 10:14 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p chest tube D/C\n Admitting Diagnosis: AORTIC VALVE STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with AVR, MVR repair\n REASON FOR THIS EXAMINATION:\n s/p chest tube D/C\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post cardiac surgery and chest tube removal.\n\n COMPARISON: at 8 a.m.\n\n FINDINGS: A right-sided chest tube has been removed. There is no convincing\n evidence for pneumothorax on this limited radiograph. Lung volumes are low.\n Swan-Ganz catheter remains at the left main pulmonary artery. Bilateral small\n pleural effusions and pulmonary vascular congestion are similar. Sternotomy\n wires are intact.\n\n IMPRESSION: Right-sided chest tube removed. No obvious pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-02-12 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1177143,
"text": " 8:55 AM\n CHEST (PA & LAT) Clip # \n Reason: eval effusion\n Admitting Diagnosis: AORTIC VALVE STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with s/p avr and mv ring pod 8\n REASON FOR THIS EXAMINATION:\n eval effusion\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj WED 11:28 AM\n PFI: Unchanged postoperative appearance.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post AVR and MVR.\n\n COMPARISON: to .\n\n FINDINGS: Right basilar atelectasis and postoperative changes are stable\n since the prior film three days ago. Double contour of the right heart border\n and hilus is unchanged. Cardiomegaly is stable. Small left pleural effusion\n is similar. Right IJ line is in unchanged position. Sternotomy wires and\n midline clips are intact.\n\n IMPRESSION: Unchanged postoperative appearance.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-02-12 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1177144,
"text": ", CSURG FA6A 8:55 AM\n CHEST (PA & LAT) Clip # \n Reason: eval effusion\n Admitting Diagnosis: AORTIC VALVE STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with s/p avr and mv ring pod 8\n REASON FOR THIS EXAMINATION:\n eval effusion\n ______________________________________________________________________________\n PFI REPORT\n PFI: Unchanged postoperative appearance.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-02-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1176606,
"text": " 5:54 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o ptx\n Admitting Diagnosis: AORTIC VALVE STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman s/p AVR/MVR-new cvl\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, single AP upright portable view.\n\n CLINICAL INFORMATION: 56-year-old male with history of chest pain, recent\n aortic valvuloplasty.\n\n COMPARISON: .\n\n FINDINGS: Single AP upright portable view of the chest was obtained.\n Bibasilar opacities are again seen, which may represent combination of\n effusion and atelectasis, although underlying consolidation due to pneumonia\n and/or aspiration cannot be excluded. Indistinctness and prominence of the\n hila could be due to vascular engorgement. A right-sided PICC line is again\n seen, distal aspect not well appreciated, but likely unchanged in position,\n extending to the mid-to-lower portion of the SVC. Cardiac and mediastinal\n silhouettes are stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-02-09 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1176727,
"text": " 8:27 PM\n CHEST (PA & LAT) Clip # \n Reason: interval chnage\n Admitting Diagnosis: AORTIC VALVE STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with mech AVR\n REASON FOR THIS EXAMINATION:\n interval chnage\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Mechanical AVR, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is better\n transparency of both lungs, notably on the left, likely to reflect improved\n ventilation. Unchanged moderate cardiomegaly with enlarged contour of the\n left heart border. Unchanged right central venous access line, unchanged\n normal alignment of the sternal wires. Aortic repair is visible.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-02-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1176373,
"text": " 8:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: AORTIC VALVE STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman s/p avr\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AVR, to assess for effusions.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Mediastinal drain and Swan-Ganz catheter remain in place. Mild\n enlargement of the cardiac silhouette persists with some evidence of elevated\n pulmonary venous pressure. The left hemidiaphragm is still not well seen,\n consistent with atelectasis and probable small effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-02-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1175983,
"text": " 7:12 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: CARDIAC SURGERY. Pleural effusion, pulmonary edema, tamponad\n Admitting Diagnosis: AORTIC VALVE STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with AVR\n REASON FOR THIS EXAMINATION:\n CARDIAC SURGERY. Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n ______________________________________________________________________________\n WET READ: IPf TUE 8:55 PM\n Lines and tube in place. Widened mediastinum, could be post-surgical\n mediastinal hematoma. If clinical concern CTA chest can be considered.\n No PTX. Low lung volumes. Retrocardiac opacity likely atelectasis.\n Pls correlate clinically and page radiology (3-xray) if need to discuss.\n ; page sent to NP at 8:55 pm on \n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Cardiac surgery, evaluation for changes.\n\n COMPARISON: Preoperative chest radiograph from .\n\n FINDINGS: Normal position of all monitoring and support devices. No evidence\n of pneumothorax. Low lung volumes. Moderate retrocardiac atelectasis.\n Mildly widened mediastinum, most likely of post-surgical origin. Minimal\n overhydration. No evidence of larger pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-02-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1176219,
"text": " 7:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: AORTIC VALVE STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman s/p cabg\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG, evaluation for pleural effusion.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The patient has been extubated, the nasogastric tube has been\n removed, but the Swan-Ganz catheter and the pleural drains are still in place.\n\n Minimally improved ventilation of the right lung parenchyma with decrease of\n pulmonary edema. On the left, the presence of a small pleural effusion cannot\n be excluded. Additional left retrocardiac atelectasis.\n\n No evidence of pneumothorax. The size of the cardiac silhouette has minimally\n decreased.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2144-02-13 00:00:00.000",
"description": "Report",
"row_id": 85036,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Mitral valve disease. Valvular heart disease.\nHeight: (in) 64\nWeight (lb): 277\nBSA (m2): 2.25 m2\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 10:41\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic arch diameter.\n\nAORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). Normal AVR leaflets.\n\nMITRAL VALVE: Mitral valve annuloplasty ring. MR present but cannot be\nquantified.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. No TS. Moderate [2+] TR.\nMild PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews. Suboptimal image quality - poor subcostal views. Suboptimal image\nquality - poor suprasternal views. Suboptimal image quality as the patient was\ndifficult to position. Suboptimal image quality - body habitus. If clinically\nindicated, a transesophageal echocardiographic examination is recommended.\n\nConclusions:\nThe left atrium is dilated. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. Overall left ventricular systolic\nfunction is normal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal. A bileaflet aortic valve prosthesis is present. The\nprosthetic aortic valve leaflets appear normal A mitral valve annuloplasty\nring is present. Mitral regurgitation is present but cannot be quantified.\nModerate [2+] tricuspid regurgitation is seen (may be significantly\nunderestimated due to the suboptimal nature of this study). There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. If clinically indicated, a\ntransesophageal echocardiographic examination is recommended to better\nquantitate the valvular regurgitation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2144-02-04 00:00:00.000",
"description": "Report",
"row_id": 85037,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for AVR. Aortic valve disease. Left ventricular function. Mitral valve disease. Preoperative assessment. Prosthetic valve function. Pulmonary hypertension. Right ventricular function. Valvular heart disease.\nHeight: (in) 64\nWeight (lb): 277\nBSA (m2): 2.25 m2\nBP (mm Hg): 123/56\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 11:50\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. Left-to-right shunt across the interatrial septum\nat rest. Small secundum ASD.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal regional LV systolic function.\nOverall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal descending aorta diameter.\n\nAORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed aortic valve\nleaflets. Critical AS (area <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Normal mitral valve\nsupporting structures. Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Moderate [2+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPrebypass\n\nA left-to-right shunt across the interatrial septum is seen at rest. A small\nsecundum atrial septal defect is present. There is mild symmetric left\nventricular hypertrophy. Regional left ventricular wall motion is normal.\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The aortic valve is\nbicuspid. The aortic valve leaflets are severely thickened/deformed. There is\ncritical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened.\nModerate to severe (3+) mitral regurgitation is seen. Moderate [2+] tricuspid\nregurgitation is seen. There is no pericardial effusion. Dr. was\nnotified in person of the results on at 900am\n\nPost bypass\n\nPatient is AV paced and receiving an infusion of phenylephrine. Biventricular\nsystolic function is unchanged. Mechanical valve seen in the aortic position.\nThe leaflets move well and the valve appears well seated. The paeak gradient\nacross the aortic valve is 20 mm Hg. The mitral regurgitation varies between 2\nto 3 +. Dr present to confirm the findings. Surgeon made aware of\nfindings. Decided to go back on CPB to fix the mitral regurgitation.\n\nPost second bypass there is a jet seen extending from the aortic root to the\nleft atrium. Dr present to confirm findings. Surgeon made aware. On CPB\nto fix it.\n\nDespite third bypass run the jet extending from the aortic root to the left\natrium persists. Dr made aware. Dr consulted. To be left\nalone for now.\n\nAnnuloplasty ring seen in the mitral position. It appears well seated. Trivial\nmitral regurgitation persists.\n\nAorta is intact post decannulation.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2144-02-04 00:00:00.000",
"description": "Report",
"row_id": 213408,
"text": "Probable sinus rhythm with low amplitude P waves. Minor ST-T wave\nabnormalities. Since the previous tracing of the rate is slower.\nP waves have lesser magnitude. ST-T wave abnormalities are now more\nprominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2144-02-09 00:00:00.000",
"description": "Report",
"row_id": 216921,
"text": "Narrow complex tachycardia of uncertain mechanism but may be atrial tachycardia\nor possible flutter. Inferolateral lead ST-T wave abnormalities are\nnon-specific. Since the previous tracing of the ventricular rate is\nfaster and further ST-T wave changes are present.\n\n"
},
{
"category": "ECG",
"chartdate": "2144-02-05 00:00:00.000",
"description": "Report",
"row_id": 216922,
"text": "Supraventricular rhythm of indeterminate origin is possibly sinus mechanism\nwith P wave in T wave. Cannot exclude accelerated junctional rhythm. Compared\nto the previous tracing of there is no diagnostic change.\n\n"
}
] |
89,528 | 120,508 | Transferred from outside hospital for cardiac catheterization after presenting with chest pain. She was found to have coronary artery disease and cardiac surgery was consulted. Post procedure she was admitted to cardiology and underwent preoperative workup. Of note she had elevated hgbA1c 7.4 and was consulted for new diabetes diagnosis. She was placed on insulin sliding scale for blood glucose management. On she was brought to the operating room for coronary artery bypass graft surgery. See operative report for further details in summary she had: coronary artery bypass graft x2 with a left internal mammary artery to the left anterior descending artery, and a reverse saphenous vein graft to the obtuse marginal artery. Her bypass time was 62 minutes, with a crossclamp of 47 minutes. She received vancomycin and cefazolin for perioperative antibiotics, and ciprofloxacin for treatment of urinary tract infection. She tolerated the operation well andpost-operatively was transferred to the intensive care unit for post operative management. That evening she required neosynephrine for blood pressure management and was transfused with packed red blood cells for post operative bleeding. In the first twenty four hours she was weaned from sedation, awoke neurological intact, and extubated without complications. She continued on neosynephrine for blood pressure management and was started on lasix for diuresis. She was transitioned to insulin sliding scale with lantus from insulin drip for blood glucose management. On post operative day two she was found to have decreased saturations and chest xray that revealed pulmonary edema, she was switched to lasix drip for aggressive diuresis with good response. However she remained relatively hypoxic and that evening she required non invasive ventilation for hypoxia. Over the next several days she continued with high oxygen requirement with non invasive ventilation, non breather mask, or high flow oxygen mask. She was weaned off neosynephrine on and started on beta blockers. Early in the am she developed atrial fibrillation and was treated with amiodarone bolus and converted back to sinus tachycardia. She continued to have intermittent episodes of atrial fibrillation treated with betablockers and amiodarone over the next few days and then she remained in sinus rhythm. On she was noted to have elevated liver functions- an abdominal ultrasound was negative. Her medications were adjusted as there was concern for drug related transaminase elevation, so metformin and amiodarone were stopped. Her liver functions progressively improved. She again had occaisional bouts of atrial finrillation and Diltiazem was added to the beta blockers with good effect. She developed acute kidney injury with baseline creatinine 0.4 peak 2.6 on . On lasix drip was stopped and diuresis held due to increased creatinine. On Pulmonary was consulted due to ongoing hypoxia with high flow oxygen requirements. She was started steroids and had chest CT scan to further evaluate hypoxia. Pulmonary continued to follow her and she was tapered from IV to oral steroids. With the addition of steroids she had worsening hyperglycemia and required insulin drip for managment. She slowly improved and was able to be weaned down to nasal cannula on . She continued to progressively improve and remained on nasal cannula, transitioned to sliding scale insulin with lantus and remained in sinus rhythm. On she was transferred from the ICU to the floor for the remainder of her care. An initial attempt to taper steroids led to increased shortness of breath they were increased back to 60 mg daily. She was restarted on lasix for diuresis requiring intravenous lasix. She continues on telemetry for rhythm management. On her steroids were dropped to 50 mg daily to restart slow taper. On she had a guaiac positive melenotic stool. Hematocrit was trending downward, requiring transfusion of 2 units of packed red cells. Proton pump inhibitor was initiated along with a Gastroenterology consult. For closer 24 hour observation, she was transferred back to CVICU for further GI workup. Her pulmonary status remained tenuous but slowly improving. She was weaned to nasal cannula and she was on 3 liters at the time of discharge. Dr. and GI discussed the risks and benefits of having a EGD performed. Initially she had been made NPO and an EGD scheduled but her hematocrit remained stable and it was felt that further workup could be done as an outpatient, so as to not set her back from a pulmonary standpoint, the EGD was not performed during admission. She remains on medication for painful swallowing thought likely secondary to fungal esophagitis due to steroids, treated with Nystatin swish and swallow and Diflucan. She was ready for discharge to , on POD #37 with plan for follow up PFTs and pulmonary appointment. Additionally her steroids continue at 20 mg daily with taper plan to be determined at follow up with Pulmonology. Gastroenterology, as well as cardiology, and cardiac surgery follow up appointments advised. stop | Abnormal septalmotion/position.AORTA: Normal aortic diameter at the sinus level. Small, echo dense effusion, mostly overlying the right ventricularfree wall. Right ventricular chamber size and free wall motion are normal.There is abnormal septal motion/position. Right ventricular chamber size and free wall motion are normal.There is a small pericardial effusion/collection subtending primarily theright ventricular free wall but possibly extensing to the inferior andposterior walls of the left ventricle. Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded.RIGHT VENTRICLE: Paradoxic septal motion consistent with prior cardiacsurgery.AORTIC VALVE: Mildly thickened aortic valve leaflets. The aortic valve leaflets are mildlythickened (?#). Moderate PAsystolic hypertension.PERICARDIUM: Small pericardial effusion. There are simple atheroma in the aortic root. No AS.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Trivial MR. LV inflow pattern c/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Left-to-right shunt acrossthe interatrial septum at rest.LEFT VENTRICLE: Mild (non-obstructive) focal hypertrophy of the basal septum.Normal regional LV systolic function. Mild mitral annularcalcification. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. A left-to-right shunt across theinteratrial septum is seen at rest consistent with a small atrial septaldefect. Mildly dilated ascendingaorta. There is a very smallpartially echofilled inferolateral pericardial effusion best seen onparasternal views with no evidence of hemodynamic compromise.Compared with the prior study (images reviewed) of , theinferolateral echo filled space is new and c/w possible small hematoma. The mitral valve appears structurally normal withtrivial mitral regurgitation. Normal RV freewall thickness.AORTA: Simple atheroma in aortic root. The tricuspid valve leaflets are mildlythickened. The aortic valve leaflets are moderatelythickened, with sclerosis and decreased motion of the noncoronary cusp. There is moderate pulmonary artery systolic hypertension. No MR.PERICARDIUM: Very small pericardial effusion. There isa small pericardial effusion. Normal aortic arch diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3).MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - body habitus.Conclusions:The left atrium is normal in size. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Diastolicydysfunction consistent with impaired LV relaxation. Moderate pulmonary artery systolic hypertension.Compared with the prior study (images reviewed) of , findings aresimilar. Moderately thickened aortic valveleaflets. The left ventricularcavity is unusually small. The ascending aortais mildly dilated. The right ventricular free wallthickness is normal. Effusion echo dense, c/w blood,inflammation or other cellular elements.GENERAL COMMENTS: The patient appears to be in sinus rhythm.Conclusions:The left atrium and right atrium are normal in cavity size. Since the previous tracing of tachycardia with atrialectopy is now present, inferor lead QRS configuration is less suggestive ofpossible prior inferior myocardial infarction and ST-T wave changes are nowseen. Normal mitral valvesupporting structures. There is mild (non-obstructive) focal hypertrophy of the basal septum.Overall left ventricular systolic function is normal (LVEF>55%). Cannot excludeprior inferior myocardial infarction. The aortic valve leaflets (3) aremildly thickened but aortic stenosis is not present. Trivialmitral regurgitation is seen. Trivial mitral regurgitation isseen. PATIENT/TEST INFORMATION:Indication: f/u effusionHeight: (in) 63Weight (lb): 156BSA (m2): 1.74 m2BP (mm Hg): 118/64HR (bpm): 80Status: InpatientDate/Time: at 16:09Test: Portable TTE (Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Mild symmetric LVH. Left ventricular function.Weight (lb): 167BP (mm Hg): 109/61HR (bpm): 70Status: InpatientDate/Time: at 09:21Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness and cavity size. Hyperdynamic LVEF >75%.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.PERICARDIUM: Small pericardial effusion. Trace aorticregurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. Regional left ventricular wallmotion is normal. The left atrium is mildly dilated. PATIENT/TEST INFORMATION:Indication: Coronary artery disease.BP (mm Hg): 120/80HR (bpm): 65Status: InpatientDate/Time: at 11:08Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.LEFT VENTRICLE: Moderate symmetric LVH.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Left ventricularwall thicknesses and cavity size are normal. Right ventricular chambersize and free wall motion are normal. Normal regional LVsystolic function. There ismoderate symmetric left ventricular hypertrophy. Suboptimal image quality -ventilator. Effusion echo dense, c/w blood,inflammation or other cellular elements.Conclusions:There is mild symmetric left ventricular hypertrophy. Tamponade.Status: InpatientDate/Time: at 09:11Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:paradoxical ventricular septal motion consistent with post-CABG.This study was compared to the prior study of .LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolicfunction (LVEF>55%). Preoperative assessment.Height: (in) 63Weight (lb): 172BSA (m2): 1.82 m2BP (mm Hg): 143/94HR (bpm): 68Status: InpatientDate/Time: at 11:09Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Delayed R wave progression.Modest ST-T wave changes. The effusion is echo dense, consistent withblood, inflammation or other cellular elements.IMPRESSION: Normal regional and global biventricular systolic function. There arethree aortic valve leaflets. Non-specific ST-T wave changes. Themitral valve leaflets are mildly thickened. Sinus rhythm with atrial premature beats. Rightventricular chamber size and free wall motion are normal. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Noprevious tracing available for comparison. Borderline low QRS voltage in the limb leads. Focal calcifications in aortic root.Normal descending aorta diameter.AORTIC VALVE: Three aortic valve leaflets. Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. | 9 | [
{
"category": "Echo",
"chartdate": "2125-07-13 00:00:00.000",
"description": "Report",
"row_id": 98666,
"text": "PATIENT/TEST INFORMATION:\nIndication: f/u effusion\nHeight: (in) 63\nWeight (lb): 156\nBSA (m2): 1.74 m2\nBP (mm Hg): 118/64\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 16:09\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Hyperdynamic LVEF >75%.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: Small pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity is unusually small. Left ventricular systolic function is hyperdynamic\n(EF 75%). Right ventricular chamber size and free wall motion are normal.\nThere is a small pericardial effusion/collection subtending primarily the\nright ventricular free wall but possibly extensing to the inferior and\nposterior walls of the left ventricle. Part of the clear space may be\nepicardial fat. The effusion is echo dense, consistent with blood,\ninflammation or other cellular elements. No evidence of cardiac tamponade.\n\nCompared to previous study of , the pericardial collection is\nreduced in volume.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2125-07-09 00:00:00.000",
"description": "Report",
"row_id": 98647,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Left ventricular function.\nWeight (lb): 167\nBP (mm Hg): 109/61\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 09:21\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Overall normal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Abnormal septal\nmotion/position.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Calcified tips of papillary muscles. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate PA\nsystolic hypertension.\n\nPERICARDIUM: Small pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thicknesses and cavity size are normal. Regional left ventricular wall\nmotion is normal. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThere is abnormal septal motion/position. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial\nmitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is moderate pulmonary artery systolic hypertension. There is\na small pericardial effusion. The effusion is echo dense, consistent with\nblood, inflammation or other cellular elements.\n\nIMPRESSION: Normal regional and global biventricular systolic function. The\nseptum has abnormal motion, which could be due to prior surgery or\ninterventricular conduction abnormality. Constrictive physiology cannot be\nexcluded. Small, echo dense effusion, mostly overlying the right ventricular\nfree wall. Moderate pulmonary artery systolic hypertension.\n\nCompared with the prior study (images reviewed) of , findings are\nsimilar. There is an echodensity seen overlying the right ventricle which\ncould be due to an effusion with cellular elements or a fat pad. It was\nprobably present on prior but prior echoes do not show this area particularly\nwell. Pulmonary pressures can be estimated and are moderately elevated.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2125-07-01 00:00:00.000",
"description": "Report",
"row_id": 98648,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Pericardial effusion. Tamponade.\nStatus: Inpatient\nDate/Time: at 09:11\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nparadoxical ventricular septal motion consistent with post-CABG.\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Paradoxic septal motion consistent with prior cardiac\nsurgery.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Calcified tips of\npapillary muscles. No MR.\n\nPERICARDIUM: Very small pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - bandages, defibrillator pads or electrodes. Suboptimal image\nquality as the patient was difficult to position. Suboptimal image quality -\nventilator. Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nLeft ventricular wall thickness, cavity size, and global systolic function are\nnormal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. The aortic valve leaflets are mildly\nthickened (?#). No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. No mitral regurgitation is seen. There is a very small\npartially echofilled inferolateral pericardial effusion best seen on\nparasternal views with no evidence of hemodynamic compromise.\n\nCompared with the prior study (images reviewed) of , the\ninferolateral echo filled space is new and c/w possible small hematoma. No\nhemodynamic compromise is suggested.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2125-06-28 00:00:00.000",
"description": "Report",
"row_id": 98649,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease.\nBP (mm Hg): 120/80\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 11:08\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Moderate symmetric LVH.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Normal RV free\nwall thickness.\n\nAORTA: Simple atheroma in aortic root. Focal calcifications in aortic root.\nNormal descending aorta diameter.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. No AS.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations.\n\nConclusions:\nPREBYPASS: Preserved LV systolic function with LVEF = 55-70% with no segmental\nwall motion abnormalities. The left atrium is mildly dilated. There is\nmoderate symmetric left ventricular hypertrophy. Right ventricular chamber\nsize and free wall motion are normal. The right ventricular free wall\nthickness is normal. There are simple atheroma in the aortic root. There are\nthree aortic valve leaflets. The aortic valve leaflets are moderately\nthickened, with sclerosis and decreased motion of the noncoronary cusp. There\nis no aortic valve stenosis. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no pericardial effusion. Diastolicy\ndysfunction consistent with impaired LV relaxation. E' = 5-6 cm/sec, impaired\nrelaxation pattern on transmitral inflow pulsed-wave Doppler.\nPOSTBYPASS: Unchanged systolic function LVEF >55% with no SWMA. No wall motion\nproblems following chest closure. No aortic dissection seen following removal\nof aortic cannula\n\n\n"
},
{
"category": "Echo",
"chartdate": "2125-06-26 00:00:00.000",
"description": "Report",
"row_id": 98650,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction. Preoperative assessment.\nHeight: (in) 63\nWeight (lb): 172\nBSA (m2): 1.82 m2\nBP (mm Hg): 143/94\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 11:09\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Left-to-right shunt across\nthe interatrial septum at rest.\n\nLEFT VENTRICLE: Mild (non-obstructive) focal hypertrophy of the basal septum.\nNormal regional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Normal mitral valve\nsupporting structures. Trivial MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - body habitus.\n\nConclusions:\nThe left atrium is normal in size. A left-to-right shunt across the\ninteratrial septum is seen at rest consistent with a small atrial septal\ndefect. There is mild (non-obstructive) focal hypertrophy of the basal septum.\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The ascending aorta\nis mildly dilated. The aortic valve leaflets (3) are mildly thickened. The\nmitral valve leaflets are mildly thickened. Trivial mitral regurgitation is\nseen. The left ventricular inflow pattern suggests impaired relaxation. There\nis no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2125-07-03 00:00:00.000",
"description": "Report",
"row_id": 275615,
"text": "Probable atrial fibrillation with rapid ventricular response. Delayed\nR wave progression is non-diagnostic. Diffuse ST-T wave abnormalities are\nnon-specific but cannot exclude ischemia. Clinical correlation is suggested.\nSince the previous tracing of the same date probable rapid atrial fibrillation\nhas replaced sinus tachycardia and further ST-T wave changes are present.\n\n"
},
{
"category": "ECG",
"chartdate": "2125-07-03 00:00:00.000",
"description": "Report",
"row_id": 275616,
"text": "Probable sinus tachycardia with frequent atrial premature beats but consider\nalso possile multifocal atrial tachycardia. Delayed R wave progression.\nModest ST-T wave changes. Findings are non-specific. Clinical correlation is\nsuggested. Since the previous tracing of tachycardia with atrial\nectopy is now present, inferor lead QRS configuration is less suggestive of\npossible prior inferior myocardial infarction and ST-T wave changes are now\nseen.\n\n"
},
{
"category": "ECG",
"chartdate": "2125-06-28 00:00:00.000",
"description": "Report",
"row_id": 275617,
"text": "Sinus rhythm. Borderline low QRS voltage in the limb leads. Cannot exclude\nprior inferior myocardial infarction. Leftward precordial R wave transition\npoint. Compared to the previous tracing of there is no major change.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2125-06-25 00:00:00.000",
"description": "Report",
"row_id": 275618,
"text": "Sinus rhythm with atrial premature beats. Non-specific ST-T wave changes. No\nprevious tracing available for comparison.\n\n"
}
] |
27,840 | 110,663 | Pt was admitted to the ICU and monitored closely. He was extubated on HD#2. His neurologic exam improved and he became less lethargic. He was following all commands. Ct of c-spine showed C6 facet fracture and he was kept in the hard collar. His diet and activity were advanced. He was transferred to the floor. He was seen by PT and OT who worked with him a couple visits and ultimately cleared him for discharge to home. | Bilateral basilar atelectasis, combined with newly appeared minimal pleural effusion. IMPRESSION: Bilateral frontal and left temporal hemorrhagic contusions, which are unchanged. Nasogastric tube terminates in esophagus and advancement suggested. LS CLEAR W/DIMINISHED BASES. low threshold for f/u CT if any change. TECHNIQUE: Non-contrast head CT. Optho c/s. 2 X 1L NS FLUID BOLUS' GIVEN.SKIN: INTACT EXCEPT FOR BILATERAL EYE HAEMATOMAS. TLC cleared, logroll precautions D/C. Skin otherwise intact.Plan: Spine service c/s. ET tube in low position 1 cm above the carina, slight retraction is suggested. Q2HR NEURO CHECKS DONE. Monitor and treat ETOH DT. CONCLUSION: Left C7 pedicle and facet fracture with slight distraction and no displacement. FINDINGS: As on CT examination of , there are bilateral atelectasis. REPEAT HEAD CT/EXTUBATE Heart size and mediastinal contours are within normal limits for AP technique. Comparison to a head CT of earlier . belly soft/nt/nd. IMPRESSION: (Over) 4:53 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: S/P FALL Field of view: 39 Contrast: OPTIRAY Amt: 80 FINAL REPORT (Cont) 1. will need c collar x6wks per neurosurg., successful extub, breathing stable. Q1H NEURO CHECKS. Full vent support, CMV, no spont resps.LS clear OG to LWS, old bloody secretions. The ethmoid sinuses are both opacified. ABG ON CURRENT SETTINGS 7.42/46/100/31. There is a nondisplaced fracture through the lesser of the left sphenoid. PT TOLERATING WELL. REDUCE NEURO CHECK INTERVALS. Otherwise, unremarkable chest. Small amount of fluid in left frontal sinus. BRISKLY REACTIVE.CV:NBP STABLE WNL. LS CLEAR TO COARSE. Pt resonding well with SBP 120's. Corneal reflex intact. breathing unlabored, o2 sats stable.neuro: slowly more awake s/p extub., mildly agitated, note worsening tremors to limbs w/ any concentrated movement. Suctioned for small amount bloody secreations. Bibasilar atelectasis is noted. C7 INTERVENTION AIMING TO EXTUBATE IF NONE REQUIRED. Sedation weaned and pt extubated, good cuff leak heard prior to extubation.Lung sounds clear. There is partial opacification of the paranasal sinuses along with sinus fractures described on the prior sinus CT. There are right and left frontal, left temporal and left parietal hemorrhagic contusions, similar to on prior study. Dependent atelectasis/consolidation, aspiration possible. Nondisplaced fracture is noted of the squamous portion of the right temporal bone. Nasogastric tube tip within the distal esophagus, advancement suggested. neurosurg and icu teams aware.resp: extub. There is a nondisplaced fracture of the medial right orbital wall and a minimally displaced fracture of the lateral wall. Tmax 100.Resp: Orally intubated. LS clear. Sinus rhythm. Follow up ABG showed acid base within normal with hyperoxymea. BS: ESSENT CLEAR BILATERALLY. cough, swallow intact. C/O FACIAL PAIN, GIVEN TWO PERCOCET WITH EFFECT. There is dependent atelectasis in the bilateral lower lobes. NO BOWEL MOVEMENT.SKIN: EYE SWELLING DRAMATICALLY REDUCED. no pronator drift noted, strength normal to all extrem, oriented x1, speech clear, hoarse d/t ett. cough improving, clearing secretions well.cv: bp stable, nsr to sinus tachy since extub., no ectope noted. SUCTIONED FOR THICK BLOOD TINGED SECRETIONS.GI/GU: BS WNL WITHOUT SSI COVERAGE. +BS. Mediastinum is normal without evidence of hematoma. 1 liter LR Fluid bolus given for tachycardia and hypotension. denies nausea.gu: foley patent cloudy, brown/green tinged urine, volume borderline adequate. Calcium repleated. Abd soft with bowel sounds present. ET tube is in a low position approximately 1 cm above the carina. There is mild underlying maxillary sinus mucosal thickening which is probably chronic. There is a small amount of fluid layering in the left frontal sinus air cell. bs present. Suctioned for moderate tan secretions. Normal tracing. note mildly worsening tremors, mild agitation. IVF CONTINUES MEANTIME. STILL DILATED. Suctioned for moderate thick bloody secretions. There is a right scalp hematoma. Again noted are multiple small hemorrhagic contusions in the right frontal and temporal lobes and in the left temporal lobe. IMPRESSION: 1. IMPRESSION: 1. Hyperdensity along the left tentorial leaf is consistent with subdural hematoma. A nondisplaced fracture of the left zygoma extends into the lateral wall of the left orbit. Bibasilar atelectasis. NGT to LWS. CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: The liver is diffusely low in attenuation consistent with fatty replacement. Repeat head CT and C-spine pending. SBP SELF REGULATING TO REMAIN <160 PER NEUROSURG. Respiratory CArePt remains orally intubated and vented. DR. U/O TAPERED OFF OVERNIGHT. cont to follow.endo: glucose levels stable, no sliding scale coverage needed.id: afebrile, no abx coverage.skin: contusions to both eyes, healing, less edematous. since extub, L pupil 7mm, R pupil 3mm, both briskly reactive. SR,BP WNL by cuff. ls w/ intermit. There is a small amount of fluid in the left frontal sinus air cell and the nasopharynx and several ethmoid air cells are opacified possibly due to blood. if no intervention required, plan to wean sedation and work towards extubation. There are low inspiratory lung volumes. aspiration). Continue IV dilantin. Pboots for profolaxsis. Pt is withdrawing to nailbed pressure. The abdominal aorta is of normal caliber without atherosclerotic change or evidence of aneurysm or dissection. No retrobulbar hematoma. SBP 110-130. Pt weaned to PSV. CT OF THE PELVIS WITHOUT AND WITH IV CONTRAST: The rectum, pelvic loops of bowel, prostate, seminal vesicles are unremarkable. AP PORTABLE CHEST AND AP PELVIS: Presence of the trauma board obscures detail. Incidentally noted, the patient is intubated and there is a nasal-oral tube in place. | 19 | [
{
"category": "Radiology",
"chartdate": "2164-02-20 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 997170,
"text": " 4:53 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: S/P FALL\n Field of view: 39 Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p fall, intubated, with wide mediastinum (AP chest)\n REASON FOR THIS EXAMINATION:\n eval: aortic pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MPtb MON 5:55 AM\n Normal mediastinum and aorta. No dissection or hematoma. No PE. Dependent\n atelectasis/consolidation, aspiration possible. Fatty liver. No free gas or\n fluid in abdomen.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male after fall down the stairs while intoxicated with\n concern for mediastinal injury.\n\n COMPARISON: No prior study.\n\n TECHNIQUE: MDCT axial images of the chest, abdomen, and pelvis pre- and post-\n Optiray IV contrast as rapid bolus per the aortic dissection protocol.\n\n CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: The aorta is normal in\n appearance without evidence of focal aneurysm, atherosclerotic change, or\n dissection. Mediastinum is normal without evidence of hematoma. There is no\n pulmonary embolism. There is dependent atelectasis in the bilateral lower\n lobes. There is no pleural fluid or pneumothorax. The NG tube terminus and\n sidehole are within the esophagus.\n\n CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: The liver is diffusely low in\n attenuation consistent with fatty replacement. No focal hepatic lesions are\n seen. The gallbladder, spleen, adrenal glands, pancreas, stomach, large and\n small bowel are unremarkable. There is no free gas or fluid within the\n abdomen. The abdominal aorta is of normal caliber without atherosclerotic\n change or evidence of aneurysm or dissection. Two round exophytic hyperdense\n lesions along the interpolar left kidney may represent hyperdense cysts\n thought they are incompletely assessed on this single phase study. Also\n present are subcentimeter left renal hypodensities which are too small to\n characterize though likely represent simple cysts. There is no evidence of\n traumatic injury of the solid organs.\n\n CT OF THE PELVIS WITHOUT AND WITH IV CONTRAST: The rectum, pelvic loops of\n bowel, prostate, seminal vesicles are unremarkable. There is a Foley catheter\n within the urinary bladder which is decompressed. There is no free fluid or\n lymphadenopathy in the pelvis.\n\n BONE WINDOWS: No concerning lesions or evidence of fracture is seen.\n\n IMPRESSION:\n (Over)\n\n 4:53 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: S/P FALL\n Field of view: 39 Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. No evidence of acute injury in the chest, abdomen or pelvis. Dependent\n atelectasis of the lower lobes.\n 2. Nasogastric tube terminates in esophagus and advancement suggested.\n 3. Fatty liver.\n 4. Small exophytic hyperdense lesions in the left kidney are likely\n hyperdense cysts. Additional tiny hypodense renal lesions are too small to\n adequately characterize. If clinically indicated, ultrasound may be obtained\n to further evaluate.\n\n ER dashboard preliminary report placed at 6:00 a.m. on .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-02-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 997167,
"text": " 3:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P FLL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 yo M s/p fall 8 stairs. transfer from OSH, intubated at OSH, infiltrate seen\n on OSH (? aspiration). intubated for gcs of 3. bleed seen at OSH\n REASON FOR THIS EXAMINATION:\n please eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MPtb MON 4:26 AM\n Multiple areas of parechymal contusion and subarachnoid hemorrhage of both\n frontal lobes, left temporal lobe. Small subdural hematoma along left\n tentorial leaf. No midline shift or appreciable mass effect. Fractures\n better seen on facial bone study, reported separately.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male after fall down stairs while intoxicated.\n\n COMPARISON: No prior study.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There are numerous small areas of parenchymal contusion and\n subarachnoid hemorrhage involving both frontal lobes and left temporal lobe.\n Hyperdensity along the left tentorial leaf is consistent with subdural\n hematoma. There is no shift of normally midline structures, mass effect,\n hydrocephalus, or evidence of infarction. Included in the field of view are\n acute nondisplaced fractures of the right frontal bone, roof, lateral and\n medial walls of the right orbit, right inferior orbital rim, squamous portion\n of the right temporal bone, left sphenoid, and left zygoma, which extends into\n the lateral wall of the left orbit. There is a small amount of fluid in the\n left frontal sinus air cell and the nasopharynx and several ethmoid air cells\n are opacified possibly due to blood. The mastoid air cells are clear. There is\n mild underlying maxillary sinus mucosal thickening which is probably chronic.\n There are a few small locules of gas within the right orbit, but no evidence\n of retroorbital hematoma.\n\n IMPRESSION:\n\n 1. Multifocal areas of parenchymal contusion and subarachnoid hemorrhage\n involving the frontal lobes and left temporal lobe.\n\n 2. Small subdural hematoma layering along the left tentorial leaf.\n\n 3. Multiple nondisplaced fractures are better seen on the companion CT sinus\n facial bone study and reference to this report is suggested.\n\n ER dashboard wet read placed at 4:30 a.m. on .\n\n (Over)\n\n 3:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P FLL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-02-20 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 997168,
"text": " 3:56 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p fall with multiple calvaria fx from OSH CT\n REASON FOR THIS EXAMINATION:\n evaluate facial fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MPtb MON 4:33 AM\n Multiple nondisplaced/minimally displaced fractures including: lateral\n and medial right orbital walls, right temporal bone; left zygoma extending\n into lateral wall of left orbit, and left sphenoid; nasal bone. Globes\n intact. No retrobulbar hematoma. Small amount of fluid in left frontal sinus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male after fall down the stairs while intoxicated with\n facial bone fractures.\n\n COMPARISON: No prior study.\n\n TECHNIQUE: Non-contrast CT of the facial bones with coronal reformats.\n\n CT OF THE FACIAL BONES WITHOUT CONTRAST: Multiple nondisplaced/minimally\n displaced fractures are noted throughout the facial bones and skull. There is\n a nondisplaced fracture of the medial right orbital wall and a minimally\n displaced fracture of the lateral wall. There are fractures of the Roof,\n inferior wall and medial wall of the right orbit. Nondisplaced fracture is\n noted of the squamous portion of the right temporal bone. There is a right\n frontal bone fracture.\n\n A nondisplaced fracture of the left zygoma extends into the lateral wall of\n the left orbit. There are fractures of the orbital roof and medial wall. There\n is a nondisplaced fracture through the lesser of the left sphenoid.\n There is a fracture of the squamous portion of the left temporal bone. There\n is a small amount of fluid layering in the left frontal sinus air cell. The\n nasal cavity is opacified as are several ethmoid air cells, possibly due to\n blood. The globes are intact. There are a few small locules of gas within the\n right orbit. There is no evidence of an intraorbital hematoma. There is no\n evidence of herniation or entrapment of extraocular muscle.\n\n IMPRESSION: Multiple nondisplaced/minimally displaced fractures involving\n both orbits, temporal bones, right frontal bone, and left sphenoid bone. No\n evidence of orbital hematoma or extraocular muscle herniation or entrapment.\n\n ER dashboard wet read placed at 4:20 a.m. on .\n\n (Over)\n\n 3:56 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-02-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 997282,
"text": " 3:55 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: f/u PLEASE DO AT 4pm\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with mod closed head injury\n REASON FOR THIS EXAMINATION:\n f/u PLEASE DO AT 4pm\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST, \n\n HISTORY: Closed head injury.\n\n Contiguous axial images were obtained through the brain. No contrast was\n administered. Comparison to a head CT of earlier .\n\n FINDINGS: There have been no significant changes since the previous study.\n Again noted are multiple small hemorrhagic contusions in the right frontal and\n temporal lobes and in the left temporal lobe. There is a small amount of\n subarachnoid hemorrhage with no evidence of increased hemorrhage since the\n earlier study. There is a right scalp hematoma. There is partial\n opacification of the paranasal sinuses along with sinus fractures described on\n the prior sinus CT.\n\n CONCLUSION: No change since the earlier study of , bilateral small\n hemorrhagic contusions with no evidence of new or increased hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-02-20 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 997281,
"text": " 3:54 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: please perform at 4 PM with repeat Head CT. thanksassess for\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p fall w/ SDH, SAH; ? C7 facet and pedicle fracture seen at\n OSH\n REASON FOR THIS EXAMINATION:\n please perform at 4 PM with repeat Head CT. thanksassess for cervical fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT CERVICAL SPINE, \n\n HISTORY: Possible facet fracture seen on outside hospital CT.\n\n Contiguous axial images were obtained through the cervical spine. No contrast\n was administered. No prior cervical spine imaging studies are available for\n comparison.\n\n FINDINGS: Alignment of the cervical spine is normal. A fracture is\n identified in the left C7 pedicle extending into the superior facet. This is\n only minimally distracted with no evidence of displacement. Images of the\n contents of the spinal canal are limited by artifacts arising from the\n shoulders. However, no intraspinal abnormalities are detected. If there are\n new neurologic symptoms, an MR examination may be helpful for further\n evaluation. The remainder of the study appears normal with no other fractures\n identified. Incidentally noted, the patient is intubated and there is a\n nasal-oral tube in place.\n\n CONCLUSION: Left C7 pedicle and facet fracture with slight distraction and no\n displacement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-02-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 997411,
"text": " 9:36 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: f/u PLEASE DO AT 6 am\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with mod closed head injury\n REASON FOR THIS EXAMINATION:\n f/u PLEASE DO AT 6 am\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old man with closed head injury followup.\n\n CT HEAD WITHOUT CONTRAST:\n\n TECHNIQUE: Contiguous axial images of the brain were obtained without IV\n contrast.\n\n COMPARISON: .\n\n There are right and left frontal, left temporal and left parietal hemorrhagic\n contusions, similar to on prior study. The subarachnoid hemorrhage effaces\n the sulci in the left frontal lobe. There is no midline shift. The ethmoid\n sinuses are both opacified. The multiple facial fractures are described in\n more detail on prior study of the sinuses.\n\n IMPRESSION: Bilateral frontal and left temporal hemorrhagic contusions, which\n are unchanged. Subarachnoid hemorrhage in the left frontal lobe. Multiple\n facial fractures as described on prior CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-02-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 997856,
"text": " 11:51 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pulm process\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p fall with C6facet fx, L temporal contusion with low O2 sats\n REASON FOR THIS EXAMINATION:\n eval for pulm process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for pulmonary process.\n\n COMPARISON: No comparison available.\n\n FINDINGS: As on CT examination of , there are bilateral\n atelectasis. Blunting of the dorsal costophrenic sinuses also suggest newly\n developed minimal pleural effusion. No other newly appeared parenchymal\n opacities. The heart size is within the normal range. The mediastinal\n contours are unremarkable. Bilateral basilar atelectasis, combined with newly\n appeared minimal pleural effusion. No newly appeared pulmonary opacities. No\n pneumothorax.\n\n\n DR. \n"
},
{
"category": "Nursing/other",
"chartdate": "2164-02-21 00:00:00.000",
"description": "Report",
"row_id": 1626152,
"text": "Respiratory Care:\nPt recieved orally intubated and vented. Sedation weaned and pt extubated, good cuff leak heard prior to extubation.Lung sounds clear. Suctioned for moderate tan secretions. Pt placed on cool aerosol via face tent 50%, SpO2 96-97%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-02-21 00:00:00.000",
"description": "Report",
"row_id": 1626153,
"text": "Respiratory CAre addendum:\nPt traveled to and from CT without incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-02-21 00:00:00.000",
"description": "Report",
"row_id": 1626154,
"text": "nursing progress note\n\nevents: follow up head CT done this am, unchanged from previous per neurosurg. PA. patient extubated w/out incident this afternoon, currently oriented x1, mildly agitated. note slowly worsening tremor to hands, feet. breathing unlabored, o2 sats stable.\n\nneuro: slowly more awake s/p extub., mildly agitated, note worsening tremors to limbs w/ any concentrated movement. prior to extub, while sedated, pupils 3mm bilat, equal and briskly reactive. since extub, L pupil 7mm, R pupil 3mm, both briskly reactive. no pronator drift noted, strength normal to all extrem, oriented x1, speech clear, hoarse d/t ett. neurosurg and icu teams aware.\n\nresp: extub. w/out incident, 50% face tent o2 intact, o2 sats stable. ls w/ intermit. wheezing, pt w/ hx asthma, uses albuterol at home. cough improving, clearing secretions well.\n\ncv: bp stable, nsr to sinus tachy since extub., no ectope noted. extrem warm, pulses intact. a line positional, good waveform when pt still.\n\ngi: ng d/c'd w/ extub, remains npo, taking ice chips. cough, swallow intact. belly soft/nt/nd. bs present. denies nausea.\n\ngu: foley patent cloudy, brown/green tinged urine, volume borderline adequate. cont to follow.\n\nendo: glucose levels stable, no sliding scale coverage needed.\n\nid: afebrile, no abx coverage.\n\nskin: contusions to both eyes, healing, less edematous. tiny abrasion to R forehead, clean.\n\nsocial: wife in throughout day, supportive. d/w wife and patient briefly availability of addiction nursing consult, to facilitate in coming days.\n\na/p: 42 yo male s/p fall, sustaining facial fx's, small ICHs, stable C7 fx. will need c collar x6wks per neurosurg., successful extub, breathing stable. note mildly worsening tremors, mild agitation. ativan per ciwa scale ongoing. addiction counseling staff to consult in coming days. cont serial neuro exams, closely monitor pupillary rxn and +/- pronator drift. low threshold for f/u CT if any change. per neuro attending, transfer to floor tomorrow if exam remains stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-02-22 00:00:00.000",
"description": "Report",
"row_id": 1626155,
"text": "1900-0700\nSEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.\n\nNEURO: PT LETHARGIC OVERNIGHT. OPENS EYES TO VOICE. MAE. FOLLOWS COMMANDS CONSISTENTLY. ORIENTED TO PLACE/SELF ONLY. ON CIWA SCALE REQUIRING LORAZEPAM ONCE OVERNIGHT. C/O FACIAL PAIN, GIVEN TWO PERCOCET WITH EFFECT. SLEPT FOR LONG PERIODS. Q2HR NEURO CHECKS DONE. PUPILS NOW 3-4MM EQUAL. BRISKLY REACTIVE.\n\nCV:NBP STABLE WNL. SBP SELF REGULATING TO REMAIN <160 PER NEUROSURG. HR SR-ST 90-110.\n\nRESP: INITIALLY ON FACETENT 50% WITH SATS 90-93%. CHANGED TO NC 4L WITH IMPROVING SATS >95%. STRONG PRODUCTIVE COUGH. EXPECTORATING THICK YELLOW SPUTUM. LS CLEAR W/DIMINISHED BASES. OCCASIONAL WHEEZE.\n\nGI/GU: DIET INCREASED TO CLEAR LIQUIDS BY NEUROSURG. PT TOLERATING WELL. IVF CONTINUES MEANTIME. +BS. BLOOD SUGAR WNL. NO BOWEL MOVEMENT.\n\nSKIN: EYE SWELLING DRAMATICALLY REDUCED. REMAIN PURPLE IN COLOUR. REMAINING SKIN INTACT.\n\nSOCIAL: WIFE SUPPORTIVE TO PT NAD VISITED LAST EVENING. NO PHONE CALLS OVERNIGHT.\n\nPLAN: ? INCREASE DIET.\n ? REDUCE NEURO CHECK INTERVALS.\n ASSESS AND TREAT PAIN.\n ? OOB TO CHAIR.\n ? CONTACT S/W RE ADDICTION NURSE CONSULT WHEN PT READY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-02-22 00:00:00.000",
"description": "Report",
"row_id": 1626156,
"text": "***please see transfer note/chart for current shift Nursing progress note**\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-02-20 00:00:00.000",
"description": "Report",
"row_id": 1626148,
"text": "NPN TSICU 0700-1900\nReview of systems:\n\nNeuro: Sedation turned off for hourly exams. Pt opens eyes sponatneously and becomes very agitated. Pupils are equal and briskly reactive. Corneal reflex intact. Pt is moving all extremities with purpose. Pt is withdrawing to nailbed pressure. At beginning of shift pt inconsistantly following commands. This afternoon pt is more consistant, giving thumbs up, squeezing with both hands, and wiggling toes. Cough and gag reflexes are intact. Propofol for sedation and Fentanyl gtt started for pain. Repeat head CT and C-spine pending. Spine service to be consulted. TLC cleared, logroll precautions D/C. Continue IV dilantin. Monitor CIWA scale for + ETOH.\n\nCV: SR-ST 90-100. No ectopy noted. SBP 88-130's. 1 liter LR Fluid bolus given for tachycardia and hypotension. Pt resonding well with SBP 120's. Arterial line placed in the left radial artery, wave form currently sharp. Pboots for profolaxsis. Calcium repleated. Bannana bag @ 80ml/hr. Tmax 100.\n\nResp: Orally intubated. CPAP 40%, 5 PEEEP, 10 PS. LS clear. Suctioned for small amount bloody secreations. SaO2 currently 97%.\n\nGI/GU: Pt is NPO. NGT to LWS. Abd soft with bowel sounds present. Foley draining clear yellow urine.\n\nEndo: RISS for blood sugar control. No insulin this shift.\n\nSkin: Bilateral black eyes. Skin otherwise intact.\n\nPlan: Spine service c/s. if no intervention required, plan to wean sedation and work towards extubation. Monitor and treat ETOH DT. Optho c/s. Support pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-02-20 00:00:00.000",
"description": "Report",
"row_id": 1626149,
"text": "Respiratory CAre\nPt remains orally intubated and vented. Pt weaned to PSV. Follow up ABG showed acid base within normal with hyperoxymea. FiO2 weaned to 40 from 50%. Lung sounds slightly coarse. Suctioned for moderate thick bloody secretions. Traveled to and from CT without incident. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-02-21 00:00:00.000",
"description": "Report",
"row_id": 1626150,
"text": "RESP CARE NOTE\nPT REMAINED ON SAME VENT SETTINGS OVERNIGHT OF PSV 10/5/40%. ABG ON CURRENT SETTINGS 7.42/46/100/31. OETT RETAPED AT 24CMS. BS: ESSENT CLEAR BILATERALLY. SUCTIONING SMALL AMTS OF THICK BLOODY SECRETIONS. RSBI 45.\nPLAN: ? REPEAT HEAD CT/EXTUBATE\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-02-21 00:00:00.000",
"description": "Report",
"row_id": 1626151,
"text": "1900-0700\nSEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.\n\nEVENTS: 2 X 1L NS BOLUS FOR LOW URINE OUTPUT.\n\nNEURO: LIGHTLY SEDATED ON PROPOFOL. Q1H NEURO CHECKS. INCONSISTENTLY FOLLOWING COMMANDS. MAE. PURPOSEFULLY REACHING FOR ETT. PUPILS DILATED BY OPTHALMOLOGY @ 1900HRS. STILL DILATED. NR. STRONG COUGH/GAG. AWAITING CT SCAN RESULT FROM 1600HRS.\n\nCV: SR 70'S. NO ECTOPY. SBP 110-130. ALINE POSITIONAL. LYTE ORDERS REQUIRED.\n\nRESP: VENTILATED ON PS 10/5/40%. LS CLEAR TO COARSE. SUCTIONED FOR THICK BLOOD TINGED SECRETIONS.\n\nGI/GU: BS WNL WITHOUT SSI COVERAGE. NPO. NGT TO LWS DRAINING COFFEE GROUND LIQUID, APPROX 350/12HRS. U/O TAPERED OFF OVERNIGHT. 2 X 1L NS FLUID BOLUS' GIVEN.\n\nSKIN: INTACT EXCEPT FOR BILATERAL EYE HAEMATOMAS. ? AS TO WHETHER ANY INTERVENTION IS REQUIRED TO C7 FRACTURE.\n\nSOCIAL: MOTHER NAD WIFE TELEPHONED LAST EVENING FOR UPDATE ON 1600HRS CT SCAN.\n\nPLAN: CONTINUE Q1HR NEURO CHECKS.\n ? C7 INTERVENTION AIMING TO EXTUBATE IF NONE REQUIRED.\n ENSURE PT COMFORT AND SAFETY.\n AGGRESSIVE PULMONARY HYGIENE.\n AWAIT CT SCAN RESULT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-02-20 00:00:00.000",
"description": "Report",
"row_id": 1626147,
"text": "TSICU Admit Note 0630\n 48yo male recieved from ED intubated/sedated s/p fall at home down 8 steps to concrete floor, mult facial fx, C7 fx, SDH,SAH on CT\n Pt sedated on Propofol, lightened for exam, moves LE's freely, UE's to painful stimuli- non-purposeful.PERL. S/P sz at OSH,has been loaded on Cerebrex.\n SR,BP WNL by cuff. IVF at 80,peripheral lines x3.\n Full vent support, CMV, no spont resps.LS clear\n OG to LWS, old bloody secretions.\n u/o adequate, clear yellow.\n social- accompanied by family, in waiting room\n Plan- Monitor neuro status\n Sedation/pain control\n pulmonary hygiene\n Clear TLS\n"
},
{
"category": "Radiology",
"chartdate": "2164-02-20 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 997166,
"text": " 3:31 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: please eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 yo M s/p fall 8 stairs. transfer from OSH, intubated at OSH, infiltrate seen\n on OSH (? aspiration)\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 47-year-old male after fall down eight stairs while intoxicated,\n transferred from outside hospital. Possible aspiration.\n\n COMPARISON: No prior study.\n\n AP PORTABLE CHEST AND AP PELVIS: Presence of the trauma board obscures\n detail. Heart size and mediastinal contours are within normal limits for AP\n technique. ET tube is in a low position approximately 1 cm above the carina.\n Nasogastric tube tip and side hole within the esophagus. There are low\n inspiratory lung volumes. Bibasilar atelectasis is noted. There is no\n evidence of focal consolidation or pleural effusion. No fractures are seen in\n the pelvis.\n\n IMPRESSION:\n\n 1. Bibasilar atelectasis. Otherwise, unremarkable chest.\n\n 2. ET tube in low position 1 cm above the carina, slight retraction is\n suggested. Nasogastric tube tip within the distal esophagus, advancement\n suggested.\n\n 3. No pelvic fracture.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2164-02-20 00:00:00.000",
"description": "Report",
"row_id": 214249,
"text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n"
}
] |
24,687 | 145,249 | 48 y.o. M with h/o HIV/AIDs, h/o TB, PCP, infections, noncompliant with his medications, recent history of falls/traumas found down for possibly three days, minimally responsive, intubated for airway protection. The course also complicated by R neck hematoma due to line placement, alkalosis, hypernatremia, hypercalcemia, improved ARF, elevated lactate, transaminitis. # AMS - multifactorial. Was found down and c-collar placed. Came with elevated CKs consistent with Rhabdomyalysis, improved with IVFs. Concern for toxic metabilic encephalopathy (infection, hypernatremia, hypercalcemia) as well as HIV encephalopathy. He was intubated for airway protection. He was treated with broad ABX as detailed below. Metabolic abnormalities improved with IVFs, and he had a negative LP for infection, but. MRI was also negative for stroke or mass lession. His mental status improved and he was extubated, but he is not at baseline (he walked out of on after signing out against medical advise). CT c-spine was negative for fracture, but his C-collar was not cleared due to ongoing altered mental status. He currently follows some commands but remains globally weak and will require a neurology consult to address this and his mental status. He was given limited narcotics for pain of undetermined source (seemed in pain with even light touch to skin). Would recommend not using too much narcotics for pain as it will likely cloud mental status. # ID - AIDs pt not on HAART. Infectious disease team was consulted and followed throughout his hospitalization. Initially, he was covered broadly initially with vanco/cefepime/flagyl. He was also on Acycovir to cover for HSV encephalitis, but this was stopped when CSF was negative for HSV. The pt underwent LP and Bronchoscopy. He had blood, urine, sputum, stool, and CSF sent for culture. Stool was positive for Cdiff on . He needs to continue on flagyl for 14 days after all other ABX completed. Sputum was positive for MRSA on , and he needs a 14 day course of vancomycin (currenly, today is day #8). He also had pseudomonas (sparse growth) in sputum and GNRs not otherwise speciated in his sputum , and Cefepime changed to Zosyn and then to Meropenem for gram negative coverage. Meropenem course is 15 days (currently, today is day #5). Of note, 1 colony of Aspergillus was grown on from sputum and a CT chest was done on which did not reveal evidence of invasive aspergillus. Galactomannan was sent and needs to be followed up. ID recommended NOT to start treatment for aspergillus. Pt needs to follow up with ID, Dr. , within 2-3 weeks. Appointment needs to be scheduled. # Hypernatremia - Felt due to poor free water intake intake and dehydration while on ground at home. He was given IVFs and free H20 and his sodium returned to (139 at time of discharge). # C-collar - CT c-spine negative, but could not clear collar due to altered mental status. Pt needs to have this cleared at rehab # Rhabdomylosis - likely due to being down, CK peaked at 3996, and improved to normal with IVFs. Renal failure resolved. # ARF - likely prerenal with component of rhabdomylosis. Cr 1.6 upon admission, improved to 0.6 by the time of discharge. # transaminitis - Known Hep C. Levels were monitored and trended down to normal by the time of d/c. # R neck hematoma - stable clinically. Serial Hcts were checked and remained stable. # PPx - H2 , Heparin SQ, senna/colace | There remains a moderate right anterior apical pneumothorax as seen on prior chest radiographs. There is a lucent area at the right lung base as well as a small lucency at the right apex consistent with pneumothorax. There are bilateral cylindric bronchiectasis , slightly progressed . 2) Persisting moderate right anteroapical pneumothorax, likely originating from a ruptured right apical bleb. New left internal jugular central venous line in standard position. Partially imaged right apical opacity and right apical subpleural blebs. Persistent right pneumothorax. There is a left internal jugular line in appropriate position. CT ABDOMEN WITH ORAL CONTRAST: Following a bronchovascular distribution there are multiple nodular opacities measuring up to 1cm within the left lung base with faint nodular opacities in the right lung base. FINDINGS: There is a right-sided PICC with its tip in the distal SVC and a left-sided IJ catheter with its tip at the atriocaval junction. ET tube and left IJ in appropriate position. Possible etiology might be a ruptured right apical bleb giving the presence of apical blebs on a current study (3, 9). IMPRESSION: Pneumothorax in the right lung. 11:05 AM CT CHEST W/O CONTRAST Clip # Reason: evidence of invasive aspergillus, ? Slight enlargement of cardiac silhouette. IMPRESSION: In comparison to , slight decrease of right-sided pneumothorax, but signs of tension persist. A hypoattenuating lesion within the tail of the pancreas is noted with Hounsfield characteristics consistent with that of a cyst which measures 1.3 x 0.8 cm. COMPARISON: CT chest of . There is a left internal jugular central line with distal tip projected over the upper SVC. The right apical pneumothorax is unchanged. Right supraclavicular fossa hematoma corresponding with recent central venous line attempt in this location. being diuresed. CXR showing pulm. +DP/PT. MICU NPNBrief ROS: Pt. remaines intubated and vented, MDI'S given pt. care note - pt. IS PRESENTLY AFEBRILE.PT. Resp. BS are course with rhonchi. to wean vent/sedation as tolerated. to wean vent/sedation as tolerated. REMAINS TACHY WITH HR RANGING IN A NST 103-130'S. PLAN REMAINS TO EXTUBATE PT. Placement confirmed with CXR.GU- Adequate u/o via foley. pulm. extubated this am. Bronch. Pt. PT. PT. Pt. Pt. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. Adeq UOP remainder of shift. )CV Stable BP and HR, sinus, rare pvc. pressure room for previous hx of TB/MRSA/psuedomonas. C. Diff spec/Cx sent, results pnding. VBG sent, WNL. VBG sent, WNL. tol ok. Transferred to MICU on propofol/intubated, hypernatremic, rhabdo, hypercalcemic, hypothermic. HAS REMAINED SLIGHTLY FEBRILE, AND TACHYCARDIC. LS clear t/o. PULSES ARE ALL STRONG, NO TREACE EDEMA NOTED.PLAN ARE TO EXTUBATE PT. Afebrile. Remains on flagyl, vanco, cefepime, and acyclovir for coverage.Plan: Cont. on Flagyl, Vanco, Meropenem, and Acyclovir. CLEAR SECRETIONS.PT. SINCE PT. MDIs as ordered.Plan: Wean from vent support as tol, ? Afebrile today. H.R. IF PT. HAS BEEN FOR SCANT AMT'S OF CLEAR SECRETIONS. Cont. Cont. Cont. Cont. Cont. nodules (? Plan is to extubate when indicated. FOLEY CATHETER REMAINS AND PT. Vanco, flagyl and meroenum continues, acyclovir dc'd. IS TOLERATING THIS. Remains on airborne/contact precautionsGI/GU: Cachectic, abd. to lightly diurese pt with goal -1L. Monitor resp status. + PP bilaterally. Scant secr prior. with BAL , results pnding.GI/GU: Cachectic, abd. he is getting albuteroland atrovent MDI Q 6. BP 120s/70s incr to 130s/70s with decr sedation. CVP HAS REMAINED 0-3, WHILE BEING DUIRESISED.PT. REMAINS INTUBATED, REFER TO CAREVUE FOR SETTINGS. HAS REMAINED AFEBRILE.PT'S V/S HAVE REMAINED WNL'S. Sxned infrequentlyl for sm.-mod. with bronchodialators. OTHERWISE REPLETE ELECTROLYTES PRN, AND WEAN VENT SETTING WHEN ABLE. HAD LOW GRADE TEMP BUT PRESENTLY 98.6.PT. + PP bilaterally, trace-pitting edema noted in bilateral LE. Low UOP; IVF boluses adm as ordered; incr UOP noted. BAL showing Aspergillus, CT of chest done this shift, results pnding.GI/GU: Cachectic, abd soft, non-tender to palpation. BUN/Cr 67/1.1 at 0200.GI: Abd soft, hypoactive BS. + PP bilaterally.Resp: Extubated . LIJ/TLC dc'd, pressure applied, no s&s of bleeding noted.ID: afebrile. IMPRESSION: Right apical pneumothorax, unchanged. CVP transduced.NEURO: Sedated w/Propofol on Vent. Left IJ line in standard position. care note - pt. T 101.5 on adm to MICU decr to 96.8rect after IVF. BUN/Cr remains elevated.Skin: Mult. Remains on flagyl, and meropenem for coverage.Plan: Discharge to rehab facility. IMPRESSION: NG tube in appropriate position, no pneumothorax. IMPRESSION: PICC in standard position. R apical ptx unchanged. Sinus tachycardia with baseline artifact. Noted foley leaking sm. +DP/PT. Pt noted to have mod. to monitor and treat for low CVP and UO. There is persistent small right apical pneumothorax. Pt with rhabdo, cont. Mild [1+] TR. PATIENT/TEST INFORMATION:Indication: ?Endocarditis.Height: (in) 69Weight (lb): 81BSA (m2): 1.41 m2BP (mm Hg): 125/50HR (bpm): 90Status: InpatientDate/Time: at 15:11Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness and cavity size. Right atrial abnormality. on antibx, remains on airborne/contact precautions for previous hx of TB/MRSA/psuedomonas. Resp. The right apical pneumothorax is unchanged. No short interval change in pneumothorax. Normal regional LVsystolic function. The mitralvalve appears structurally normal with trivial mitral regurgitation. OG intact to LIS w/bile output.ID: BC x2 sent; Fungal/Myco cult sent x1; Sputum sent; Urine sent for Legionella;ELECTROLYTES: KCL 20meq for K of 3.1; D5W for Hypernatremia DC'd when Na 152. HR 90s at 0545 w/IVF off and sedation down to Propofol 35mcg BP 1teens-130s/60-80s (Hypertensive on adm to ED). There is mild pulmonary artery systolichypertension. LIJ intact w/CVP. Cervical collar still in place until neck pain improved.CV: ST 120-130s on adm, decr to 70s with IVF/sedation. | 48 | [
{
"category": "Radiology",
"chartdate": "2145-12-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 993695,
"text": " 5:54 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ich\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with aids, found down\n REASON FOR THIS EXAMINATION:\n eval for ich\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:21 PM\n No acute traumatic injury detected. Findings c/w advanced HIV\n encephalopathy, confluent low attn in deep white matter may be related to HIV\n enceph or possibly due to underlying infx (PML).\n WET READ VERSION #1 7:00 PM\n No acute abnormality detected.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT head without contrast.\n\n INDICATION: 48-year-old male with AIDS found down.\n\n COMPARISON: CT head , MRI head .\n\n FINDINGS: No hemorrhage, mass lesion, shift of normally midline structures or\n evidence of major territorial infarct is apparent. The major intracranial\n cisterns are preserved. There is moderate prominence of the ventricles and\n sulci which are stable, consistent with mild atrophy. Confluent regions of\n hypoattenuation are present in the white matter of the periventricular and\n deep white matter which are stable from yet new from .\n\n There is mild leftward nasal septal deviation with septal bony spur. The\n visualized paranasal sinuses and mastoid air cells are clear. The orbital\n regions are grossly unremarkable. The osseous structures are grossly\n unremarkable.\n\n IMPRESSION:\n 1. No acute hemmorage or mass effect.\n\n 2. Mild cerebral atrophy which is not age appropriate consistent with HIV\n encephalopathy.\n\n 3. Confluent regions of hypoattenuation in the deep white matter which is\n unchanged from yet new since . While this may represent sequlae\n of HIV encephalopathy, an underlying infectious etiology such as PML may be\n considered and an MRI may be helpful.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-09 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 993696,
"text": " 5:54 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with aids, found down\n REASON FOR THIS EXAMINATION:\n eval for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:21 PM\n Partially imaged right apex opacity. No acute traumatic injury detected.\n\n Hematoma around right jugular v - likely due to line placement attempts\n WET READ VERSION #1 7:19 PM\n Partially imaged right apex opacity. No acute traumatic injury detected.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT C-spine without contrast and reconstructions.\n\n INDICATION: 48-year-old male with HIV/AIDS found down.\n\n TECHNIQUE: MDCT axially acquired images were obtained from the cervical spine\n without contrast. Multiplanar reformatted images were obtained.\n\n FINDINGS: No evidence of acute fracture or dislocation is detected. Spinal\n alignment is normal without listhesis. The patient is intubated without\n prevertebral soft tissue abnormality detected. The lateral masses of C1 are\n well apposed on C2. The dens is intact.\n\n The thyroid gland is grossly unremarkable. Within the right lung apex there\n is an approximately 8-mm partially imaged focal opacity. Mild emphysematous\n changes are also noted within the right lung apex with subpleural bleb\n formation. The left lung apex is clear.\n\n Within the right supraclavicular fossa there is a developing hematoma\n measuring approximately 5cm x 2cm in the axial plane and corresponds to recent\n central venous line attempt in this region.\n\n IMPRESSION:\n 1. Right supraclavicular fossa hematoma corresponding with recent central\n venous line attempt in this location.\n\n 2. No evidence of acute fracture or dislocation.\n\n 3. Partially imaged right apical opacity and right apical subpleural blebs.\n\n Discussed with Dr. at 8:34 pm .\n (Over)\n\n 5:54 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-09 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 993697,
"text": " 5:54 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: po only\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with aids, found down, ? septic\n REASON FOR THIS EXAMINATION:\n po only\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:23 PM\n Bronchovascular nodules in lower lobes (R>>L)- favor aspiration/pneumonia\n given \"found down\" however opportunistic infx process also possible (CMV, Tb,\n etc).\n WET READ VERSION #1 7:51 PM\n Infectious process in the left lung base only partially imaged.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT abdomen and pelvis with oral contrast and reconstructions.\n\n INDICATION: 48-year-old female with AIDS/HIV, found down and sepsis,\n intubated.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axially acquired images were obtained from the lung bases to\n the symphysis with oral contrast only. Multiplanar reformatted images were\n obtained. No IV contrast was administered given patient's acutely elevated\n creatinine.\n\n CT ABDOMEN WITH ORAL CONTRAST: Following a bronchovascular distribution there\n are multiple nodular opacities measuring up to 1cm within the left lung base\n with faint nodular opacities in the right lung base. No pleural effusion or\n pneumothorax detected.\n\n Evaluation of intra-abdominal and intrapelvic parenchymal organs is very\n limited given lack of IV contrast administration. No abnormalities are\n detected within the liver, spleen, adrenal glands and abdominal large and\n small bowel given the above stated limitations. Clips within the gallbladder\n fossa are consistent with previous cholecystectomy. There is a\n hypoattenuating lesion within the interpolar region of the left kidney\n measuring 1.7 cm in greatest dimension also noted on scan from consistent\n with a simple cyst. The kidneys appear otherwise unremarkable given stated\n limitations. A hypoattenuating lesion within the tail of the pancreas is\n noted with Hounsfield characteristics consistent with that of a cyst which\n measures 1.3 x 0.8 cm. This lesion was also present in . A nasogastric\n tube is noted curled within the stomach. No free fluid or free air is\n detected within the abdomen. There is no small- bowel obstruction. There is\n generalized cachexia.\n\n CT PELVIS WITHOUT CONTRAST: A Foley catheter is detected in a collapsed\n bladder. There is stool throughout the colon. No free air or free fluid is\n detected within the pelvis.\n (Over)\n\n 5:54 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: po only\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n OSSEOUS STRUCTURES: There is a sclerotic focus in the L4 vertebral body most\n consistent with a bone island also present on study from . No suspicious\n lytic or sclerotic lesions are detected. Spinal alignment is normal aside\n from mild grade 1 retrolisthesis of L5 on S1.\n\n IMPRESSION:\n 1. Nodular opacities within a bronchovascular distribution most notable in\n the left lung base and less so on the right most consistent with aspiration\n pneumonia given clinical history. However given immunocompromised status\n atypical infections including tuberculosis must be considered and respirtory\n precautions advised.\n 2. Cystic pancreatic tail lesion also noted on study from without\n detectable change.\n 3. Generalized cachexia, likely AIDS-wasting syndrome.\n\n Findings discussed with Dr. at 8:34 pm .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 993659,
"text": " 2:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with intubation\n REASON FOR THIS EXAMINATION:\n post intubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Unresponsive, found down, status post intubation, hypoxia.\n\n COMPARISONS: .\n\n SINGLE VIEW CHEST, AP SUPINE: The ET tube is slightly low lying and is\n approximately 3 cm above the carina. An NG tube tip is within the stomach.\n Surgical clips are seen overlying the left upper quadrant. There are patchy\n airspace opacities within the left lower lobe which correspond to tree-in-\n opacities seen on previous chest CT from . Otherwise, the\n lungs are clear. Surgical clips are seen in the right upper quadrant.\n\n IMPRESSION:\n 1. Slightly low lying ET tube, approximately 3 cm above the carina. This\n could be withdrawn slightly.\n 2. Small, patchy opacities at the left lung base which appear to correspond\n to tree-in- opacities seen on previous chest CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-10 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 993867,
"text": " 9:29 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: assess for mass, evidence of encephalitis\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AIDS, Hep C, h/o TB, found down for 2nd time in 1 month\n REASON FOR THIS EXAMINATION:\n assess for mass, evidence of encephalitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MR HEAD WITHOUT AND WITH CONTRAST\n\n HISTORY: 48-year-old man with AIDS and hepatitis C. History of tuberculosis.\n Found down. Is there evidence of tumor or infection?\n\n Sagittal and axial short TR, short TE spin echo imaging was performed through\n the brain. Axial imaging was performed with long TR, long TE fast spin echo,\n FLAIR, gradient echo, and diffusion technique. After administration of\n gadolinium intravenous contrast, axial and coronal short TR, short TE spin\n echo imaging was performed. Comparison to a head CT of .\n\n FINDINGS: There is extensive white matter hyperintensity on the long TR\n images. There is no abnormal enhancement after contrast administration, and\n there are no changes to suggest bacterial or fungal infection. The white\n matter abnormalities are commonly seen in patients with advanced HIV\n encephalopathy. The diffusion images demonstrate several small foci of\n increased intensity in the corpus callosum. These areas may represent tiny\n infarcts and raise the possibility of meningeal inflammation and meningitis.\n The alternative possibility for such a small distal infarctions would be very\n unusual pattern of embolic infarction. The findings on the MR examination are\n overall similar to those on CT, allowing for the difference in imaging\n modality.\n\n CONCLUSION:\n 1. No evidence of bacterial or fungal infection. However, extensive white\n matter hyperintensity is often found in patients with HIV encephalopathy.\n 2. Several foci of apparent infarction or encephalitis in the corpus callosum\n raise the possibility of meningitis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 994102,
"text": " 3:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for consolidation (worsening?) also crackles on exa\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AIDS, s/p intubation for lethargy, now with likely PNA\n REASON FOR THIS EXAMINATION:\n evaluate for consolidation (worsening?) also crackles on exam b/l with elevated\n BNP\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old with AIDS, intubated, evaluate for consolidation.\n\n Comparison: \n\n Portable AP chest radiograph.\n\n There is a lucent area at the right lung base as well as a small lucency at\n the right apex consistent with pneumothorax. The lungs are hyperinflated. The\n ET tube is in appropriate position 6 cm above the carina. There is a left\n internal jugular line in appropriate position. The tip of the NG tube is\n below the diaphragm, most likely i the stomach. There is persistent opacity\n at the left lung base consistent with a pneumonia.\n\n IMPRESSION: Pneumothorax in the right lung. Discussed with Dr. \n at the time of dictation. Consolidation at left lung base which is similar to\n prior. ET tube and left IJ in appropriate position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 994626,
"text": " 8:34 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: new placement PICC R AC\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with\n REASON FOR THIS EXAMINATION:\n new placement PICC R AC\n ______________________________________________________________________________\n FINAL REPORT\n , 8:44.\n\n INDICATION: Line placement.\n\n There is a new right-sided PICC line with the tip projecting over the expected\n course of the distal SVC. The right apical pneumothorax is unchanged.\n Prominent interstitial markings remain. The right IJ line is in standard\n position.\n\n IMPRESSION: Right PICC in standard position. Persistent right pneumothorax.\n No other short interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-16 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 994667,
"text": " 11:05 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: evidence of invasive aspergillus, ? does need contrast to se\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AIDs, found to have MRSA pna and growing aspergillus in\n sputum\n REASON FOR THIS EXAMINATION:\n evidence of invasive aspergillus, ? does need contrast to see this?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old with AIDS, found with MRSA pneumonia and Aspergillus\n growing in the sputum. Evaluate for invasive Aspergillus.\n\n COMPARISON: CT chest of .\n TECHNIQUE: Axial MDCT images through the lungs without IV contrast with\n coronal reformatted images.\n\n FINDINGS: There is a right-sided PICC with its tip in the distal SVC and a\n left-sided IJ catheter with its tip at the atriocaval junction. There remains\n a moderate right anterior apical pneumothorax as seen on prior chest\n radiographs. Possible etiology might be a ruptured right apical bleb giving\n the presence of apical blebs on a current study (3, 9).\n\n There has been marked interval progression of the diffuse centrilobular\n ground-glass nodules with consolidation at the lung bases bilaterally. This\n predominantly affects the lower lobes, but there has also been worsening in\n the upper lobes, particularly in the right upper lobe. There are bilateral\n cylindric bronchiectasis , slightly progressed .\n\n There are subcentimeter mediastinal lymph nodes and a tiny pericardial\n effusion, slightly increased\n\n Limited non-contrast imaging through the upper abdomen demonstrates an NG\n tube, simple cyst in the left kidney, cystic lesion in the tail of the\n pancreas, and an ill-defined heterogeneous lesion in the left lobe of the\n liver. No lesion is appreciated on the CT abdomen of or abdominal\n and right upper quadrant ultrasound from . No osseous lesions are\n appreciated. Coronal and sagittal reformatted images confirm the above\n findings.\n\n IMPRESSION:\n 1) Marked worsening of centrolobular ground glass nodules predominantly in the\n lower lobes, to a lesser degree in the upper lobes, with consolidation at the\n lung bases. While the findings are most suggestive of a bacterial process and\n there are no specific CT findings to suggest invasive aspergillus, the latter\n cannot be excluded.\n 2) Persisting moderate right anteroapical pneumothorax, likely originating\n from a ruptured right apical bleb.\n 3) Pancreatic tail cystic lesion; as stated previously differential includes\n pancreatic cystic neoplasm vs pseudocyst.\n (Over)\n\n 11:05 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: evidence of invasive aspergillus, ? does need contrast to se\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4) Question of a left lobe liver lesion, not seen previously; ultrasound or CT\n could further assess if clinically warranted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 993877,
"text": " 4:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AIDs, hep C, found down, unclear etiology, intubated for\n airway protection\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH, 4:56 A.M.:\n\n CLINICAL HISTORY: 48-year-old man with AIDS, hepatitis C, found down, unclear\n etiology, intubated for airway protection.\n\n COMPARISON: .\n\n The tip of the endotracheal tube is seen approximately 3 cm above the carina.\n The nasogastric tube is seen coursing into the stomach. The most distal\n portion of the nasogastric tube is not included on this radiograph. The left\n internal jugular central line is unchanged with its tip in the superior vena\n cava. The lungs are clear with the exception of a small patchy opacity in the\n left lower lobe. There is no pneumothorax.\n\n IMPRESSION: Small patchy opacity projecting over the left costophrenic angle.\n Diagnostic considerations include pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 994266,
"text": " 3:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?CHANGE, ETT, PULM EDEMA\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AIDs, PNA, intubated\n REASON FOR THIS EXAMINATION:\n daily Xray\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH:\n\n COMPARISON: .\n\n INDICATION: AIDS, pneumothorax.\n\n In comparison with the previous examination of , the extent of\n the right-sided pneumothorax has slightly decreased. However, there are still\n signs of tension, with a depression the right-sided hemidiaphragm. Slight\n shift of the mediastinal organs to the left. The cardiac silhouette has\n increased in diameter by about 1-2 cm. All other findings are unchanged.\n\n IMPRESSION: In comparison to , slight decrease of right-sided\n pneumothorax, but signs of tension persist. Slight enlargement of cardiac\n silhouette. No other relevant changes.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2145-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 993979,
"text": " 4:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AIDs, found down, resp failure, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Syncope. Intubated.\n\n Single portable radiograph of the chest demonstrates worsening airspace\n opacity involving the left lower lung when compared with . Support\n lines are unchanged. No pneumothorax. Surgical staples project over the left\n apex. Cardiomediastinal contours are normal.\n\n IMPRESSION:\n\n Worsening left lower lung airspace opacity. Diagnostic considerations include\n worsening pneumonia.\n\n Support lines in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 994476,
"text": " 11:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate the change in PTX\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AIDS, s/p extubation with L sided PTX\n REASON FOR THIS EXAMINATION:\n evaluate the change in PTX\n ______________________________________________________________________________\n FINAL REPORT\n Chest, portable AP view dated and compared to examination.\n\n HISTORY: 48-year-old man with AIDS, status post extubation with left-sided\n pneumothorax. Evaluate for change.\n\n FINDINGS: In the interval, the right apical pneumothorax has slightly\n increased in size. The lung intersitial markings are slightly prominent.\n Projected over the left lung field is a nodular like density, which could\n either represent a nipple, or true lesion. The heart and cardiomediastinal\n structures are unremarkable. There is a left internal jugular central line\n with distal tip projected over the upper SVC. No pleural effusion is noted.\n\n IMPRESSION:\n 1. Slight increase in the size of the snmall right apical pneumothorax.\n 2. Nodular like density projects over the left lower lung zone which could\n represent a nipple or a true lung lesion. Nipple markers shoul dbe specified\n on the subsequent chest x-ray.\n 3. Prominent mild interstitial marking in both lungs are seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 993674,
"text": " 3:55 PM\n CHEST PORT. LINE PLACEMENT; REPEAT, (REQUEST BY RADIOLOGIST) Clip # \n Reason: assess for PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with s/p L IJ TLC placement - initial pCXR w/ ? left PTX\n REASON FOR THIS EXAMINATION:\n assess for PTX\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: 48-year-old male with new left internal jugular central venous\n line placement. Please evaluate for pneumothorax.\n\n FINDINGS: Comparison is made to radiograph obtained minutes before. No left\n apical pleural edge is detected to suggest developing pneumothorax. Lines and\n tubes are unchanged since very recent comparison. The appearance of the chest\n is stable and please see prior report for details.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 993671,
"text": " 3:33 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: assess line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with s/p left IJ TLC insertion\n REASON FOR THIS EXAMINATION:\n assess line placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: 48-year-old male with left internal jugular central venous line\n insertion.\n\n COMPARISON: Same date approximately one hour previous.\n\n FINDINGS: The endotracheal tube is approximately 4 cm above the carina.\n Nasogastric tube remains with tip and side port in the stomach. A new left IJ\n central venous catheter with tip at the expected region of the distal SVC. In\n the left lung apex a dense horizontally oriented linear opacity is believed to\n represent bedding overlying the patient rather than a pleural edge. The\n cardiomediastinal silhouette is stable in appearance. Aside from patchy ill-\n defined opacities within the left lung base the lungs are otherwise clear.\n\n IMPRESSION:\n 1. New left internal jugular central venous line in standard position.\n Otherwise stable examination.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-14 00:00:00.000",
"description": "Report",
"row_id": 1583102,
"text": "respiratory care\npt was weaned from the vent and placed on NC tol well. see respiratory page of carevue for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-15 00:00:00.000",
"description": "Report",
"row_id": 1583103,
"text": "1900-0700 rn notes micu\n\n48y.o M with h/o AIDS, HCV, astma. h/o TB and PCP admitted after was found down, was intubated for airwy protection and was found to be in respiratoru distress d/t LLL PNA and altered mental status possible d/t HIV enchephalopathy., head CT neg, neck CT, no evidence for fructure, r neck hematoma d/t several line placment.per pt has small R pneumothorax, that now decreasing in size.\n\npt extubated .\n\nneruo: pt alert, but unable to assess oreinetion,pt nod head,unclear if understant good English, moaning for pain,no spont movement of extremeties notes. given Morphine 2mg IV q4hr for pain in back and R arm. pt's R arm more swollen than left and painfull to move, MD aware.\n\nresp: NC 3L, LS clear on left, diminished at bases. pt has weak cough,unable to suction ,pt bites suction tube.sat 97-99%.\n\ncv: HR 100's, ST, no ectopy, BP 120-140/70, morning labs pending.\n\ngi/gu: foley drainged yellow/clear urine, 60-100cc/hr. ABD soft, BS hypoactive, pt NPO, after giving ice-chips, pt start coughing.Po meds not given.\n\nid: contact precaution, pos C diff, MRSA in sputum. tmax 100.3, blood cx and uirne cx sent. cont vanco, meropenem, acyclovir.\n\nsocial: full code after discussing with pt's brother who HCP.no contact from family.\n\nplan: cont monitoring neruo/resp/cardio status\n monitoring temp\n follow lytes repletes as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-15 00:00:00.000",
"description": "Report",
"row_id": 1583104,
"text": "MICU NPN\nBrief ROS:\n Pt. mental staus is unchanged through shift, he is awake and occ nods appropriately but that is inconsistant. He will nod yes to simple questions but seems to nod yes in most reponses. He has called out in pain when he's been moved, \"come on man!\" or other activities(collar care). He moves his arms small amts, able to grip but not using arms much, too weak. J collar in place, attempted to d/c collar but pt. said he had pain in his neck, on his clinical exam. Has not rcv'd pain med this shift. He is very sensitive to any movement or activity but when he's left alone, he appears comfortable. OOB with physical therapy(pivoted out of bed, hardly any wt bearing, pad under pt.)\n\nCV Stable BP and HR, sinus, rare pvc. Skin warm and dry, palpable periph pulses.\n\nResp- Adequate sats this shift on NC, 3L. RR16-20. Breath sounds are clear when pt. able to take a strong enough breath, rul, otherwise diminished. Coughing fairly well, but non-productive.\n\nGI- NPO. Placed NGT for possible tube feeds or meds. Placement confirmed with CXR.\n\nGU- Adequate u/o via foley. No lasix this shift.\n\nID- Afeb this shift. Vanco, flagyl and meroenum continues, acyclovir dc'd. Awaiting PICC placement for long term antibiotics.\n\nSkin- Very this pt., many bony prominences. Considered first step bed but ordered was cancelled when ICU bed was realized to be just as effective as first step mattress. Duoderm over coccyx. Otherwise no further areas of breakdown.\n\nSocial- No family members in to see pt., no communication.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-14 00:00:00.000",
"description": "Report",
"row_id": 1583100,
"text": "PT. REMAINS A FULL CODE AT THIS TIME.\n\nPT. HAS ALLERGIES TO BACTRIM DS, LINEZOLID, AND INDOMETHACIN.\n\nPT. REMAINLIGHTLY SEDATED ON PROPOFOL GTT AT 10MCG. PT. DID AROUSE MORE THAN HE HAS FOR THE PAST THREE DAYS. PT. LOOKS AT YOU WHEN HE IS SPOKEN TO CONSISTENTLY. PT. STILL DOES NOT FOLLOW ANY COMMANDS, NOR IS HE NOTED TO MOVE ANY EXTREMITIES. PT. HAD LOW GRADE TEMP BUT PRESENTLY 98.6.\n\nPT. REMAINS NSR 80-90'S WITH NO NOTED ECTOPY. B/P REMAINS STABLE AS WELL 120-130'S/60-70'S. CVP 2-6. PULSES ARE ALL STRONG, NO TREACE EDEMA NOTED.\n\nPLAN ARE TO EXTUBATE PT. TODAY. PT. IS PRESENTLY ON SIMV FROM FULL SUPPORT OVERNIGHT. PRESENTLY DOING WELL. REFER TO CAREVUE FOR LATEST SETTINGS. O2 SAT REMAIN 100%, UNABLE TO OBTAIN A ABG. RESP RATE SINCE SWITCH TO SIMV IS 24-39. LUNGS ARE SLIGHTLY CLEARER THAN BEFORE WITH MID TO UPPER LOBES CLEAR BILAT, AND BILAT BASES DIMINISHED. PT. HAS BEEN FOR INCREASINGLY AMT'S OF NOW YELLOW TINGED SECTREIONS WHICH HAS CHANGED FROM MOD. CLEAR SECRETIONS.\n\nPT. RECEIVED TUBEFEEDS OF PROBALANCE TIL MIDNIGHT, THEN CLAMPED FOR POSSIBLE EXTUBATION. ABD. REMAINS BENIGN IN ASSESSMENT. PT. HAS MUSHROOM CATHETER IN WHICH CONTINUES TO DRAIN SMALL AMT'S OF LIQUID BROWN, GUAIC NEG STOOL. FOLEY CATHETER REMAINS INTACT AND DRAINING APPRO 60CC/HR OF CLEAR YELLOW URINE. PT. MET GOAL LAST EVENING OF -500CC RE: HIS I&O'S. PT. CONTINUES ON CONTACT PRECAUTIONS FOR CDIFF AND REMAINS ON FLAGYL, AS WELL AS MEROPENUM, VANCO, AND ACYCLOVIR FOR IV ANTIBOITIC COVERAGE.\n\nSKIN CONTINUES TO EXHIBIT MULTIPLE ECCHYMOTIC AREAS ALL OVER. NO BREAK IN SKIN INTGRITY NOTED. TLC REMIANS INTACT,SECURED, AND FUNCTIONING WELL.\n\nPLAN IS FOR EXTUBATION TODAY. PT. HAS ALREADY BEEN TURNED DOWN ON HIS VENT SETTINGS AND PT. IS TOLERATING THIS. IF PT. NEEDS TO BE RE INTUBATED FAMILY WISHES THIS, AND PT. WILL THAN BE PLANNED FOR FUTURE TRACH AND PEG.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-14 00:00:00.000",
"description": "Report",
"row_id": 1583101,
"text": "Nursing Progress Note MICU 7\n0700-1900\nCode: Full\nAllergies: Bactrim, Indomethacin, Linezolid\nAccess: Left IJ TLCL\n\nNeuro: Weaned off Propofol gtt today for extubation. Alert, following simple commands, will sqeeze hand, nods yes or no. Non-verbal. Attempting to mouth words.\n\nCV: BP 120's to 150's systolic. HR 70's to 80's NSR, no ectopy. CVP 4-8. Pt. being diuresed. Received 20mg Lasix IVP. Currently negative 660 since MN. Recevied 60meqs KCL this am for K of 2.8. Repeat K 3.3, ecevieing additional 60meqs KCL.\n\nResp: Pt. extubated this am. Sats 98-100% on 3 Liters. Lung sounds coarse throughout. Junky cough, coughing up secretions to back of throat, but biting down during suctioning. CXR showed LLL PNA and right lung pneumothorax.\n\nID: Positive C-Diff. Positive MRSA in sputum. Pt. on Flagyl, Vanco, Meropenem, and Acyclovir. Afebrile today. WBC 4.6. ID following. Pt. needs Vanco trough in am.\n\nGI/GU: Mushroom cath intact, draining loose brown stool. Abdomen flat, non-tender. Foley drainging clear yellow urine.\n\nPlan: Continue abx. Await pending cultures. Monitor resp status. Anticipate need for placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-13 00:00:00.000",
"description": "Report",
"row_id": 1583097,
"text": "Nursing Note: 0700-1900\nNo significant events for time noted.\n\n\nNEURO: Received lightly sedated on Propofol; turned off during AM rounds with no appreciable improvement in mental status. Opens eyes spontaneously but does not track; no commands; no spontaneous movt noted. Grimaces with any intervention.\n\nRESP: Tolerated PSV 5/5 entire shift; changed to 10/5 at 1900 for increased tachpynea and tachycardia. RR high 20s-30s with increase up to 40s during repositioning. for small - mod amt of thick sputum; cough/gag impaired. Sats maintained at or near 100% LS coarse/diminished at bases. Final BAL negative.\n\nC/V: HR 90s-100s, SR with increase up to 120 at 1900. NBP 120s-140s. Diuresed with goal of negative 500cc/24hr. No appreciable edema.\nCVP 2-11.\n\nID: Tmax 100.3 PO; covered with several antibiotics including Flagyl for C-Diff.\n\nGI/GU: TF Probalance increased to 20cc/hr via OGT. U/O marginal at times with low of 15cc/hr. Mushroom cath placed for liquid diarrhea, guiac negative.\n\nSKIN: Several abrasions present on lower extremities and buttocks.\n\nDISPO: Full code; brother to come in for meeting with team regarding plans for extubation and further tx. Contact precautions.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-13 00:00:00.000",
"description": "Report",
"row_id": 1583098,
"text": "Nursing Addendum: 1750\nPlaced on A/C 500X20/5/.4 for increased RR, HR and BP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-14 00:00:00.000",
"description": "Report",
"row_id": 1583099,
"text": "Respiratory Care\nPt intubatd on vent support. No ABGs. Unable to complete AM RSBI trial RR>33. Vent support weaned to SIMV see care vue for details. PT eyes open and appears to be looking around, looked at this therapist when addressed by name, but not cooperative. Sx for large amounts light yellow secretions, bites on ET tube making more then one pass of Sx cath difficult. BS coarse but improved after sx. MDIs as ordered.\nPlan: Wean from vent support as tol, ? extubation later today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-12 00:00:00.000",
"description": "Report",
"row_id": 1583090,
"text": "PT. REMAINS A FULL CODE AT THIS TIME.\n\nPT. REMAINS ON AIRBOUNRE, AND CONTACT PRECAUTIONS.\n\nPT. REMAINS LIGHTLY SEDATED ON 30MCG OF PROPOFOL. PT. CONTINUES TO SPONTANEOUSLY OPENS HIS EYES, BUT HAS NOT TRACKED, NOR DOES HE FOLLOW ANY COMMANDS THROUGHOUT THIS SHIFT. NO MOVEMENT NOTED TO ANY OF PT'S EXTREMITIES DURING THIS SHIFT. PT. REMAINS IN J COLLAR, AFTER BOTH CT HEAD AND NECK ARE NEGATIVE. PT. HAS REMAINED AFEBRILE.\n\nPT'S V/S HAVE REMAINED WNL'S. H.R. 80-90'S WITH NO NOTED ECTOPY. B/P RANGING 120-140'S/70-80'S. PULSES A RE EASILY PALPABLE, WITH NO NOTED EDEMA NOTED. CVP HAS RANGED 2-8, NO FLUID BOLUSES GIVEN.\n\nPT. REMAINS INTUBATED, REFER TO CAREVUE FOR SETTINGS. NO CHANGES MADE DURING THIS SHIFT. PT. HAS BEEN FOR SCANT AMT'S OF CLEAR SECRETIONS. LUNG SOUNDS REMAIN CLEAR THROUGHOUT. O2 SATS HAVE BEEN 97-100%. PLAN FOR POSSIBLE EXTUBATION TODAY.\n\nPT'S TUBE FEEDS HAVE BEEN HELD SINCE MIDNIGHT IN PLANS FOR POSSIBLE EXTUBATION. ABD. REMAINS BENIGN IN ASSESSMENT. BOWELS SOUNDS ARE EASILY AUDIBLE, AND PT. HAS HAD THREE MOD-LARGE LIQUID GREEN/BROWN, TRACE GUAIC POSITIVE STOOLS. FOLEY CATHETER REMAINE IN PLACE DRAINING MODERATE AMT'S OF CLEAR YELLOW URINE, 80-140CC/HR.\n\nSKIN EXHIBITS MULTIPLE ECCHYMOTIC AREAS. NO BREAK IN SKIN INTEGRITY NOTED. COCCYX REGION IS SLIGHTLY REDDENED, BARRIER CREAM APPLIED. LEFT I.J. TLC REMAINS INTACT, SECURED, AND FUNCTIONG WELL. PT. WAS PLACED IN BILAT MULTIPODUS BOOTS, PREVENTING FOOT DROP, AND BREAKDOWN TO HIS HEELS.\n\nPLAN IS TO COLLECT THE TWO REMAINING INDUCED SPUTUM SPECIMENS TO R/O PT. FOR TB. PLAN IS TO HAVE HOUSE STAFF READDRESS CODE STATUS WITH PT'S BROTHER WHO IS HIS HCP. QUESTIONING WHETHER HCP IS UNDERSTANDING ALL THE INFORMATION TOLD TO HIM IN ENGLISH. PLAN REMAINS TO EXTUBATE PT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-12 00:00:00.000",
"description": "Report",
"row_id": 1583091,
"text": "Resp care\n\nPt has been light t/o shift, he is alert and awake most of the time. Sx Q 3-5 hrs for mod amts of white to yellow, mostly thickish, secr. Second AFB sent this morning.No ABG tonight, Pt remaing on PSV 5/+5 40%.RSBI was < 70. Pt may be extubated later today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-12 00:00:00.000",
"description": "Report",
"row_id": 1583092,
"text": "Resp. care note - pt. remaines intubated and vented, MDI'S given pt. tol ok.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-12 00:00:00.000",
"description": "Report",
"row_id": 1583093,
"text": "Nursing Progress Note 0700-1900\nPlease see carevue and FHP for additional data.\n\nDispo: FULL code\nAllergies: Bactrim DS/ Indomethacin/ Linezolid\nAccess: LSC/TLC\n\nNuero: Pt adequately sedated on 30 mcg/hr propofol. Daily wake-up performed, opened eyes spontaneously, does not track, does not MAE. Propofol gtt turned back on for comfort with plan to diurese first before extubating. PERRLA 3mm/bsk bilaterally. Pt remains in J collar, both head/neck CT neg. Bilateral wrist restraints applied for safety. MRI + for HIV encephalopathy.\n\nCV: HR 90-115s NSR/ST with no ectopy noted. NBP 120-140s/70-80s. Potassium 3.3, repleted with 40 mEq of KCL. + PP bilaterally, trace-pitting edema noted in bilateral LE. Rec'd 20 mg ivp lasix with -1.3L out. Pt currently +11L LOS.\n\nResp: Pt intubated on vent setting CPAP/PS 10/5, with sats 100%. Attemped SBT at beginning of shift on vent settings CPAP/PS 0/5, pt tolerated for 2hrs before becoming tachypneic with RR 40s, and increased WOB noted. VBG sent, WNL. At that time pt with few crackles in bases and noted to have increased secretions than yesterday, sxning q1-2hr for mod-copious amounts of white thick secretions. Also noted to have copious frothy white oral secretions, frequent oral care performed. Plan to diurese before extubating. LS clear t/o. BAL - for TB, sputum cx remain pnding, plan to collect last sputum spec tomorrow. Remains on airborne/contact precautions\n\nGI/GU: Cachectic, abd. soft. + BS, with green/brown liquid-soft stool x1 this shift. + C. Diff, remains on airborne/contact precautions. OGT secure and patent, remained clamped this shift for ? of possible extubation. Foley catheter secure and patent, draining adequate amounts of clear yellow urine.\n\nSkin: Mult. areas with eccymosis and abrasions noted to LE and buttocks. Pt was found down at home. Barrier cream applied to abrasions on buttocks. All areas ota, no drainage noted.\n\nID: Tmax 99.9, remains on flagyl, vanco, acyclovir, and meropenum for coverage.\n\nSocial: No contact from family this shift.\n\nPlan: Cont. to lightly diurese pt with goal -1L. Cont. pulm. toilet. Cont. to wean vent/sedation as tolerated. f/u on culture data. Plan to house staff readdress code status with pt's brother who is his HCP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-13 00:00:00.000",
"description": "Report",
"row_id": 1583094,
"text": "Resp Care\n\nPt appears to have worsening pneumonia per CXR and dyspnea. Spo2 remains good but there has been increase in secretions and pt is tachypneic to 35 in PSV mode. He was rested on AC overnight wth RR 20 x vt 500. Pt has no a-line and no ABG drawn. Morning RSBI was 135. BS are course with rhonchi. he is getting albuteroland atrovent MDI Q 6.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-13 00:00:00.000",
"description": "Report",
"row_id": 1583095,
"text": "PT. REMAINS A FULL CODE AT THIS TIME.\n\nPT. REMAINS LIGHTLY SEDATED ON PROPOFOL GTT AT 30MCQ. PT. OPENS EYES BUT CONTINUES NOT TO TRACK, OR MOVE EXTREMITIES. PT. EXHIBITED LOW GRADE TEMP OF 100.7 RECEIVED TYLENOL 650MG WITH DESIRED EFFECTS REACHED. PT. IS PRESENTLY AFEBRILE.\n\nPT. REMAINS TACHY WITH HR RANGING IN A NST 103-130'S. NO NOTED ECTOPY NOTED. B/P REMAINS STABLE AND WNL'S 95-130'S/60-70'S. PULSES ALL REMAIN STRONG AND EASILY PALPABLE. NO EDEMA NOTED. K=3.1 THIS AM WITH TOTAL OF 40MEQ KCL GIVEN. CVP HAS REMAINED 0-3, WHILE BEING DUIRESISED.\n\nPT. WAS CHANGED FROM PRESSURE SUPPORT VENT SETTINGS BACK TO FULL SUPPORT AT 2300 LAST HS. PT. WAS A QUESTIONABLE EXTUBATION YESTERDAY BUT FAILED SBT AFTER 2HRS. SINCE PT. HAS REMAINED SLIGHTLY FEBRILE, AND TACHYCARDIC. REFER TO CAREVUE FOR LATEST SETTINGS. PT. SECRETIONS HAVE INCREASED OVER THE PAST 48HRS. SECRETIONS ARE THICK AND CLEAR. O2 SATS REMAIN 98-100% NO ALINE, NO ABG'S DRAWN.\n\nPT. WAS RESTARTED ON HIS TUBE FEEDS OF PROBALANCE AT 10CC/HR SINCE PT. WILL NOT BE ATTEMPTED TO BE WEANED FROM VENTILATOR TODAY. TEAM TO ADDRESS GOAL RATE, PRESENTLY AT 10CC HR. ABD. IS BENIGN IN ASSESSMENT. BOWEL SOUNDS ARE EASILY AUDIBLE AND PT. HAS HAD TWO LIQUID GREEN BROWN STOOLS THI SSHIFT, WHICH WHERE GUAIC NEG. PT. IS POSITIVE FOR CDIFF AND REMAINS ON FLAGYL. FOLEY CATHETER REMAINS AND PT. HAS BEEN SUCCESSFULLY DIURESISED FOR OVER 2LITERS OF CLEAR YELLOW URINE, WHICH WAS GOAL.\n\nSLIN EXHIBITS MULTIPLE ECCHYMOTIC AEARS FROM UPON ADMISSION. NO BREAK IN SKIN INTEGRITY. PT. HAS A DIME SIZED AREA TO RIGHT GLUTEAL FOLD WHICH BARRIER CREAM HAS BEEN APPLIED. LEFT TLC REMAINS INTACT, SECURED AND FUNCTIONING WELL. PT. HAS BILAT MULTIPODUS BOOTS ON DUE TO FOOT DROP.\n\nPLAN IS TO CLARIFY WHETHER PT'S BROTHER WOULD BENEFIT FROM A FAMILY MEETING. IT IS QUESTIONABLE ON HOW MUCH ENGLISH PT'S BROTHER UNDERSTANDS. AND WITH PT'S WORSENING CONDITION, ?CODE STATUS. OTHERWISE REPLETE ELECTROLYTES PRN, AND WEAN VENT SETTING WHEN ABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-13 00:00:00.000",
"description": "Report",
"row_id": 1583096,
"text": "respiratory care\npt on the vent changes made tol fairly well. see respiratory page of carevue for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-11 00:00:00.000",
"description": "Report",
"row_id": 1583085,
"text": "MICU 7 RN Note 1900-0700\n\nFULL CODE per brother and PCP Dr .\n\nEVENTS: MRI head; Neg press room; Propofol weaned; VBG; CXR\n\nNEURO: Sedated w/Propofol 50mcg until after MRI; weaned 30mcg w/pt arousable to pain and secretions but not following commands. Bites on tube. Will continue to wean in preparation for extubation. Tox screen + for opiates (MSContin at home). CT showed mild global cerebral atrophy/advanced HIV Encephalopathy. Cervical collar changed to J. MRI results pending\n\nCV: SR 70-80s w/occ incr to 90s. BP 120s/70s incr to 130s/70s with decr sedation. CVP 6-9. +DP/PT. BairHugger used prior to MRI for low temp (not registering/skin cool). Temp incr to >97 oral prior to transport to MRI at ~2130. Warm blankets used for transport; pt maintained temp thereafter.\n\nRESP: CPAP/PS; RR 20s incr to 32 at 0400 due to incr secr; suction mod amt thin white; RR returned to 22 w/Vt of 400ml. Scant secr prior. Sats 100%. Lungs clear except at 0400; coarse, cleared w/sx.\n\nGU: Foley intact; UOP low at 1900-bolused w/500cc LR. Adeq UOP remainder of shift. Light yellow.\n\nGI: OG tube placement verified by ausc. Abd soft, nondist, hypoactive BS. Small BM at midnight; soft/solid. Likely AIDS wasting syndrome per ID consult.\n\nID: Empiric Acyclovir for HSV/Viral Meningitis; Cefepime/Flagyl/Vanco\nCSF, Stool and BAL pending. Moved to Neg pressure room after MRI. Afebrile.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-11 00:00:00.000",
"description": "Report",
"row_id": 1583086,
"text": "Resp Care Note\n\nPt has some mod thk white to yellow secr. RSBI today is ~ 65. He was reduced from PSV 10 to PSV 5 with Peep +5, 40% O2. Pt went to MRI last night for head scan, results are pending. Plan is to extubate when indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-11 00:00:00.000",
"description": "Report",
"row_id": 1583087,
"text": "Nursing Progress Note 0700-1900\nPlease see carevue and FHP for additional data.\n\nDispo: FULL code\nAllergies: Bactrim DS/ Indomethacin/ Linezolid\nAccess: LIJ/TLC\n\nThis is a 48yo male with a history sign. for ETOH/hepatitis, asthma, HIV/AIDs, TB, PCP x2, pericarditis, pnuemococcal pna with bacteremia , LLL pna, MAC on BAL, nueropathy, disseminated herpes zoster , depression, psuedomonal pna. Pt was found down at home by VNA \"indian style\" in urine ?2-3days. Responded to touch with grimaces, did not follow commands. Previous adm. after being found down outside. Intubated for airway protection AMS. Transferred to MICU on propofol/intubated, hypernatremic, rhabdo, hypercalcemic, hypothermic. Head/neck CT neg, J collar remains in place for safety.\n\nNuero: Pt adequately sedated on 30 mcg/hr propofol gtt. pt with gtt turned off at 0600. Pt opened eyes spontaneously, tracking, but did not follow commands, did not MAE. Pt failed SBT and propofol gtt turned back on for comfort. Pt now opens eyes spontaneously, but does not follow commands, does not MAE, grimaces with mouth care. PERRLA 3mm/bsk bilaterally. MRI scan of head , results pnding. CT scan showing cerebral atrophy/ advanced HIV encephalopathy. LP , preliminary results not sign. for bacterial meningitis, official results still pnding. J collar remains on, collar care done. No seizure activity noted. Bilateral wrist restraints remain on for safety.\n\nCV: HR 80s-90s NSR with no ectopy noted. NBP 130-140s/70-80s. Last Na 148, trending down. 1st liter of 2L LR hanging at 150cc/hr. Plan to hang 2nd bag once 1st liter is complete. CVP 4-7. Potassium 3.5, rec'd 40 mEq KCL. + PP bilaterally. Pt noted to have trace LE pitting edema.\n\nResp: Pt intubated on vent settings CPAP/PS 5/5, with sats 100%. VBG sent, WNL. Attempted SBT (0/0) this am while sedation was off, pt's RR increased to 40s, and TV dropped. Bronchodialators started this shift. Sxned infrequentlyl for sm.-mod. amounts of white thick secretions. CXR showing pulm. nodules (? TB), today CXR unchanged. Bronch. with BAL , results pnding.\n\nGI/GU: Cachectic, abd. soft. + BS, with loose/soft stool x1 this shift, likely AIDS wasting syndrome per ID consult. C. Diff spec/Cx sent, results pnding. OGT secure and patent, TF started this shift probalance full strength at 10cc/hr, with goal rate of 45cc/hr. Will check TF residual at 1900. Foley catheter secure and patent draining adequate amounts of clear yellow urine.\n\nSkin: Mult. areas with eccymosis and abrasions to LE and buttocks. Was found down at home, all areas ota, no drainage noted.\n\nID: Afebrile this shift, Tmax 98.5. Remains on flagyl, vanco, cefepime, and acyclovir for coverage.\n\nPlan: Cont. to wean vent/sedation as tolerated. Plan to f/u on cx data. Cont. on antibiotic, remains on airborne/contact precautions/neg. pressure room for previous hx of TB/MRSA/psuedomonas. Cont. to monitor lytes. Cont. with bronchodialators. Plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-11 00:00:00.000",
"description": "Report",
"row_id": 1583088,
"text": "Nursing Progress Note 0700-1900\n(Continued)\nto hold TF at midnight for possible extubation tomorrow. Cont. providing supportive care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-11 00:00:00.000",
"description": "Report",
"row_id": 1583089,
"text": "Resp. care note - pt. remaines intubated and vented, no vent changes made at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-10 00:00:00.000",
"description": "Report",
"row_id": 1583080,
"text": "MICU 7 RN Note 1900-0700\n\nFull Code per pt's brother and pt's PCP Dr .\n\nPRECAUTIONS: TB; MRSA; Pseudomonas (history of)\n\nPt found down at home by VNA; sitting in urine, duration uncertain. Last seen by brother on . Recent admission on after found down outside.\n\nEVENTS: Admitted to MICU 7 from ED Vented/Sedated. Antibiotics. LR for volume. D5W for Hypernatremia. BairHugger for hypothermia. CVP transduced.\n\nNEURO: Sedated w/Propofol on Vent. On adm to , pt lethargic, answered questions but w/few words. Angry on previous adm when asked about history. Intubated for airway protection and for change in mental status. Currently on Propofol 35 mcg/kg/min; arouses to painful stim. Incr to 45mcg for part of night. PERRL 3-4mm. Head and Cspine negative. Cervical collar still in place until neck pain improved.\n\nCV: ST 120-130s on adm, decr to 70s with IVF/sedation. HR 90s at 0545 w/IVF off and sedation down to Propofol 35mcg BP 1teens-130s/60-80s (Hypertensive on adm to ED). CVP 6-8. Temp in ED 96rect; placed on BairHugger; temp incr to 102; Tylenol in ED. T 101.5 on adm to MICU decr to 96.8rect after IVF. BairHugger from 0100 to 0500 when temp reached 98.3oral. IVF complete. LIJ intact w/CVP. All ports patent. +DP/PT. No edema. Cachectic. Bruising/abrasions noted. Coccyx intact/reddened. RIJ site- hematoma 3cm from several attempts. Hct decr from 35.7 to 27.9 after IVF; no signs of bleeding.\n\nRESP: AC changed to CPAP/PS; Back-up apnea ventilation started after pt bolused w/Propofol. Resp changed to MVV afterwhich pt ventilated spont on Propofol 45mcg. LS clear; very little sputum (sent for AFB). Oral care done; small amount oral secr. VBG sent; only Lactic acid resulted.\n\nGU: Foley intact; Yellow to light yellow. Low UOP; IVF boluses adm as ordered; incr UOP noted. BUN/Cr high (was 15/0.6 previous adm ). CT contrast not used. BUN/Cr 67/1.1 at 0200.\n\nGI: Abd soft, hypoactive BS. No BM. OG intact to LIS w/bile output.\n\nID: BC x2 sent; Fungal/Myco cult sent x1; Sputum sent; Urine sent for Legionella;\n\nELECTROLYTES: KCL 20meq for K of 3.1; D5W for Hypernatremia DC'd when Na 152. AM chem pending.\n\nPLAN: Bronchoscopy for BAL then extubation, Possible LP, Antibiotic therapy, Hydration for Rhabd; ABG; MD adm note for additional detail.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-10 00:00:00.000",
"description": "Report",
"row_id": 1583081,
"text": "resp care\n\nPt has complicated hx which includes AIDS,TB,PNEUMOCYSTIC pneu,pericarditis,neuropathy, and deseminated herpes zoster.pt had been discharged @ end of but was then found down @ home with mental status changes. He has been tachypneic but oxygenation is good. Pt has small amts of tk secr sx from # 8 ETT. Plan for today is to bronch for BAL and send sample for AFB and smear. Vent mode was changed to PSV to minimize respiratory aspect of alkalosis but when sedation is bolused he become hypopneic or apneic. Mode was changed to MMV, mechanical breathes have been rarely used by pt. RSBI this A.M. is ~ 80. See flow sheet for furthur details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-10 00:00:00.000",
"description": "Report",
"row_id": 1583082,
"text": "MICU 7 RN addendum\n\nD5W on 160/hour. with MD how many hours.\n\nLR at 250/hr x 1L\n\nK= 3.3 last two labs. 40meq KCL ordered. First 20 up at 0645.\n\nGreen top sent for pH\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-10 00:00:00.000",
"description": "Report",
"row_id": 1583083,
"text": "Nursing Progress Note 0700-1900\nPlease see carevue and FHP for additional data.\n\nDispo: FULL code\nAllergies: Bactrim DS, Indomethacin, Linezolid\nAccess: LIJ/MUL\n\nNuero: Pt adequately sedated on 50 mcg/hr of propofol. pt on 35 mcg/hr of propofol, daily wake-up performed, pt opens eyes to stimulus/voice, tracks with eyes, does not follow commands. Will grimace with painful stimuli. Propofol gtt increased for bronchoscopy and for trip to MRI. PERRLA 3mm/bsk bilaterally. Cervical collar remains on for safety, CT of head and spine negative. LP today to r/o meningitis, CSF cx/spec sent, results pnding. No seizure activity noted. Bilateral wrist restraints applied for safety.\n\nCV: HR 70s-80s NSR with rare PVCs noted. NBP 115-140s/70-80s. Na 148 trending down, corrected with D5W on previous shift. K 3.2, will plan to replete with 60 mEq of KCL. CVP 3-5. + PP bilaterally. Hct remains stable.\n\nResp: Pt intubated on vent setting CPAP/PS 40% 10/5 PEEP, with sats 100%, RR 17-21. Sxned infrequently for no secretions. Bed side Bronch. today to r/o TB, uneventful, BAL sent, results pnding. CXR showing pulmonary nodules. Pt noted to have mod. amounts of clear thick drainage from oral cavity and nasal cavity, MD aware.\n\nGI/GU: Cachectic, abd soft. + BS, with brown liquid stool x1 this shift, C. diff/cx sent, results pnding. OGT secure and patent, rec'd pt on LIS, with only 50cc green bilious out, remains clamped. Foley catheter secure and patent draining adequate amounts of clear yellow urine. Noted foley leaking sm. amounts of urine on bed, changed urimeter bag, remains intact. BUN/Cr remains elevated.\n\nSkin: Mult. areas with ecccymosis and abrasions noted to LEs and buttocks. Was found down at home, all areas ota, no drainage noted.\n\nID: Remains on flagyl, vanco, and cefepime for coverage. Tmax 98.9, Tmin 96.9, bairhugger remained off for this shift.\n\nSocial: Called brother today, updated by this RN, questions answered.\n\nPlan: Awaiting MRI, plan to wean sedation/vent after MRI with plans to extubate. Intubated only for airway protection AMS. Plan to f/u on cx data. Pt with rhabdo, cont. to monitor and treat for low CVP and UO. Cont. on antibx, remains on airborne/contact precautions for previous hx of TB/MRSA/psuedomonas. Cont. to monitor lytes. Cont. providing supportive care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-10 00:00:00.000",
"description": "Report",
"row_id": 1583084,
"text": "Respiratory Care:\nPt remains orally intubated and vented. Pt weaned from MMV to PSV. Placed for few hrs on AC for and after bronch d/t sedation then back to PSV. BAL obtained and sent to lab. Lung sounds clear. for none. Plan is to go to MRI then wean to extubate. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-16 00:00:00.000",
"description": "Report",
"row_id": 1583105,
"text": "1900-0700 rn notes micu\n\n48 y.o male with h/o AIDS, HCV,astma, h/o TB and PCP admitted after was found down, was intubated for airway protection and found to be in respiratory distress d/t LLL PNA, changes in mental status likely d/t AIDS encephalopathy.neck head Ct neg, shown small R pneumothorax.\n\n was extubated.\n\nneuro: pt alert,but does not answer questions, at time says yes, occass nod head and makes soe incomp sounds with some words, traking with eyes, follows simple commands inconsistently, opens eyes spont. no spont movement of extremeties, very sensitive for repositon, moaning for pain, given Morphin 2ng with some effect.\n\nreps; NC 2L, sat 99-100%, LS diminished. pt has weak, productive cough, but swallow , unbale to suction, pt bites suction.\n\ncv: HR 90's, NSR, no ectopy, BP stable 130-140/70's, morning labs pending.\n\ngu/gi: foley drainged yellow/clear urine, 30cc/hr. ABD soft/flat,BS +, mushroom cath drainged loose brown stool, NGT placed,confirmed with , start TF ,needs speech/swallow eval, pt starts couhgingafter ice chips.\n\nid: afebrile, cont flagyl for c. diff, vanco/meropenem for MRSA in sputum.\n\nsocial: full code,pt brother HCP, no contact from family.\n\nplan: cont monitoring neuro/resp/cardio status\n needs PICC line for long term ABX, IV team aware.\n rehab after picc line placement\n ?c/o to floor.\n"
},
{
"category": "Echo",
"chartdate": "2145-12-13 00:00:00.000",
"description": "Report",
"row_id": 59712,
"text": "PATIENT/TEST INFORMATION:\nIndication: ?Endocarditis.\nHeight: (in) 69\nWeight (lb): 81\nBSA (m2): 1.41 m2\nBP (mm Hg): 125/50\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 15:11\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%. Mid-cavitary gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. Regional left ventricular wall motion is normal. Left\nventricular systolic function is hyperdynamic (EF>75%). A 24mmHg peak\nmid-cavitary gradient is identified. Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nno mitral valve prolapse. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , left ventricular\nsystolic function is now dynamic with a higher heart rate and mild resting\nmid-cavitary gradient.\nIs there a history to suggest a high output state (e.g., thiamine deficiency,\nhyperthyroidism, anemia, fever, etc.?\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-16 00:00:00.000",
"description": "Report",
"row_id": 1583106,
"text": "Nursing Progress Note 0700-1900\nPlease see carevue and FHP and Page 2 for additional data.\n\nDispo: FULL code\nAllergies: Bactrim DS/ Indomethacin/ Linezolid\nAccess: RtAnt/PICC\n\nNuero: Pt alert, able to make some incomplete sounds/few words. Follows some simple commands, but unable to distinguish true orientation communication barrier. Global weakness noted. Pt able to nod \"yes\" to pain, rec'd 2mg morphine ivp x1 this shift with good effect. Pt very sensitive to pain, will moan with turning/touch. PERRLA 3mm/bsk bilaterally, will track with eyes.\n\nCV: HR 70-80s NSR with no ectopy noted. NBP 130-140s/70-80s. + PP bilaterally.\n\nResp: Extubated . Pt now on 2L nc with sats 100%. Pt with junky-non-productive weak cough. LS diminished t/o. RR 27-31, no SOB/ increased WOB noted. BAL showing Aspergillus, CT of chest done this shift, results pnding.\n\nGI/GU: Cachectic, abd soft, non-tender to palpation. + BS, mushroom catheter draining mod. amounts of brown/greenish liquid stool. Replaced NGT with pedi-tube, awaiting verification by x-ray. TF on for most of shift, off currently until CXR confirms placement of tube. TF were running at 35cc/hr, with no residuals noted, will plan to advance to goal rate of 45cc/hr. Needs speech/swallow eval. Foley catheter draining adequate amounts of clear yellow urine.\n\nSkin: Mult. areas with abrasions, no drainage noted, ota.\n\nAccess: RtAnt/PICC placed today, verified by x-ray. LIJ/TLC dc'd, pressure applied, no s&s of bleeding noted.\n\nID: afebrile. Vanco held for vanco level of 25.6. Remains on flagyl, and meropenem for coverage.\n\nPlan: Discharge to rehab facility. Cont. providing supportive care.\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 994551,
"text": " 5:19 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate NGT placement\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AIDS, s/p extubation\n REASON FOR THIS EXAMINATION:\n evaluate NGT placement\n ______________________________________________________________________________\n WET READ: DSsd WED 6:48 PM\n NGT in stomach. R apical ptx unchanged. \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AIDS, status post extubation, evaluate NG tube placement.\n\n COMPARISON: , 11:33 a.m. The NG tube is in appropriate\n position within the stomach. There is no pneumothorax. The right apical\n pneumothorax is similar size. Prominent interstitial lung markings. The\n heart and mediastinum are normal. The left IJ central line has distal tip\n projected over the expected course of the proximal SVC.\n\n IMPRESSION: NG tube in appropriate position, no pneumothorax. No other short\n interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 994712,
"text": " 2:57 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p dobhoff placement\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with HIV\n REASON FOR THIS EXAMINATION:\n s/p dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST\n\n INDICATION: Dobbhoff placement.\n\n COMPARISON: at 8:44.\n\n The Dobbhoff is in appropriate position within the fundus of the stomach. No\n other interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 994639,
"text": " 9:37 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: s/p picc\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AIDS\n REASON FOR THIS EXAMINATION:\n s/p picc\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: at 8:44.\n\n INDICATION: PICC placement.\n\n The PICC projects over the course of expected SVC with the tip again at 1.2 cm\n below the carina. There is persistent small right apical pneumothorax. Left\n IJ line in standard position.\n\n IMPRESSION: PICC in standard position. No short interval change in\n pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 994596,
"text": " 3:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for change in PTX, please perform with a nipple \n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with AIDS, extubated, with spontaneous PTX\n REASON FOR THIS EXAMINATION:\n evaluate for change in PTX, please perform with a nipple marker\n ______________________________________________________________________________\n FINAL REPORT\n at 3:54 a.m.\n\n PORTABLE AP CHEST.\n\n INDICATION: Spontaneous pneumothorax, evaluate for change.\n\n COMPARISON: at 17:50.\n\n The right apical pneumothorax is unchanged. There are still somewhat\n prominent interstitial markings. The cardiomediastinal silhouette is normal.\n The left IJ line is in standard position.\n\n IMPRESSION: Right apical pneumothorax, unchanged. Prominent interstitial\n markings without pulmonary edema.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2145-12-09 00:00:00.000",
"description": "Report",
"row_id": 105574,
"text": "Sinus tachycardia with baseline artifact. Right atrial abnormality.\nTented T waves in precordial leads suggestive of hyperkalemia.\nCompared to previous tracing of marked tenting and increased\nvoltage of precordial T waves suggestive of acute metabolic derangement such as\nhyperkalemia.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2145-12-09 00:00:00.000",
"description": "Report",
"row_id": 105532,
"text": "Sinus rhythm. Right atrial abnormality. Anteroseptal myocardial infarction.\nCompared to previous tracing tented and high amplitude precordial T waves are\nno longer present.\nTRACING #2\n\n"
}
] |
46,093 | 139,857 | 23F admitted for bilateral pulmonary embolisms s/p laparoscopic appendectomy on . She underwent a CTA of her chest, which showed extensive bilateral pulmonary emboli. She was started on a heparin drip and transferred to the ICU. Cardiology and Vascular Surgery were consulted. They recommended therapeutic enoxaparin, which was given. To assess the strain on the heart, an echocardiogram was performed, which showed right free wall hypokinesis, 2+ tricuspid regurgitation, and dilation of the right ventricle. On , heme was consulted, and they recommended lifelong discontinuation of her oral contraceptive pills. They also advised a six-month course of warfarin. She underwent a repeat echo, which showed no change. On , a repeat CTA/CTV of th echest was performed as well as a CT of the pelvis to evaluate thrombus burden and to evaluated for iliofemoral clot, respectively. A repeat echo was unchanged. She was put on a regular diet, which she tolerated well. On , she was advanced to PO pain meds. Given her experience, she had anxiety, and so social work was consulted to evaluate for therapy options. From a cardiovascular standpoint, catheter directed thorombolysis was planned for the next morning, so she was switched over to a heparin drip. On , catheter directed thrombolysis was attempted but ultimately aborted before tPa was given secondary to her right pulmonary artery pressures being found to be normal. A repeat echo showed minimal dilation of the ventricle. She was transferred to the floor in stable condition. Cardiology recommended 3 weeks of fondaparinux (7.5 mg SC daily) every day with a transition to warfarin as an outpatient. On , she was doing well and discharged home in stable condition. | There is no pericardial effusion.IMPRESSION: Minimally dilated right ventricle with normal global and regionalbiventricular systolic function.Compared with the prior study (images reviewed) of , the findings aresimilar. There is no pericardial effusion.IMPRESSION: Moderately dilated and mildly hypokinetic right ventricle withrelative preservation of apical function ( sign). No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium and right atrium are normal in cavity size. Moderate [2+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. There is unchanged straightening of the intraventricular septum and mild dilatation of the right ventricle concerning for right heart strain. Normal regional and global left ventricular systolicfunction. The mitral valve appears structurally normal withtrivial mitral regurgitation. There is mild pulmonary artery systolic hypertension.There is a trivial pericardial effusion located along the right ventricularapex. The right ventricular cavity is mildly dilated with normal freewall contractility. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No AR.MITRAL VALVE: Normal mitral valve leaflets. The right ventricularcavity is mildly dilated with normal free wall contractility. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.TRICUSPID VALVE: Normal tricuspid valve leaflets. The right ventricular cavity is mildlydilated with mild global free wall hypokinesis. Trace left pleural effusion is unchanged. Mild global RV free wallhypokinesis.MITRAL VALVE: Normal mitral valve leaflets. Normal RV systolic function.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Normal aortic valve leaflets (3). No echocardiographicsigns of tamponade.Conclusions:Focused views:Regional left ventricular wall motion is normal. Moderate global RV free wallhypokinesis.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Normal aortic valve leaflets (3). The right ventricular cavity is moderatelydilated with moderate global free wall hypokinesis. Mild PAsystolic hypertension.PERICARDIUM: Trivial/physiologic pericardial effusion. The estimated pulmonaryartery systolic pressure is normal. Normal RV systolic function.Abnormal septal motion/position consistent with RV pressure/volume overload.AORTIC VALVE: Normal aortic valve leaflets (3). The diameters of aorta at the sinus, ascending and archlevels are normal. No MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. No MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. The aortic valve leaflets (3) appear structurally normalwith good leaflet excursion and no aortic stenosis or aortic regurgitation.The mitral valve appears structurally normal with trivial mitralregurgitation. The diameters of aorta atthe sinus, ascending and arch levels are normal. Moderate [2+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Extensive bilateral pulmonary emboli, unchanged in extent since the , study. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Elongated mitralvalve leaflets.TRICUSPID VALVE: Tricuspid leaflets do not fully coapt. The aortic valve leaflets (3)appear structurally normal with good leaflet excursion and no aortic stenosisor aortic regurgitation. There is moderate pulmonary artery systolichypertension. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:Left ventricular wall thickness, cavity size and regional/global systolicfunction are normal (LVEF >55%). The mitral valve leaflets arestructurally normal. Right ventricular function.Height: (in) 65Weight (lb): 145BSA (m2): 1.73 m2BP (mm Hg): 102/71HR (bpm): 71Status: InpatientDate/Time: at 10:56Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Normal regional LV systolic function. There is no pericardial effusion.Compared with the findings of the prior study (images reviewed) of ,the right ventricular cavity may be slightly smaller. Borderline mediastinal lymphadenopathy in the prevascular and subcarinal spaces is likely reactive and also unchanged. ProminentEustachian valve (normal variant).LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Mildly dilated RV cavity. IMPRESSION: No evidence of deep venous thrombosis in either lower extremity. Mild [1+] TR. Moderate pulmonary arterysystolic hypertension. Noaortic regurgitation is seen. Dilated tricuspidannulus with moderate tricuspid regurgitation. Right ventricular systolic function was mildly reduced on the priorechocardiogram, albeit not reported. Moderate [2+] tricuspid regurgitationis seen. No suspicious lytic or sclerotic lesions are identified. The bladder appears normal. There is normal compressibility, flow and augmentation. PATIENT/TEST INFORMATION:Indication: Pulmonary embolus.Status: InpatientDate/Time: at 15:00Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%).RIGHT VENTRICLE: Moderately dilated RV cavity. Subdiaphragmatically, only the top portion of the liver is imaged, which appears to have no focal liver lesions. Estimated pulmonary artery systolic pressure is now similarto slightly lower. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:No atrial septal defect is seen by 2D or color Doppler. There isabnormal septal motion/position consistent with right ventricularpressure/volume overload. PATIENT/TEST INFORMATION:Indication: Right ventricular function. Moderate [2+] tricuspidregurgitation is seen. Moderate [2+] tricuspidregurgitation is seen. Overall normal LVEF(>55%).RIGHT VENTRICLE: Mildly dilated RV cavity. : (in) 65Weight (lb): 145BSA (m2): 1.73 m2BP (mm Hg): 102/65HR (bpm): 65Status: InpatientDate/Time: at 13:15Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA and RA cavity sizes.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%).RIGHT VENTRICLE: Mildly dilated RV cavity. There is a small amount of mildy complex pelvic free fluid. There are no echocardiographic signs of tamponade.Compared with the prior study dated (images reviewed), findings aresimilar. : (in) 65Weight (lb): 145BSA (m2): 1.73 m2BP (mm Hg): 90/54HR (bpm): 95Status: InpatientDate/Time: at 11:25Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. Overall left ventricularsystolic function is normal (LVEF>55%). Overall leftventricular systolic function is normal (LVEF>55%). (Over) 10:59 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT PELVIS W/CONTRAST Clip # Reason: CT pulmonary angio for evaluation of pulmonary embolism clot Admitting Diagnosis: PULMONARY EMBOLISM FINAL REPORT (Cont) 2. There is no mitral valve prolapse. No pericardial effusion. There is no aortic valve stenosis. CT OF THE PELVIS: The pelvic veins are patent with no evidence of thrombus. TECHNIQUE: Bilateral lower extremity Doppler ultrasound. FINDINGS: Grayscale and Doppler son of the right and left common femoral, superficial femoral, popliteal, posterior tibial and peroneal veins were performed. | 6 | [
{
"category": "Echo",
"chartdate": "2134-07-28 00:00:00.000",
"description": "Report",
"row_id": 104217,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pulmonary embolus. Right ventricular function.\nHeight: (in) 65\nWeight (lb): 145\nBSA (m2): 1.73 m2\nBP (mm Hg): 102/71\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 10:56\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nConclusions:\nFocused views:\n\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). The right ventricular cavity is mildly\ndilated with mild global free wall hypokinesis. The mitral valve leaflets are\nstructurally normal. No mitral regurgitation is seen. Moderate [2+] tricuspid\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is a trivial pericardial effusion located along the right ventricular\napex. There are no echocardiographic signs of tamponade.\n\nCompared with the prior study dated (images reviewed), findings are\nsimilar. Right ventricular systolic function was mildly reduced on the prior\nechocardiogram, albeit not reported.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2134-07-30 00:00:00.000",
"description": "Report",
"row_id": 104148,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. S/p cath. . PE's.\n: (in) 65\nWeight (lb): 145\nBSA (m2): 1.73 m2\nBP (mm Hg): 102/65\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 13:15\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%). The right ventricular cavity is mildly dilated with normal free\nwall contractility. The diameters of aorta at the sinus, ascending and arch\nlevels are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic stenosis or aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse. The estimated pulmonary\nartery systolic pressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Minimally dilated right ventricle with normal global and regional\nbiventricular systolic function.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2134-07-27 00:00:00.000",
"description": "Report",
"row_id": 104149,
"text": "PATIENT/TEST INFORMATION:\nIndication: Right ventricular function. Pulmonary embolus.\n: (in) 65\nWeight (lb): 145\nBSA (m2): 1.73 m2\nBP (mm Hg): 90/54\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 11:25\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. Prominent\nEustachian valve (normal variant).\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\nAbnormal septal motion/position consistent with RV pressure/volume overload.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. Overall left\nventricular systolic function is normal (LVEF>55%). The right ventricular\ncavity is mildly dilated with normal free wall contractility. There is\nabnormal septal motion/position consistent with right ventricular\npressure/volume overload. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve leaflets are structurally\nnormal. No mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation\nis seen. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of ,\nthe right ventricular cavity may be slightly smaller. Tricsupd regurgitation\nappears similar. Estimated pulmonary artery systolic pressure is now similar\nto slightly lower.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2134-07-26 00:00:00.000",
"description": "Report",
"row_id": 104150,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pulmonary embolus.\nStatus: Inpatient\nDate/Time: at 15:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Elongated mitral\nvalve leaflets.\n\nTRICUSPID VALVE: Tricuspid leaflets do not fully coapt. Moderate [2+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nLeft ventricular wall thickness, cavity size and regional/global systolic\nfunction are normal (LVEF >55%). The right ventricular cavity is moderately\ndilated with moderate global free wall hypokinesis. The diameters of aorta at\nthe sinus, ascending and arch levels are normal. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic stenosis\nor aortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. The mitral valve leaflets are elongated. The\ntricuspid valve leaflets fail to fully coapt. Moderate [2+] tricuspid\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Moderately dilated and mildly hypokinetic right ventricle with\nrelative preservation of apical function ( sign). Dilated tricuspid\nannulus with moderate tricuspid regurgitation. Moderate pulmonary artery\nsystolic hypertension. Normal regional and global left ventricular systolic\nfunction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-07-26 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1250551,
"text": " 5:01 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: PE HYPOTENSION ASSESS FOR DVT\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with PE and hypotension\n REASON FOR THIS EXAMINATION:\n assess for DVT\n ______________________________________________________________________________\n WET READ: OXZa MON 7:02 PM\n No evidence of deep venous thrombosis in either lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pulmonary embolism and hypotension.\n\n TECHNIQUE: Bilateral lower extremity Doppler ultrasound.\n\n COMPARISON: None available.\n\n FINDINGS: Grayscale and Doppler son of the right and left common\n femoral, superficial femoral, popliteal, posterior tibial and peroneal veins\n were performed. There is normal compressibility, flow and augmentation.\n\n IMPRESSION: No evidence of deep venous thrombosis in either lower extremity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-07-28 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1250759,
"text": " 10:59 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT PELVIS W/CONTRAST Clip # \n Reason: CT pulmonary angio for evaluation of pulmonary embolism clot\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old woman with b/l submassive pe.\n REASON FOR THIS EXAMINATION:\n CT pulmonary angio for evaluation of pulmonary embolism clot burden. Please\n also time for CTV of iliac/pelvic veins to assess clot burden there.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 23-year-old woman with bilateral submassive PEs. Please\n evaluate for PEs as well as the pelvis to evaluate for clot in the veins.\n\n COMPARISON: CT as well as reference CT from .\n\n TECHNIQUE: CT of the chest was performed post-contrast with coronal,\n sagittal, and oblique reformats. Subsequently, post-contrast CT images of the\n pelvis were obtained with coronal and sagittal reconstructions.\n\n CT OF THE CHEST: There are extensive bilateral pulmonary emboli involving the\n main right and left pulmonary arteries, extending into the lobar, segmental\n and subsegmental levels bilaterally. Overall, the clot burden is not\n significantly changed from the study from two days prior. There is unchanged\n straightening of the intraventricular septum and mild dilatation of the right\n ventricle concerning for right heart strain.\n\n Borderline mediastinal lymphadenopathy in the prevascular and subcarinal\n spaces is likely reactive and also unchanged. Trace left pleural effusion is\n unchanged. No pericardial effusion. The aorta and remaining great vessels are\n unremarkable. A prominent thymus is present.\n\n No worrisome pulmonary nodules or opacities are noted for infectious processes\n or for infarctions. Tracheobronchial tree appears patent to the subsegmental\n level.\n\n Subdiaphragmatically, only the top portion of the liver is imaged, which\n appears to have no focal liver lesions. There is noted to be extensive amount\n of debris in the stomach.\n\n CT OF THE PELVIS: The pelvic veins are patent with no evidence of thrombus.\n\n There is no pelvic or inguinal lymphadenopathy by CT criteria. The patient is\n status post appendectomy. Uterus and bilateral adnexa appear unremarkable.\n There is a small amount of mildy complex pelvic free fluid. The bladder\n appears normal. No suspicious lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n 1. Extensive bilateral pulmonary emboli, unchanged in extent since the , study. There is continued evidence of right heart strain and\n correlation with echocardiography is recommended.\n (Over)\n\n 10:59 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT PELVIS W/CONTRAST Clip # \n Reason: CT pulmonary angio for evaluation of pulmonary embolism clot\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Patent pelvic veins.\n\n 3. Extensive amount of debris material in the stomach, new since the prior\n study from .\n\n These findings were discussed with Dr. at 2:15 p.m. in person by\n Dr. upon review of the study.\n\n"
}
] |
62,186 | 114,430 | Pt was admitted from ED in good condition with the diagnosis of small bowel obstruction. He was given hemodialysis for an elevated potassium. His small bowel obstruction was treated conservatively with IV hydration, PPI's, and nothing by mouth. On HD2, the patient's ostomy began to put out stool and gas. He was advanced to a clear, then regular diet on HD3. By HD 4 the patient was comfortable eating a regular diet, having stool and gas from his ostomy, without abdominal pain or distention. He was then deemed safe for discharge home. Of note, the patient had a set of troponins that were drawn in the ED for the symptom of epigastric pain. An EKG was normal, and the pt was hemodynamically stable. Thus his troponin elevation was thought to be due to his renal failure and not from cardiac ischemia. He was restarted kept on coumadin throughout his hospitalization and made sure his INR levels were therapeutic by his discharge, as he came with subtherapeutic levels. He was discharged on with an INR of 3.0 and will closely follow-up his levels with the coumadin clinic from the labs drawn at . | Compared to theprevious tracing of ventricular ectopy is absent. Otherwise, noapparent diagnostic interim change. Prior inferolateralmyocardial infarction. Borderline low limb lead voltage. | 1 | [
{
"category": "ECG",
"chartdate": "2159-02-01 00:00:00.000",
"description": "Report",
"row_id": 279113,
"text": "Atrial fibrillation with rapid ventricular response. Prior inferolateral\nmyocardial infarction. Borderline low limb lead voltage. Compared to the\nprevious tracing of ventricular ectopy is absent. Otherwise, no\napparent diagnostic interim change.\n\n"
}
] |
22,841 | 126,010 | Admitted to ICU. On day one, patient was awake and making purposeful spontaneous movements with the left upper extremity. Was unresponsive to all prompts including when done in Russian, her primary language. On early AM of (about 36 hours after admission) was found to have decreased mental status with eyes closed, still unresponsive, sluggish right pupil and absent left corneal reflex. Respiratory status was tenuous and patient did not seem to be protecting airway adequately. Stat head CT showed massive progression of edema in Left MCA/ACA distribution with significant mass effect and shift. There was subfalcine herniation and some uncal herniation. Son was called immediately and arrive shortly for discussion of plan of care. Patient's poor prognosis was discussed and inspite of the poor outlook, the son requested full code and aggressive supportive measures including intubation. On early AM, the patient was suddenly noted to be hypertensive and tachycardic. Son was called immediately and given the poor outlook requested code change to DNR. Later around 0700, patient's pressures fell to around 70/30 and the son requested initiation of pressors. Stated that he understood futility of pressors, but requested them based on wanting a grandson in to be able to make it up before her dying. Later in early afternoon requested that pressors be shut off. Patient's pressures dropped as expected. After a second conversation son requested that pt. be made comfortable, and extubated, and this was performed in the afternoon. Pt.'s breathing slowed and at 6:35 she passed away. Son declined autopsy. | Please See Carevue for Specifics.Neuro: Posturing upper exts, rightward gaze, nonresponsive. Please See Carevue for Specifics.Neuro unchanged, see assessment one flow sheet. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Resp Care Note:Pt cont intib with OETT and on mech vent as per Carevue. abd soft and positive bowel sounds.gu: pt continues on mannitol. Dr. aware and up to eval pt. abd is soft and postive bowel sounds.a: continue with mannitol. mannitol as ordered. NGT placed at bedside with bilious drainage.GU: foley, c/y/u.SKIN: Intact. right corneal reflex absent.left corneal reflex intact.posturing upper extremities to noxious stimuli. condition updated: pt unresponsive. Resp CarePt remains intubated and on full vent support in the A/C mode. sbp 150-190/70.resp: pt remains on cmv. neuro checks.r: ?repeat head ct this am. +left corneal reflex, -right corneal reflex. PLAN: continue mech ventilation. rhonchi noted. Pt in NARD on current vent settings; no vent changes required overnoc. Pt in NARD on current vent settings; no vent changes required overnoc. conditon updateD: left pupil is nonreactive to light. Lung sounds coarse improve with suct sm th tan sput. condition updateneuro: neuro exam unchanged, pupils are equal and reactive, left gaze/nystagmus perist - though occasionally will track in room. sbp remains within goal of 140-200. peripheral pulses weakly palpable. BS are diminshed and mv's being maintained in the 6-7L range Mannitol started.Cardio: NSR, no ectopy, no edema. right pupil less reactive this am. continue to monitor for afib. Lung sounds sl coarse suct sm th tan sput. Lung sounds sl coarse suct sm th tan sput. and replete lights as ordered. No breakdown.SOC: Full code per sons request.POC: Continue to monitor MS, VS, ?repeat head CT, continue mannitol, awaiting aline placement from SICU team. size 3. right pupil 2 reacts sluggishly. foley is patent.gi: ngt is patent and draining bilious drainage. Please See Carevue for Specifics. 6am right pupil reactings more sluggish and Dr. from neurology aware. ABGs stable; no vent changes required overnoc. Cont mech vent support. Cont mech vent support. Cont mech vent support. Spont./purposeful movement noted with left arm, withdraws all other extremities nailbed pressure. Appears comfortable.cv: nsr without ectopy. sbp 160-180/60-70. left pupil reacts sluggish. Tmax 100.6. Triple flex RLE, flexes LLE. status stable. Pt. sx'd for smallthick yellow. Emotional support has been offer to pt and family.POC: Monitor VS, continue mannitol, keep family up to date with changes in pt condition, continue to offer emotioanl support to pt and family. Left pupil 3mm and nonreactive with rightward gaze. UpdateSee careview for details......Neuro: Nuero assessment unchanged until 0400 then R pupil 4mm non react and L pupil 3mm and nonreact, no response from UE's, flexion from LE's, HR and BP elevated, Dr called and Neuro med notified, Family called and at bedsideCV: 0400 HR 120's from 60's and increasing up to 150's, IV lopressor given x3 with little results, BP 200's/100's, no change from lopressorResp: vent unchanged, lungs clear, sats 100%GI: abd soft, ngt dng bilious dngGU: fair UO via foleyFamily at bedside, spoke with Neuro Med MD regarding pt status, Pt made DNR , emotional support given SOFT, +BS, NO BM, NPOGU: FOLEY DRAING ADEQUATE AMTS. Aortic knob is calcified. FINDINGS: There is a large acute proximal left MCA infarct as is demonstrated by the slow diffusion within the left frontal, parietal and temporal lobes. TECHNIQUE: Non-contrast axial head CT. The mediastinal and cardiac contours are within normal limits. There is mild mass effect as evidenced by a slight distortion of the body and frontal of the ipsilateral lateral ventricle. Possible left ventricular hypertrophy. IMPRESSION: Right main stem bronchial intubation. There is an area of opacity in the region of the right middle lobe, and a less well-defined area of opacity in the left lower lobe. ABD SOFT NT/ND. LS COARSE, DECREASED YANKEAR SXN PRN FOR ORAL SECRETIONS.GI-NPO. Intraventricular conduction delay. IMPRESSION: There are faint areas of opacity in the right middle lobe and left lower lobe, which may represent areas of atelectasis or aspiration. aspiration FINAL REPORT REASON FOR EXAMINATION: Decreased saturation. SUPINE AP VIEW OF THE CHEST: New endotracheal tube is malpositioned with tip projecting over the right mainstem bronchus. The right internal carotid, middle cerebral, anterior cerebral, and posterior cerebral arteries appear normal. The osseous structures are unremarkable, and the visualized paranasal sinuses are only remarkable for mild mucosal thickening of the right sphenoid, and a small fluid level in the right maxillary sinus. +BS.GU-VOIDIING VIA FOLEY ADEQ AMTS CL YELLOW URINE.COMFORT-APPEARS COMFORTABLE.ENDO-SSRI.ID-TAMX 99.5P-CON'T WITH CURRENT PLAN. Mediastinal and hilar contours are normal. There is dilation of the right lateral ventricle secondary to the subfalcine herniation. CONDITION UPDATEARRIVED FROM ER AT 2245.NEURO: ALERT, APHASIC, LEFT SIDED GAZE AND + NYSTAGMUS., + COUGH, IMPAIRED GAG, SPONT./PUPOSEFUL MOVEMENTS NOTED ON LEFT ARM/LEG, WITHDRAWS RIGHT LEG TO NAILBED PRESSURE AND POSTURES RIGHT ARM TO NAILBED PRESSURE, PUPILS ARE EQUAL AND BRISKLY REACTIVE. IMPRESSION: Non-visualization of the entire left middle cerebral artery from its origin. FINDINGS: Duplex color Doppler demonstrate no plaque or wall thickening, normal peak systolic velocities, normal ICA to CCA ratios, and normal antegrade flow involving both vertebral arteries. NEURO CHECKS. TECHNIQUE: Non-contrast CT scan of the head. 2-cm herniation of the midline structures with subfalcine and uncal herniation. PORTABLE AP CHEST RADIOGRAPH: The patient is slightly rotated. Sinus rhythm. The brainstem is deformed by the uncal herniation. There is no abnormal magnetic susceptibility, although the sequence is degraded due to significant patient motion artifact. The anterior cerebral artery on the left appears to fill across a small anterior communicating artery. SKIN W+D. IMPRESSION: Large developing left MCA infarction. AP supine portable chest radiograph compared to . There is osteopenia of the osseous structures. FINDINGS: The left internal carotid artery is not visualized at its bifurcation with the anterior and middle cerebral arteries. | 24 | [
{
"category": "Nursing/other",
"chartdate": "2100-09-11 00:00:00.000",
"description": "Report",
"row_id": 1561179,
"text": "condition update\nd: pt unresponsive. postures upper extremities to painful stimuli. left pupil reacts sluggish. right reacts briskly. 6am right pupil reactings more sluggish and Dr. from neurology aware. triple flexion of right lower extremities to painful stimuli, flexion of left lower extremity. pt continues on mannitol for cerebral edema.\ncardiac: pt in nsr rate of 60-70's. sbp 160-180/60-70. temp max is 100.6.\nresp: abg sent this am and po2 greater than 200. pt suctioned for thick tan sputum. 02 sat is difficult to get good waveform due to hand being cold.\ngu: urine output is adequate. foley is patent.\ngi: ngt is patent and draining bilious drainage. abd is soft and postive bowel sounds.\na: continue with mannitol. neuro checks.\nr: ?repeat head ct this am. right pupil less reactive this am. Dr. aware and up to eval pt.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-11 00:00:00.000",
"description": "Report",
"row_id": 1561180,
"text": "Please See Carevue for Specifics.\n\nNeuro unchanged, see assessment one flow sheet. Family aware of pt condition and awaiting other family members to visit pt before withdrawing care. Pt has been kept comfortable throughout shift. Emotional support has been offer to pt and family.\n\nPOC: Monitor VS, continue mannitol, keep family up to date with changes in pt condition, continue to offer emotioanl support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-12 00:00:00.000",
"description": "Report",
"row_id": 1561181,
"text": "Resp Care Note:\n\nPt cont intib with OETT and on mech vent as per Carevue. Lung sounds sl coarse suct sm th tan sput. Pt in NARD on current vent settings; no vent changes required overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-10 00:00:00.000",
"description": "Report",
"row_id": 1561175,
"text": "condition update\nneuro: neuro exam unchanged, pupils are equal and reactive, left gaze/nystagmus perist - though occasionally will track in room. Spont./purposeful movement noted with left arm, withdraws all other extremities nailbed pressure. Appears comfortable.\ncv: nsr without ectopy. sbp remains within goal of 140-200. peripheral pulses weakly palpable. Impaired gag, + cough.\nresp: brief episode of desaturation to 87% at approx , bilat. rhonchi noted. 100% face tent applied and pt nt suctioned for small amts. thick white sputum, 02 sat subsequently increased to 99-100% on 4l n.c. Dr. was notifed and at bedside to evaluate. Dr. discussed intubation with the son/daughter-in-law, they indicated that it is their wish at this time that we proceed with intubation should it become necessary.\ngi: abd. soft, +bs, no bm. NPO.\ngu: foley draining adequate atms. clear yellow urine.\nendo: no ssri coverage necessary.\nsocial: son indicated that he would like to meet with neurology team today for an update.\nplan: echo today, ? family meeting, ? social work consult, monitor resp. status, dobhoff placement for feeding, pulmonary toileting, ? transfer to 5 if resp. status stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-10 00:00:00.000",
"description": "Report",
"row_id": 1561176,
"text": "Respiratory Care\n\n Pt intubated for airway protection and placed on mech ventilation. Brought to CT for scan of head. B/S dim in bases. sx'd for smallthick yellow. Sample sent for culture and gram stain. PLAN: continue mech ventilation. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-10 00:00:00.000",
"description": "Report",
"row_id": 1561177,
"text": "Please See Carevue for Specifics.\n\nNeuro: Posturing upper exts, rightward gaze, nonresponsive. Both SICU and neuro teams aware of findings. STAT head CT this morning showed severe right cerebral shift. +left corneal reflex, -right corneal reflex. Left pupil 3mm and nonreactive with rightward gaze. Right pupil 3mm, brisk and rightward gaze. Triple flex RLE, flexes LLE. Pt. unable to protect airway, aspirated, and then was intubated at bedside. Propofol at 10mcg/kg/min for ETT comfort. Mannitol started.\n\nCardio: NSR, no ectopy, no edema. SBP goal maintained 140-200. Tmax 100.6. UA C+S sent.\n\nRespir: Aspirated this morning, O2 stat dropped briefly to 80's and was intubated for airway protection. AC: 450x16, peep 5, FiO2 .50. ABG WNL.\n\nGI: Abd is soft, +BSx4, no stool this shift. NGT placed at bedside with bilious drainage.\n\nGU: foley, c/y/u.\n\nSKIN: Intact. No breakdown.\n\nSOC: Full code per sons request.\n\nPOC: Continue to monitor MS, VS, ?repeat head CT, continue mannitol, awaiting aline placement from SICU team. Discuss all POC with family. EEG tomorrow if continues to be full code. Continue to offer pt and pt family emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-11 00:00:00.000",
"description": "Report",
"row_id": 1561178,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse improve with suct sm th tan sput. ABGs stable; no vent changes required overnoc. O3 sat monitoring not accurate at present ABG drawn to confirm adequate gas exchange. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-12 00:00:00.000",
"description": "Report",
"row_id": 1561182,
"text": "conditon update\nD: left pupil is nonreactive to light. size 3. right pupil 2 reacts sluggishly. right corneal reflex absent.left corneal reflex intact.\nposturing upper extremities to noxious stimuli. triple flexing of right lower extremity. pt contininues on mannitol q8.\ncardiac: nsr rate 70-90. pt with several episodes of afib rate in the 120's. no sustained and converted to nsr on own. Dr. aware and labs sent. 20 kcl added to iv fluid and 2gms of mag sulfate given. sbp 150-190/70.\nresp: pt remains on cmv. resp rate16. breath sounds are coarse and diminished in the bases. pt suctioned for thick yellow sputum.\ngi: ngt patent and draining bilious drainage. abd soft and positive bowel sounds.\ngu: pt continues on mannitol. foley patent and draining clear yellow sputum.\na: continue with neuro checks. mannitol as ordered. continue to support family and answer any questions.\nr: no change in neuro status. continue to monitor for afib. and replete lights as ordered.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-12 00:00:00.000",
"description": "Report",
"row_id": 1561183,
"text": "Resp Care\n\nPt remains intubated and on full vent support in the A/C mode. BS are diminshed and mv's being maintained in the 6-7L range\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-12 00:00:00.000",
"description": "Report",
"row_id": 1561184,
"text": "Please See Carevue for Specifics. Neuro status unchanged.\n\nPOC: Family meeting tomorrow to make pt . Continue to offer emotional support to pt and pt family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-13 00:00:00.000",
"description": "Report",
"row_id": 1561185,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds sl coarse suct sm th tan sput. Pt in NARD on current vent settings; no vent changes required overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-13 00:00:00.000",
"description": "Report",
"row_id": 1561186,
"text": "Update\nSee careview for details......\n\nNeuro: Nuero assessment unchanged until 0400 then R pupil 4mm non react and L pupil 3mm and nonreact, no response from UE's, flexion from LE's, HR and BP elevated, Dr called and Neuro med notified, Family called and at bedside\n\nCV: 0400 HR 120's from 60's and increasing up to 150's, IV lopressor given x3 with little results, BP 200's/100's, no change from lopressor\n\nResp: vent unchanged, lungs clear, sats 100%\n\nGI: abd soft, ngt dng bilious dng\n\nGU: fair UO via foley\n\nFamily at bedside, spoke with Neuro Med MD regarding pt status, Pt made DNR , emotional support given\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-13 00:00:00.000",
"description": "Report",
"row_id": 1561187,
"text": "Pt now and awaiting arrival of family members prior to withdrawing ventilatory support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-13 00:00:00.000",
"description": "Report",
"row_id": 1561188,
"text": "Please See Carevue for SPecifics.\n\nPt placed on a Morphine gtt for comfrt and was extubated. 25minutes after extubation, pt expired. Family present with pt and emotional support was given.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-09 00:00:00.000",
"description": "Report",
"row_id": 1561173,
"text": "CONDITION UPDATE\nARRIVED FROM ER AT 2245.\nNEURO: ALERT, APHASIC, LEFT SIDED GAZE AND + NYSTAGMUS., + COUGH, IMPAIRED GAG, SPONT./PUPOSEFUL MOVEMENTS NOTED ON LEFT ARM/LEG, WITHDRAWS RIGHT LEG TO NAILBED PRESSURE AND POSTURES RIGHT ARM TO NAILBED PRESSURE, PUPILS ARE EQUAL AND BRISKLY REACTIVE. PT COMFORTABLE. MRI OBTAINED WITHOUT DIFFICULTY. RUSSIAN SPEAKING ONLY, PT DID NOT FOLLOW COMMMANDS AT 2300 WITH SON PRESENT TO TRANSLATE.\nCV: SBP WITHIN GOAL RANGE OF 140-190, HR NS 60-70'S, NO ECTOPY NOTED.\nRESP: LS COARSE DIMINISHED, + NON-PRODUCTIVE COUGH, 02 SAT 98-100% ON 2L N.C.\nGI: ABD. SOFT, +BS, NO BM, NPO\nGU: FOLEY DRAING ADEQUATE AMTS. CLEAR YELLOW URINE.\nENDO: SSRI NOT NECESSARY\nSOCIAL:SON AND DAUGHTER IN LAW AT BEDSIDE UP ARRIVAL FROM ER, UPDATED BY RN.\nPLAN: CARDIAC ECHO TODAY, FOLLOW CARDIAC ENZYMES, TIGHT GLYCEMIC CONTROL, MONITOR RESP. STATUS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-09-09 00:00:00.000",
"description": "Report",
"row_id": 1561174,
"text": "NSG NOTE\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT AWAKE, OPENS EYES SPONT. PERRL. + NYSTAGMUS. DOES NOT TRACK. MOVES LEFT ARM PURPOSEFULLY SPONT. MOVES BILAT FEET OCC SPONT ON BED, BUT ONLY SL. NO SPONT MOVEMENT OF RIGHT ARM BUT DOES WITHDRAW SL TO PAIN. DOES NOT FOLLOW COMMANDS. NOT SPEAKING OR MAKING SOUNDS. IMPAIRED GAG BUT GOOD COUGH. PT FAILED SWALLOW EVAL D/T MS. HAD CAROTID STUDY TODAY.\n\nCV-HR 70'S, NSR. NO ECTOPY. SBP MOSTLY 150-170. SKIN W+D. +PP. PBOOTS ON. TO HAVE ECHO TODAY.\n\nRESP-O2 SAT 100% ON 2LNC. LS COARSE, DECREASED YANKEAR SXN PRN FOR ORAL SECRETIONS.\n\nGI-NPO. ABD SOFT NT/ND. +BS.\n\nGU-VOIDIING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nCOMFORT-APPEARS COMFORTABLE.\n\nENDO-SSRI.\n\nID-TAMX 99.5\n\nP-CON'T WITH CURRENT PLAN. NEURO CHECKS. SUPPORT. TX TO SDU WHEN BED AVAIL.\n"
},
{
"category": "ECG",
"chartdate": "2100-09-09 00:00:00.000",
"description": "Report",
"row_id": 251718,
"text": "Sinus rhythm. Left axis deviation. Intraventricular conduction delay. Late\ntransition. Possible left ventricular hypertrophy. Compared to the previous\ntracing the late transition is new.\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-09-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 922537,
"text": " 8:27 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: SLURRED SPEECH, FACIAL DROOP\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with CODE STROKE\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AHPb WED 9:00 PM\n large left mca developing infarction. mr is more sensitive for stroke.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Code stroke, eval for bleed.\n\n TECHNIQUE: Non-contrast axial head CT.\n\n FINDINGS: There is a large hypodense region within the left MCA territory\n with sulcal effacement and loss of both superficial and deep -white matter\n differentiation, including obscuration of the borders of the lentiform\n nucleus and the insular ribbon, representing developing large infarction.\n There is mild mass effect as evidenced by a slight distortion of the body and\n frontal of the ipsilateral lateral ventricle. Other white matter\n hypodensities likely represent sequelae of a more chronic small vessel\n infarction. The left MCA itself is not clearly identified, but there is no\n evidence for \"dense\" artery sign. The osseous structures are unremarkable, and\n the visualized paranasal sinuses are only remarkable for mild mucosal\n thickening of the right sphenoid, and a small fluid level in the right\n maxillary sinus. The mastoid air cells are clear.\n\n IMPRESSION: Large developing left MCA infarction. No evidence for\n intracranial hemorrhage. These findings were discussed with the Neurology\n team in person, and a wet read was provided at the ED dashboard at the time of\n the study.\n\n NOTE ADDED IN ATTENDING REVIEW: Even allowing for the extensive vascular\n calcification, there is a probable \"hyperdense MCA sign\" (Se 2, I10) which, in\n this context, likely represents relatively acute thrombosis of this vessel,\n accounting for the large territorial infarct. This could be confirmed by\n cranial MRA, if warranted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-09-10 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 922784,
"text": " 10:14 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?interval change\n Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with known L MCA infarct now posturing and signs of poor\n peripheral perfusion\n REASON FOR THIS EXAMINATION:\n ?interval change\n CONTRAINDICATIONS for IV CONTRAST:\n CRI\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with left known MCA infarct, not posturing and\n signs of poor peripheral perfusion. Question of interval change.\n\n TECHNIQUE: Non-contrast CT scan of the head.\n\n COMPARISON: Non-contrast CT scan of the head from and MRI of\n the head from .\n\n FINDINGS: There is massive increase in the amount of edema in the left MCA\n territory infarct, causing approximately 2 cm of midline shift, and subfalcine\n and uncal herniation. There is dilation of the right lateral ventricle\n secondary to the subfalcine herniation. There is no acute intracranial\n hemorrhage. The -white differentiation in the right cerebrum is\n maintained. The brainstem is deformed by the uncal herniation. There are no\n acute hemorrhages in the brainstem or cerebellum. The visualized paranasal\n sinuses are clear. There are no bony or soft tissue abnormalities.\n\n IMPRESSION: Massive increase in the left-sided edema in the known left MCA\n infarct. 2-cm herniation of the midline structures with subfalcine and uncal\n herniation.\n\n Results were discussed with Dr. at 2 p.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-09-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 922545,
"text": " 9:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? aspiration\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with L-MCA stroke\n REASON FOR THIS EXAMINATION:\n ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: None.\n\n PORTABLE AP CHEST RADIOGRAPH: The patient is slightly rotated. The\n mediastinal and cardiac contours are within normal limits. No pleural\n effusions or pneumothorax is seen. There is an area of opacity in the region\n of the right middle lobe, and a less well-defined area of opacity in the left\n lower lobe. There is osteopenia of the osseous structures. There is\n tracheobronchial tree calcification.\n\n IMPRESSION: There are faint areas of opacity in the right middle lobe and\n left lower lobe, which may represent areas of atelectasis or aspiration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-09-09 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 922597,
"text": " 9:04 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: LEFT MCA STROKE\n Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with L-MCA stroke\n REASON FOR THIS EXAMINATION:\n ? carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID STUDY DATED 3RD\n\n HISTORY: Left MCA stroke.\n\n FINDINGS: Duplex color Doppler demonstrate no plaque or wall thickening,\n normal peak systolic velocities, normal ICA to CCA ratios, and normal\n antegrade flow involving both vertebral arteries.\n\n IMPRESSION: Normal study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-09-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 922766,
"text": " 9:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with L-MCA stroke now posturing\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Posturing from left MCA stroke.\n\n COMPARISON: .\n\n SUPINE AP VIEW OF THE CHEST: New endotracheal tube is malpositioned with tip\n projecting over the right mainstem bronchus. Nasogastric tube tip projects\n over the distal stomach. Heart is normal size. Mediastinal and hilar\n contours are normal. Aortic knob is calcified. Pulmonary vascularity is\n normal and the lungs are clear. The pleurae are normal.\n\n IMPRESSION: Right main stem bronchial intubation.\n\n Findings discussed with Dr. at 10 a.m., .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-09-09 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 922570,
"text": " 2:22 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: assess stroke\n Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with L-MCA stroke per exam and CT head\n REASON FOR THIS EXAMINATION:\n assess stroke\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with left MCA stroke, for exam.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted sequences were obtained through\n the brain with diffusion-weighted imaging.\n\n FINDINGS: There is a large acute proximal left MCA infarct as is demonstrated\n by the slow diffusion within the left frontal, parietal and temporal lobes.\n This appears to involve the entire left middle cerebral artery including the\n basal ganglion. There is some sulcal effacement due to mild mass effect.\n\n There are some scattered periventricular T2 white matter hyperintensities\n likely due to chronic microvascular infarct.\n\n There is no abnormal magnetic susceptibility, although the sequence is\n degraded due to significant patient motion artifact. There is no evidence of\n herniation or midline shift.\n\n IMPRESSION: Acute infarct involving the entire left MCA territory.\n\n MRA TECHNIQUE: 3D time-of-flight MRA of the circle of .\n\n FINDINGS: The left internal carotid artery is not visualized at its\n bifurcation with the anterior and middle cerebral arteries. The left\n middle cerebral artery is completely not visualized. The anterior cerebral\n artery on the left appears to fill across a small anterior communicating\n artery. The right internal carotid, middle cerebral, anterior cerebral, and\n posterior cerebral arteries appear normal. The vertebrobasilar artery is also\n unremarkable.\n\n These findings correspond with a large proximal left MCA infarct the patient\n has demonstrated on the MRI.\n\n IMPRESSION: Non-visualization of the entire left middle cerebral artery from\n its origin.\n\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2100-09-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 922572,
"text": " 4:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? aspiration\n Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with L-MCA stroke\n REASON FOR THIS EXAMINATION:\n ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Decreased saturation.\n\n AP supine portable chest radiograph compared to .\n\n The heart size is mildly enlarged but stable. The mediastinal contours are\n unremarkable. Mild redistribution of the pulmonary vessels towards the upper\n lung zones could be due to the patient's position but mild pulmonary edema\n cannot be excluded. There is no new consolidations or lung masses suspicious\n for new aspiration process. If clinically suspected, a radiological follow up\n in 24 hours is recommended.\n\n\n"
}
] |
42,035 | 126,956 | 81 yo F with dementia, chronic bronchectasis from presumed recurrent microaspiration presents with acute SOB and cough x2 days found to be in hypercarbic respiratory failure responsive to BIPAP with clinical exam and CXR suggestive of right lower lobe pneumonia. . # Aspiration Pneumonia: Patient presented with hypercarbic respiratory failure, and video swallow sig for silent aspiration. In the ICU she required brief BiPAP and subsequently remained stable on nasal canuli. While in the ICU patient experienced transient hypotension that resolved with ivfs. Given her peripheral eosinophilia, IgE, b-glucan, and galactomanan were sent and were negative. Urin legionella was negative. She was started on zosyn and vancomycin for a 9 day course of HAP to end . Upon transfer to the floor, patient was treated with abx, mucinex, nebulizers and chest PT. She was slowly weaned down on her oxygen. Upon discharge she was sating low 90s on 1-2L nc. Sputum cultures prelim grew gram pos cocci, final cultures pending on discharge. Speech and swallow evaluated the patient and noted silent aspirations (see below). -- Continue iv antibiotics end date -- Continue nebulizers and mucinex until pneumonia resolves -- Continue 1-2L oxygen nasal cannula, wean as tolerated with goal of O2 sat in low 90s. . # Oropharyngeal Dysphagia: On video swallow, patient was noted to have mild OP dysphagia with aspiration during consecutive sips of liquids. A barium swallow was done that showed esophageal dysmotility see below. Patient was aware of aspiration risk with feeding but declined enteral nutritional support. -- PO diet of regular solids and thin liquids -- oral care -- 1:1 supervision with meals to encourage pacing with small bites and sips, as consecutive sips caused aspiration . # Esophageal Dymotility: Barium swallow significant for esophageal dysmotility but no evidence of anatomic abnormalities or reflux. GI was consulted who did not feel that the esophageal dysmotility would increase risk of aspiration. Patient is to follow as an outpatient with GI for likely EGD and mannometry for further work up. . # Dementia - continue home meds of namenda, aricept . # Osteoprosis - continue alendronate QWeek, calicum +D . # Eosinophila: AEC ~ 1300. Patient has had eosinophilia in the past thought to be secondary to drug vs infection. On this admission, b-glucan and galactomannan negative. IgE 86. A work up for eosinophilia with stool cx for ova and parasites, ANCA, Ig's, B12, lymphocyte phenotypes, and cortisol was initiated. Patient to follow up with allergy as outpatient. | LS wheezy and rhonchi on expiration. - f/u precipitins to aspergillus, total IgE . - f/u precipitins to aspergillus, total IgE . Hypothermic upon admit. Admitted to ICU with ?RLL infiltrate and bronchiectasis exacerbation. - monitor UOP - maintain 2 PIVs - fluid bolus prn if UOP decreases - hold off on invasive monitoring for now. - monitor UOP - maintain 2 PIVs - fluid bolus prn if UOP decreases - hold off on invasive monitoring for now. Aspiration pnu. - defer to outpatient work up . - defer to outpatient work up . - insert foley to monitor UOP - maintain 2 PIVs - fluid bolus prn - hold off on invasive monitoring for now. Nebulizer treatments administered ATC. Action: Albuterol and atrovent nebs as needed. Action: Albuterol and atrovent nebs as needed. Action: Albuterol and atrovent nebs as needed. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight gain. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight gain. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight gain. LS clear to diminished. # AG Metabolic Acidosis resolved . # AG Metabolic Acidosis resolved . - repeat CBC after fluid resuscitation . - repeat CBC after fluid resuscitation . - repeat CBC after fluid resuscitation . Assessment and Plan PNEUMONIA, ASPIRATION RESPIRATORY FAILURE, ACUTE (NOT ARDS/) . Assessment and Plan PNEUMONIA, ASPIRATION RESPIRATORY FAILURE, ACUTE (NOT ARDS/) . Response: Tolerating po intake. Response: Tolerating po intake. Response: Tolerating po intake. CPT and acapelo valve done. CPT and acapelo valve done. CPT and acapelo valve done. # Osteoprosis - continue alendronate QWeek, calicum +D . # Osteoprosis - continue alendronate QWeek, calicum +D . # Osteoprosis - continue alendronate QWeek, calicum +D . # Osteoprosis - continue alendronate QWeek, calicum +D . # Osteoprosis - continue alendronate QWeek, calicum +D . Cr 0.8 Lact 1.1 Neg Lgella 81 yo with dementia and bronchiectasis and ?recurrent aspiration now with respiratory distress in setting of possible new RLL infiltrate. # Dementia - continue home meds of namenda, aricept . # Dementia - continue home meds of namenda, aricept . # Dementia - continue home meds of namenda, aricept . # Dementia - continue home meds of namenda,aricept . # Dementia - continue home meds of namenda,aricept . Bld cx sent and CXR ?right basilar infiltrate vs baseline bronchiectasis. Treated with azithro/ceftriaxone/prednisolone and ativan. Unchanged subtle predominantly peribronchial opacities in the right lower lung that could represent early pneumonia. LS clear to diminished. LS clear to diminished. - insert foley to monitor UOP - maintain 2 PIVs - fluid bolus prn - hold off on invasive monitoring for now. Action: Albuterol and atrovent nebs as needed. Nebulizer treatments administered ATC. Nebulizer treatments administered ATC. Tolerating po intake. CPT and acapelo valve done. Assessment and Plan PNEUMONIA, ASPIRATION RESPIRATORY FAILURE, ACUTE (NOT ARDS/) . Evaluate to rule out anatomic abnormalities and esophageal dysmotility disorder. - repeat CBC after fluid resuscitation . Pressures dropped with BiPAP but responded to IVF. - monitor UOP - maintain 2 PIVs - fluid bolus prn - hold off on invasive monitoring for now. # AG Metabolic Acidosis resolved . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight gain. Oxygen weaned as tolerated. Oxygen weaned as tolerated. A CXR showed hyperinfilation. # Transient Hypotension - Responsive to arousal and fluids. # Transient Hypotension - Responsive to arousal and fluids. COMPARISON: Prior chest radiograph . Administer abx and nebs as ordered. Administer abx and nebs as ordered. Delayedprecordial R wave transition. - will check precipitins to aspergillus, total IgE . - will check precipitins to aspergillus, total IgE . TECHNIQUE: Single contrast upper GI was performed. Of note, last admission to for similar complaints felt recurrent microaspiration and acute bronchiectasis flair with mucous plugging. Evaluate for swallowing dysfunction. 81 yo with dementia and bronchiectasis and ?recurrent aspiration now with respiratory distress in setting of possible new RLL infiltrate. Left anterior fascicular block. 7.36/35/166 on BiPAP. Initial VBG 7.17/60/82. CXR as above, prior Chest CT from reviewed and this showed bilateral bronchiectasis, mucus plugging and areas of ground glass nodules (all consistent with atypical mycobacterial colonization vs infection). Remains afebrile. # Osteoprosis - continue alendronate QWeek, calicum +D . # Osteoprosis - continue alendronate QWeek, calicum +D . # Dementia - continue home meds of namenda, aricept . # Dementia - continue home meds of namenda, aricept . Biatrial abnormality. IMPRESSION: Abnormal primary peristaltic waves with clearance by secondary peristalsis consistent with esophageal dysmotility disorder. Wean oxygen as tolerated. Wean oxygen as tolerated. TECHNIQUE: Video oropharyngeal swallow. She received 1L NS IVF. Pulmonary toileting. Pulmonary toileting. Found to be more short of breath and anxious this am at and was sent in for evaluation. Productive cough after pulmonary toilet. | 22 | [
{
"category": "Physician ",
"chartdate": "2117-01-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 714965,
"text": "Chief Complaint: Dyspnea\n HPI:\n 81 yo F w hx of bronchiectasis, dementia, presumed microaspiration and\n recurrent aspiration pneumonias, presents with 2 days of SOB, Cough\n from long-term care facility. She denied fevers, CP, abd pain. A+O x 3.\n DNR/DNI in chart, but pt made clear that she wants to intubated if\n necessary in the ED.\n .\n In the ED, initial vs were: T 98.9 HR 82 BP 158/98 RR 28 POx 85%.\n Initial VBG 7.17/60/82. She was started on BIPAP and repeat ABG\n 7.36/35/166. Blood cultures were drawn. A CXR showed hyperinfilation.\n Patient was given azithromycin 500mg IV, ceftriaxone 1gm IV,\n Methylprednisolone 125mg IV, lorazepam 2mg IV for comfort w/ BIPAP. BP\n decreased to SBP 80s w/BIPAP but improved with fluids. She received 1L\n NS IVF. IV access 2 - 18g. VS prior to transfer were HR 74 BP 105/57 RR\n 30 POX 98% on 5L.\n .\n On the floor, she felt much improved but complained of being cold. She\n confirmed a few days of shortness of breath and productive cough prior\n to presentation. She denies fevers, chills, recent URI, chest pain,\n nausea, vomiting, diarrhea, aspiration episodes. Does report weight\n loss but can't quantify time or amount. Also states she has been\n hospitalized a little while ago for pneumonia but can't tell me when or\n where.\n .\n Of note, last admission to for similar complaints felt \n recurrent microaspiration and acute bronchiectasis flair with mucous\n plugging.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:00 PM\n Vancomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Other medications:\n updated from \n Alendronate 70 mg PO 1X/WEEK (THURS)\n ARicept 10mg po once daily\n Benzonatate 100mg po TID\n Gabapentin 600 mg PO BID\n Namenda 10 mg PO daily \n Mucinex ER 600mg po BID\n Acetaminophen 500 mg PO Q6H prn pain\n Aspirin 81 mg One PO DAILY\n Omeprazole 20mg po daily\n Calcium 500 + D (D3) 500-125 mg-unit One PO twice a day.\n Albuterol Sulfate 90 mcg HFA Two (2) Puff Inhalation Q6H\n Lidocaine 5 %(700 mg/patch) Adhesive Patch DAILY (Daily): 12\n hours on, 12 off.\n Past medical history:\n Family history:\n Social History:\n - bronchiectasis - felt recurrent microaspiration, was due for\n video swallow at rehab facility \n - Dementia\n - Neuropathy\n - Osteoporosis\n - Chronic venous stasis ulcer\n - Gallbladder polyp seen on u/s - needed follow up in \n - presumed recurrent aspiration pneumonia\n - Chronic Venous Stasis Ulcer\n - h/o AFB positive - MYCOBACTERIUM CHELONAE\n non-contributory\n Occupation: The pt previously worked as a graphic designer and a\n painter\n with watercolors.\n Drugs: none\n Tobacco: none\n Alcohol: social\n Other: She denies any known exposure to asbestos or tuberculosis. Now\n living at .\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight gain. Denies\n headache, sinus tenderness, rhinorrhea or congestion. Denies chest\n pain, chest pressure, palpitations, or weakness. Denies nausea,\n vomiting, diarrhea, constipation, abdominal pain, or changes in bowel\n habits. Denies dysuria, frequency, or urgency. Denies arthralgias or\n myalgias. Denies rashes or skin changes.\n Flowsheet Data as of 02:55 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.6\nC (96\n HR: 63 (63 - 71) bpm\n BP: 78/53(59) {76/47(54) - 106/63(74)} mmHg\n RR: 31 (21 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 555 mL\n PO:\n TF:\n IVF:\n 555 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 555 mL\n Respiratory\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n SpO2: 98%\n ABG: 7.41/39/68//0\n Physical Examination\n General: Alert, oriented to , few days after , no\n acute distress, cachetic\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Speaking in full sentences without excessory muscle use, Diffuse\n expiratory rhonchi, loudest at right base, no wheezing, + wet cough\n CV: HS distant, Regular rate and rhythm, normal S1 + S2, no murmurs,\n rubs, gallops appreciated\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: cool toes b/l but remainder of extremities warm, weak palpable\n pulses b/l, no clubbing, cyanosis or edema\n Neuro: CN II-XII without focal defect, weakness throughout but moving\n all extremeties symmetrically\n Labs / Radiology\n 233 K/uL\n 15.2 g/dL\n 46.9 %\n 8.1 K/uL\n [image002.jpg]\n \n 2:33 A12/26/ 01:06 PM\n \n 10:20 P12/26/ 01:32 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.1\n Hct\n 46.9\n Plt\n 233\n TC02\n 26\n Other labs: Lactic Acid:1.1 mmol/L\n Fluid analysis / Other labs: 9:10 ABG pH 7.17 pCO260 pO282 HCO323\n 9:53 ABG pH 7.36 pCO235 pO2166 HCO3 AGap=23\n ------------< 286\n 6.2 18 1.1\n Comments: K: Hemolyzed, Grossly\n K: Hemolysis Falsely Elevates K\n K: Notified On At 1000\n estGFR: 48/58 (click for details)\n MCV 97 WBC11.4 HGB 17.6 ∆ PLTs 312 HCT 57.1 ∆\n N:41.7 L:44.9 M:4.1 E:7.6 Bas:1.8\n Imaging: CXR - dictated - hyperinflation, interstital\n promience bilaterally, increased opacity of right lung base\n superimposed on baseline emphysema\n Microbiology: Blood Cx pending\n sputum pending\n ECG: EKG: compared w/ NSR at 84, NI, P pulmonale, poor R wave\n progression, no ST/T wave abnormalities from prior.\n Assessment and Plan\n 81 yo F with dementia, chronic bronchectasis from presumed recurrent\n microaspiration presents with acute SOB and cough x2 days found to be\n in hypercarbic respiratory failure responsive to BIPAP with clinical\n exam and CXR suggestive of right lower lobe pneumonia.\n .\n # Hypercarbic Respiratory Failure - Differential includes recurrent\n bronchiectasis with worsening of mucous plugging from\n bronchitis/pneumonia vs. inital COPD exacerbation (has no history of\n COPD but CT scan from showed mild centrilobular emphysema). CXR\n raises question of RLL infiltrate. Role of atypical mycobacterium is\n unclear. Suspect colonization but has only had one positive AFB culture\n - 3 are still pending at the state lab.\n - aggressive pulmonary toilet with mucinex, albuterol/ipratropium nebs\n - send \n - obtain sputum cx\n - confirm with HCP patient's wishes regarding intubation\n - switch ABX coverage to health-care associated coverage\n - repeat CXR after fluid resuscitation to better assess for infiltrate\n (ordered for 4PM)\n - given question of recurrent microaspiration event, will hold\n omeprazole unless clear clinical indication arises as increase risk for\n pulmonary infection outweights benefit\n - plan for video swallow on this admission to further eval aspiration\n .\n # Transient Hypotension - Responsive to arousal and fluids. She has no\n cardiac history. Baseline around SBP 120s.\n - insert foley to monitor UOP\n - maintain 2 PIVs\n - fluid bolus prn\n - hold off on invasive monitoring for now.\n .\n # AG Metabolic Acidosis -\n - check lactate, repeat lytes after fluid resuscitation\n .\n # Leukocytosis - Appears hemoconcentrated on labs. be PNA.\n - repeat CBC after fluid resuscitation\n .\n # Dementia - continue home meds of namenda, aricept\n .\n # Osteoprosis - continue alendronate QWeek, calicum +D\n .\n # Eosinophila - Long standing. Lower than baseline, dating back to\n 3/. AEC 866. Question if related to recurrent respiratory\n infections. Unlikely to have parasite/ syndrome. Also ANCA\n positive disease unlikely. Course is not consistent with either acute\n or chronic eosinophilic pneumonia. She has never had bronch to rule\n this out. Other possibilities include hypersensitivity pneumonitis,\n ABPA.\n - will check precipitins to aspergillus, total IgE\n .\n # FEN: no IVF for now, replete electrolytes, NPO for now, will resume\n heart healthy diet w/ TID supplement if respiratory status remains\n stable(has not required dietary modification for aspiration in past)\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots, aspiration\n precautions\n # Access: peripherals\n # Communication: Patient and Sister(HCP), home\n cell - left message with sister to call \n # Code: DNR confirmed - ? DNI\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2117-01-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 714956,
"text": "Chief Complaint: Dyspnea\n HPI:\n 81 yo F w hx of bronchiectasis, dementia, presumed microaspiration and\n recurrent aspiration pneumonias, presents with 2 days of SOB, Cough\n from long-term care facility. She denied fevers, CP, abd pain. A+O x 3.\n DNR/DNI in chart, but pt made clear that she wants to intubated if\n necessary in the ED.\n .\n In the ED, initial vs were: T 98.9 HR 82 BP 158/98 RR 28 POx 85%.\n Initial VBG 7.17/60/82. She was started on BIPAP and repeat ABG\n 7.36/35/166. Blood cultures were drawn. A CXR showed hyperinfilation.\n Patient was given azithromycin 500mg IV, ceftriaxone 1gm IV,\n Methylprednisolone 125mg IV, lorazepam 2mg IV for comfort w/ BIPAP. BP\n decreased to SBP 80s w/BIPAP but improved with fluids. She received 1L\n NS IVF. IV access 2 - 18g. VS prior to transfer were HR 74 BP 105/57 RR\n 30 POX 98% on 5L.\n .\n On the floor, she felt much improved but complained of being cold. She\n confirmed a few days of shortness of breath and productive cough prior\n to presentation. She denies fevers, chills, recent URI, chest pain,\n nausea, vomiting, diarrhea. Does report weight loss but can't quantify\n time or amount. Also states she has been hospitalized a little while\n ago for pneumonia but can't tell me when or where.\n .\n Of note, last admission to for similar complaints felt \n recurrent microaspiration and acute bronchiectasis flair with mucous\n plugging.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:00 PM\n Vancomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Other medications:\n updated from \n Alendronate 70 mg PO 1X/WEEK (THURS)\n ARicept 10mg po once daily\n Benzonatate 100mg po TID\n Gabapentin 600 mg PO BID\n Namenda 10 mg PO daily \n Mucinex ER 600mg po BID\n Acetaminophen 500 mg PO Q6H prn pain\n Aspirin 81 mg One PO DAILY\n Omeprazole 20mg po daily\n Calcium 500 + D (D3) 500-125 mg-unit One PO twice a day.\n Albuterol Sulfate 90 mcg HFA Two (2) Puff Inhalation Q6H\n Lidocaine 5 %(700 mg/patch) Adhesive Patch DAILY (Daily): 12\n hours on, 12 off.\n Past medical history:\n Family history:\n Social History:\n - bronchiectasis - felt recurrent microaspiration, was due for\n video swallow at rehab facility \n - Dementia\n - Neuropathy\n - Osteoporosis\n - Chronic venous stasis ulcer\n - Gallbladder polyp seen on u/s - needed follow up in \n - presumed recurrent aspiration pneumonia\n - Chronic Venous Stasis Ulcer\n - h/o AFB positive - MYCOBACTERIUM CHELONAE\n non-contributory\n Occupation: The pt previously worked as a graphic designer and a\n painter\n with watercolors.\n Drugs: none\n Tobacco: none\n Alcohol: social\n Other: She denies any known exposure to asbestos or tuberculosis. Now\n living at .\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight gain. Denies\n headache, sinus tenderness, rhinorrhea or congestion. Denies chest\n pain, chest pressure, palpitations, or weakness. Denies nausea,\n vomiting, diarrhea, constipation, abdominal pain, or changes in bowel\n habits. Denies dysuria, frequency, or urgency. Denies arthralgias or\n myalgias. Denies rashes or skin changes.\n Flowsheet Data as of 02:55 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.6\nC (96\n HR: 63 (63 - 71) bpm\n BP: 78/53(59) {76/47(54) - 106/63(74)} mmHg\n RR: 31 (21 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 555 mL\n PO:\n TF:\n IVF:\n 555 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 555 mL\n Respiratory\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n SpO2: 98%\n ABG: 7.41/39/68//0\n Physical Examination\n General: Alert, oriented to , few days after , no\n acute distress, cachetic\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Speaking in full sentences without excessory muscle use, Diffuse\n expiratory rhonchi, loudest at right base, no wheezing, + wet cough\n CV: HS distant, Regular rate and rhythm, normal S1 + S2, no murmurs,\n rubs, gallops appreciated\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: cool toes b/l but remainder of extremities warm, weak palpable\n pulses b/l, no clubbing, cyanosis or edema\n Neuro: CN II-XII without focal defect, weakness throughout but moving\n all extremeties symmetrically\n Labs / Radiology\n 233 K/uL\n 15.2 g/dL\n 46.9 %\n 8.1 K/uL\n [image002.jpg]\n \n 2:33 A12/26/ 01:06 PM\n \n 10:20 P12/26/ 01:32 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.1\n Hct\n 46.9\n Plt\n 233\n TC02\n 26\n Other labs: Lactic Acid:1.1 mmol/L\n Fluid analysis / Other labs: 9:10 ABG pH 7.17 pCO260 pO282 HCO323\n 9:53 ABG pH 7.36 pCO235 pO2166 HCO3 AGap=23\n ------------< 286\n 6.2 18 1.1\n Comments: K: Hemolyzed, Grossly\n K: Hemolysis Falsely Elevates K\n K: Notified On At 1000\n estGFR: 48/58 (click for details)\n MCV 97 WBC11.4 HGB 17.6 ∆ PLTs 312 HCT 57.1 ∆\n N:41.7 L:44.9 M:4.1 E:7.6 Bas:1.8\n Imaging: CXR - dictated - hyperinflation, interstital\n promience bilaterally, increased opacity of right lung base\n superimposed on baseline emphysema\n Microbiology: Blood Cx pending\n sputum pending\n ECG: EKG: compared w/ NSR at 84, NI, P pulmonale, poor R wave\n progression, no ST/T wave abnormalities from prior.\n Assessment and Plan\n 81 yo F with dementia, chronic bronchectasis from presumed recurrent\n microaspiration presents with acute SOB and cough x2 days found to be\n in hypercarbic respiratory failure responsive to BIPAP with clinical\n exam and CXR suggestive of right lower lobe pneumonia.\n .\n # Hypercarbic Respiratory Failure - Differential includes recurrent\n bronchiectasis with worsening of mucous plugging from\n bronchitis/pneumonia vs. inital COPD exacerbation (has no history of\n COPD but CT scan from showed mild centrilobular emphysema). CXR\n raises question of RLL infiltrate.\n - aggressive pulmonary toilet with mucinex, albuterol/ipratropium nebs\n - send \n - obtain sputum cx\n - confirm with HCP patient's wishes regarding intubation\n - switch ABX coverage to health-care associated coverage\n - repeat CXR after fluid resuscitation to better assess for infiltrate\n (ordered for 4PM)\n - given question of recurrent microaspiration event, will hold\n omeprazole unless clear clinical indication arises as increase risk for\n pulmonary infection outweights benefit\n - plan for video swallow on this admission to further eval aspiration\n .\n # AG Metabolic Acidosis -\n - check lactate, repeat lytes after fluid resuscitation\n .\n # Leukocytosis - Appears hemoconcentrated on labs. be PNA.\n - repeat CBC after fluid resuscitation\n .\n # Dementia - continue home meds of namenda,aricept\n .\n # Osteoprosis - continue alendronate QWeek, calicum +D\n .\n # Eosinophila - Long standing. Lower than baseline, dating back to\n 3/. AEC 866.\n - defer to outpatient work up\n .\n # FEN: no IVF for now, replete electrolytes, NPO for now, will resume\n heart healthy diet w/ TID supplement if respiratory status remains\n stable(has not required dietary modification for aspiration in past)\n # Prophylaxis: Subcutaneous heparin, pneumoboots, aspiration\n precautions\n # Access: peripherals\n # Communication: Patient and Sister(HCP), home\n cell \n # Code: DNR confirmed - ? DNI\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2117-01-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 714957,
"text": "Chief Complaint: Dyspnea\n HPI:\n 81 yo F w hx of bronchiectasis, dementia, presumed microaspiration and\n recurrent aspiration pneumonias, presents with 2 days of SOB, Cough\n from long-term care facility. She denied fevers, CP, abd pain. A+O x 3.\n DNR/DNI in chart, but pt made clear that she wants to intubated if\n necessary in the ED.\n .\n In the ED, initial vs were: T 98.9 HR 82 BP 158/98 RR 28 POx 85%.\n Initial VBG 7.17/60/82. She was started on BIPAP and repeat ABG\n 7.36/35/166. Blood cultures were drawn. A CXR showed hyperinfilation.\n Patient was given azithromycin 500mg IV, ceftriaxone 1gm IV,\n Methylprednisolone 125mg IV, lorazepam 2mg IV for comfort w/ BIPAP. BP\n decreased to SBP 80s w/BIPAP but improved with fluids. She received 1L\n NS IVF. IV access 2 - 18g. VS prior to transfer were HR 74 BP 105/57 RR\n 30 POX 98% on 5L.\n .\n On the floor, she felt much improved but complained of being cold. She\n confirmed a few days of shortness of breath and productive cough prior\n to presentation. She denies fevers, chills, recent URI, chest pain,\n nausea, vomiting, diarrhea. Does report weight loss but can't quantify\n time or amount. Also states she has been hospitalized a little while\n ago for pneumonia but can't tell me when or where.\n .\n Of note, last admission to for similar complaints felt \n recurrent microaspiration and acute bronchiectasis flair with mucous\n plugging.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:00 PM\n Vancomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Other medications:\n updated from \n Alendronate 70 mg PO 1X/WEEK (THURS)\n ARicept 10mg po once daily\n Benzonatate 100mg po TID\n Gabapentin 600 mg PO BID\n Namenda 10 mg PO daily \n Mucinex ER 600mg po BID\n Acetaminophen 500 mg PO Q6H prn pain\n Aspirin 81 mg One PO DAILY\n Omeprazole 20mg po daily\n Calcium 500 + D (D3) 500-125 mg-unit One PO twice a day.\n Albuterol Sulfate 90 mcg HFA Two (2) Puff Inhalation Q6H\n Lidocaine 5 %(700 mg/patch) Adhesive Patch DAILY (Daily): 12\n hours on, 12 off.\n Past medical history:\n Family history:\n Social History:\n - bronchiectasis - felt recurrent microaspiration, was due for\n video swallow at rehab facility \n - Dementia\n - Neuropathy\n - Osteoporosis\n - Chronic venous stasis ulcer\n - Gallbladder polyp seen on u/s - needed follow up in \n - presumed recurrent aspiration pneumonia\n - Chronic Venous Stasis Ulcer\n - h/o AFB positive - MYCOBACTERIUM CHELONAE\n non-contributory\n Occupation: The pt previously worked as a graphic designer and a\n painter\n with watercolors.\n Drugs: none\n Tobacco: none\n Alcohol: social\n Other: She denies any known exposure to asbestos or tuberculosis. Now\n living at .\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight gain. Denies\n headache, sinus tenderness, rhinorrhea or congestion. Denies chest\n pain, chest pressure, palpitations, or weakness. Denies nausea,\n vomiting, diarrhea, constipation, abdominal pain, or changes in bowel\n habits. Denies dysuria, frequency, or urgency. Denies arthralgias or\n myalgias. Denies rashes or skin changes.\n Flowsheet Data as of 02:55 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.6\nC (96\n HR: 63 (63 - 71) bpm\n BP: 78/53(59) {76/47(54) - 106/63(74)} mmHg\n RR: 31 (21 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 555 mL\n PO:\n TF:\n IVF:\n 555 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 555 mL\n Respiratory\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n SpO2: 98%\n ABG: 7.41/39/68//0\n Physical Examination\n General: Alert, oriented to , few days after , no\n acute distress, cachetic\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Speaking in full sentences without excessory muscle use, Diffuse\n expiratory rhonchi, loudest at right base, no wheezing, + wet cough\n CV: HS distant, Regular rate and rhythm, normal S1 + S2, no murmurs,\n rubs, gallops appreciated\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: cool toes b/l but remainder of extremities warm, weak palpable\n pulses b/l, no clubbing, cyanosis or edema\n Neuro: CN II-XII without focal defect, weakness throughout but moving\n all extremeties symmetrically\n Labs / Radiology\n 233 K/uL\n 15.2 g/dL\n 46.9 %\n 8.1 K/uL\n [image002.jpg]\n \n 2:33 A12/26/ 01:06 PM\n \n 10:20 P12/26/ 01:32 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.1\n Hct\n 46.9\n Plt\n 233\n TC02\n 26\n Other labs: Lactic Acid:1.1 mmol/L\n Fluid analysis / Other labs: 9:10 ABG pH 7.17 pCO260 pO282 HCO323\n 9:53 ABG pH 7.36 pCO235 pO2166 HCO3 AGap=23\n ------------< 286\n 6.2 18 1.1\n Comments: K: Hemolyzed, Grossly\n K: Hemolysis Falsely Elevates K\n K: Notified On At 1000\n estGFR: 48/58 (click for details)\n MCV 97 WBC11.4 HGB 17.6 ∆ PLTs 312 HCT 57.1 ∆\n N:41.7 L:44.9 M:4.1 E:7.6 Bas:1.8\n Imaging: CXR - dictated - hyperinflation, interstital\n promience bilaterally, increased opacity of right lung base\n superimposed on baseline emphysema\n Microbiology: Blood Cx pending\n sputum pending\n ECG: EKG: compared w/ NSR at 84, NI, P pulmonale, poor R wave\n progression, no ST/T wave abnormalities from prior.\n Assessment and Plan\n 81 yo F with dementia, chronic bronchectasis from presumed recurrent\n microaspiration presents with acute SOB and cough x2 days found to be\n in hypercarbic respiratory failure responsive to BIPAP with clinical\n exam and CXR suggestive of right lower lobe pneumonia.\n .\n # Hypercarbic Respiratory Failure - Differential includes recurrent\n bronchiectasis with worsening of mucous plugging from\n bronchitis/pneumonia vs. inital COPD exacerbation (has no history of\n COPD but CT scan from showed mild centrilobular emphysema). CXR\n raises question of RLL infiltrate.\n - aggressive pulmonary toilet with mucinex, albuterol/ipratropium nebs\n - send \n - obtain sputum cx\n - confirm with HCP patient's wishes regarding intubation\n - switch ABX coverage to health-care associated coverage with\n Vanco/Zosyn\n - repeat CXR after fluid resuscitation to better assess for infiltrate\n (ordered for 4PM)\n - given question of recurrent microaspiration event, will hold\n omeprazole unless clear clinical indication arises as increase risk for\n pulmonary infection outweights benefit\n - plan for video swallow on this admission to further eval aspiration\n .\n # AG Metabolic Acidosis -\n - check lactate, repeat lytes after fluid resuscitation\n .\n # Leukocytosis - Appears hemoconcentrated on labs. be PNA.\n - repeat CBC after fluid resuscitation\n .\n # Dementia - continue home meds of namenda,aricept\n .\n # Osteoprosis - continue alendronate QWeek, calicum +D\n .\n # Eosinophila - Long standing. Lower than baseline, dating back to\n 3/. AEC 866.\n - defer to outpatient work up\n .\n # FEN: no IVF for now, replete electrolytes, NPO for now, will resume\n heart healthy diet w/ TID supplement if respiratory status remains\n stable(has not required dietary modification for aspiration in past)\n # Prophylaxis: Subcutaneous heparin, pneumoboots, aspiration\n precautions\n # Access: peripherals\n # Communication: Patient and Sister(HCP), home\n cell \n # Code: DNR confirmed - ? DNI\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2117-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715023,
"text": "Pneumonia, aspiration\n Assessment:\n Afebrile. WBC count 7.8. LS clear to diminished. Sats WNL on 3L NC\n and 12L 40% face tent.\n Action:\n Zosyn administered as ordered. Oxygen weaned as tolerated. Nebulizer\n treatments administered ATC. Pulmonary toileting.\n Response:\n Patient currently on 2L NC, 12L 40% face tent. Patient able to\n expectorate thick, tan secretions.\n Plan:\n Continue to monitor respiratory status. Wean oxygen as tolerated.\n Administer abx and nebs as ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2117-01-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 715116,
"text": "Pneumonia, aspiration\n Assessment:\n Alert and oriented, h/o dementia. Sister at bedside. Remains\n afebrile. SR 70\ns, no ectopy. SBP > 100. Easily palpable pedal\n pulses bilaterally. Lungs with expiratory wheezes bilaterally. O2 sat\n > 95% on 2L NC.\n Abdomen soft, nd. BS positive. H/O silent aspiration. Foley to\n gravity, clear yellow urine, good hourly urine output. Blood glucose\n WNL.\n Action:\n Albuterol and atrovent nebs as needed.\n Diet changed to cardiac heart healthy attending MD .\n Swallows pills observed by RN with no apparent aspiration.\n CPT and acapelo valve done.\n Vancomycin and Zosyn per orders for pneumonia.\n Response:\n Tolerating po intake.\n Urine output improved with increased po intake.\n Productive cough after pulmonary toilet.\n Remains stable with o2 sat > 95% on 2L NC.\n Plan:\n Video swallow in AM to assess aspiration risk.\n Pulmonary toilet.\n"
},
{
"category": "Nursing",
"chartdate": "2117-01-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 715102,
"text": "Pneumonia, aspiration\n Assessment:\n Alert and oriented, h/o dementia. Sister at bedside. Remains\n afebrile. SR 70\ns, no ectopy. SBP > 100. Easily palpable pedal\n pulses bilaterally. Lungs with expiratory wheezes bilaterally. O2 sat\n > 95% on 2L NC.\n Abdomen soft, nd. BS positive. H/O silent aspiration. Foley to\n gravity, clear yellow urine, good hourly urine output. Blood glucose\n WNL.\n Action:\n Albuterol and atrovent nebs as needed.\n Diet changed to cardiac heart healthy attending MD .\n Swallows pills observed by RN with no apparent aspiration.\n CPT and acapelo valve done.\n Vancomycin and Zosyn per orders for pneumonia.\n Response:\n Tolerating po intake.\n Urine output improved with increased po intake.\n Productive cough after pulmonary toilet.\n Remains stable with o2 sat > 95% on 2L NC.\n Plan:\n Video swallow in AM to assess aspiration risk.\n Pulmonary toilet.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n DNR\n Height:\n Admission weight:\n 60 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: COPD\n CV-PMH:\n Additional history: Dementia, osteoperosis, venous stasis ulcer,\n gallbladder KDA, neuropathy, AFB culture, pneumonia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:90\n D:47\n Temperature:\n 97.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 34 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95%\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 100 mL\n 24h total out:\n 617 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 01:50 AM\n Potassium:\n 4.6 mEq/L\n 01:50 AM\n Chloride:\n 110 mEq/L\n 01:50 AM\n CO2:\n 22 mEq/L\n 01:50 AM\n BUN:\n 18 mg/dL\n 01:50 AM\n Creatinine:\n 0.9 mg/dL\n 01:50 AM\n Glucose:\n 102\n 10:00 AM\n Hematocrit:\n 42.1 %\n 01:50 AM\n Valuables / Signature\n Patient valuables: glasses\n Other valuables:\n Clothes:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: none\n Jewelry: none\n Transferred from: \n Transferred to: 215\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2117-01-24 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 715109,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 11:49 AM\n SPUTUM CULTURE - At 04:54 PM\n BLOOD CULTURED - At 04:55 PM\n times 2 in ED\n URINE CULTURE - At 04:55 PM\n -confirmed 'yes okay to intubate if needed' with patient and her sister\n -SBP in 80s and 90s while sleeping o/n; low 100s while awake\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:00 PM\n Vancomycin - 02:32 PM\n Piperacillin/Tazobactam (Zosyn) - 02:15 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:55 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.2\nC (95.3\n HR: 74 (63 - 83) bpm\n BP: 86/51(59) {76/25(46) - 109/74(82)} mmHg\n RR: 41 (13 - 41) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,910 mL\n 50 mL\n PO:\n 60 mL\n TF:\n IVF:\n 1,850 mL\n 50 mL\n Blood products:\n Total out:\n 1,165 mL\n 270 mL\n Urine:\n 1,165 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n 745 mL\n -220 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n SpO2: 98%\n ABG: 7.41/39/68/22/0\n PaO2 / FiO2: 170\n Physical Examination\n GEN\n nad, resting comfortably, alert\n CV\n rrr, no murmurs\n PULM\n decreased breath sounds b/l and rhonchi\n ABD\n soft, nt\n EXTR\n cachectic, no edema\n Labs / Radiology\n 233 K/uL\n 13.9 g/dL\n 98 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 18 mg/dL\n 110 mEq/L\n 142 mEq/L\n 42.1 %\n 7.8 K/uL\n [image002.jpg]\n 01:06 PM\n 01:32 PM\n 01:50 AM\n WBC\n 8.1\n 7.8\n Hct\n 46.9\n 42.1\n Plt\n 233\n 233\n Cr\n 0.9\n 0.9\n TCO2\n 26\n Glucose\n 99\n 98\n Other labs: PT / PTT / INR:11.9/26.9/1.0, Differential-Neuts:74.8 %,\n Lymph:18.1 %, Mono:6.4 %, Eos:0.3 %, Lactic Acid:1.1 mmol/L, LDH:270\n IU/L, Ca++:8.9 mg/dL, Mg++:2.0 mg/dL, PO4:3.8 mg/dL\n Negative urine legionella.\n Assessment and Plan\n PNEUMONIA, ASPIRATION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 81 yo F with dementia, chronic bronchectasis from presumed recurrent\n microaspiration presents with acute SOB and cough x2 days found to be\n in hypercarbic respiratory failure responsive to BIPAP with clinical\n exam and CXR suggestive of right lower lobe pneumonia.\n .\n # Hypercarbic Respiratory Failure - Differential includes recurrent\n bronchiectasis with worsening of mucous plugging from\n bronchitis/pneumonia vs. inital COPD exacerbation (has no history of\n COPD but CT scan from showed mild centrilobular emphysema). CXR\n raises question of RLL infiltrate. Role of atypical mycobacterium is\n unclear. Suspect colonization but has only had one positive AFB culture\n - 3 are still pending at the state lab.\n - aggressive pulmonary toilet with mucinex, albuterol/ipratropium nebs\n - try cough-elator, acapella, incentive spirometer\n - chest PT\n - re-obtain sputum cx\n - switch ABX coverage to health-care associated coverage = on vanc and\n zosyn empirically (D1 = )\n - given question of recurrent microaspiration event, will hold\n omeprazole unless clear clinical indication arises as increase risk for\n pulmonary infection outweights benefit\n - plan for video swallow on this admission to further eval aspiration\n (likely Monday )\n - wean O2 as tolerated\n .\n # Transient Hypotension - Responsive to arousal and fluids. She has no\n cardiac history. Baseline around SBP 120s. Noted SBP to be 80s and 90s\n o/n. Good UOP, through Foley.\n - monitor UOP\n - maintain 2 PIVs\n - fluid bolus prn if UOP decreases\n - hold off on invasive monitoring for now.\n .\n # AG Metabolic Acidosis\n resolved\n .\n # Leukocytosis - Appeared hemoconcentrated on labs. be PNA.\n Resolved.\n .\n # Dementia - continue home meds of namenda, aricept\n .\n # Osteoprosis - continue alendronate QWeek, calicum +D\n .\n # Eosinophila - Long standing. Lower than baseline, dating back to\n 3/. AEC 866. Question if related to recurrent respiratory\n infections. Unlikely to have parasite/ syndrome. Also ANCA\n positive disease unlikely. Course is not consistent with either acute\n or chronic eosinophilic pneumonia. She has never had bronch to rule\n this out. Other possibilities include hypersensitivity pneumonitis,\n ABPA.\n - f/u precipitins to aspergillus, total IgE\n .\n # FEN: no IVF for now, replete electrolytes, heart healthy diet w/ TID\n supplement as respiratory status has remained stable, but with\n aspiration precautions.\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots, aspiration\n precautions but ok to eat.\n # Access: peripherals\n # Communication: Patient and Sister(HCP), home\n cell \n # Code: DNR confirmed. Ok to intubate if needed.\n # Disposition: Call-out to floor today.\n ------ Protected Section ------\n Critical Care Attending Addendum\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with the\n note above, including assessment and plan.\n 81 yo woman w/bronchiectasis and dementia who presents with 2 days\n cough, phlegm and shortness of breath. Found to be more short of breath\n and anxious at and was sent in for evaluation. Has\n history of eosinophilia without known cause, also has had one of many\n AFB sputum cultures grow out mycobacteria chelonae (all others\n negative). Admitted to ICU with ?RLL infiltrate and bronchiectasis\n exacerbation. Overnight - confirmed ok w/intubation if need be, DNR.\n T98.3 RR13-41 98% on NC 2L HR 88 7.41/39/69 on BiPAP. On exam, awake\n alert, asking appropriate questions - oriented x 1 (name, hospital,\n near ). No JVD, no , lungs w/decreased breath sounds R > L,\n diffuse exp rhonchi also worse at R base. No murmur, rub, gallop - no\n cyanosis, clubbing, edema. Weak, but palpable pulses. Neuro motor\n intact. Cr 0.8 Lact 1.1 Neg Lgella\n 81 yo with dementia and bronchiectasis and ?recurrent aspiration now\n with respiratory distress in setting of possible new RLL infiltrate. We\n will treat broadly for either bronchiectasis flare and/or aspiration\n event with antibiotics pending cultures and try for aggressive\n pulmonary hygiene with incentive spirometry, trial of maximal\n in/exsufflator, acapella, chest PT, and mucinex. We will get a video\n swallow and treat with PPI. We will send additional serological\n evaluation (IgE and aspergillus precipitants) for ?ABPA and underlying\n eosinophilia. Unlikely to be mycobacterial infection, but we will\n recheck AFB smear and culture. If not improving, and video swallow\n negative, would consider repeat chest CT and bronchoscopy during this\n admission to assess for untreated / unusual pathogens. Pt is DNR,\n sister is proxy.\n , MD\n ------ Protected Section Addendum Entered By: , MD\n on: 13:41 ------\n"
},
{
"category": "Nursing",
"chartdate": "2117-01-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715009,
"text": "81 yo F w hx of bronchiectasis, dementia, presumed microaspiration and\n recurrent aspiration pneumonias, presents with 2 days of SOB, Cough\n from long-term care facility. Placed on Bipap for 30min with good\n improvement. She denied fevers, CP, abd pain. A+O x 3. DNR/DNI in\n chart, but pt made clear that she wants to intubated if necessary in\n the ED. Started on ABX and admitted to TSICU for possible pneumonia.\n .\n NKDA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient coming up from ED on 5 liters NC with SaO2 87%. Strong\n productive cough with thick tan secretions. LS wheezy and rhonchi on\n expiration. Hypothermic upon admit.\n Action:\n Pulm toileting, started ABX, fluids for hypotension.\n Response:\n BP improving with IVF, patient stating she is now warm.\n Plan:\n Continue to monitor respiratory status, video swallow eval for ?\n Aspiration pnu.\n"
},
{
"category": "Nursing",
"chartdate": "2117-01-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 715081,
"text": "Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2117-01-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 715082,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 11:49 AM\n SPUTUM CULTURE - At 04:54 PM\n BLOOD CULTURED - At 04:55 PM\n times 2 in ED\n URINE CULTURE - At 04:55 PM\n -confirmed 'yes okay to intubate if needed' with patient and her sister\n -SBP in 80s and 90s while sleeping o/n; low 100s while awake\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:00 PM\n Vancomycin - 02:32 PM\n Piperacillin/Tazobactam (Zosyn) - 02:15 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:55 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.2\nC (95.3\n HR: 74 (63 - 83) bpm\n BP: 86/51(59) {76/25(46) - 109/74(82)} mmHg\n RR: 41 (13 - 41) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,910 mL\n 50 mL\n PO:\n 60 mL\n TF:\n IVF:\n 1,850 mL\n 50 mL\n Blood products:\n Total out:\n 1,165 mL\n 270 mL\n Urine:\n 1,165 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n 745 mL\n -220 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n SpO2: 98%\n ABG: 7.41/39/68/22/0\n PaO2 / FiO2: 170\n Physical Examination\n GEN\n nad, resting comfortably, alert\n CV\n rrr, no murmurs\n PULM\n decreased breath sounds b/l and rhonchi\n ABD\n soft, nt\n EXTR\n cachectic, no edema\n Labs / Radiology\n 233 K/uL\n 13.9 g/dL\n 98 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 18 mg/dL\n 110 mEq/L\n 142 mEq/L\n 42.1 %\n 7.8 K/uL\n [image002.jpg]\n 01:06 PM\n 01:32 PM\n 01:50 AM\n WBC\n 8.1\n 7.8\n Hct\n 46.9\n 42.1\n Plt\n 233\n 233\n Cr\n 0.9\n 0.9\n TCO2\n 26\n Glucose\n 99\n 98\n Other labs: PT / PTT / INR:11.9/26.9/1.0, Differential-Neuts:74.8 %,\n Lymph:18.1 %, Mono:6.4 %, Eos:0.3 %, Lactic Acid:1.1 mmol/L, LDH:270\n IU/L, Ca++:8.9 mg/dL, Mg++:2.0 mg/dL, PO4:3.8 mg/dL\n Negative urine legionella.\n Assessment and Plan\n PNEUMONIA, ASPIRATION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 81 yo F with dementia, chronic bronchectasis from presumed recurrent\n microaspiration presents with acute SOB and cough x2 days found to be\n in hypercarbic respiratory failure responsive to BIPAP with clinical\n exam and CXR suggestive of right lower lobe pneumonia.\n .\n # Hypercarbic Respiratory Failure - Differential includes recurrent\n bronchiectasis with worsening of mucous plugging from\n bronchitis/pneumonia vs. inital COPD exacerbation (has no history of\n COPD but CT scan from showed mild centrilobular emphysema). CXR\n raises question of RLL infiltrate. Role of atypical mycobacterium is\n unclear. Suspect colonization but has only had one positive AFB culture\n - 3 are still pending at the state lab.\n - aggressive pulmonary toilet with mucinex, albuterol/ipratropium nebs\n - try cough-elator, acapella, incentive spirometer\n - chest PT\n - re-obtain sputum cx\n - switch ABX coverage to health-care associated coverage = on vanc and\n zosyn empirically (D1 = )\n - given question of recurrent microaspiration event, will hold\n omeprazole unless clear clinical indication arises as increase risk for\n pulmonary infection outweights benefit\n - plan for video swallow on this admission to further eval aspiration\n (likely Monday )\n - wean O2 as tolerated\n .\n # Transient Hypotension - Responsive to arousal and fluids. She has no\n cardiac history. Baseline around SBP 120s. Noted SBP to be 80s and 90s\n o/n. Good UOP, through Foley.\n - monitor UOP\n - maintain 2 PIVs\n - fluid bolus prn if UOP decreases\n - hold off on invasive monitoring for now.\n .\n # AG Metabolic Acidosis\n resolved\n .\n # Leukocytosis - Appeared hemoconcentrated on labs. be PNA.\n Resolved.\n .\n # Dementia - continue home meds of namenda, aricept\n .\n # Osteoprosis - continue alendronate QWeek, calicum +D\n .\n # Eosinophila - Long standing. Lower than baseline, dating back to\n 3/. AEC 866. Question if related to recurrent respiratory\n infections. Unlikely to have parasite/ syndrome. Also ANCA\n positive disease unlikely. Course is not consistent with either acute\n or chronic eosinophilic pneumonia. She has never had bronch to rule\n this out. Other possibilities include hypersensitivity pneumonitis,\n ABPA.\n - f/u precipitins to aspergillus, total IgE\n .\n # FEN: no IVF for now, replete electrolytes, heart healthy diet w/ TID\n supplement as respiratory status has remained stable, but with\n aspiration precautions.\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots, aspiration\n precautions but ok to eat.\n # Access: peripherals\n # Communication: Patient and Sister(HCP), home\n cell \n # Code: DNR confirmed. Ok to intubate if needed.\n # Disposition: Call-out to floor today.\n"
},
{
"category": "Nursing",
"chartdate": "2117-01-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 715086,
"text": "Pneumonia, aspiration\n Assessment:\n Alert and oriented, h/o dementia. Sister at bedside. Remains\n afebrile. SR 70\ns, no ectopy. SBP > 100. Easily palpable pedal\n pulses bilaterally. Lungs with expiratory wheezes bilaterally. O2 sat\n > 95% on 2L NC.\n Abdomen soft, nd. BS positive. H/O silent aspiration. Foley to\n gravity, clear yellow urine, good hourly urine output. Blood glucose\n WNL.\n Action:\n Albuterol and atrovent nebs as needed.\n Diet changed to cardiac heart healthy attending MD .\n Swallows pills observed by RN with no apparent aspiration.\n CPT and acapelo valve done.\n Vancomycin and Zosyn per orders for pneumonia.\n Response:\n Tolerating po intake.\n Urine output improved with increased po intake.\n Productive cough after pulmonary toilet.\n Remains stable with o2 sat > 95% on 2L NC.\n Plan:\n Video swallow in AM to assess aspiration risk.\n Pulmonary toilet.\n"
},
{
"category": "Physician ",
"chartdate": "2117-01-23 00:00:00.000",
"description": "Physician Resident/Attending Admission Note - MICU",
"row_id": 714976,
"text": "Chief Complaint: Dyspnea\n HPI:\n 81 yo F w hx of bronchiectasis, dementia, presumed microaspiration and\n recurrent aspiration pneumonias, presents with 2 days of SOB, Cough\n from long-term care facility. She denied fevers, CP, abd pain. A+O x 3.\n DNR/DNI in chart, but pt made clear that she wants to intubated if\n necessary in the ED.\n .\n In the ED, initial vs were: T 98.9 HR 82 BP 158/98 RR 28 POx 85%.\n Initial VBG 7.17/60/82. She was started on BIPAP and repeat ABG\n 7.36/35/166. Blood cultures were drawn. A CXR showed hyperinfilation.\n Patient was given azithromycin 500mg IV, ceftriaxone 1gm IV,\n Methylprednisolone 125mg IV, lorazepam 2mg IV for comfort w/ BIPAP. BP\n decreased to SBP 80s w/BIPAP but improved with fluids. She received 1L\n NS IVF. IV access 2 - 18g. VS prior to transfer were HR 74 BP 105/57 RR\n 30 POX 98% on 5L.\n .\n On the floor, she felt much improved but complained of being cold. She\n confirmed a few days of shortness of breath and productive cough prior\n to presentation. She denies fevers, chills, recent URI, chest pain,\n nausea, vomiting, diarrhea, aspiration episodes. Does report weight\n loss but can't quantify time or amount. Also states she has been\n hospitalized a little while ago for pneumonia but can't tell me when or\n where.\n .\n Of note, last admission to for similar complaints felt \n recurrent microaspiration and acute bronchiectasis flair with mucous\n plugging.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:00 PM\n Vancomycin - 02:32 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Other medications:\n updated from \n Alendronate 70 mg PO 1X/WEEK (THURS)\n ARicept 10mg po once daily\n Benzonatate 100mg po TID\n Gabapentin 600 mg PO BID\n Namenda 10 mg PO daily \n Mucinex ER 600mg po BID\n Acetaminophen 500 mg PO Q6H prn pain\n Aspirin 81 mg One PO DAILY\n Omeprazole 20mg po daily\n Calcium 500 + D (D3) 500-125 mg-unit One PO twice a day.\n Albuterol Sulfate 90 mcg HFA Two (2) Puff Inhalation Q6H\n Lidocaine 5 %(700 mg/patch) Adhesive Patch DAILY (Daily): 12\n hours on, 12 off.\n Past medical history:\n Family history:\n Social History:\n - bronchiectasis - felt recurrent microaspiration, was due for\n video swallow at rehab facility \n - Dementia\n - Neuropathy\n - Osteoporosis\n - Chronic venous stasis ulcer\n - Gallbladder polyp seen on u/s - needed follow up in \n - presumed recurrent aspiration pneumonia\n - Chronic Venous Stasis Ulcer\n - h/o AFB positive - MYCOBACTERIUM CHELONAE\n non-contributory\n Occupation: The pt previously worked as a graphic designer and a\n painter\n with watercolors.\n Drugs: none\n Tobacco: none\n Alcohol: social\n Other: She denies any known exposure to asbestos or tuberculosis. Now\n living at .\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight gain. Denies\n headache, sinus tenderness, rhinorrhea or congestion. Denies chest\n pain, chest pressure, palpitations, or weakness. Denies nausea,\n vomiting, diarrhea, constipation, abdominal pain, or changes in bowel\n habits. Denies dysuria, frequency, or urgency. Denies arthralgias or\n myalgias. Denies rashes or skin changes.\n Flowsheet Data as of 02:55 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.6\nC (96\n HR: 63 (63 - 71) bpm\n BP: 78/53(59) {76/47(54) - 106/63(74)} mmHg\n RR: 31 (21 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 555 mL\n PO:\n TF:\n IVF:\n 555 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 555 mL\n Respiratory\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n SpO2: 98%\n ABG: 7.41/39/68//0\n Physical Examination\n General: Alert, oriented to , few days after , no\n acute distress, cachetic\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Speaking in full sentences without excessory muscle use, Diffuse\n expiratory rhonchi, loudest at right base, no wheezing, + wet cough\n CV: HS distant, Regular rate and rhythm, normal S1 + S2, no murmurs,\n rubs, gallops appreciated\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: cool toes b/l but remainder of extremities warm, weak palpable\n pulses b/l, no clubbing, cyanosis or edema\n Neuro: CN II-XII without focal defect, weakness throughout but moving\n all extremeties symmetrically\n Labs / Radiology\n 233 K/uL\n 15.2 g/dL\n 46.9 %\n 8.1 K/uL\n [image002.jpg]\n \n 2:33 A12/26/ 01:06 PM\n \n 10:20 P12/26/ 01:32 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.1\n Hct\n 46.9\n Plt\n 233\n TC02\n 26\n Other labs: Lactic Acid:1.1 mmol/L\n Fluid analysis / Other labs: 9:10 ABG pH 7.17 pCO260 pO282 HCO323\n 9:53 ABG pH 7.36 pCO235 pO2166 HCO3 AGap=23\n ------------< 286\n 6.2 18 1.1\n Comments: K: Hemolyzed, Grossly\n K: Hemolysis Falsely Elevates K\n K: Notified On At 1000\n estGFR: 48/58 (click for details)\n MCV 97 WBC11.4 HGB 17.6 ∆ PLTs 312 HCT 57.1 ∆\n N:41.7 L:44.9 M:4.1 E:7.6 Bas:1.8\n Imaging: CXR - dictated - hyperinflation, interstital\n promience bilaterally, increased opacity of right lung base\n superimposed on baseline emphysema\n Microbiology: Blood Cx pending\n sputum pending\n ECG: EKG: compared w/ NSR at 84, NI, P pulmonale, poor R wave\n progression, no ST/T wave abnormalities from prior.\n Assessment and Plan\n 81 yo F with dementia, chronic bronchectasis from presumed recurrent\n microaspiration presents with acute SOB and cough x2 days found to be\n in hypercarbic respiratory failure responsive to BIPAP with clinical\n exam and CXR suggestive of right lower lobe pneumonia.\n .\n # Hypercarbic Respiratory Failure - Differential includes recurrent\n bronchiectasis with worsening of mucous plugging from\n bronchitis/pneumonia vs. inital COPD exacerbation (has no history of\n COPD but CT scan from showed mild centrilobular emphysema). CXR\n raises question of RLL infiltrate. Role of atypical mycobacterium is\n unclear. Suspect colonization but has only had one positive AFB culture\n - 3 are still pending at the state lab.\n - aggressive pulmonary toilet with mucinex, albuterol/ipratropium nebs\n - send \n - obtain sputum cx\n - confirm with HCP patient's wishes regarding intubation\n - switch ABX coverage to health-care associated coverage\n - repeat CXR after fluid resuscitation to better assess for infiltrate\n (ordered for 4PM)\n - given question of recurrent microaspiration event, will hold\n omeprazole unless clear clinical indication arises as increase risk for\n pulmonary infection outweights benefit\n - plan for video swallow on this admission to further eval aspiration\n .\n # Transient Hypotension - Responsive to arousal and fluids. She has no\n cardiac history. Baseline around SBP 120s.\n - insert foley to monitor UOP\n - maintain 2 PIVs\n - fluid bolus prn\n - hold off on invasive monitoring for now.\n .\n # AG Metabolic Acidosis -\n - check lactate, repeat lytes after fluid resuscitation\n .\n # Leukocytosis - Appears hemoconcentrated on labs. be PNA.\n - repeat CBC after fluid resuscitation\n .\n # Dementia - continue home meds of namenda, aricept\n .\n # Osteoprosis - continue alendronate QWeek, calicum +D\n .\n # Eosinophila - Long standing. Lower than baseline, dating back to\n 3/. AEC 866. Question if related to recurrent respiratory\n infections. Unlikely to have parasite/ syndrome. Also ANCA\n positive disease unlikely. Course is not consistent with either acute\n or chronic eosinophilic pneumonia. She has never had bronch to rule\n this out. Other possibilities include hypersensitivity pneumonitis,\n ABPA.\n - will check precipitins to aspergillus, total IgE\n .\n # FEN: no IVF for now, replete electrolytes, NPO for now, will resume\n heart healthy diet w/ TID supplement if respiratory status remains\n stable(has not required dietary modification for aspiration in past)\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots, aspiration\n precautions\n # Access: peripherals\n # Communication: Patient and Sister(HCP), home\n cell - left message with sister to call \n # Code: DNR confirmed - ? DNI\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n ------ Protected Section ------\n Critical Care Attending Addendum\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with the\n note above, including assessment and plan.\n 81 yo woman w/bronchiectasis and dementia who presents with 2 days\n cough, phlegm and shortness of breath. No hemoptysis, no chest pain,\n fever, or chills. Found to be more short of breath and anxious this am\n at and was sent in for evaluation. No obvious aspiration,\n choking, GERD. No sick contacts. history of eosinophilia without\n known cause, also has had one of many AFB sputum cultures grow out\n mycobacteria chelonae (all others negative). Reports having had\n seasonal, but not H1N1, vaccine this year.\n In ED RR elev to mid 20's, sat 88% RA, extremely anxious - treated with\n ativan and bipap. 7.36/35/166 on BiPAP. Treated with\n azithro/ceftriaxone/prednisolone and ativan. Pressures dropped with\n BiPAP but responded to IVF. Bld cx sent and CXR ?right basilar\n infiltrate vs baseline bronchiectasis. Labs notable for\n hemoconcentration w/HCT 57 on arrival.\n Now on exam, awake alert, asking appropriate questions - oriented x 1\n (name, hospital, near ) - HR 92, BP 107/49, RR 20, Sat 96% on\n 70% O2, Afebrile. No JVD, no , lungs w/decreased breath sounds R >\n L, diffuse exp rhonchi also worse at R base. No murmur, rub, gallop -\n no cyanosis, clubbing, edema. Weak, but palpable pulses. Neuro motor\n intact. CXR as above, prior Chest CT from reviewed and this\n showed bilateral bronchiectasis, mucus plugging and areas of ground\n glass nodules (all consistent with atypical mycobacterial colonization\n vs infection).\n 81 yo with dementia and bronchiectasis and ?recurrent aspiration now\n with respiratory distress in setting of possible new RLL infiltrate. We\n will treat broadly for either bronchiectasis flare and/or aspiration\n event with antibiotics pending cultures and try for aggressive\n pulmonary hygiene with incentive spirometry, chest PT, and mucinex. We\n will get a video swallow and treat with PPI. Metabolic acidosis and\n leukocytosis has improved with rehydration. We will send additional\n serological evaluation (IgE and aspergillus precipitants) for ?ABPA and\n underlying eosinophilia. Unlikely to be mycobacterial infection, but we\n will recheck AFB smear and culture. If not improving, and video swallow\n negative, would consider repeat chest CT and bronchoscopy during this\n admission to assess for untreated / unusual pathogens. Pt is DNR,\n sister is proxy.\n , MD\n Patient is Critically Ill\n Total Time: 50 Minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 16:46 ------\n"
},
{
"category": "Nursing",
"chartdate": "2117-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715032,
"text": "Pneumonia, aspiration\n Assessment:\n Afebrile. WBC count 7.8. LS clear to diminished. Sats WNL on 3L NC\n and 12L 40% face tent.\n Action:\n Zosyn administered as ordered. Oxygen weaned as tolerated. Nebulizer\n treatments administered ATC. Pulmonary toileting.\n Response:\n Patient currently on 2L NC, 12L 40% face tent. Patient able to\n expectorate thick, tan secretions.\n Plan:\n Continue to monitor respiratory status. Wean oxygen as tolerated.\n Administer abx and nebs as ordered. Plan for video swallow.\n"
},
{
"category": "Nursing",
"chartdate": "2117-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715049,
"text": "Pneumonia, aspiration\n Assessment:\n Afebrile. WBC count 7.8. LS clear to diminished. Sats WNL on 3L NC\n and 12L 40% face tent.\n Action:\n Zosyn administered as ordered. Oxygen weaned as tolerated. Nebulizer\n treatments administered ATC. Pulmonary toileting.\n Response:\n Patient currently on 2L NC, 12L 40% face tent. Patient able to\n expectorate thick, tan secretions.\n Plan:\n Continue to monitor respiratory status. Wean oxygen as tolerated.\n Administer abx and nebs as ordered. Plan for video swallow.\n"
},
{
"category": "Physician ",
"chartdate": "2117-01-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 715037,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 11:49 AM\n SPUTUM CULTURE - At 04:54 PM\n BLOOD CULTURED - At 04:55 PM\n times 2 in ED\n URINE CULTURE - At 04:55 PM\n -confirmed 'yes okay to intubate if needed' with patient and her sister\n -SBP in 80s and 90s while sleeping o/n; low 100s while awake\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:00 PM\n Vancomycin - 02:32 PM\n Piperacillin/Tazobactam (Zosyn) - 02:15 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:55 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.2\nC (95.3\n HR: 74 (63 - 83) bpm\n BP: 86/51(59) {76/25(46) - 109/74(82)} mmHg\n RR: 41 (13 - 41) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,910 mL\n 50 mL\n PO:\n 60 mL\n TF:\n IVF:\n 1,850 mL\n 50 mL\n Blood products:\n Total out:\n 1,165 mL\n 270 mL\n Urine:\n 1,165 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n 745 mL\n -220 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Aerosol-cool\n SpO2: 98%\n ABG: 7.41/39/68/22/0\n PaO2 / FiO2: 170\n Physical Examination\n GEN\n CV\n PULM\n ABD\n EXTR\n Labs / Radiology\n 233 K/uL\n 13.9 g/dL\n 98 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 18 mg/dL\n 110 mEq/L\n 142 mEq/L\n 42.1 %\n 7.8 K/uL\n [image002.jpg]\n 01:06 PM\n 01:32 PM\n 01:50 AM\n WBC\n 8.1\n 7.8\n Hct\n 46.9\n 42.1\n Plt\n 233\n 233\n Cr\n 0.9\n 0.9\n TCO2\n 26\n Glucose\n 99\n 98\n Other labs: PT / PTT / INR:11.9/26.9/1.0, Differential-Neuts:74.8 %,\n Lymph:18.1 %, Mono:6.4 %, Eos:0.3 %, Lactic Acid:1.1 mmol/L, LDH:270\n IU/L, Ca++:8.9 mg/dL, Mg++:2.0 mg/dL, PO4:3.8 mg/dL\n Negative urine legionella.\n Assessment and Plan\n PNEUMONIA, ASPIRATION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 81 yo F with dementia, chronic bronchectasis from presumed recurrent\n microaspiration presents with acute SOB and cough x2 days found to be\n in hypercarbic respiratory failure responsive to BIPAP with clinical\n exam and CXR suggestive of right lower lobe pneumonia.\n .\n # Hypercarbic Respiratory Failure - Differential includes recurrent\n bronchiectasis with worsening of mucous plugging from\n bronchitis/pneumonia vs. inital COPD exacerbation (has no history of\n COPD but CT scan from showed mild centrilobular emphysema). CXR\n raises question of RLL infiltrate. Role of atypical mycobacterium is\n unclear. Suspect colonization but has only had one positive AFB culture\n - 3 are still pending at the state lab.\n - aggressive pulmonary toilet with mucinex, albuterol/ipratropium nebs\n - obtain sputum cx\n - switch ABX coverage to health-care associated coverage\n - CXR today f/u, and order one for tomorrow\n - given question of recurrent microaspiration event, will hold\n omeprazole unless clear clinical indication arises as increase risk for\n pulmonary infection outweights benefit\n - plan for video swallow on this admission to further eval aspiration\n .\n # Transient Hypotension - Responsive to arousal and fluids. She has no\n cardiac history. Baseline around SBP 120s. Noted SBP to be 80s and 90s\n o/n. Good UOP, through Foley.\n - monitor UOP\n - maintain 2 PIVs\n - fluid bolus prn\n - hold off on invasive monitoring for now.\n .\n # AG Metabolic Acidosis\n resolved\n .\n # Leukocytosis - Appeared hemoconcentrated on labs. be PNA.\n Resolved.\n .\n # Dementia - continue home meds of namenda, aricept\n .\n # Osteoprosis - continue alendronate QWeek, calicum +D\n .\n # Eosinophila - Long standing. Lower than baseline, dating back to\n 3/. AEC 866. Question if related to recurrent respiratory\n infections. Unlikely to have parasite/ syndrome. Also ANCA\n positive disease unlikely. Course is not consistent with either acute\n or chronic eosinophilic pneumonia. She has never had bronch to rule\n this out. Other possibilities include hypersensitivity pneumonitis,\n ABPA.\n - will check precipitins to aspergillus, total IgE\n .\n # FEN: no IVF for now, replete electrolytes, NPO for now, will resume\n heart healthy diet w/ TID supplement if respiratory status remains\n stable(has not required dietary modification for aspiration in past)\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots, aspiration\n precautions\n # Access: peripherals\n # Communication: Patient and Sister(HCP), home\n cell \n # Code: DNR confirmed. Ok to intubate if needed.\n # Disposition: ICU pending clinical improvement\n"
},
{
"category": "Nursing",
"chartdate": "2117-01-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 715130,
"text": "Pneumonia, aspiration\n Assessment:\n Alert and oriented, h/o dementia. Sister at bedside. Remains\n afebrile. SR 70\ns, no ectopy. SBP > 100, when sleeping SBP dropd to\n the 80\ns. Easily palpable pedal pulses bilaterally. Lungs with\n expiratory wheezes bilaterally. O2 sat > 95% on 2L NC.\n Abdomen soft, nd. BS positive. H/O silent aspiration. Foley to\n gravity, clear yellow urine, good hourly urine output. Blood glucose\n WNL.\n Action:\n Albuterol and atrovent nebs as needed.\n Diet changed to cardiac heart healthy attending MD .\n Swallows pills observed by RN with no apparent aspiration.\n CPT and acapelo valve done.\n NS 500 cc iv bolus given.\n Vancomycin and Zosyn per orders for pneumonia.\n Response:\n SBP 90-100\ns after fluid bolus.\n Tolerating po intake.\n Urine output improved with increased po intake.\n Productive cough after pulmonary toilet.\n Remains stable with o2 sat > 95% on 2L NC.\n Plan:\n Video swallow in AM to assess aspiration risk.\n Pulmonary toilet.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 60 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: COPD\n CV-PMH:\n Additional history: Dementia, osteoperosis, venous stasis ulcer,\n gallbladder KDA, neuropathy, AFB culture, pneumonia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:106\n D:57\n Temperature:\n 96.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 27 insp/min\n Heart Rate:\n 80 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94%\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 650 mL\n 24h total out:\n 752 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 01:50 AM\n Potassium:\n 4.6 mEq/L\n 01:50 AM\n Chloride:\n 110 mEq/L\n 01:50 AM\n CO2:\n 22 mEq/L\n 01:50 AM\n BUN:\n 18 mg/dL\n 01:50 AM\n Creatinine:\n 0.9 mg/dL\n 01:50 AM\n Glucose:\n 114\n 03:00 PM\n Hematocrit:\n 42.1 %\n 01:50 AM\n Valuables / Signature\n Patient valuables: with sister\n valuables:\n Clothes: with sister\n / : $20 per sister, with her\n / Credit cards sent home with: none\n Jewelry: with sister\n Transferred from: \n Transferred to: 215\n Date & time of Transfer: \n"
},
{
"category": "ECG",
"chartdate": "2117-01-23 00:00:00.000",
"description": "Report",
"row_id": 293565,
"text": "Sinus rhythm. Biatrial abnormality. Low limb lead voltage. Delayed\nprecordial R wave transition. Left anterior fascicular block. Compared to the\nprevious tracing of the rate has increased. Otherwise, no diagnostic\ninterim change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-01-25 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1113975,
"text": " 11:24 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: please evaluate for swallowing dysfunction\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with recurrent microaspirations\n REASON FOR THIS EXAMINATION:\n please evaluate for swallowing dysfunction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old woman with recurrent microaspirations. Evaluate for\n swallowing dysfunction.\n\n TECHNIQUE: Video oropharyngeal swallow.\n\n SWALLOWING VIDEO FLUOROSCOPY: Oropharyngeal swallowing video fluoroscopy was\n performed in conjunction with the speech and swallow division. Multiple\n consistencies of barium were administered. Barium is noted to pass freely\n through the oropharynx, without evidence of obstruction. Noted evidence of\n penetration for thick and thin consistencies. There was evidence of\n aspiration with multiple sips.\n\n IMPRESSION:\n\n Penetration for thin and thick consistencies. Aspiration with multiple quick\n swallows.\n\n For details and recommendations, please refer to speech and swallow division\n note in OMR.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-01-26 00:00:00.000",
"description": "BAS/UGI AIR/SBFT",
"row_id": 1114143,
"text": " 10:13 AM\n BAS/UGI AIR/SBFT Clip # \n Reason: please perform barium swallow to evaluate for anatomic abnor\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with oropharyngeal dysphagia, chronic microaspirations and\n aspiration pneumonitis\n REASON FOR THIS EXAMINATION:\n please perform barium swallow to evaluate for anatomic abnormalities,\n dysmotility d/o\n ______________________________________________________________________________\n WET READ: TUE 11:57 AM\n Impaired primary peristalsis with clearance by secondary peristalsis\n consistent with diffuse esophageal motility disorder.\n No evidence of anatomical abnormalities.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old woman with oropharyngeal dysphagia, chronic micro\n aspiration and aspiration pneumonitis. Evaluate to rule out anatomic\n abnormalities and esophageal dysmotility disorder.\n\n TECHNIQUE: Single contrast upper GI was performed.\n\n FINDINGS: Barium was noted to pass freely through the esophagus. Primary\n peristaltic stripping wave was not observed, however, there was clearance of\n barium by secondary peristaltic contraction. No hiatal hernia or\n gastroesophageal reflux was demonstrated. The stomach distended and emptied\n normally, and no abnormality was detected within the stomach.\n\n IMPRESSION: Abnormal primary peristaltic waves with clearance by secondary\n peristalsis consistent with esophageal dysmotility disorder. No anatomic\n abnormalities identified. A wet read was provided and findings were discussed\n with Dr. at 14:15 on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-01-25 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1114021,
"text": " 3:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pt had a left sided picc line placed,59cm and needs tip conf\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with PICC who needs it for IV antibiotics.\n REASON FOR THIS EXAMINATION:\n Pt had a left sided picc line placed,59cm and needs tip confirmation please\n page at .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post PICC line for IV antibiotics, needs tip confirmation.\n\n COMPARISON: Prior chest radiograph .\n\n Chest Radiograph portable view only:\n\n The PICC line is seen with the tip terminating in the lower SVC. Interval\n increase of right lower lung opacity is noted, obscuring the right\n hemidiaphragm line. In addition, there is a possible retrocardiac opacity in\n the left lower lung. There is no pneumothorax or pleural effusion. Cardiac,\n mediastinal and hilar contours are normal.\n\n IMPRESSION:\n 1. PICC line with the tip terminating in the lower SVC.\n 2. Interval increase of right lower lung opacity with possible left\n retrocardiac opacity in the left lower lung.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-01-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1113787,
"text": " 3:39 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval for infiltrate after IVF administration\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with h/o bronchectasis presents from NH w/ respiratory\n distress, s/p IVF\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate after IVF administration\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of bronchiectasis, respiratory distress, evaluation for\n pneumonia.\n\n COMPARISON: , 8:44.\n\n FINDINGS: As compared to the previous examination, there is no relevant\n change. No evidence of pulmonary edema. Unchanged subtle predominantly\n peribronchial opacities in the right lower lung that could represent early\n pneumonia. Otherwise, signs of overinflation. The presence of a hiatal\n hernia cannot be excluded. Unchanged size of the cardiac silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-01-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1113747,
"text": " 8:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with sob\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old woman with shortness of breath.\n\n COMPARISON: A series of prior chest radiographs, most recently .\n\n CHEST, PORTABLE FRONTAL VIEW: The patient is rotated to the left. The lungs\n are hyperinflated, with flattening of the hemidiaphragms. There is\n interstitial prominence bilaterally, and there may be subtle increased opacity\n at the right lung base. Streaky left upper lobe opacity is not seen on\n subsequent chest radiograph and may have represented external artifact. Heart\n size is normal. Mild convex left curvature of the thoracic spine is unchanged.\n\n IMPRESSION: Subtle increased opacity at the right lung base may reflect\n infection superimposed on emphysema.\n\n"
}
] |
2,378 | 172,805 | 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an episode of tachycardia (junctional rhythm), asymptomatic, now resolved. COPD is stable, but has significant oxygen desaturation with minimal exertion. # S/p Left total hip arthroplasty : - Pain controlled: On Tylenol 650mg Q6hrs and Oxycodone 5mg Q6hrs prn- - DVT prophylaxis with Lovenox 40mg Daily until INR on Warfarin. - Weight bear as tolerated with posterior precautions (pillow between knees when rolled) | Assessment and Plan 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an episode of tachycardia (junctional rhythm), and hypotension, asymptomatic # Hypotension: One episode of sbp 60s o/n, asymptomatic. Pt transferred to ICU post op hypotension (80/50) and poorly controlled tachycardia to 110s. 81 yo with h/o severe COPD (Sylvestri), SVT/Atrial Fibrillation, diastolic CHF, HTN, PE, admitted for elective L THA performed (EBL 500cc), transferred to for tachycardia and hypotension. 81 yo with h/o severe COPD (Sylvestri), SVT/Atrial Fibrillation, diastolic CHF, HTN, PE, admitted for elective L THA performed (EBL 500cc), transferred to for tachycardia and hypotension. Pt AO x 3,afebrile,HR 80-110,ABP dropped to 70s systolic NBP correlates with ABP. Action: Monitor BP Response: Plan: Tachycardia, Other Assessment: PT heart rate remained Action: Cont to monitor HR and BP Response: Pt maintained HR Plan: Clinical impression / Prognosis: 81 yo F w/ complex PMH adm to ICU hypotension and tachycardia following elective L THR . Hemodynamic Response Aerobic Capacity HR BP RR O[2 ]sat HR BP RR O[2] sat RPE Supine 78 101/54 97% 2.5L Rest 78 101/54 97% 2.5L Sit 80s-110s / Activity 80s-110s / 94% 2.5L Stand / Recovery 102-120 75/45 94% 2.5L Total distance walked: NA Minutes: Pulmonary Status: NARD, even unlabored breathing. in a junctional rythym\ And hypotensive. in a junctional rythym\ And hypotensive. 10:00 - NSR Assessment and Plan 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an episode of tachycardia (junctional rhythm), asymptomatic, now resolved. d/w Ortho (attg. Pt AO x 3,afebrile,HR 80-110,ABP dropped to 70s systolic NBp correlates with ABP. Drsg d/i. Drsg d/i. WBC 6.1 HBG 8.7 ∆ HCT 26.5 ∆ PLT 193 MCV 90 . MB: 5 Trop-T: <0.01 Ca: 7.9 Mg: 1.7 P: 3.4 . Bs Cv: a-line d/ced. Bs Cv: a-line d/ced. Now d/ced. Now d/ced. # Tachycardia. # Tachycardia. hemovac removed. Presently receiving a 1L fluid LR bolus. Presently receiving a 1L fluid LR bolus. - repeat pm Hct as patient started on coumadin . PT: 12.2 PTT: 22.6 INR: 1.0 . Assessment and Plan 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an episode of tachycardia (junctional rhythm), asymptomatic, improved overnight with PRBC, fluid bolus. Adaptic placed and kling. in nsr with infrequent bursts of a-fib. in nsr with infrequent bursts of a-fib. 81 yo with h/o severe COPD (Sylvestri), SVT/Atrial Fibrillation, diastolic CHF, HTN, PE, admitted for elective L THA performed (EBL 500cc), transferred to for tachycardia and hypotension. 81 yo with h/o severe COPD (Sylvestri), SVT/Atrial Fibrillation, diastolic CHF, HTN, PE, admitted for elective L THA performed (EBL 500cc), transferred to for tachycardia and hypotension. Pt AO x 3,afebrile,HR 80-110,ABP stable. Pt AO x 3,afebrile,HR 80-110,ABP stable. 139 | 108 | 13 / AGap=10 ---------------- 87 3.5 | 25 | 0.7 \ . - repeat pm Hct as patient started on coumadin . - repeat pm Hct as patient started on coumadin . - repeat pm Hct as patient started on coumadin . - repeat pm Hct as patient started on coumadin . - WBAT - posterior precautions (pillow between knees when rolled) ICU Care Nutrition: Clears, advance as tolerated Comments: Glycemic Control: Lines: 18 Gauge - 12:56 AM Prophylaxis: DVT: Boots, LMW Heparin(Systemic anticoagulation: Coumadin) Stress ulcer: H2 blocker VAP: Comments: Communication: ICU consent signed Code status: Full code Disposition: Transfer to floor - WBAT - posterior precautions (pillow between knees when rolled) ICU Care Nutrition: Clears, advance as tolerated Comments: Glycemic Control: Lines: 18 Gauge - 12:56 AM Prophylaxis: DVT: Boots, LMW Heparin(Systemic anticoagulation: Coumadin) Stress ulcer: H2 blocker VAP: Comments: Communication: ICU consent signed Code status: Full code Disposition: Transfer to floor Right lateral aspect of knee has skin tear with steristrips intact., adaptic and dry sterile dsg applied at 1700. Right lateral aspect of knee has skin tear with steristrips intact., adaptic and dry sterile dsg applied at 1700. Right lateral aspect of knee has skin tear with steristrips intact., adaptic and dry sterile dsg applied at 1700. Dsg changed by ortho this am, draining moderate amounts of serous drainage. Dsg changed by ortho this am, draining moderate amounts of serous drainage. Dsg changed by ortho this am, draining moderate amounts of serous drainage. Given delayed progress 2* post-op hypotension, tachycardia and decreased strength recommend rehab upon d/c when medically stable. | 42 | [
{
"category": "Physician ",
"chartdate": "2142-04-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403714,
"text": "Chief Complaint: CC: Hip Pain\n Admission: tachycardia s/p L THA\n 24 Hour Events:\n Overnight events:\n - transfused 1 unit PRBCs\n - Bolused 500cc LR\n - HR trended down from 100 to 70s.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 73 (73 - 111) bpm\n BP: 94/52(67) {84/52(65) - 126/76(96)} mmHg\n RR: 15 (11 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 412 mL\n 1,021 mL\n PO:\n TF:\n IVF:\n 112 mL\n 1,021 mL\n Blood products:\n 300 mL\n Total out:\n 1,350 mL\n 175 mL\n Urine:\n 50 mL\n 165 mL\n NG:\n Stool:\n Drains:\n 100 mL\n 10 mL\n Balance:\n -938 mL\n 846 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 194 K/uL\n 10.6 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 135 mEq/L\n 31.6 %\n 9.0 K/uL\n [image002.jpg]\n 03:35 AM\n WBC\n 9.0\n Hct\n 31.6\n Plt\n 194\n Cr\n 0.7\n TropT\n 0.02\n Glucose\n 126\n Other labs: PT / PTT / INR:12.6//1.1, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an\n episode of tachycardia (junctional rhythm), asymptomatic, improved\n overnight with PRBC, fluid bolus.\n .\n # Tachycardia. Stayed in SR overnight. Rate hovered around 100,\n dropped to 70s with 500cc bolus of fluid. BP stable.\n - continue metoprolol 12.5 mg PO bid\n - start warfarin 4mg PO daily at 1600 given h/o atrial fibrillation,\n follow INR\n - cycle cardiac enzymes, last set today at 11:00.\n .\n #. Anemia. HCt post-op 26, Given 1u PRBC now Hct 31.5\n - Trend HCt, consider transfusing if his HCt does not increase\n appropriately.\n .\n # COPD/eosinophilic lung disease\n - continue albuterol prn, tiopropium, advair, prednisone\n .\n # CHF/CAD\n - continue metoprolol, lasix\n - continue atorvastatin\n .\n # s/p L THA\n - pain control, morphine PCA, standing tylenol/NSAID per ortho, change\n to oral narcotics when tolerating PO.\n - dvt ppx lovenox, bridging to coumadin\n - Vanco at 11AM tomorrow.\n - WBAT\n - posterior precautions (pillow between knees when rolled)\n .\n FEN: No IVF, replete electrolytes, clears, advance as tolerated\n .\n Prophylaxis: lovenox, boots, famotidine\n ICU Care\n Nutrition:\n Comments: Clears, advance as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT: Boots, LMW Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor. d/w Ortho (attg. , res. )\n & (fel. ) re : where he will go.\n"
},
{
"category": "ECG",
"chartdate": "2142-04-27 00:00:00.000",
"description": "Report",
"row_id": 111183,
"text": "Baseline artifact. Probable sinus rhythm with early beats that are probably\nventricular. Low voltage throughout. Artifact precludes further\ncharacterization. Since the previous tracing the QRS voltage is probably lower.\nT wave amplitude is less. Clinical correlation is suggested.\n\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403773,
"text": "81F h/o COPD, chronic eosinophilic lung disease, SVT, diastolic CHF,\n HTN, PE\n09 admitted for hip replacement which was uneventful EBL\n 500cc, spinal anesthesia, noted to have SBP 80s in PACU, accelerated\n junctional rhythm rate 110, given lopressor with rate control however,\n bp dropped so bolused with neo. Transferred to ICU for close\n hemodynamic monitoring.\n s/p left hip replacement.\n Assessment:\n 2^nd day after left hip replacement.\n Pt AO x 3,afebrile,HR 80-110,NBP remains low systolic upto 80\n acceptable.\n Diminished urine output\n Pt denies any pain except with movements( pt prefer to be on her\n back) otherwise remains comfortable.\n Action:\n Haemodinamic monitoring ,\n MD 500 ml X 2 bolus.\n pillow between legs.surgical site dry and intact.\n Response:\n Pt was comfortable overnight\n Plan:\n Haemodinamic monitoring\n Possible c/o to 11R if haemodinamically remains stable.\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403868,
"text": "81 yo with h/o severe COPD (Sylvestri), SVT/Atrial Fibrillation,\n diastolic CHF, HTN, PE, admitted for elective L THA performed \n (EBL 500cc), transferred to for tachycardia and hypotension.\n In the PACU, patient was hypotensive to 80/50 and had tachycardia with\n rates into the 110s. EKG demonstrated an accelerated junctional rhythm\n with rate in 100s with depressions in the lateral leads\n Hypotension (not Shock)\n Assessment:\n Received pt with BP 98/52, BP dropped throughout morning to 60-70\n systolically, asymptomatic mentating well. T-max 100 for shift.\n Action:\n 500cc NS bolus provided x2 with brief increases in BP. Hct drawn at\n 1200 for 25.8, 1unit of PRBC provided over 2 hours.\n Response:\n SBP currently 120\ns. Afebrile for the rest of shift\n Plan:\n Monitor BP, monitor hct, monitor temp.\n Arthritis, osteo (osteoarthritis, OA)\n Assessment:\n Pt had THR of Left hip. Unable to lift legs up on bed.\n Action:\n Pt with pillow between legs to maintain proper abduction. Left hip dsg\n changed by ortho today, also changed at 1715 moderate amounts of\n serosanguinos drainage. PT in to work with patient in bed this\n afternoon. Pt remained in bed t/o shift low BP.\n Response:\n After PT worked with pt she is able to lift both legs off the bed. Dsg\n CDI\n Plan:\n Get pt OOB to chair tomorrow, cont to increase mobility, cont to have\n pt with pillow btwn legs especially for T and R\n -Family in to see patient t/o the afternoon. Updated on POC from this\n RN\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 403949,
"text": "81F h/o COPD, chronic eosinophilic lung disease, SVT, diastolic CHF,\n HTN, PE\n09 admitted for hip replacement which was uneventful EBL\n 500cc, spinal anesthesia, noted to have SBP 80s in PACU, accelerated\n junctional rhythm rate 110, given lopressor with rate control however,\n bp dropped so bolused with neo. Transferred to ICU for close\n hemodynamic monitoring, treatment of tachycardia and hypotension.\n Arthritis, osteo (osteoarthritis, OA)\n Assessment:\n Pt with Left THR. Dsg changed by ortho this am, draining moderate\n amounts of serous drainage. Staples intact, site with no s/s of\n infection. Pt Afebrile. No c/o pain.\n Action:\n Pt turned and repositioned with pillow between legs. Pain managed with\n Tylenol q6 hours and 5mg of oxycodone provided infrequently for\n breakthrough pain.\n Response:\n Pt tolerating turns well. Able to fully weight bare OOB to chair. Pain\n well managed with pain regiment.\n Plan:\n T and R with pillow between legs to maintain abduction. OOB to chair,\n PT\n Hypotension (not Shock)\n Assessment:\n Pt\ns BP remained\n mentating well, good urine output.\n Action:\n Monitor BP\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n PT heart rate remained\n Action:\n Cont to monitor HR and BP\n Response:\n Pt maintained HR\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403796,
"text": "81F h/o COPD, chronic eosinophilic lung disease, SVT, diastolic CHF,\n HTN, PE\n09 admitted for hip replacement which was uneventful EBL\n 500cc, spinal anesthesia, noted to have SBP 80s in PACU, accelerated\n junctional rhythm rate 110, given lopressor with rate control however,\n bp dropped so bolused with neo. Transferred to ICU for close\n hemodynamic monitoring.\n s/p left hip replacement.\n Assessment:\n 2^nd day after left hip replacement. Noted minimal oozing at\n surgical site dressing.\n Pt AO x 3,T max 100.8 at 0630 ,HR 80-110 NSR with frequent pvc\ns,NBP\n was low at the beginning of the shift systolic upto 80\ns,pt was\n mentating well,urine output was adequate.No fluid bolus overnight.B/L\n crackles on auscultation team notified.RL 80 ml/hr onflow.\n Pt denies any pain except with movements( pt prefer to be on her\n back) otherwise remains comfortable.\n Action:\n Haemodinamic monitoring\n Pillow between legs,surgical site dry and intact.\n No pain meds required last night\n Response:\n Pt was comfortable overnight\n Did not require any fluid bolus last night.\n Plan:\n Haemodinamic monitoring\n Please follow up on lab data.\n MD k the temp later and cultures if needed.\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403985,
"text": "Chief Complaint: CC: Hypotension\n Admission: tachycardia/hypotension s/p L THA\n 24 Hour Events:\n -hypotensive to 70/40s but completely asx and good UOP\n -hct dropped to 25.8, got 1 unit PRBCs\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:56 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.9\nC (98.4\n HR: 79 (60 - 95) bpm\n BP: 108/62(73) {60/32(41) - 127/77(80)} mmHg\n RR: 16 (10 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,266 mL\n PO:\n 2,000 mL\n TF:\n IVF:\n 987 mL\n Blood products:\n 279 mL\n Total out:\n 1,200 mL\n 360 mL\n Urine:\n 1,200 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,066 mL\n -360 mL\n Respiratory support\n SpO2: 99%\n ABG: ///28/\n Physical Examination\n General: alert, oriented, no acute distress\n HEENT: Sclera anicteric, DMM\n Neck: supple\n Lungs: expiratory wheezes, productive cough\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema.\n Left hip surgical site, with dressing in place.\n Labs / Radiology\n 143 K/uL\n 8.8 g/dL\n 102 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 103 mEq/L\n 136 mEq/L\n 25.9 %\n 6.7 K/uL\n [image002.jpg]\n 03:35 AM\n 12:41 PM\n 06:11 AM\n 11:51 AM\n 07:47 PM\n 05:17 AM\n WBC\n 9.0\n 9.4\n 10.1\n 6.7\n Hct\n 31.6\n 28.7\n 25.8\n 27.1\n 25.9\n Plt\n 194\n 170\n 145\n 143\n Cr\n 0.7\n 0.8\n TropT\n 0.02\n 0.02\n Glucose\n 126\n 102\n Other labs: PT / PTT / INR:17.3//1.6, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:2.0 mg/dL, PO4:4.0 mg/dL\n Radiology:\n 3/13 L hip\n Frontal radiograph of the pelvis and frontal and lateral radiographs of\n the\n left hip again demonstrate a left total hip arthroplasty. Alignment of\n the\n components is satisfactory. There is no periprosthetic fracture.\n Overlying\n skin staples are again noted. Bilateral femoral vascular calcifications\n are\n again seen.\n IMPRESSION:\n Left total hip arthroplasty with satisfactory alignment.\n Assessment and Plan\n 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an\n episode of tachycardia (junctional rhythm), and hypotension,\n asymptomatic\n # Hypotension: One episode of sbp 60s o/n, asymptomatic.\n - follow Hct to eval for bleed\n - will hold BB, lasix for low BP and minimize narcotics\n .\n # Tachycardia: No episodes o/n.\n - holding BB due to hypotension\n - telemetry\n .\n #. Anemia: Patient with Hct drop yesterday to 25, given 1U PRBC up to\n 27, now 25.9. She as a JP drain in place and was noted to have some\n oozing at surgical site. Patient is currently being anticoagulated\n (LMWH bridge to coumadin) which could complicate bleeding from or at\n surgical site.\n - transfuse 1 U PRBC, recheck hct\n .\n # COPD/eosinophilic lung disease\n lungs sound noisy, needs to clear\n secretions\n - incentive spirometry\n - continue albuterol prn, tiopropium, advair, prednisone\n - encourage activity\n .\n # CHF/CAD\n - hold metoprolol, lasix\n - cont atorvastatin\n .\n # s/p L THA\n - pain control, oxycodone prn, standing tylenol/NSAID per ortho,\n - dvt ppx lovenox, bridging to coumadin, stop lovenox once INR 2.0\n - WBAT\n - posterior precautions (pillow between knees when rolled)\n ICU Care\n Nutrition: advance as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT: Boots, lovenox, coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full Code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403674,
"text": "Chief Complaint: CC: Hip Pain\n Admission: tachycardia s/p L THA\n 24 Hour Events:\n Overnight events:\n - transfused 1 unit PRBCs\n - Bolused 500cc LR\n - HR trended down from 100 to 70s.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 73 (73 - 111) bpm\n BP: 94/52(67) {84/52(65) - 126/76(96)} mmHg\n RR: 15 (11 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 412 mL\n 1,021 mL\n PO:\n TF:\n IVF:\n 112 mL\n 1,021 mL\n Blood products:\n 300 mL\n Total out:\n 1,350 mL\n 175 mL\n Urine:\n 50 mL\n 165 mL\n NG:\n Stool:\n Drains:\n 100 mL\n 10 mL\n Balance:\n -938 mL\n 846 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 194 K/uL\n 10.6 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 135 mEq/L\n 31.6 %\n 9.0 K/uL\n [image002.jpg]\n 03:35 AM\n WBC\n 9.0\n Hct\n 31.6\n Plt\n 194\n Cr\n 0.7\n TropT\n 0.02\n Glucose\n 126\n Other labs: PT / PTT / INR:12.6//1.1, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition:\n Comments: Clears, advance as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT: Boots, LMW Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403676,
"text": "Chief Complaint: CC: Hip Pain\n Admission: tachycardia s/p L THA\n 24 Hour Events:\n Overnight events:\n - transfused 1 unit PRBCs\n - Bolused 500cc LR\n - HR trended down from 100 to 70s.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 73 (73 - 111) bpm\n BP: 94/52(67) {84/52(65) - 126/76(96)} mmHg\n RR: 15 (11 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 412 mL\n 1,021 mL\n PO:\n TF:\n IVF:\n 112 mL\n 1,021 mL\n Blood products:\n 300 mL\n Total out:\n 1,350 mL\n 175 mL\n Urine:\n 50 mL\n 165 mL\n NG:\n Stool:\n Drains:\n 100 mL\n 10 mL\n Balance:\n -938 mL\n 846 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 194 K/uL\n 10.6 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 135 mEq/L\n 31.6 %\n 9.0 K/uL\n [image002.jpg]\n 03:35 AM\n WBC\n 9.0\n Hct\n 31.6\n Plt\n 194\n Cr\n 0.7\n TropT\n 0.02\n Glucose\n 126\n Other labs: PT / PTT / INR:12.6//1.1, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an\n episode of tachycardia (junctional rhythm), asymptomatic, improved\n overnight with PRBC, fluid bolus.\n .\n # Tachycardia. Stayed in SR overnight. Rate hovered around 100,\n dropped to 70s with 500cc bolus of fluid.\n - continue metoprolol 12.5 mg PO bid\n - start warfarin 4mg PO daily at 1600 given h/o atrial fibrillation.\n - cycle cardiac enzymes\n .\n #. Anemia. HCt post-op 26, Given 1u PRBC now Hct 31.5\n - Trend HCt, consider transfusing if his HCt does not increase\n appropriately.\n .\n # COPD/eosinophilic lung disease\n - continue albuterol prn, tiopropium, advair, prednisone\n .\n # CHF/CAD\n - continue metoprolol, lasix\n - continue atorvastatin\n .\n # s/p L THA\n - pain control, morphine PCA, standing tylenol/NSAID per ortho\n - dvt ppx lovenox, bridging to coumadin\n - Vanco at 11AM tomorrow.\n - WBAT\n - posterior precautions (pillow between knees when rolled)\n .\n FEN: No IVF, replete electrolytes, clears, advance as tolerated\n .\n Prophylaxis: lovenox, boots, famotidine\n ICU Care\n Nutrition:\n Comments: Clears, advance as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT: Boots, LMW Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Rehab Services",
"chartdate": "2142-04-27 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 403713,
"text": "Attending Physician: , \n Referral date: \n Medical Diagnosis / ICD 9: THR / 715.96\n Reason of referral: eval and treat\n History of Present Illness / Subjective Complaint: 81 yo F w/ severe\n COPD adm for scheduled L THR. Pt transferred to ICU post op \n hypotension (80/50) and poorly controlled tachycardia to 110s.\n Past Medical / Surgical History: COPD, OA, A Fib, CHF, myocarditis with\n EF 20-25%, hyperlipidemia, PAD, HTN, chronic esinophilic lung disease,\n hypoalbuminima, CDiff, MSSA PNA\n Medications:\n Radiology: L hip X ray- pening\n Labs:\n 31.6\n 10.6\n 194\n 9.0\n [image002.jpg]\n Other labs:\n Activity Orders: WBAT LLE, Activity as Tolerated\n Social / Occupational History: -driving, -employment, +40 year tob\n history- not currently smoking, lives w/ husband and daughter who are\n available to assist\n Living Environment: Lives in single level house w/ 2 or 3 stairs to\n enter.\n Prior Functional Status / Activity Level: PTA pt was ambulating w/ RW\n and reports \"I was unable to stand by myself.\" Pt. reports sleeping in\n a recliner chair for respiratory comfort.\n Objective Test\n Arousal / Attention / Cognition / Communication: A+Ox3, pleasant and\n cooperative. Follows all single and multi-step commands.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 78\n 101/54\n 97% 2.5L\n Rest\n 78\n 101/54\n 97% 2.5L\n Sit\n 80s-110s\n /\n Activity\n 80s-110s\n /\n 94% 2.5L\n Stand\n /\n Recovery\n 102-120\n 75/45\n 94% 2.5L\n Total distance walked: NA\n Minutes:\n Pulmonary Status: NARD, even unlabored breathing. +wet, weak non\n productive cough. Pt reports this is baseline.\n Integumentary / Vascular: A line, +PIV x2, +foley, +hemovac L lateral\n thigh, tele, NC, lateral left THR dressing CDI, R knee wrapped with\n dressing for unknown need. RN to f/u.\n Sensory Integrity: Inact to LT sensation throughout BLE\n Pain / Limiting Symptoms: Denies pain at rest and with mobility.\n Reports \"I feel the same as I did last week.\"\n Posture: Forward head, rounded shoulders\n Range of Motion\n Muscle Performance\n BUE actively WNL\n ROM RLE actively WNL\n PROM LLE tolerated hip flexion to 45 degrees in supine and 75 degrees\n sitting EOB, knee flexion to 90, ankle WNL, hip abduction 50% of R,\n rotation 50% of R\n BUE >/= , RLE hip flexion cannot perform SLR, knee flexion , knee\n extension >, DF , PF >2+/5, LLE hip flexion 2-/5, knee flexion\n NT, knee extension NT, DF , PF >\n Motor Function: MAE in isolation given limitations of LLE THR\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt was able to advance BLE to EOB from supine w/ HOB\n elevated. Sit to stand w/ Mod A to full upright posture and hip to 0\n degrees. Pt advanced B LE with small lateral steps to recliner chair.\n . step length, wide BOS, increased trunk sway and Min A to maintain\n upright.\n **Pt did go into AFib following transfer to chair. RN aware.\n Rolling:\n\n\n T\n\n\n\n Supine /\n Sidelying to Sit:\n\n T\n\n\n\n Transfer:\n\n\n\n T\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Maintained static sitting at EOB w/ feet and back unsupported\n and BUE support. -LOB x 2 minutes. Static and dynamic standing posture\n poor.\n Education / Communication: PT: Role of PT, , D/ options\n RN: pt status\n Intervention:\n Other:\n Diagnosis:\n Impaired Mobility\n Impaired Endurance\n Impaired Gas Exchange\n Impaired Balance\n Knowledge Deficit: Role of PT, , WB status\n Impaired ROM\n Impaired Strength\n Impaired Hemodynamic Response to Activity.\n Clinical impression / Prognosis: 81 yo F w/ complex PMH adm to ICU \n hypotension and tachycardia following elective L THR . Pt p/w\n above impairments c/w joint arthroplasty. Pt. is motivated to\n participate with PT. Pt. mobilized to EOB well and stood with little\n to no pain. Pt did demonstrate AFib and variable BP with mobility.\n Anticipate once medically stable that she will be a strong rehab\n candidate.\n Goals\n Time frame: 1 week\n 1.\n Independent w/ bed mobility\n 2.\n Independent w/ sit to stand w/ RW\n 3.\n Supervision ambulating 50' w/ RW\n 4.\n Negotiate up and down 3 stairs with rail and Supervision\n 5.\n Be independent with HEP\n 6.\n Tolerate hip flexion to 90, abduction symmetrical to R.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: daily\n Pt will f/u for ther-ex, mobility, ambulation, balance and education\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403669,
"text": "81F h/o COPD, chronic eosinophilic lung disease, SVT, diastolic CHF,\n HTN, PE\n09 admitted for hip replacement which was uneventful EBL\n 500cc, spinal anesthesia, noted to have SBP 80s in PACU, accelerated\n junctional rhythm rate 110, given lopressor with rate control however,\n bp dropped so bolused with neo. Transferred to ICU for close\n hemodynamic monitoring.\n s/p left hip replacement.\n Assessment:\n Admitted from PACU after left hip replacement.JP drain in place\n draining bloody drainage total of 210 after admission,coumadin 4mg\n given last night as ordered.\n Pt AO x 3,afebrile,HR 80-110,ABP dropped to 70\ns systolic NBP\n correlates with ABP.\n Diminished urine output\n Pt has morphine PCA c/o pain after movement ( pt prefer to be on her\n back) otherwise remains comfortable.\n Action:\n Haemodinamic monitoring ,Rl 80 ml/hr onflow.\n Morphine PCA for pain management.\n MD 500 ml X 2 bolus.\n Abduction pillow between legs.surgical site dry and intact.\n Zofran 4 mg /IV for c/o nausea.\n Response:\n Pt was comfortable on morphine PCA\n Plan:\n Seen by ortho this AM,plan to d/c drain later\n Haemodinamic monitoring\n Vancomycin @ 1100\n Possible c/o to 11R if haemodinamically remains stable.\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403777,
"text": "81F h/o COPD, chronic eosinophilic lung disease, SVT, diastolic CHF,\n HTN, PE\n09 admitted for hip replacement which was uneventful EBL\n 500cc, spinal anesthesia, noted to have SBP 80s in PACU, accelerated\n junctional rhythm rate 110, given lopressor with rate control however,\n bp dropped so bolused with neo. Transferred to ICU for close\n hemodynamic monitoring.\n s/p left hip replacement.\n Assessment:\n 2^nd day after left hip replacement.\n Pt AO x 3,afebrile,HR 80-110,NBP was low at the beginning of the\n shift systolic upto 80\ns,pt was mentating well,urine output was\n adequate.No fluid bolus overnight.\n Pt denies any pain except with movements( pt prefer to be on her\n back) otherwise remains comfortable.\n Action:\n Haemodinamic monitoring\n Pillow between legs,surgical site dry and intact.\n Response:\n Pt was comfortable overnight\n Did not require any fluid bolus last night.\n Plan:\n Haemodinamic monitoring\n Possible c/o to 11R if haemodinamically remains stable.\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403876,
"text": "81 yo with h/o severe COPD (Sylvestri), SVT/Atrial Fibrillation,\n diastolic CHF, HTN, PE, admitted for elective L THA performed \n (EBL 500cc), transferred to for tachycardia and hypotension.\n In the PACU, patient was hypotensive to 80/50 and had tachycardia with\n rates into the 110s. EKG demonstrated an accelerated junctional rhythm\n with rate in 100s with depressions in the lateral leads\n Hypotension (not Shock)\n Assessment:\n Received pt with BP 98/52, BP dropped throughout morning to 60-70\n systolically, asymptomatic mentating well. Urine output adequate T-max\n 100 for shift.\n Action:\n 500cc NS bolus provided x2 with brief increases in BP. Hct drawn at\n 1200 for 25.8, 1unit of PRBC provided over 2 hours.\n Response:\n SBP currently 120\ns. Afebrile for the rest of shift\n Plan:\n Monitor BP, monitor hct at 20:00, monitor temp. ensure good urine\n output.\n Arthritis, osteo (osteoarthritis, OA)\n Assessment:\n Pt had THR of Left hip. Unable to lift legs up on bed.\n Action:\n Pt with pillow between legs to maintain proper abduction. Left hip dsg\n changed by ortho today, also changed at 1715 moderate amounts of\n serosanguinos drainage. PT in to work with patient in bed this\n afternoon. Pt remained in bed t/o shift low BP.\n Response:\n After PT worked with pt she is able to lift both legs off the bed. Dsg\n CDI\n Plan:\n Get pt OOB to chair tomorrow, cont to increase mobility, cont to have\n pt with pillow btwn legs especially for T and R\n -Family in to see patient t/o the afternoon. Updated on POC from this\n RN\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 403966,
"text": "Chief Complaint: Hypotension\n Tachycardia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n -Transfusion of 1 unit PRBC\n History obtained from Medical records\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:56 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Heme / Lymph: Anemia\n Flowsheet Data as of 12:19 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.7\nC (96.3\n HR: 74 (60 - 79) bpm\n BP: 112/57(60) {70/39(52) - 121/77(80)} mmHg\n RR: 18 (10 - 19) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,266 mL\n 540 mL\n PO:\n 2,000 mL\n 540 mL\n TF:\n IVF:\n 987 mL\n Blood products:\n 279 mL\n Total out:\n 1,200 mL\n 600 mL\n Urine:\n 1,200 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,066 mL\n -60 mL\n Respiratory support\n SpO2: 97%\n ABG: ///28/\n Physical Examination\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.8 g/dL\n 143 K/uL\n 102 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 103 mEq/L\n 136 mEq/L\n 25.9 %\n 6.7 K/uL\n [image002.jpg]\n 03:35 AM\n 12:41 PM\n 06:11 AM\n 11:51 AM\n 07:47 PM\n 05:17 AM\n WBC\n 9.0\n 9.4\n 10.1\n 6.7\n Hct\n 31.6\n 28.7\n 25.8\n 27.1\n 25.9\n Plt\n 194\n 170\n 145\n 143\n Cr\n 0.7\n 0.8\n TropT\n 0.02\n 0.02\n Glucose\n 126\n 102\n Other labs: PT / PTT / INR:17.3//1.6, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:2.0 mg/dL, PO4:4.0 mg/dL\n Fluid analysis / Other labs: AG-5\n Imaging: Hip--Prosthetics in position\n Assessment and Plan\n 81 yo female s/p THR now admitted with post operative hypotension and\n tachycardia treated with IVF support, transfusion and minimization of\n potentially offending medictions without clear evidence of new\n significant septic insult to account for clinical picture.\n 1) HYPOTENSION (NOT SHOCK)\n -Lopressor/Lasix held\n _BP improved today\n -Will continue with transfusion\n -Follow exam\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n -Continue with incentive spirometry\n -Will need to continue with MDI\n -Will need to mobilize as soonas possible with hip replacment\n completed.\n ATRIAL FIBRILLATION (AFIB)-\n -Will return lopressor with stability of BP seen ir elevation in HR\n returns.\n S/P THR-\n -Anticoagulation in place\n -Mobilization as possible\n ICU Care\n Nutrition: PO diet\n Glycemic Control:\n Lines:\n 18 Gauge - 12:55 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: LMWH Heparin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403768,
"text": " Problem - Description In Comments\n Assessment:\n Pt. continues to require fluid boluses for low u/.o\ns and low bp\n Action:\n Resp: non-productive cough. Sats 98%. Presently on 2L np.\n Dim. Bs\n Cv: a-line d/c\ned. Bp prior to d/cing was 100\n Bp by cuff in 80\ns. mean\ns in 50\ns. given 2x 500cc fluid boluses.\n Presently receiving a 1L fluid LR bolus.\n Left arm\ns bp in higher then right.\n Pt. in nsr with infrequent bursts of a-fib. Pt. also noted to have\n frequent pvc\ns. k+ 4.5 this am.\n Given 20meq kcl po this pm. Repeat cardiac \ns sent.\n Renal: u/o\ns continue to be on the low side. Fluid boluses also being\n given for u/o\ns. ivfs continue at 80cc/hr.\n Neuro: alert and orientated. Slept in naps.\n Gi: + bs\ns. no stools. Taking clear liquids and full liquids well. No\n c/o nausea.\n Ortho: jp drained 150cc/shift. Drsg d/i. infrequent use of pca pump.\n Now d/c\ned. Able to take po\n Oob to chair with PT this am and later returned to bed with RN\ns. able\n to stand and pivot. Min. pain.\n Dr. into see pt. hemovac removed.\n Coags: given 1mg of Coumadin this pm.\n Skin integrity: drsg removed. Pt. has a large skin tear\n on the outer side of her right knee. Adaptic placed and kling. Pt. also\n has a skin tear on her left upper arm.\n USE PAPER TAPE ONLY.\n Response:\n Bp responding well toboluses.for short time. u/o\ns slowly increasing.\n Less frequent pvc\ns noted post k+ replacement.\n Plan:\n Cont. to assess bp and u/.o\ns. may need additional repletion. Plan is\n for lasix tomorrow ( would check with ho prior to giving). Check mental\n status. Oob to chair tomorrow. Keep pillow between her legs while in\n bed. Encourage po\n Pt. underwent a THR on in the pm. Arrived here from the OR as pt.\n in a junctional rythym\\\n And hypotensive.\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403658,
"text": "81F h/o COPD, chronic eosinophilic lung disease, SVT, diastolic CHF,\n HTN, PE\n09 admitted for hip replacement which was uneventful EBL\n 500cc, spinal anesthesia, noted to have SBP 80s in PACU, accelerated\n junctional rhythm rate 110, given lopressor with rate control however,\n bp dropped so bolused with neo. Transferred to ICU for close\n hemodynamic monitoring.\n s/p left hip replacement.\n Assessment:\n Admitted from PACU after left hip replacement.JP drain place draining\n bloody drainage.\n Pt AO x 3,afebrile,HR 80-110,ABP dropped to 70\ns systolic NBp\n correlates with ABP.\n Pt has morphine PCA c/o pain after movement ( pt prefer to be on her\n back)\n Action:\n Haemodinamic monitoring ,Rl 80 ml/hr onflow.\n Morphine PCA for pain management.\n Md 500 ml bolus.\n adduction pillow between legs.\n Response:\n Pt was comfortable on morphine PCA\n Plan:\n Haemodinamic monitoring\n Vancomycin @ 1100\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403648,
"text": "81F h/o COPD, chronic eosinophilic lung disease, SVT, diastolic CHF,\n HTN, PE\n09 admitted for hip replacement which was uneventful EBL\n 500cc, spinal anesthesia, noted to have SBP 80s in PACU, accelerated\n junctional rhythm rate 110, given lopressor with rate control however,\n bp dropped so bolused with neo. Transferred to ICU for close\n hemodynamic monitoring.\n s/p left hip replacement.\n Assessment:\n Admitted from PACU after left hip replacement.JP drain place draining\n bloody drainage.\n Pt AO x 3,afebrile,HR 80-110,ABP stable.\n Pt has morphine PCA c/o pain after movement\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403651,
"text": "81F h/o COPD, chronic eosinophilic lung disease, SVT, diastolic CHF,\n HTN, PE\n09 admitted for hip replacement which was uneventful EBL\n 500cc, spinal anesthesia, noted to have SBP 80s in PACU, accelerated\n junctional rhythm rate 110, given lopressor with rate control however,\n bp dropped so bolused with neo. Transferred to ICU for close\n hemodynamic monitoring.\n s/p left hip replacement.\n Assessment:\n Admitted from PACU after left hip replacement.JP drain place draining\n bloody drainage.\n Pt AO x 3,afebrile,HR 80-110,ABP stable.\n Pt has morphine PCA c/o pain after movement ( pt prefer to be on her\n back)\n Action:\n Haemodinamic monitoring ,Rl 80 ml/hr onflow.\n Morphine PCA for pain management.\n adduction pillow\n Response:\n Pt was comfortable on morphine PCA\n Plan:\n Haemodinamic monitoring\n Vancomycin @ 1100\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-27 00:00:00.000",
"description": "ICU attending note",
"row_id": 403645,
"text": "TITLE:\n Chart reviewed, patient examined, case discussed in detail with house\n staff. I was present for delivery of all key aspects of care. I agree\n with the house staff admission note. In addition, I would\n add/emphasize:\n 81F h/o COPD, chronic eosinophilic lung disease followed by Dr.\n , SVT, diastolic CHF, HTN, PE\n09 admitted for hip replacement\n which was uneventful EBL 500cc, spinal anesthesia, noted to have\n SBP 80s in PACU, accelerated junctional rhythm rate 110, given\n lopressor with rate control however, bp dropped so bolused with neo.\n Transferred to ICU for close hemodynamic monitoring.\n Exam:\n Afebrile, P106, BP 105/71, 96% 2LNC\n Lungs (ant) bs, clear, prolonged expiratory phase\n CV tachy, RR\n Abd soft NT mildly distended, no BS\n Hct 26.5\n AP/\n 81F h/o tachyarrthymias s/p total hip with spinal anesthesia with\n episode of hypotension and accelerated junctional rhythm post-op\n requiring lopressor and neo.\n Tachyarrthmia\n -known history\n -post-op setting anemia and hypovolemic state likely trigger\n Relative hypotension\n -SBP 130s on antihypertensives so relative hypotension\n -IVF resusciation\n Anemia related to blood to blood loss\n -pre-op hct 38, 26.5 post-op\n -transfusing pRBC\n COPD\n -cont current MDIs\n -cont slow pred taper as outlined by Dr. \n CAD/CHF\n -cont lopressor, lasix, atorvastatin\n -no evidence of acute cardiac disease\n -ST depressions rate related\n normalized once rate controlled\n Hip replacement\n -ortho following\n -cont per post-op protocol\n -DVT prophylaxis\n Patient is critically ill. Time spent on care 35 minutes.\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-27 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 403646,
"text": "Chief Complaint: Tachycardia\n HPI:\n 81 yo with h/o severe COPD (Sylvestri), SVT/Atrial Fibrillation,\n diastolic CHF, HTN, PE, admitted for elective L THA performed \n (EBL 500cc), transferred to for tachycardia and hypotension.\n In the PACU, patient was hypotensive to 80/50 and had tachycardia with\n rates into the 110s. EKG demonstrated an accelerated junctional rhythm\n with rate in 100s with depressions in the lateral leads. She was\n asymptomatic. She was given lopressor 5mg IV x 2 and phenylephrine 100\n mcg x 8. Her heart rate came down to ~70 and bp increased to 110s/60s,\n and was sinus rhythm on EKG. She was started on a morphine PCA, and\n given 1u PRBC. She was transferred to the ICU for further\n management of hemodynamics.\n .\n On the floor, patient was asymptomatic except for post-op L hip pain.\n Patient admitted from: OR / PACU\n History obtained from Patient\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution neb q6hrs prn\n ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth qwk\n ATORVASTATIN [LIPITOR] - 40 mg 1 Tablet(s) by mouth once a day\n BENZONATATE - 100 mg Capsule - 2 Capsule(s) by mouth tid prn cough\n FLUTICASONE - 50 mcg Spray, Suspension - 2 squirts(s) in each nostril\n once daily\n FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose Disk\n with Device - one inhalation once or twice daily\n FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth every other day\n GABAPENTIN - 100 mg Capsule - 1 Capsule(s) by mouth HS (at bedtime)\n METOPROLOL- 25 mg Tab Sustained Release 24 hr - 0.5 (One half) Tab po\n once a day\n OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - prn\n PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - daily\n POTASSIUM CHLORIDE [KLOR-CON 10] - 10 mEq Tablet Sustained \n PREDNISONE - 5 mg Tablet - 1 (One) Tablet(s) by mouth every other day\n TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, 1 puff\n once daily\n WARFARIN - 2 mg Tablet - Take up to 2 Tablet(s) by mouth daily or as\n directed\n ASPIRIN - (OTC) - 81 mg Tablet, EC qd\n CALCIUM CARBONATE-VITAMIN D3 [CALCARB 600 WITH VITAMIN D]\n LORATADINE - 10 mg Tablet - 1 (One) Tablet(s) by mouth at bedtime\n MULTIVITAMINS-IRON (HEMATINIC) [CENTAVITE A-Z COMPLETE-MINERAL]- 27\n mg-0.4 NEBULIZER - Kit - use albuterol solution in nebulizer up to\n every 4 hours prn\n SACCHAROMYCES BOULARDII [FLORASTOR] - dosage uncertain\n Past medical history:\n Family history:\n Social History:\n - AF/AT\n - COPD\n - diastolic CHF, EF 55%\n - Osteoarthritis\n - H/o myocarditis in with EF 20-25% at that time, cath negative\n - Hyperlipidemia\n - Peripheral artery disease\n - HTN\n - Migraine HA\n - Chronic eosinophilic lung disease (chronic eosinophilic pneumonia or\n Churg- syndrome)\n - Hypoalbuminemia\n - History of angioneurotic edema on therapy\n - h/o C. diff colitis\n - h/o PNA\n Pt's mother's side notable for \"extensive\" heart disease (several of\n her family members died from this); pt's father died of \"cancer of the\n spleen.\" No history of diabetes or stroke.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt has a previous 40 pack-year history of smoking (stopped 25\n yrs ago). She does not drink alcohol and denies other drug use.\n She lives with her husband and has three grown children.\n Review of systems:\n Flowsheet Data as of 02:03 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 35.1\nC (95.2\n Tcurrent: 35.1\nC (95.2\n HR: 106 (73 - 107) bpm\n BP: 102/67(80) {102/61(80) - 126/76(96)} mmHg\n RR: 13 (11 - 22) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 412 mL\n 157 mL\n PO:\n TF:\n IVF:\n 112 mL\n 157 mL\n Blood products:\n 300 mL\n Total out:\n 1,350 mL\n 0 mL\n Urine:\n 50 mL\n NG:\n Stool:\n Drains:\n 100 mL\n Balance:\n -938 mL\n 157 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to):\n person, place and time, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n ABG: pH 7.38 pCO2 42 pO2 106 HCO3 26 BaseXS 0\n freeCa:1.10\n Lactate:1.5\n .\n 139 | 108 | 13 / AGap=10\n ---------------- 87\n 3.5 | 25 | 0.7 \\\n .\n MB: 5 Trop-T: <0.01\n Ca: 7.9 Mg: 1.7 P: 3.4\n .\n WBC 6.1\n HBG 8.7 ∆\n HCT 26.5 ∆\n PLT 193\n MCV 90\n .\n PT: 12.2 PTT: 22.6 INR: 1.0\n .\n Micro: None\n .\n Images: None\n .\n EKG:\n 8:00 - NSR\n 9:00 - junctional rhythm, tachycardia 110, nl intervals diffuse\n ST elevations.\n 10:00 - NSR\n Assessment and Plan\n 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an\n episode of tachycardia (junctional rhythm), asymptomatic, now resolved.\n .\n # Tachycardia. As this tachycardia resolved spontaneously, it is\n unlikely to represent infection, or PE. Per patient she occasionally\n has episodes of tachycardia that are asymptomatic. She has a\n documented history of atrial tachycardia and atrial fibrillation,\n though during this episode, P waves were not discernable on ECG. This\n is likely representative of a baseline conduction problem, in this case\n possibly initiated by post-op pain or anemia. She had diffuse ST\n elevations on her ECG, likely representing demand ischemia, but we will\n still rule out myocardial infarction. She remained asymptomatic during\n this episode of tachycardia and her blood pressure remained stable and\n resolved with adminstration of lopressor.\n - continue metoprolol 12.5 mg PO bid\n - start warfarin 4mg PO daily at 1600\n - cycle cardiac enzymes\n .\n #. Anemia. HCt post-op 26, last Hct 38. Given 1u PRBC en route to\n \n - Trend HCt, consider transfusing if his HCt does not increase\n appropriately.\n .\n # COPD/eosinophilic lung disease\n - continue albuterol prn, tiopropium, advair, prednisone\n .\n # CHF/CAD\n - continue metoprolol, lasix\n - continue atorvastatin\n .\n # s/p L THA\n - pain control, morphine PCA, standing tylenol/NSAID per ortho\n - dvt ppx lovenox, bridging to coumadin\n - Vanco at 11AM tomorrow.\n - WBAT\n - posterior precautions (pillow between knees when rolled)\n .\n FEN: No IVF, replete electrolytes, clears, advance as tolerated\n .\n Prophylaxis: lovenox, boots, famotidine\n .\n ICU Care\n Nutrition:\n Comments: Clears, advance as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT: Boots, LMW Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403647,
"text": " Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403755,
"text": "Chief Complaint: CC: Hip Pain\n Admission: tachycardia s/p L THA\n 24 Hour Events:\n Overnight events:\n - transfused 1 unit PRBCs\n - Bolused 500cc LR\n - HR trended down from 100 to 70s.\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 73 (73 - 111) bpm\n BP: 94/52(67) {84/52(65) - 126/76(96)} mmHg\n RR: 15 (11 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 412 mL\n 1,021 mL\n PO:\n TF:\n IVF:\n 112 mL\n 1,021 mL\n Blood products:\n 300 mL\n Total out:\n 1,350 mL\n 175 mL\n Urine:\n 50 mL\n 165 mL\n NG:\n Stool:\n Drains:\n 100 mL\n 10 mL\n Balance:\n -938 mL\n 846 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 194 K/uL\n 10.6 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 135 mEq/L\n 31.6 %\n 9.0 K/uL\n [image002.jpg]\n 03:35 AM\n WBC\n 9.0\n Hct\n 31.6\n Plt\n 194\n Cr\n 0.7\n TropT\n 0.02\n Glucose\n 126\n Other labs: PT / PTT / INR:12.6//1.1, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an\n episode of tachycardia (junctional rhythm), asymptomatic, improved\n overnight with PRBC, fluid bolus.\n .\n # Tachycardia. Stayed in SR overnight. Rate hovered around 100,\n dropped to 70s with 500cc bolus of fluid. BP stable.\n - continue metoprolol 12.5 mg PO bid\n - start warfarin 4mg PO daily at 1600 given h/o atrial fibrillation,\n follow INR\n - cycle cardiac enzymes, last set today at 11:00.\n .\n #. Anemia. HCt post-op 26, Given 1u PRBC now Hct 31.5\n - Trend HCt, consider transfusing if his HCt does not increase\n appropriately.\n .\n # COPD/eosinophilic lung disease\n - continue albuterol prn, tiopropium, advair, prednisone\n .\n # CHF/CAD\n - continue metoprolol, lasix\n - continue atorvastatin\n .\n # s/p L THA\n - pain control, morphine PCA, standing tylenol/NSAID per ortho, change\n to oral narcotics when tolerating PO.\n - dvt ppx lovenox, bridging to coumadin\n - Vanco at 11AM tomorrow.\n - WBAT\n - posterior precautions (pillow between knees when rolled)\n .\n FEN: No IVF, replete electrolytes, clears, advance as tolerated\n .\n Prophylaxis: lovenox, boots, famotidine\n ICU Care\n Nutrition:\n Comments: Clears, advance as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT: Boots, LMW Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor. d/w Ortho (attg. , res. )\n & (fel. ) re : where he will go.\n ------ Protected Section ------\n CRITICAL CARE\n Borderline BP through day with declining UO. C/O thirst but no SOB.\n Exam remains notable for holosyst m but no crackles.\n Although hct is stable she appears hypovolemic. We are giving IVF with\n close observation of resp status. BP is low at baseline but this is\n lower than she usually goes. Will watch closely for next 12 hrs\n Time spent 40 min\n Critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 18:05 ------\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403756,
"text": " Problem - Description In Comments\n Assessment:\n Pt. continues to require fluid boluses for low u/.o\ns and low bp\n Action:\n Resp: non-productive cough. Sats 98%. Presently on 2L np.\n Dim. Bs\n Cv: a-line d/c\ned. Bp prior to d/cing was 100\n Bp by cuff in 80\ns. mean\ns in 50\ns. given 2x 500cc fluid boluses.\n Presently receiving a 1L fluid LR bolus.\n Left arm\ns bp in higher then right.\n Pt. in nsr with infrequent bursts of a-fib. Pt. also noted to have\n frequent pvc\ns. k+ 4.5 this am.\n Given 20meq kcl po this pm.\n Renal: u/o\ns continue to be on the low side. Fluid boluses also being\n given for u/o\n Neuro: alert and orientated. Slept in naps.\n Gi: + bs\ns. no stools. Taking clear liquids and full liquids well. No\n c/o nausea.\n Ortho: jp drained 150cc/shift. Drsg d/i. infrequent use of pca pump.\n Now d/c\ned. Able to take po\n Oob to chair with PT this am and later returned to bed with RN\ns. able\n to stand and pivot. Min. pain.\n Coags: given 1mg of Coumadin this pm.\n Response:\n Bp responding well toboluses. u/o\ns slowly increasing. Less frequent\n pvc\ns noted post k+ replacement.\n Plan:\n Cont. to assess bp and u/.o\ns. may need additional repletion. Plan is\n for lasix tomorrow ( would check with ho prior to giving).\n Pt. underwent a THR on in the pm. Arrived here from the OR as pt.\n in a junctional rythym\\\n And hypotensive.\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403855,
"text": "81 yo with h/o severe COPD (Sylvestri), SVT/Atrial Fibrillation,\n diastolic CHF, HTN, PE, admitted for elective L THA performed \n (EBL 500cc), transferred to for tachycardia and hypotension.\n In the PACU, patient was hypotensive to 80/50 and had tachycardia with\n rates into the 110s. EKG demonstrated an accelerated junctional rhythm\n with rate in 100s with depressions in the lateral leads\n Hypotension (not Shock)\n Assessment:\n Received pt with BP 98/52, BP dropped throughout morning to 60-70\n systolically, asymptomatic mentating well. T-max 100 for shift. Hct\n drawn at 1200 for 25.8\n Action:\n 500cc NS bolus provided x2 with brief increases in BP. 1unit of PRBC\n provided over 2 hours.\n Response:\n Plan:\n Arthritis, osteo (osteoarthritis, OA)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403916,
"text": "Chief Complaint: CC: Hypotension\n Admission: tachycardia/hypotension s/p L THA\n 24 Hour Events:\n -hypotensive to 70/40s but completely asx and good UOP\n -hct dropped to 25.8, got 1 unit PRBCs\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:56 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.9\nC (98.4\n HR: 79 (60 - 95) bpm\n BP: 108/62(73) {60/32(41) - 127/77(80)} mmHg\n RR: 16 (10 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,266 mL\n PO:\n 2,000 mL\n TF:\n IVF:\n 987 mL\n Blood products:\n 279 mL\n Total out:\n 1,200 mL\n 360 mL\n Urine:\n 1,200 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,066 mL\n -360 mL\n Respiratory support\n SpO2: 99%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 143 K/uL\n 8.8 g/dL\n 102 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 103 mEq/L\n 136 mEq/L\n 25.9 %\n 6.7 K/uL\n [image002.jpg]\n 03:35 AM\n 12:41 PM\n 06:11 AM\n 11:51 AM\n 07:47 PM\n 05:17 AM\n WBC\n 9.0\n 9.4\n 10.1\n 6.7\n Hct\n 31.6\n 28.7\n 25.8\n 27.1\n 25.9\n Plt\n 194\n 170\n 145\n 143\n Cr\n 0.7\n 0.8\n TropT\n 0.02\n 0.02\n Glucose\n 126\n 102\n Other labs: PT / PTT / INR:17.3//1.6, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:2.0 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA)\n TACHYCARDIA, OTHER\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITHOUT ACUTE EXACERBATION\n ATRIAL FIBRILLATION (AFIB)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403917,
"text": "Chief Complaint: CC: Hypotension\n Admission: tachycardia/hypotension s/p L THA\n 24 Hour Events:\n -hypotensive to 70/40s but completely asx and good UOP\n -hct dropped to 25.8, got 1 unit PRBCs\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:56 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.9\nC (98.4\n HR: 79 (60 - 95) bpm\n BP: 108/62(73) {60/32(41) - 127/77(80)} mmHg\n RR: 16 (10 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,266 mL\n PO:\n 2,000 mL\n TF:\n IVF:\n 987 mL\n Blood products:\n 279 mL\n Total out:\n 1,200 mL\n 360 mL\n Urine:\n 1,200 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,066 mL\n -360 mL\n Respiratory support\n SpO2: 99%\n ABG: ///28/\n Physical Examination\n General: alert, oriented, no acute distress\n HEENT: Sclera anicteric, DMM\n Neck: supple\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema.\n Left hip surgical site, with dressing in place.\n Labs / Radiology\n 143 K/uL\n 8.8 g/dL\n 102 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 12 mg/dL\n 103 mEq/L\n 136 mEq/L\n 25.9 %\n 6.7 K/uL\n [image002.jpg]\n 03:35 AM\n 12:41 PM\n 06:11 AM\n 11:51 AM\n 07:47 PM\n 05:17 AM\n WBC\n 9.0\n 9.4\n 10.1\n 6.7\n Hct\n 31.6\n 28.7\n 25.8\n 27.1\n 25.9\n Plt\n 194\n 170\n 145\n 143\n Cr\n 0.7\n 0.8\n TropT\n 0.02\n 0.02\n Glucose\n 126\n 102\n Other labs: PT / PTT / INR:17.3//1.6, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:2.0 mg/dL, PO4:4.0 mg/dL\n Radiology:\n 3/13 L hip\n Frontal radiograph of the pelvis and frontal and lateral radiographs of\n the\n left hip again demonstrate a left total hip arthroplasty. Alignment of\n the\n components is satisfactory. There is no periprosthetic fracture.\n Overlying\n skin staples are again noted. Bilateral femoral vascular calcifications\n are\n again seen.\n IMPRESSION:\n Left total hip arthroplasty with satisfactory alignment.\n Assessment and Plan\n 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an\n episode of tachycardia (junctional rhythm), asymptomatic, improved\n overnight with PRBC, fluid bolus.\n # Hypotension: Patient BP has been ranging from 70/40s-110s/60s. She is\n completely asymptomatic with low BP\ns and is maintaining good UOP.\n Possibilities include bleeding in to L hip post-op, medication related\n (lasix, BB and narcotics) or falsely low BP due to atherosclerosis.\n - pm Hct to eval for bleed\n - will hold BB, lasix and minimize narcotics\n - consider holding coumadin\n .\n # Tachycardia: No episodes o/n.\n - holding BB due to hypotension\n - telemetry\n .\n #. Anemia: Patient with Hct drop yesterday to 15, given 1U PRBC up to\n 27, now 25.9.. She as a JP drain in place and was noted to have some\n oozing at surgical site. Patient is currently being anticoagulated\n (LMWH bridge to coumadin) which could complicate bleeding from or at\n surgical site.\n - repeat pm Hct as patient started on coumadin\n .\n # COPD/eosinophilic lung disease\n - continue albuterol prn, tiopropium, advair, prednisone\n .\n # CHF/CAD\n - hold metoprolol, lasix\n - cont atorvastatin\n .\n # s/p L THA\n - pain control, oxycodone prn, standing tylenol/NSAID per ortho,\n - dvt ppx lovenox, bridging to coumadin\n - WBAT\n - posterior precautions (pillow between knees when rolled)\n ICU Care\n Nutrition: advance as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT: Boots, lovenox, coumadin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full Code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403922,
"text": "81F h/o COPD, chronic eosinophilic lung disease, SVT, diastolic CHF,\n HTN, PE\n09 admitted for hip replacement which was uneventful EBL\n 500cc, spinal anesthesia, noted to have SBP 80s in PACU, accelerated\n junctional rhythm rate 110, given lopressor with rate control however,\n bp dropped so bolused with neo. Transferred to ICU for close\n hemodynamic monitoring, treatment of tachycardia and hypotension.\n Tachycardia, Other\n Assessment:\n NSR this noc via continuous cardiac monitoring;\n Action:\n Maintained adequate b/p to prevent tachycardia;\n Response:\n NSR all noc;\n Plan:\n Continue to follow cardiac monitoring,\n Check results a.m. labs re electrolytes.\n Arthritis, osteo (osteoarthritis, OA)\n Assessment:\n Pt s/p L THR; left hip incision intact, hip angle protected w/ pillows;\n Action:\n Receiving tylenol 650 mg po q 6 hrs rtc;\n Pt also asked for additional pain med at hs, received oxycodone 5 mg po\n at that time.\n Response:\n Pt comfortable this noc, rested well; able to reposition pt w/ pt\n remaining comfortable.\n Plan:\n Continue to follow exam;\n Pst THR protocol cares.\n Hypotension (not Shock)\n Assessment:\n Pts b/p drifts down when sleeping\n Action:\n Pt lightly awoken for taking b/p readings;\n p.m. lopressor again held;\n Response:\n Showed pts b/p to be adequate;\n Urine output also showed adequate b/p and perfusion to kidneys\n Plan:\n Continue to maintain adequate sbp.\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 403851,
"text": "81 yo with h/o severe COPD (Sylvestri), SVT/Atrial Fibrillation,\n diastolic CHF, HTN, PE, admitted for elective L THA performed \n (EBL 500cc), transferred to for tachycardia and hypotension.\n In the PACU, patient was hypotensive to 80/50 and had tachycardia with\n rates into the 110s. EKG demonstrated an accelerated junctional rhythm\n with rate in 100s with depressions in the lateral leads\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Arthritis, osteo (osteoarthritis, OA)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 404006,
"text": "81F h/o COPD, chronic eosinophilic lung disease, SVT, diastolic CHF,\n HTN, PE\n09 admitted for hip replacement which was uneventful EBL\n 500cc, spinal anesthesia, noted to have SBP 80s in PACU, accelerated\n junctional rhythm rate 110, given lopressor with rate control however,\n bp dropped so bolused with neo. Transferred to ICU for close\n hemodynamic monitoring, treatment of tachycardia and hypotension.\n Arthritis, osteo (osteoarthritis, OA)\n Assessment:\n Pt with Left THR. Dsg changed by ortho this am, draining moderate\n amounts of serous drainage. Staples intact, site with no s/s of\n infection. Pt Afebrile. No c/o pain.\n Action:\n Pt turned and repositioned with pillow between legs. Pain managed with\n Tylenol q6 hours and 5mg of oxycodone provided infrequently for\n breakthrough pain. Pt walked a small amount with PT today.\n Response:\n Pt tolerating turns well. Able to fully weight bare OOB to chair. Pain\n well managed with pain regiment. Dsg changed this afternoon large\n amounts of serosanguinos drainage. While ambulating with PT pt desated\n to 80\ns HR increased to 100\ns and BP elevated to 140\ns systolically.\n Plan:\n Maintain posterior dislocation precautions: ie avoiding internal\n rotation of left hip, avoiding hip flexion past 90 degree\ns, always\n turn and reposition and get to standing with pillow between legs. OOB\n to chair, PT to follow\n Hypotension (not Shock)\n Assessment:\n Pt\ns SBP remained high 90\ns-120\ns mentating well, good urine output.\n Hct this am 25.9\n Action:\n Encouraged PO fluids to maintain BP. Provided 1 unit of PRBC.\n Response:\n Pt maintained SBP 90\ns-120\ns, Hct after transfusion was 31.1\n Plan:\n Cont to monitor BP, encourage PO fluids, monitor Hct and urine output.\n Tachycardia, Other\n Assessment:\n PT heart rate remained 60\ns-70\ns t/o most of shift. Increasing to the\n 90\ns with activity.\n Action:\n Cont to monitor HR\n Response:\n HR remained stable t/o shift. No further increases.\n Plan:\n Cont to monitor HR, monitor hct, monitor fluid status.\n -Pt foley was d/c\nd today at 1700 DTV at 0100.\n -Pt has several skin tears. Right lateral aspect of knee has skin tear\n with steristrips intact., adaptic and dry sterile dsg applied \n at 1700. Left upper arm has medium sized skin tear with adaptic and dry\n sterile dsg place this am. Pt lower back has skin tear with\n Mepilex dsg applied . Pt has very fragile skin, can only\n tolerate paper tape.\n -Pt has not had a BM since admission. No complaints of constipation.\n +Bsx4 abd only slightly distended. Pt given ducolax this am PO.\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 404012,
"text": "81F h/o COPD, chronic eosinophilic lung disease, SVT, diastolic CHF,\n HTN, PE\n09 admitted for hip replacement which was uneventful EBL\n 500cc, spinal anesthesia, noted to have SBP 80s in PACU, accelerated\n junctional rhythm rate 110, given lopressor with rate control however,\n bp dropped so bolused with neo. Transferred to ICU for close\n hemodynamic monitoring, treatment of tachycardia and hypotension.\n Arthritis, osteo (osteoarthritis, OA)\n Assessment:\n Pt with Left THR. Dsg changed by ortho this am, draining moderate\n amounts of serous drainage. Staples intact, site with no s/s of\n infection. Pt Afebrile. No c/o pain.\n Action:\n Pt turned and repositioned with pillow between legs. Pain managed with\n Tylenol q6 hours and 5mg of oxycodone provided infrequently for\n breakthrough pain. Pt walked a small amount with PT today.\n Response:\n Pt tolerating turns well. Able to fully weight bare OOB to chair. Pain\n well managed with pain regiment. Dsg changed this afternoon large\n amounts of serosanguinos drainage. While ambulating with PT pt desated\n to 80\ns HR increased to 100\ns and BP elevated to 140\ns systolically.\n Plan:\n Maintain posterior dislocation precautions: ie avoiding internal\n rotation of left hip, avoiding hip flexion past 90 degree\ns, always\n turn and reposition and get to standing with pillow between legs. OOB\n to chair, PT to follow\n Hypotension (not Shock)\n Assessment:\n Pt\ns SBP remained high 90\ns-120\ns mentating well, good urine output.\n Hct this am 25.9\n Action:\n Encouraged PO fluids to maintain BP. Provided 1 unit of PRBC.\n Response:\n Pt maintained SBP 90\ns-120\ns, Hct after transfusion was 31.1\n Plan:\n Cont to monitor BP, encourage PO fluids, monitor Hct and urine output.\n Tachycardia, Other\n Assessment:\n PT heart rate remained 60\ns-70\ns t/o most of shift. Increasing to the\n 90\ns with activity.\n Action:\n Cont to monitor HR\n Response:\n HR remained stable t/o shift. No further increases.\n Plan:\n Cont to monitor HR, monitor hct, monitor fluid status.\n -Pt foley was d/c\nd today at 1700 DTV at 0100.\n -Pt has several skin tears. Right lateral aspect of knee has skin tear\n with steristrips intact., adaptic and dry sterile dsg applied \n at 1700. Left upper arm has medium sized skin tear with adaptic and dry\n sterile dsg place this am. Pt lower back has skin tear with\n Mepilex dsg applied . Pt has very fragile skin, can only\n tolerate paper tape.\n -Pt has not had a BM since admission. No complaints of constipation.\n +Bsx4 abd only slightly distended. Pt given ducolax this am PO.\n ------ Protected Section ------\n Demographics\n Attending MD:\n \n Admit diagnosis:\n LEFT HIP OSTEOARTHRISTIS/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 71.5 kg\n Daily weight:\n Allergies/Reactions:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Precautions:\n PMH: COPD\n CV-PMH: CHF, Hypertension\n Additional history: afib, PE\n Surgery / Procedure and date: S/P L THR \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:114\n D:56\n Temperature:\n 96.6\n Arterial BP:\n S:86\n D:49\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,543 mL\n 24h total out:\n 1,480 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 05:17 AM\n Potassium:\n 3.8 mEq/L\n 05:17 AM\n Chloride:\n 103 mEq/L\n 05:17 AM\n CO2:\n 28 mEq/L\n 05:17 AM\n BUN:\n 12 mg/dL\n 05:17 AM\n Creatinine:\n 0.8 mg/dL\n 05:17 AM\n Glucose:\n 102 mg/dL\n 05:17 AM\n Hematocrit:\n 31.1 %\n 04:34 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4\n Transferred to: 5\n Date & time of Transfer: \n ------ Protected Section Addendum Entered By: ,RN\n on: 18:48 ------\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 403833,
"text": "Chief Complaint: Tachycardia and Hypotension post operatively from\n Total Hip Replacement.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - START 09:11 AM\n ARTERIAL LINE - STOP 07:00 PM\n CALLED OUT\n Intermittent tachycardia noted overnight and with intermittent\n hypotension requiring IVF bolus seen across this morning.\n History obtained from Medical records\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:56 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever, 100.8\n Cardiovascular: Tachycardia\n Flowsheet Data as of 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.8\nC (100\n HR: 92 (73 - 94) bpm\n BP: 114/44(62) {77/39(51) - 119/61(72)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,062 mL\n 917 mL\n PO:\n 750 mL\n TF:\n IVF:\n 4,312 mL\n 917 mL\n Blood products:\n Total out:\n 725 mL\n 550 mL\n Urine:\n 565 mL\n 550 mL\n NG:\n Stool:\n Drains:\n 160 mL\n Balance:\n 4,337 mL\n 367 mL\n Respiratory support\n SpO2: 92%\n ABG: ////\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Bowel sounds present\n Extremities: mild bruising at operative site, distal sensation and\n pulse in tact.\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.5 g/dL\n 170 K/uL\n 126 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 135 mEq/L\n 28.7 %\n 9.4 K/uL\n [image002.jpg]\n 03:35 AM\n 12:41 PM\n 06:11 AM\n WBC\n 9.0\n 9.4\n Hct\n 31.6\n 28.7\n Plt\n 194\n 170\n Cr\n 0.7\n TropT\n 0.02\n 0.02\n Glucose\n 126\n Other labs: PT / PTT / INR:16.3//1.4, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 81 yo female with history of COPD/CHF now with left total hip\n replacement and admitted with junctional tachycardia and\n hypotension from PACU\n Hypotension-_This was seen in the immediate post operative state and\n has persistent through to this morning. This may be multifactorial and\n related to medications with beta-blockers in place and narcotics for\n pain control. Alternatively acute insults such as blood loss, cardiac\n dysfnction, obstructive sources of impaired cardiac function all are\n important to consider.\n -Will follow HCT and wound site appears reassuring\n -No evidence for sepsis\n -Will monitor for respiratory distress or any evidence of significant\n hypoxia to consider possible source of PE\n -Will evaluate patient cardiac history or evaluate with ECHO\n -Vasodilatory source may be considered with possible effects of\n narcotic medications\n -Will avoid beta blockers with possible contribution to relative\n slowing of HR\n -Will monitor for SVT in this setting\n Total Hip Replacement-\n -Lovenox with Coumadin 1mg qd\n -Naprosyn /Tylenol 650mg q 6 hours\n -Wound clean and without evidence of bleeding\n COPD-Chronic and without exacerbation\n -Advair to continue\n -Albuterol PRN\n ICU Care\n Nutrition: PO diet\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403838,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - patient noted to have some oozing around surgical site\n - patient had several episodes of SVT (?AVNRT) up to 130\ns that broke\n spontaneously\n - spiked to 100.8 o/n\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:56 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 08:09 AM\n Famotidine (Pepcid) - 09:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 92 (73 - 94) bpm\n BP: 114/44(62) {75/39(51) - 119/61(72)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,062 mL\n 621 mL\n PO:\n 750 mL\n TF:\n IVF:\n 4,312 mL\n 621 mL\n Blood products:\n Total out:\n 725 mL\n 370 mL\n Urine:\n 565 mL\n 370 mL\n NG:\n Stool:\n Drains:\n 160 mL\n Balance:\n 4,337 mL\n 251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 9.5 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 135 mEq/L\n 28.7 %\n 9.4 K/uL\n [image002.jpg]\n 03:35 AM\n 12:41 PM\n 06:11 AM\n WBC\n 9.0\n 9.4\n Hct\n 31.6\n 28.7\n Plt\n 194\n 170\n Cr\n 0.7\n TropT\n 0.02\n 0.02\n Glucose\n 126\n Other labs: PT / PTT / INR:16.3//1.4, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an\n episode of tachycardia (junctional rhythm), asymptomatic, improved\n overnight with PRBC, fluid bolus.\n # Hypotension: Patient BP has been ranging from 70/40s-110s/60s. She is\n completely asymptomatic with low BP\ns and is maintaining good UOP.\n Possibilities include bleeding in to L hip post-op, medication related\n (lasix, BB and narcotics) or falsely low BP due to atherosclerosis.\n - pm Hct to eval for bleed\n - will hold BB, lasix and minimize narcotics\n .\n # Tachycardia: Patient has several episodes of possible SVT (likely\n AVNRT)up to 130\ns bpm on tele o/n but converted to NSR at 90\ns bpm\n without intervention. INR currently 1.4 from 1.1 yesterday.\n - holding BB due to hypotension\n - will monitor tele and try to obtain EKG if in SVT\n .\n #. Anemia: Patient with Hct drop post-op to 26. Given 1u PRBC-> Hct\n 31.6 and has trended down to 28.7 this am. She as a JP drain in place\n and was noted to have some oozing at surgical site. Patient is\n currently being anticoagualted (LMWH bridge to coumadin) which could\n complicate bleeding from or at surgical site.\n - repeat pm Hct as patient started on coumadin\n .\n # COPD/eosinophilic lung disease\n - continue albuterol prn, tiopropium, advair, prednisone\n .\n # CHF/CAD\n - hold metoprolol, lasix\n - cont atorvastatin\n .\n # s/p L THA\n - pain control, morphine, standing tylenol/NSAID per ortho,\n - dvt ppx lovenox, bridging to coumadin\n - WBAT\n - posterior precautions (pillow between knees when rolled)\n ICU Care\n Nutrition: advance as tolerated\n Comments:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT: Boots, LMW Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed\n Code status: Full code\n Disposition: ICU for now\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403839,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - patient noted to have some oozing around surgical site\n - patient had several episodes of SVT (?AVNRT) up to 130\ns that broke\n spontaneously\n - spiked to 100.8 o/n\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:56 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 08:09 AM\n Famotidine (Pepcid) - 09:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 92 (73 - 94) bpm\n BP: 114/44(62) {75/39(51) - 119/61(72)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,062 mL\n 621 mL\n PO:\n 750 mL\n TF:\n IVF:\n 4,312 mL\n 621 mL\n Blood products:\n Total out:\n 725 mL\n 370 mL\n Urine:\n 565 mL\n 370 mL\n NG:\n Stool:\n Drains:\n 160 mL\n Balance:\n 4,337 mL\n 251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 9.5 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 135 mEq/L\n 28.7 %\n 9.4 K/uL\n [image002.jpg]\n 03:35 AM\n 12:41 PM\n 06:11 AM\n WBC\n 9.0\n 9.4\n Hct\n 31.6\n 28.7\n Plt\n 194\n 170\n Cr\n 0.7\n TropT\n 0.02\n 0.02\n Glucose\n 126\n Other labs: PT / PTT / INR:16.3//1.4, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an\n episode of tachycardia (junctional rhythm), asymptomatic, improved\n overnight with PRBC, fluid bolus.\n # Hypotension: Patient BP has been ranging from 70/40s-110s/60s. She is\n completely asymptomatic with low BP\ns and is maintaining good UOP.\n Possibilities include bleeding in to L hip post-op, medication related\n (lasix, BB and narcotics) or falsely low BP due to atherosclerosis.\n - pm Hct to eval for bleed\n - will hold BB, lasix and minimize narcotics\n .\n # Tachycardia: Patient has several episodes of possible SVT (likely\n AVNRT)up to 130\ns bpm on tele o/n but converted to NSR at 90\ns bpm\n without intervention. INR currently 1.4 from 1.1 yesterday.\n - holding BB due to hypotension\n - will monitor tele and try to obtain EKG if in SVT\n .\n #. Anemia: Patient with Hct drop post-op to 26. Given 1u PRBC-> Hct\n 31.6 and has trended down to 28.7 this am. She as a JP drain in place\n and was noted to have some oozing at surgical site. Patient is\n currently being anticoagualted (LMWH bridge to coumadin) which could\n complicate bleeding from or at surgical site.\n - repeat pm Hct as patient started on coumadin\n .\n # COPD/eosinophilic lung disease\n - continue albuterol prn, tiopropium, advair, prednisone\n .\n # CHF/CAD\n - hold metoprolol, lasix\n - cont atorvastatin\n .\n # s/p L THA\n - pain control, morphine, standing tylenol/NSAID per ortho,\n - dvt ppx lovenox, bridging to coumadin\n - WBAT\n - posterior precautions (pillow between knees when rolled)\n ICU Care\n Nutrition: advance as tolerated\n Comments:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT: Boots, LMW Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed\n Code status: Full code\n Disposition: ICU for now\n ------ Protected Section ------\n Physical Exam:\n General: alert, oriented, no acute distress\n HEENT: Sclera anicteric, DMM\n Neck: supple\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema.\n Left hip surgical site, with dressing in place.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:14 ------\n"
},
{
"category": "Nursing",
"chartdate": "2142-04-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 404002,
"text": "81F h/o COPD, chronic eosinophilic lung disease, SVT, diastolic CHF,\n HTN, PE\n09 admitted for hip replacement which was uneventful EBL\n 500cc, spinal anesthesia, noted to have SBP 80s in PACU, accelerated\n junctional rhythm rate 110, given lopressor with rate control however,\n bp dropped so bolused with neo. Transferred to ICU for close\n hemodynamic monitoring, treatment of tachycardia and hypotension.\n Arthritis, osteo (osteoarthritis, OA)\n Assessment:\n Pt with Left THR. Dsg changed by ortho this am, draining moderate\n amounts of serous drainage. Staples intact, site with no s/s of\n infection. Pt Afebrile. No c/o pain.\n Action:\n Pt turned and repositioned with pillow between legs. Pain managed with\n Tylenol q6 hours and 5mg of oxycodone provided infrequently for\n breakthrough pain. Pt walked a small amount with PT today.\n Response:\n Pt tolerating turns well. Able to fully weight bare OOB to chair. Pain\n well managed with pain regiment. Dsg cganged this afternoon large\n amounts of serosanguinos drainage. While ambulating with PT pt desated\n to 80\ns HR increased to 100\ns and BP elevated to 140\ns systolically.\n Plan:\n Maintain posterior dislocation precautions: ie avoiding internal\n rotation of left hip, avoiding hip flexion past 90 degree\ns always turn\n and reposition and get to standing with pillow between legs. OOB to\n chair, PT to follow\n Hypotension (not Shock)\n Assessment:\n Pt\ns SBP remained high 90\ns-120\ns mentating well, good urine output.\n Hct this am 25.9\n Action:\n Encouraged PO fluids to maintain BP. Provided 1 unit of PRBC.\n Response:\n Pt maintained SBP 90\ns-120\ns, Hct after transfusion was 31.1\n Plan:\n Cont to monitor BP, encourage PO fluids, monitor Hct, monitor urine\n output.\n Tachycardia, Other\n Assessment:\n PT heart rate remained 60\ns-70\ns t/o most of shift. Increasing to the\n 90\ns with activity.\n Action:\n Cont to monitor HR\n Response:\n HR remained stable t/o shift. No further increases.\n Plan:\n Cont to monitor HR, monitor hct, monitor fluid status.\n -Pt foley was d/c\nd today at 1700 DTV at 0100.\n -Pt has several skin tears. Right lateral aspect of knee has skin tear\n with steristrips intact., adaptic and dry sterile dsg applied \n at 1700. Left upper arm has medium sized skin tear with adaptic and dry\n sterile dsg place this am. Pt lower back has skin tear with\n Mepilex dsg applied . Pt has very fragile skin, can only\n tolerate paper tape.\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403800,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 09:11 AM\n ARTERIAL LINE - STOP 07:00 PM\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:56 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 08:09 AM\n Famotidine (Pepcid) - 09:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 92 (73 - 94) bpm\n BP: 114/44(62) {75/39(51) - 119/61(72)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,062 mL\n 621 mL\n PO:\n 750 mL\n TF:\n IVF:\n 4,312 mL\n 621 mL\n Blood products:\n Total out:\n 725 mL\n 370 mL\n Urine:\n 565 mL\n 370 mL\n NG:\n Stool:\n Drains:\n 160 mL\n Balance:\n 4,337 mL\n 251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 9.5 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 135 mEq/L\n 28.7 %\n 9.4 K/uL\n [image002.jpg]\n 03:35 AM\n 12:41 PM\n 06:11 AM\n WBC\n 9.0\n 9.4\n Hct\n 31.6\n 28.7\n Plt\n 194\n 170\n Cr\n 0.7\n TropT\n 0.02\n 0.02\n Glucose\n 126\n Other labs: PT / PTT / INR:16.3//1.4, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403801,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 09:11 AM\n ARTERIAL LINE - STOP 07:00 PM\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:56 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 08:09 AM\n Famotidine (Pepcid) - 09:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 92 (73 - 94) bpm\n BP: 114/44(62) {75/39(51) - 119/61(72)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,062 mL\n 621 mL\n PO:\n 750 mL\n TF:\n IVF:\n 4,312 mL\n 621 mL\n Blood products:\n Total out:\n 725 mL\n 370 mL\n Urine:\n 565 mL\n 370 mL\n NG:\n Stool:\n Drains:\n 160 mL\n Balance:\n 4,337 mL\n 251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 9.5 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 135 mEq/L\n 28.7 %\n 9.4 K/uL\n [image002.jpg]\n 03:35 AM\n 12:41 PM\n 06:11 AM\n WBC\n 9.0\n 9.4\n Hct\n 31.6\n 28.7\n Plt\n 194\n 170\n Cr\n 0.7\n TropT\n 0.02\n 0.02\n Glucose\n 126\n Other labs: PT / PTT / INR:16.3//1.4, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an\n episode of tachycardia (junctional rhythm), asymptomatic, improved\n overnight with PRBC, fluid bolus.\n .\n # Tachycardia. Stayed in SR overnight. Rate hovered around 100,\n dropped to 70s with 500cc bolus of fluid. BP stable.\n - continue metoprolol 12.5 mg PO bid\n - start warfarin 4mg PO daily at 1600 given h/o atrial fibrillation,\n follow INR\n - cycle cardiac enzymes, last set today at 11:00.\n .\n #. Anemia. HCt post-op 26, Given 1u PRBC now Hct 31.5\n - Trend HCt, consider transfusing if his HCt does not increase\n appropriately.\n .\n # COPD/eosinophilic lung disease\n - continue albuterol prn, tiopropium, advair, prednisone\n .\n # CHF/CAD\n - continue metoprolol, lasix\n - continue atorvastatin\n .\n # s/p L THA\n - pain control, morphine PCA, standing tylenol/NSAID per ortho, change\n to oral narcotics when tolerating PO.\n - dvt ppx lovenox, bridging to coumadin\n - Vanco at 11AM tomorrow.\n - WBAT\n - posterior precautions (pillow between knees when rolled)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403804,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 09:11 AM\n ARTERIAL LINE - STOP 07:00 PM\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:56 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 08:09 AM\n Famotidine (Pepcid) - 09:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 92 (73 - 94) bpm\n BP: 114/44(62) {75/39(51) - 119/61(72)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,062 mL\n 621 mL\n PO:\n 750 mL\n TF:\n IVF:\n 4,312 mL\n 621 mL\n Blood products:\n Total out:\n 725 mL\n 370 mL\n Urine:\n 565 mL\n 370 mL\n NG:\n Stool:\n Drains:\n 160 mL\n Balance:\n 4,337 mL\n 251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 9.5 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 135 mEq/L\n 28.7 %\n 9.4 K/uL\n [image002.jpg]\n 03:35 AM\n 12:41 PM\n 06:11 AM\n WBC\n 9.0\n 9.4\n Hct\n 31.6\n 28.7\n Plt\n 194\n 170\n Cr\n 0.7\n TropT\n 0.02\n 0.02\n Glucose\n 126\n Other labs: PT / PTT / INR:16.3//1.4, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an\n episode of tachycardia (junctional rhythm), asymptomatic, improved\n overnight with PRBC, fluid bolus.\n .\n # Tachycardia: Patient has several episodes of possible SVT (likely\n AVNRT)up to 130\ns bpm on tele o/n but converted to NSR at 90\ns bpm\n without intervention. INR currently 1.4 from 1.1 yesterday.\n - consider increasing metoprolol as patient persistently tachycardic\n and possible SVT.\n - start warfarin 4mg PO daily at 1600 given h/o atrial fibrillation,\n follow INR\n .\n #. Anemia: Patient with Hct drop post-op to 26. Given 1u PRBC-> Hct\n 31.6 and has trended down to 28.7 this am. She as a JP drain in place\n and was noted to have some oozing at surgical site. Patient is\n currently being anticoagualted (LMWH bridge to coumadin) which could\n complicate bleeding from or at surgical site.\n - repeat pm Hct as patient started on coumadin\n .\n # COPD/eosinophilic lung disease\n - continue albuterol prn, tiopropium, advair, prednisone\n .\n # CHF/CAD\n - continue metoprolol, lasix\n - continue atorvastatin\n .\n # s/p L THA\n - pain control, morphine PCA, standing tylenol/NSAID per ortho, change\n to oral narcotics when tolerating PO.\n - dvt ppx lovenox, bridging to coumadin\n - Vanco at 11AM tomorrow.\n - WBAT\n - posterior precautions (pillow between knees when rolled)\n ICU Care\n Nutrition: Clears, advance as tolerated\n Comments:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT: Boots, LMW Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed\n Code status: Full code\n Disposition: Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2142-04-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 403805,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - START 09:11 AM\n ARTERIAL LINE - STOP 07:00 PM\n Allergies:\n Losartan\n angioedema/lip\n Lisinopril (Oral)\n Cough;\n Penicillins\n itching;\n Ultram (Oral) (Tramadol Hcl)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:56 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 08:09 AM\n Famotidine (Pepcid) - 09:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 92 (73 - 94) bpm\n BP: 114/44(62) {75/39(51) - 119/61(72)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,062 mL\n 621 mL\n PO:\n 750 mL\n TF:\n IVF:\n 4,312 mL\n 621 mL\n Blood products:\n Total out:\n 725 mL\n 370 mL\n Urine:\n 565 mL\n 370 mL\n NG:\n Stool:\n Drains:\n 160 mL\n Balance:\n 4,337 mL\n 251 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 9.5 g/dL\n 126 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 104 mEq/L\n 135 mEq/L\n 28.7 %\n 9.4 K/uL\n [image002.jpg]\n 03:35 AM\n 12:41 PM\n 06:11 AM\n WBC\n 9.0\n 9.4\n Hct\n 31.6\n 28.7\n Plt\n 194\n 170\n Cr\n 0.7\n TropT\n 0.02\n 0.02\n Glucose\n 126\n Other labs: PT / PTT / INR:16.3//1.4, CK / CKMB /\n Troponin-T:415/5/0.02, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 81 yo F with h/o COPD, CHF now s/p L THA (), presents with an\n episode of tachycardia (junctional rhythm), asymptomatic, improved\n overnight with PRBC, fluid bolus.\n .\n # Tachycardia: Patient has several episodes of possible SVT (likely\n AVNRT)up to 130\ns bpm on tele o/n but converted to NSR at 90\ns bpm\n without intervention. INR currently 1.4 from 1.1 yesterday.\n - consider increasing metoprolol as patient persistently tachycardic\n and possible SVT.\n - start warfarin 4mg PO daily at 1600 given h/o atrial fibrillation,\n follow INR\n .\n #. Anemia: Patient with Hct drop post-op to 26. Given 1u PRBC-> Hct\n 31.6 and has trended down to 28.7 this am. She as a JP drain in place\n and was noted to have some oozing at surgical site. Patient is\n currently being anticoagualted (LMWH bridge to coumadin) which could\n complicate bleeding from or at surgical site.\n - repeat pm Hct as patient started on coumadin\n .\n # COPD/eosinophilic lung disease\n - continue albuterol prn, tiopropium, advair, prednisone\n .\n # CHF/CAD\n - continue metoprolol, lasix\n - continue atorvastatin\n .\n # s/p L THA\n - pain control, morphine PCA, standing tylenol/NSAID per ortho, change\n to oral narcotics when tolerating PO.\n - dvt ppx lovenox, bridging to coumadin\n - Vanco at 11AM tomorrow.\n - WBAT\n - posterior precautions (pillow between knees when rolled)\n ICU Care\n Nutrition: Clears, advance as tolerated\n Comments:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:56 AM\n Prophylaxis:\n DVT: Boots, LMW Heparin(Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed\n Code status: Full code\n Disposition: Transfer to floor\n"
},
{
"category": "Rehab Services",
"chartdate": "2142-04-29 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 403992,
"text": "Subjective:\n \"My hip hurts less now compared to before surgery\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for patient education\n Updated medical status: hip x-ray :Left total hip arthroplasty with\n satisfactory alignment.\n Activity\n Clarification\n I\n S\n CG\n \n Mod\n Max\n Rolling:\n\n\n T\n\n\n Supine/\n Sidelying to Sit:\n Sit ->sup\n\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n SW\n\n\n\n T\n\n\n Ambulation:\n SW\n\n\n T\n\n\n\n Stairs:\n n/a\n\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Sit\n 84\n 115/53\n 18\n 93% RA\n Activity\n Sit\n 102\n 146/66\n 28\n 87-90% RA\n Recovery\n Supine\n 90\n 127/54\n 95% RA\n Total distance walked: 10'\n Minutes:\n Gait: Pt amb ~10ft w/SW CG, inc , forward flex w/inc WB through\n BUE. vc for sequencing, pacing, PLB. Distance limited 2* pt SOB and inc\n WOB, sats improved 87->96% sitting eob <2 minutes\n Balance: no gross LOB w/mobility as above\n Education / Communication: pt/pt family present re: role of PT, ,\n d/c planning, pt I recall 0/3 hip precautions-re-ed re: posterior hip\n precautions. spoke w/RN re: pt status\n Other: dressing L hip w/mod drainage, RN aware. pt c/o 0/10 L\n hip pain at rest, w/mobility.\n Assessment: Pt is 81yoF POD 3 s/p L THA. Pt today with improved\n activity tolerance initiating gait training w/SW. Pt limited by SOB\n w/mobility a/w hx of COPD and deconditioning. Given delayed progress 2*\n post-op hypotension, tachycardia and decreased strength recommend rehab\n upon d/c when medically stable.\n Anticipated Discharge: Rehab\n Plan: Therex, ROM, transfers/bed mobility, gait w/RW ->BAC, pt ed, d/c\n planning\n Face time: 15:55-16:20\n"
},
{
"category": "Radiology",
"chartdate": "2142-04-28 00:00:00.000",
"description": "L HIP UNILAT MIN 2 VIEWS LEFT",
"row_id": 1125447,
"text": " 9:47 AM\n HIP UNILAT MIN 2 VIEWS LEFT Clip # \n Reason: hardware position\n Admitting Diagnosis: LEFT HIP OSTEOARTHRISTIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with total hip replacement\n REASON FOR THIS EXAMINATION:\n hardware position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left total hip arthroplasty.\n\n COMPARISON: .\n\n FINDINGS:\n\n Frontal radiograph of the pelvis and frontal and lateral radiographs of the\n left hip again demonstrate a left total hip arthroplasty. Alignment of the\n components is satisfactory. There is no periprosthetic fracture. Overlying\n skin staples are again noted. Bilateral femoral vascular calcifications are\n again seen.\n\n IMPRESSION:\n\n Left total hip arthroplasty with satisfactory alignment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-04-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1125575,
"text": " 5:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: LEFT HIP OSTEOARTHRISTIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with COPD, CHF, with hypoxia, s/p hip repair and 5L of fluid.\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n WET READ: SPfc SUN 6:16 PM\n Right costo-phrenic angle is beyond the field of view.\n Heart/mediastinal/hilar contours are stable. Left retrocardiac opacity is\n progressed from likely reflecting either atelectasis or aspiration\n in this post-operative patient. No evidence of pulmonary edema. Mild\n blunting of the left costophrenic angle suggests a possible pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: Hypoxia.\n\n FINDINGS: Cardiomediastinal contours as well as pulmonary vascularity are\n unchanged in appearance, except for development of retrocardiac opacities,\n probably due to atelectasis in the recent postoperative setting. Small left\n pleural effusion has also developed. Right cardiophrenic angle has been\n excluded and cannot be evaluated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-04-27 00:00:00.000",
"description": "PELVIS PORTABLE",
"row_id": 1125269,
"text": " 12:36 AM\n PELVIS PORTABLE Clip # \n Reason: eval hardware\n Admitting Diagnosis: LEFT HIP OSTEOARTHRISTIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with total hip replacement\n REASON FOR THIS EXAMINATION:\n eval hardware\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old woman with total hip replacement. Evaluate for\n hardware.\n\n COMPARISONS: Left hip .\n\n TECHNIQUE: Portable AP pelvis.\n\n FINDINGS: The patient is status post total left hip arthroplasty with anatomic\n alignment and no hardware complications identified. Moderate degenerative\n changes are noted within the right hip. The sacroiliac and pubic symphysis\n joints are unremarkable. Vascular calcifications are noted bilaterally. No\n fractures or dislocations identified. Expected post surgical changes are\n present.\n\n IMPRESSION: Status post left total hip arthroplasty with expected post-\n surgical changes and no evidence of hardware complications.\n\n\n\n\n"
}
] |
31,415 | 132,530 | Gallstone pancreatitis - ERCP was done the first time that failed and hence she was taken again for ERCP under anesthesia. This time baloon dilation was done of the sphincter at ampulla and complicated by bleeding. She was monitored overnight in ICU, hematocrit remained stable and was sent to floor. At discharge the hematocrit was at baseline. THE liver function tests improved after the procedure and bilirubinw as down to normal. The patient was stable at discharge. Prophylactic levofloxacin and metronidazole were given for a total of 7 days. The patient will be called by Dr / (ERCP team) for a repeat ERCP in 8 weeks. | Denies any pain/discomfort.Pulm: Weaned off RA. OOB to BSC w/ min. FINDINGS: There is an unchanged appearance to a dilated common bile duct with early phase of the cholangiogram demonstrating a small linear filling defect within the distal CBD, likely related to a prominent valve or biliary web. MRCP dilated CBD. last temp 99.0. pos distal pulses. Repleting lytes as tolerated. + ppp x 4.GI/GU: + bs noted. Lungs clear/diminished in bases. Evaluate for choledocholithiasis. The dilated CBD appears to taper down to the region of the ampulla, suggestive of restenosis per ERCP report. cont to update pt on POC. Comparison is made to a prior ERCP dated . Comparison is made to prior ERCP dated . cont to monitor vitals and resp status. Subsequent cholangiogram demonstrates unchanged appearance to moderately dilated CBD and CHD with no frank intrahepatic ductal dilatation or focal filling defects are identified. Abd soft, nt, nd. Voiding in BSC.SOCIAL: No contact w/ family.PLAN; Monitor per prtocol. Per ERCP report anatomy consistent with situs inversus was identified. GS Pancreaitis. Coughing up clear phlegm.CV: SB-ST w/ no ectopy. ERCP attempted but became aggitated promtpting procedure to be aborted REASON FOR THIS EXAMINATION: Assess for CBD stone FINAL REPORT HISTORY: Reattempt of ERCP. Afebrile. BP stable. Nursing Note: 1900-0700 full codeNeuro: pt 3, and cooperative with care. denies pain. NBP 120-145/60-75. no cough.CV: HR 53-65 SR, no ectopy. Q6hr HCT. Other past med hx: Situs inversus (reverse of heart), Gallstone pancreatitis this admission, GERD, last ERCP , Choly, ovarian cyst.ROS:Neuro: AAOx3, PERLA. c/o gas pain and heart burn and received mylanta prn with good effect.GU: voided x1 via bedside commode, unable to measure amt.IV: 20g PIV right AC infiltrated with NS infusion, PIV d/c'd and arm elevated and warm pack placed. No edema noted. Sov2 stable. ERCP performed previously with sphincterotomy. no BM. No BM. MAE. Now with ? IV team called to place new IV line.Skin: skin dry and intact.Social: pts sons in to visit during PM.Plan: continue to follow HCT's and monitor for S/S of bleeding. For full details please consult the ERCP report available on CareWeb. ERCP Nine spot fluoroscopic images were obtained by Gastroenterology without a radiologist present. For full details, please consult the ERCP report available on CareWeb. ambulated to bedside commode overnight with supervision, no dizziness on ambulation.Resp: sats 96-99 on room air, lungs clear and diminished, deep breathing encouraged. HCT @ 2100 = 35. no signs of bleeding noted.GI: pos bowel sounds, tolerating clear liquid diet ordered. Per ERCP report, a double pigtail biliary stent was placed at the end of the procedure, however no images were obtained demonstrating positioning. ERCP Fourteen spot fluoroscopic images were obtained by gastroenterology without a radiologist present. Admitted to MICU at 13:00 for closer observation and due to high risk for rebleed. assistance this afternoon. 20g PIV on left FA infiltrated as well. 12:44 PM ERCP BILIARY&PANCREAS BY GI UNIT Clip # Reason: r/o CBD stone Admitting Diagnosis: OBSTRUCTIVE JAUNDICE FINAL REPORT HISTORY: 60-year-old female with recent admission for pancreatitis and MRCP demonstrating dilated CBD now with recurrent questionable gallstone pancreatitis. 5:39 PM ERCP BILIARY&PANCREAS BY GI UNIT Clip # Reason: Assess for CBD stone Admitting Diagnosis: OBSTRUCTIVE JAUNDICE MEDICAL CONDITION: 60 yo female with recent admission with pancreatitis and elevated bilirubin. Arrived in stable condition and in no acute distress. The procedure was terminated early due to patient discomfort. This is difficult to confirm on these non-labeled films. Subsequent imaging displays a balloon dilatation of the distal CBD with a curvilinear waist-filling defect noted within the mid balloon, subsequently noted to expand with a continued balloon insufflation. | 4 | [
{
"category": "Radiology",
"chartdate": "2137-06-24 00:00:00.000",
"description": "ERCP BILIARY&PANCREAS BY GI UNIT",
"row_id": 968000,
"text": " 12:44 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: r/o CBD stone\n Admitting Diagnosis: OBSTRUCTIVE JAUNDICE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old female with recent admission for pancreatitis and MRCP\n demonstrating dilated CBD now with recurrent questionable gallstone\n pancreatitis. Evaluate for choledocholithiasis.\n\n Comparison is made to a prior ERCP dated .\n\n ERCP\n\n Nine spot fluoroscopic images were obtained by Gastroenterology without a\n radiologist present. Per ERCP report anatomy consistent with situs inversus\n was identified. This is difficult to confirm on these non-labeled films.\n Subsequent cholangiogram demonstrates unchanged appearance to moderately\n dilated CBD and CHD with no frank intrahepatic ductal dilatation or focal\n filling defects are identified. The dilated CBD appears to taper down to the\n region of the ampulla, suggestive of restenosis per ERCP report. The\n procedure was terminated early due to patient discomfort. For full details\n please consult the ERCP report available on CareWeb.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-06-25 00:00:00.000",
"description": "ERCP BILIARY&PANCREAS BY GI UNIT",
"row_id": 968173,
"text": " 5:39 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Assess for CBD stone\n Admitting Diagnosis: OBSTRUCTIVE JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 yo female with recent admission with pancreatitis and elevated bilirubin.\n MRCP dilated CBD. ERCP performed previously with sphincterotomy. Now with ? GS\n Pancreaitis. ERCP attempted but became aggitated promtpting procedure to be\n aborted\n REASON FOR THIS EXAMINATION:\n Assess for CBD stone\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Reattempt of ERCP.\n\n Comparison is made to prior ERCP dated .\n\n ERCP\n\n Fourteen spot fluoroscopic images were obtained by gastroenterology without a\n radiologist present.\n\n FINDINGS: There is an unchanged appearance to a dilated common bile duct with\n early phase of the cholangiogram demonstrating a small linear filling defect\n within the distal CBD, likely related to a prominent valve or biliary web.\n Subsequent imaging displays a balloon dilatation of the distal CBD with a\n curvilinear waist-filling defect noted within the mid balloon, subsequently\n noted to expand with a continued balloon insufflation. Per ERCP report, a\n double pigtail biliary stent was placed at the end of the procedure, however\n no images were obtained demonstrating positioning. For full details, please\n consult the ERCP report available on CareWeb.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-06-25 00:00:00.000",
"description": "Report",
"row_id": 1663068,
"text": "MICU Admitting and Nursing progress note:\n\nThis is a 61 y/o african-american lady who was admitted from PACU where she underwent an ERCP under General Anesthesia; s/p splinctecotomy, which was complicated by blood loss. Admitted to MICU at 13:00 for closer observation and due to high risk for rebleed. Arrived in stable condition and in no acute distress. Other past med hx: Situs inversus (reverse of heart), Gallstone pancreatitis this admission, GERD, last ERCP , Choly, ovarian cyst.\n\nROS:\n\nNeuro: AAOx3, PERLA. MAE. OOB to BSC w/ min. assistance this afternoon. Denies any pain/discomfort.\n\nPulm: Weaned off RA. Sov2 stable. Lungs clear/diminished in bases. Coughing up clear phlegm.\n\nCV: SB-ST w/ no ectopy. BP stable. Afebrile. No edema noted. + ppp x 4.\n\nGI/GU: + bs noted. Abd soft, nt, nd. No BM. Voiding in BSC.\n\nSOCIAL: No contact w/ family.\n\nPLAN; Monitor per prtocol. Repleting lytes as tolerated. Q6hr HCT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-06-26 00:00:00.000",
"description": "Report",
"row_id": 1663069,
"text": "Nursing Note: 1900-0700 full code\n\nNeuro: pt 3, and cooperative with care. denies pain. ambulated to bedside commode overnight with supervision, no dizziness on ambulation.\n\nResp: sats 96-99 on room air, lungs clear and diminished, deep breathing encouraged. no cough.\n\nCV: HR 53-65 SR, no ectopy. NBP 120-145/60-75. last temp 99.0. pos distal pulses. HCT @ 2100 = 35. no signs of bleeding noted.\n\nGI: pos bowel sounds, tolerating clear liquid diet ordered. no BM. c/o gas pain and heart burn and received mylanta prn with good effect.\n\nGU: voided x1 via bedside commode, unable to measure amt.\n\nIV: 20g PIV right AC infiltrated with NS infusion, PIV d/c'd and arm elevated and warm pack placed. 20g PIV on left FA infiltrated as well. IV team called to place new IV line.\n\nSkin: skin dry and intact.\n\nSocial: pts sons in to visit during PM.\n\nPlan: continue to follow HCT's and monitor for S/S of bleeding. cont to monitor vitals and resp status. cont to update pt on POC.\n\n"
}
] |
31,040 | 131,233 | A/P: 81 F w/ HTN, seizure disorder, DM, Alzeimers, deafness p/w UTI and PNA from OSH | IMPRESSION: AP chest compared to : Lung volumes are lower and mild interstitial pulmonary edema is new obscuring region questioned as possible pneumonia in the infrahilar left lung yesterday. IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Left infrahilar consolidation could be atelectasis or pneumonia particularly due to aspiration. Electrolyte slightly elevated potassium was 5.3 and is now 4.3.Skin: Patient has a stage II pressure ulcer on her coccyx that measres 4cmX6cm. Than patient recieved 5mg zyprexa at 0200 IM with no results. Diffuse non-specific ST segment depression.Compared to the previous tracing atrial ectopy is new.TRACING #2 Patient lung sounds are coarse and slightly deminished in the bases. On the patient right heel patient has a purple area that is about 5cm in diameter and also an allehvyn was placed on the area.IV: 22g right hand draw back wonderful blood return. Small left pleural effusion causing left basilar opacification; difficult in this setting to excluded basilar infectious consolidation as well. 6:21 PM CHEST (PORTABLE AP) Clip # Reason: pls eval for signs of consolid/infilt/PNA, edema, effusion Admitting Diagnosis: PNEUMONIA;URINARY TRACT INFECTION MEDICAL CONDITION: 81 year old woman with dementia, respiratory distress, fever REASON FOR THIS EXAMINATION: pls eval for signs of consolid/infilt/PNA, edema, effusion WET READ: RSRc FRI 10:41 PM Mild perihilar edema. Also placed a cooling blanket on the patient until temperature fell below 100.8. Patient bowel sounds active all four quadrents.GU: Patient at 0600 started to complain of the urge to pee. Vascular engorgement in the lungs is borderline and mediastinal veins have normal caliber. - FINAL REPORT AP CHEST, 6:29 P.M., HISTORY: Dementia, respiratory distress and fever, suspect pneumonia. Some of the medication she spit back out and everything that could be changed to IV to make sure that patient recieves all medicaitons. The doctors to haldol 2mg IV which has had no effect on patient agitation, delirium, restlessness, and patient continues to be unable to sleep. Patient has been weaned down to 3L NC. Sinus rhythm with atrial ectopy. Foley catheter was flushed and patent. Heart size is now top normal, upper lobe pulmonary vessels and the hila more engorged consistent with cardiac decompensation. Patient continued to recieve IV antibiotics, q4h 650mg PR tylenol. Also in the morning hours turned on the relaxing channel on the TV to maybe help patient calm down and sleep, no results.Cardiovascular: Patient at 2100 had a temp of 104 rectally. Patient creatinine this morning remined at 1.5 and BUN 46. Diffuse non-specific ST segment depression. At around 0200 cooloing blanket was turned off. Minor non-specific ST-T wave abnormalities. Will possiblly need to change out foley catheter with a new one to make sure that sediment has not reduced the flow of urine. 3:15 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change Admitting Diagnosis: PNEUMONIA;URINARY TRACT INFECTION MEDICAL CONDITION: 81 year old woman with PNA, new o2 req REASON FOR THIS EXAMINATION: eval for interval change FINAL REPORT AP CHEST, 4:15 A.M., HISTORY: Probable pneumonia. Patient also has a skin tear on left buttock in which a aquagel was placed with a tegaderm covering the area. 20g place left forearm and is patient. Hypoxia. Patient first recieved seroquil 50mg cruched in apple sauce at 2200 with no results. Will continue to monitor patient O2sats.GI: Patient was able to take some PO medications last night crushed up in apple sauce with a little water. Patient current temp is 98.7.Pulmonary: At the beginning of the shift patient was on a NRB 100%. Patient also recieved a bath at 2400 to help calm her and patient slept for about 15minutes. A thermometer probe was placed and for monitoring purposes and 650mg tylenol PR given. Finally at 0500 patient became increasingly worse screaming out that her mother just died and papa. Pleural effusion is small on the left, absent on the right. Wound is purple with reddened edges and partial thinkening. Nursing Progress NoteNeuro: Patient for the entire shift has been very confused, delusional, agitated, restless, and unable to sleep throughout the night. Will continue to monitor patient neurological status and assess for any needs or changes in the environment that may help to reduce patient stimulation. Small right pleural effusion may have developed. Small left pleural effusion is stable. Patient also has blood cultures drawn , also urine culture and UA sent late. Compared to theprevious tracing there is no significant change.TRACING #1 Normal sinus rhythm. Continue to monitor patient temperature frequently watch for spikes. Sinus rhythm. Heart size normal. No pneumothorax. No pneumothorax. Allevyn placed and is intact dated and signed. | 6 | [
{
"category": "Radiology",
"chartdate": "2180-05-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1012652,
"text": " 6:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval for signs of consolid/infilt/PNA, edema, effusion\n Admitting Diagnosis: PNEUMONIA;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with dementia, respiratory distress, fever\n REASON FOR THIS EXAMINATION:\n pls eval for signs of consolid/infilt/PNA, edema, effusion\n ______________________________________________________________________________\n WET READ: RSRc FRI 10:41 PM\n Mild perihilar edema. Small left pleural effusion causing left basilar\n opacification; difficult in this setting to excluded basilar infectious\n consolidation as well. -\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:29 P.M., \n\n HISTORY: Dementia, respiratory distress and fever, suspect pneumonia.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Left infrahilar consolidation could be atelectasis or pneumonia particularly\n due to aspiration. Pleural effusion is small on the left, absent on the\n right. No pneumothorax. Heart size normal. Vascular engorgement in the\n lungs is borderline and mediastinal veins have normal caliber.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-05-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1012694,
"text": " 3:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PNEUMONIA;URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with PNA, new o2 req\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:15 A.M., \n\n HISTORY: Probable pneumonia. Hypoxia.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes are lower and mild interstitial pulmonary edema is new obscuring\n region questioned as possible pneumonia in the infrahilar left lung yesterday.\n Heart size is now top normal, upper lobe pulmonary vessels and the hila more\n engorged consistent with cardiac decompensation. Small left pleural effusion\n is stable. Small right pleural effusion may have developed. No pneumothorax.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-05-06 00:00:00.000",
"description": "Report",
"row_id": 1659656,
"text": "Nursing Progress Note\nNeuro: Patient for the entire shift has been very confused, delusional, agitated, restless, and unable to sleep throughout the night. Patient first recieved seroquil 50mg cruched in apple sauce at 2200 with no results. Than patient recieved 5mg zyprexa at 0200 IM with no results. Finally at 0500 patient became increasingly worse screaming out that her mother just died and papa. The doctors to haldol 2mg IV which has had no effect on patient agitation, delirium, restlessness, and patient continues to be unable to sleep. Will continue to monitor patient neurological status and assess for any needs or changes in the environment that may help to reduce patient stimulation. Patient also recieved a bath at 2400 to help calm her and patient slept for about 15minutes. Also in the morning hours turned on the relaxing channel on the TV to maybe help patient calm down and sleep, no results.\n\nCardiovascular: Patient at 2100 had a temp of 104 rectally. A thermometer probe was placed and for monitoring purposes and 650mg tylenol PR given. Also placed a cooling blanket on the patient until temperature fell below 100.8. Patient continued to recieve IV antibiotics, q4h 650mg PR tylenol. At around 0200 cooloing blanket was turned off. Continue to monitor patient temperature frequently watch for spikes. Patient also has blood cultures drawn , also urine culture and UA sent late. Patient current temp is 98.7.\n\nPulmonary: At the beginning of the shift patient was on a NRB 100%. Patient has been weaned down to 3L NC. Patient lung sounds are coarse and slightly deminished in the bases. Will continue to monitor patient O2sats.\n\nGI: Patient was able to take some PO medications last night crushed up in apple sauce with a little water. Some of the medication she spit back out and everything that could be changed to IV to make sure that patient recieves all medicaitons. Patient bowel sounds active all four quadrents.\n\nGU: Patient at 0600 started to complain of the urge to pee. Foley catheter was flushed and patent. Will possiblly need to change out foley catheter with a new one to make sure that sediment has not reduced the flow of urine. Patient creatinine this morning remined at 1.5 and BUN 46. Electrolyte slightly elevated potassium was 5.3 and is now 4.3.\n\nSkin: Patient has a stage II pressure ulcer on her coccyx that measres 4cmX6cm. Allevyn placed and is intact dated and signed. Wound is purple with reddened edges and partial thinkening. Patient also has a skin tear on left buttock in which a aquagel was placed with a tegaderm covering the area. On the patient right heel patient has a purple area that is about 5cm in diameter and also an allehvyn was placed on the area.\n\nIV: 22g right hand draw back wonderful blood return. 20g place left forearm and is patient.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2180-05-07 00:00:00.000",
"description": "Report",
"row_id": 213477,
"text": "Sinus rhythm. Diffuse non-specific ST segment depression. Compared to the\nprevious tracing there is no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2180-05-06 00:00:00.000",
"description": "Report",
"row_id": 213478,
"text": "Normal sinus rhythm. Minor non-specific ST-T wave abnormalities. No previous\ntracing available for comparison.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-05-08 00:00:00.000",
"description": "Report",
"row_id": 216753,
"text": "Sinus rhythm with atrial ectopy. Diffuse non-specific ST segment depression.\nCompared to the previous tracing atrial ectopy is new.\nTRACING #2\n\n"
}
] |
71,473 | 124,934 | As per above the patient was transferred from OSH via to for trauma management. He arrived intubated and sedated. STAT trauma protocol was activated on arrival and patient was evaluated by acute care surgery service. In the trauma bay there was concern for a tension pneumorthorax as patient was hypotensive with mediastinal shift on trauma bay chest xray despite right chest tube at outside hospital. Malpositioned chest tube was removed and R chest tube was re-positioned with good effect. Further imaging was obtained in the ED showing extravasation from injured spleen and liver. Patient was brought emergently to the OR for exploratory laparotomy, splenectomy and repair of small hepatic defect. Patient was then transferred to the TSICU with an open abdomen for further management. | There is no appreciable right pleural effusion, there is a moderate degree of right upper lobe atelectasis, revealed by upward retraction of the minor fissure below consolidated upper lobe. A small amount of subcutaneous emphysema in the right lateral chest wall remains. Portions of the chest are excluded by an underlying trauma backboard. There is calcification adjacent to the lateral epicondyle which can be seen with sequela of lateral epicondylitis, age indeterminate. Extensive subcutaneous gas about the lower right chest wall and upper abdomen has decreased somewhat. FINDINGS: The patient presented with a standard orogastric tube and an orogastric Dobhoff tube whose tip was found to be in the proximal duodenum. Persistent leftward mediastinal shift/tension pneumothorax despite right chest tube as above. Small amount of subcutaneous air tracking inferiorly, some anterior and likely due to prior surgery. Since the prior study, there has been marked reduction in the right-sided pneumothorax, only a small residual anterior pneumothorax remains. IMPRESSION: No deep venous thrombosis in either lower extremity. Endotracheal tube and esophageal catheter coursing inferior to the diaphragm with tip out of view of the radiograph are unchanged. There remains a moderate amount of subcutaneous air tracking throughout the entire right anterior chest and right flank, inferiorly all the way to the pubic symphysis. Significant subcutaneous emphysema remains and somewhat obscures the right hemithorax; however, no significant residual right pneumothorax is seen. FINDINGS: An endotracheal tube is present and approximately 1.4 cm from the carina directed towards the left mainstem bronchus. FINDINGS: As compared to the prior examination, lung volumes remain low with bibasilar opacities which could represent atelectasis, contusion or hemorrhage. Minimally increasing areas of atelectasis at the right and left lung base. FINDINGS: As compared to the previous radiograph, the monitoring and support devices, including the right-sided chest tube are in unchanged position. There is scattered opacification of the included left lung particularly in the retrocardiac region. The prior CT scan demonstrated a tension pneumothorax. Right chest tube is again seen and there may be a tiny apical pneumothorax. A right-sided subclavian catheter reaches the low SVC. Right adrenal hematoma. FINDINGS: A Dobbhoff tube has now been repositioned and courses inferior to the diaphragm with tip in the region of the gastric antrum. Unchanged displaced right rib fractures. Right clavicular fracture. Right apical pleural drain in place. ET tube is in standard placement, left subclavian line ends in the upper right atrium within 2 cm of the estimated location of the superior cavoatrial junction. The course of the line is unremarkable, the tip of the line projects over the inflow tract of the right atrium, it could be pulled back by approximately 2 cm to ensure position in the vena cava. ET tube is in standard placement, nasogastric tube passes below the diaphragm and out of view. Right tension pneumothorax; right chest tube and posterior pleural space, not evacuating this pneumothorax; mediastinal deviation and compression of the right and left lungs are concerning for tension pneumothorax. Encephalomalacia is noted in the right frontal lobe, compatible with prior infarct. Right apical pleural tube unchanged in position. Also unchanged is a small amount of hyperdense material in the atrium of the left lateral ventricle, posterior to the choroid plexus, which likely represents blood. Right-sided subclavian central venous catheter terminates in the right atrium. The right chest tube is in unchanged position. Right-sided chest tube is in place. Persistent bilateral lower lobe opacities, left greater than right with adjacent moderate left and small right pleural effusions. The visualized portion of the paranasal sinuses demonstrate thickened right maxillary sinus walls, and opacified right maxillary sinus, compatible with a chronic process. Chest wall subcutaneous emphysema is decreased. Endotracheal tube is in standard position. Small right pleural effusion is present. FINDINGS: As compared to the previous radiograph, the patient has received a new right subclavian central venous access line. AP UPRIGHT VIEW OF THE CHEST: Endotracheal tube terminates 3.6 cm above the carina. FINDINGS: The Dobbhoff tube is within the same location and the malrotated jejunum in the right lower quadrant. The study is otherwise unchanged with incidentally noted skin staples in the right abdomen, a stable small right pleural effusion, and type G2 IVC filter in place. FINDINGS: Two supine AP views of the abdomen show the previously advanced nasointestinal tube in the same location as demonstrated in the fluoroscopic image from . CT FINDINGS: Limited non-contrast CT performed pre-drainage. Trace AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. .TRICUSPID VALVE: Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. An ET tube terminates in the mid thoracic trachea appropriately. Left pleuraleffusion.Conclusions:The left atrium is mildly dilated. A right subclavian approach central venous catheter terminates in the proximal right atrium. Trace aortic regurgitation is seen. PATIENT/TEST INFORMATION:Indication: Right ventricular function.Height: (in) 71Weight (lb): 181BSA (m2): 2.02 m2BP (mm Hg): 93/45HR (bpm): 62Status: InpatientDate/Time: at 22:35Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Patient is on phenylephrine 0.5 mcg/kg/minLEFT ATRIUM: Mild LA enlargement. FINDINGS: Since , the endotracheal tube and orogastric tubes have been removed. Normal ascending aortadiameter. No PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: The patient appears to be in sinus rhythm. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness and cavity size. FINDINGS: Grayscale and Doppler son of bilateral subclavian vein, right internal jugular, axillary, brachial, basilic and cephalic veins were performed. There is abnormal septalmotion/position consistent with right ventricular pressure/volume overload.The aortic valve leaflets (3) are mildly thickened. The right ventricular cavity is dilated withmoderate global free wall hypokinesis. Moderate global RV free wall hypokinesis.Abnormal septal motion/position consistent with RV pressure/volume overload.AORTA: Normal aortic diameter at the sinus level. The lungs show moderate bibasilar atelectasis and a right-sided chest tube terminate in the apex. TECHNIQUE: Upper extremity ultrasound with Doppler. COMPARISONS: Fluoroscopic nasointestinal tube placement dated , CT chest and abdomen dated . | 45 | [
{
"category": "Radiology",
"chartdate": "2189-08-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1206236,
"text": " 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for intrapulmonary process\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 yM s/p fall from 15 feet, discovered to have non-operative SAH/IVH,\n bilateral rib fractures and hemoperitoneum s/p splenectomy and hepatorrhaphy\n REASON FOR THIS EXAMINATION:\n please evaluate for intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male status post fall from 15 feet. Nonoperative\n subarachnoid and intraventricular hemorrhages, bilateral rib fractures and\n hemoperitoneum status post splenectomy. Interval evaluation.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Multiple prior examinations, most recent dated .\n\n FINDINGS: As compared to the prior examination, lung volumes remain low with\n bibasilar opacities which could represent atelectasis, contusion or\n hemorrhage. Significant subcutaneous emphysema remains and somewhat obscures\n the right hemithorax; however, no significant residual right pneumothorax is\n seen. Right-sided chest tube is unchanged in position. Endotracheal tube and\n esophageal catheter coursing inferior to the diaphragm with tip out of view of\n the radiograph are unchanged. A left-sided central venous catheter is in\n place with tip near the superior cavoatrial junction. There are several\n right-sided rib fractures.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-18 00:00:00.000",
"description": "O PORTABLE ABDOMEN IN O.R.",
"row_id": 1206001,
"text": " 4:04 PM\n PORTABLE ABDOMEN IN O.R. Clip # \n Reason: CK FOR MISSING SPONGE\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 1:22 PM\n No sponge in the abdomen.\n\n PFI VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluation for retained foreign body during operation.\n\n FINDINGS: Three frontal views of the abdomen as well as the radiograph of the\n suspected foreign object were obtained. No foreign object is seen within the\n abdomen.\n\n IMPRESSION: No evidence of retained foreign object.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-18 00:00:00.000",
"description": "O PORTABLE ABDOMEN IN O.R.",
"row_id": 1206002,
"text": ", J. TSICU 4:04 PM\n PORTABLE ABDOMEN IN O.R. Clip # \n Reason: CK FOR MISSING SPONGE\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n PFI REPORT\n No sponge in the abdomen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-21 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1206452,
"text": " 12:00 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: e/f DVT\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p splenectomy, intubated, with difficulty oxygenating\n REASON FOR THIS EXAMINATION:\n e/f DVT\n ______________________________________________________________________________\n WET READ: SPfc FRI 2:33 PM\n no DVT in either lower extremity\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Poor oxygenation and question of deep venous thrombosis.\n\n COMPARISON: None available.\n\n FINDINGS: Waveforms in the common femoral veins are symmetric bilaterally\n with appropriate responses to Valsalva maneuvers. In both lower extremities,\n the common femoral, proximal greater saphenous, superficial femoral and\n popliteal veins are normal with appropriate compressibility, wall-to-wall flow\n on color Doppler analysis and response to waveform augmentation. Wall-to-wall\n flow and compressibility is also present in the posterior tibial and peroneal\n veins bilaterally.\n\n IMPRESSION: No deep venous thrombosis in either lower extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-18 00:00:00.000",
"description": "RO ELBOW (AP, LAT & OBLIQUE) RIGHT IN O.R.",
"row_id": 1206014,
"text": " 5:38 PM\n ELBOW (AP, LAT & OBLIQUE) RIGHT IN O.R.; UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT IN O.R.Clip # \n Reason: ORIF RIGHT ELBOW\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ORIF right elbow.\n\n RIGHT ELBOW, TWO VIEWS.\n\n Fluoroscopic assistance provided to the surgeon in the OR without the\n radiologist present. Two spot views obtained. These show hardware in\n relation to a proximal ulnar fracture or osteotomy site. No fluoro time\n recorded on the electronic requisition. Correlation with real-time findings\n and when appropriate, conventional radiographs is recommended for full\n assessment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-25 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1206951,
"text": " 10:57 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: please evaluate gallbladder, cbd, biloma\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with history of liver laceration and splenectomy now with\n elevated tbili and dbili\n REASON FOR THIS EXAMINATION:\n please evaluate gallbladder, cbd, biloma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of liver laceration and splenectomy with elevated\n bilirubin. Please assess for biliary pathology.\n\n TECHNIQUE: Complete abdominal ultrasound.\n\n COMPARISONS: CT torso from .\n\n FINDINGS: The liver is normal aside from scattered areas of increased\n echogenicity which could reflect focal areas of fatty deposition. No focal\n lesions are seen. There is no intrahepatic biliary ductal dilatation. The\n common bile duct is not dilated measuring 4-5 mm. The gallbladder is\n surgically absent. Trace perihepatic free fluid is seen. The pancreas is not\n well assessed due to overlying bowel gas. The patient is status post\n splenectomy with complex fluid likely hematoma in the splenectomy bed as\n expected. There is no hydronephrosis.\n\n IMPRESSION:\n 1. No evidence of biliary pathology with normal common and intrahepatic\n biliary ducts. Status post cholecystectomy.\n 2. Status post splenectomy with hematoma in the splenectomy bed and trace\n perihepatic free fluid.\n 3. Patchy areas of increased echogenicity in liver could reflect focal fatty\n deposition.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-24 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 1206830,
"text": " 2:58 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place nasal dobhoff post-pyloric\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n Contrast: OPTIRAY Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old male with non-operative SAH/IVH, bilateral rib fractures and\n hemoperitoneum s/p splenectomy and hepatorrhaphy now s/p packing removal and\n abdominal closure now with ARDS and GNR bacteremia\n REASON FOR THIS EXAMINATION:\n please place nasal dobhoff post-pyloric\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old man with intracerebral hemorrhage and multiple traumatic\n visceral injuries presents for post-pyloric advancement of orogastric Dobhoff\n tube under fluoroscopic guidance.\n\n COMPARISONS: CT abdomen dated .\n\n FINDINGS: The patient presented with a standard orogastric tube and an\n orogastric Dobhoff tube whose tip was found to be in the proximal duodenum.\n Using a wire and under direct fluoroscopic visualization, the Dobhoff tube was\n advanced around the C-loop of the duodenum. The wire was removed and a small\n amount of barium was introduced, which confirmed the location of the tip in\n the small bowel, in the right lower quadrant of the abdomen. The prior CT\n confirmed that he possessed a jejunum that descended to the right of midline.\n\n IMPRESSION: Successful post-pyloric advancement of the orogastric Dobhoff\n tube.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1206556,
"text": " 6:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f intrapulmonary process\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p 5 feet, w/ liver lac, s/p splenectomy, intubated -\n difficulty oxygenating\n REASON FOR THIS EXAMINATION:\n e/f intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post fall, liver laceration, status post splenectomy,\n intubation, rule out intrapulmonary process.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices, including the right-sided chest tube are in unchanged position. The\n soft tissue gas collections in the right chest wall have decreased in extent.\n There is no appreciable pneumothorax or pneumofluidothorax. Known and\n unchanged right rib fractures. Minimally increasing areas of atelectasis at\n the right and left lung base. Unchanged size of the cardiac silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-20 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1206366,
"text": " 8:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?ARDS\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man intubated w/ worsening saturations\n REASON FOR THIS EXAMINATION:\n ?ARDS\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation with possible ARDS.\n\n FINDINGS: In comparison with the study of earlier in this date, the right\n chest tube remains in place and there is no evidence of pneumothorax. Other\n monitoring and support devices are unchanged. Extensive subcutaneous gas\n about the lower right chest wall and upper abdomen has decreased somewhat.\n\n Continued opacification in the retrocardiac region suggestive of substantial\n collapse of the left lower lobe. Low lung volumes may account for some of the\n prominence of pulmonary vessels, though some elevated pulmonary venous\n pressure should be considered. Blunting of both costophrenic angles persists\n consistent with small effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1206897,
"text": " 5:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f intrapulmonary process and pneumothorax\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p traumatic fall, w/ pneuthorax s/p CT on water seal\n REASON FOR THIS EXAMINATION:\n e/f intrapulmonary process and pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male, status post traumatic fall with pneumothorax\n and chest tube placement. Interval evaluation.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Multiple prior examinations, most recent dated .\n\n FINDINGS: The lung volumes remain low with bibasilar atelectasis which may be\n minimally increased on this exam. No pneumothorax is seen. Small right\n pleural effusion may be present. The heart size is normal. Right-sided\n central line reaches the superior cavoatrial junction. Endotracheal tube is\n in standard position. An esophageal catheter courses inferior to the\n diaphragm with tip out of view of the radiograph. Multiple right-sided rib\n fractures are again seen. A small amount of subcutaneous emphysema in the\n right lateral chest wall remains.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-21 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1206484,
"text": " 2:46 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: e/f intraabdominal abscess\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p fall, w/ SAH/ICH, liver lac, s/p splenectomy, rib fx w/\n leukocytosis\n REASON FOR THIS EXAMINATION:\n e/f intraabdominal abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall with subarachnoid hemorrhage and liver laceration with\n leukocytosis.\n\n TECHNIQUE: Multidetector CT imaging was performed from the thoracic inlet\n through to the pubic symphysis during intravenous contrast administration.\n Initial non-contrast imaging of the chest was also performed. Sagittal and\n coronal reformatted images were generated.\n\n CT OF THE CHEST WITH AND WITHOUT CONTRAST, FINDINGS: Study is compared to the\n prior exam of . Since the prior study, there has been marked\n reduction in the right-sided pneumothorax, only a small residual anterior\n pneumothorax remains. Additionally, the extent of mediastinal shift due to a\n prior pneumothorax has decreased as well. There remains a moderate amount of\n subcutaneous air tracking throughout the entire right anterior chest and right\n flank, inferiorly all the way to the pubic symphysis. This, however, has\n decreased compared to the prior exam.\n\n Endotracheal tube and NG tube are noted. Mild atherosclerotic disease of the\n aorta, no hilar, mediastinal, or axillary adenopathy of significance. The\n pulmonary parenchyma demonstrates patchy infiltrates involving the left upper\n lobe, right middle lobe, and lower lobes. In addition, there is consolidation\n versus collapse involving portions of both lower lobes, essentially unchanged\n compared to the prior exam.\n\n The bony structures demonstrate extensive right-sided lateral and posterior\n rib fractures.\n\n CT OF THE ABDOMEN WITH CONTRAST, FINDINGS: Again seen is a heterogeneous\n enhancement involving the liver consistent with hepatic contusion, there is no\n subcapsular hemorrhage or extension of the heterogeneous low-density areas to\n the capsule to suggest actual fracture. The portal vein remains patent, the\n biliary tree is not dilated. The overall appearance is similar to the prior\n exam. The patient is status post splenectomy, expected fluid within the\n splenic bed, no definite rim enhancement. The pancreas, adrenal glands, and\n kidneys show no acute abnormalities and no change compared to the prior study.\n Ill-defined density (series 3B, image 97), just to the left of the midline may\n represent a small area of fat necrosis. No free air, visualized loops of\n large and small bowel appear grossly normal.\n (Over)\n\n 2:46 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: e/f intraabdominal abscess\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF THE PELVIS WITH CONTRAST, FINDINGS: Bladder wall thickening and\n associated prostatic enlargement. Pelvic assessment is mildly limited due to\n beam hardening artifact from a left hip replacement. There is sigmoid\n diverticulosis, there is no definite free fluid, IVC filter is identified,\n there is atherosclerotic disease. There is subcutaneous edema, potentially\n from fluid overload. Small amount of subcutaneous air tracking inferiorly,\n some anterior and likely due to prior surgery.\n\n IMPRESSION:\n 1. Given consideration of persistent leukocytosis, findings suggest this to\n be the result of scattered ill-defined pulmonary infiltrates as described as\n well as bibasilar consolidation versus collapse.\n\n 2. Expected fluid in the splenic bed, overall benign appearance.\n\n 3. Hence, no findings within the abdomen or pelvis to explain leukocytosis.\n\n 4. No change in multiple right-sided rib fractures, decrease in subcutaneous\n air, only small residual right pneumothorax remaining with decrease in\n mediastinal shift, decrease in subcutaneous air, no change in hepatic\n contusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-17 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 1205843,
"text": " 3:03 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 15:07 HOURS\n\n HISTORY: Fall from roof.\n\n COMPARISON: Chest CT uploaded from outside institution.\n\n FINDINGS: An endotracheal tube is present and approximately 1.4 cm from the\n carina directed towards the left mainstem bronchus. A nasogastric tube is\n noted with the side hole projecting over the left upper quadrant with the\n distal tip extending off the inferior edge of the radiograph. Portions of the\n chest are excluded by an underlying trauma backboard. The extreme left\n costophrenic angle has been excluded from view. A left subclavian approach\n central line is noted. The distal tip projects over the right atrium. A\n right chest tube is present from a basal entry directed towards the apex. No\n clear visceral pleural line is noted. The prior CT scan demonstrated a\n tension pneumothorax. There is extensive subcutaneous emphysema along the\n lateral right chest wall and extending up into the right neck. There is\n scattered opacification of the included left lung particularly in the\n retrocardiac region. The lung volumes on the right are particularly low but\n otherwise well aerated. The mediastinum is markedly widened. Heart size is\n difficult to assess.\n\n IMPRESSION:\n\n 1. Persistent leftward mediastinal shift/tension pneumothorax despite right\n chest tube as above. No clear visceral pleural line is seen, although the\n patient was imaged in the supine position. Extensive subcutaneous emphysema is\n noted along the lateral right chest wall extending up into the right neck and\n down along the right flank.\n\n 2. Retract endotracheal tube 3 cm for optimal placement.\n\n 3. Wide mediastinum with ill-defined margins. Mediastinal vascular injury\n would not necessarily be excluded on the basis of this examination. However,\n the CT of the aorta has been cleared of injury in the outside hospital chest\n CT.\n\n 4. Ill-defined opacity particularly in the retrocardiac left lower lobe may\n be due to atelectasis, aspiration, or contusion.\n\n Dr. was notified regarding #1 above via phone into the OR at\n approximately 5:45 pm. He indicated he was already aware.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1206650,
"text": " 5:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for improvement in intrapulmonary process\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 yM s/p fall from 15 feet now with non-operative SAH/IVH, bilateral rib\n fractures and hemoperitoneum s/p splenectomy and hepatorrhaphy now s/p packing\n removal and abdominal closure now with ARDS\n REASON FOR THIS EXAMINATION:\n please evaluate for improvement in intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral rib fractures, hemoperitoneum, ARDS, evaluation for\n potential improvement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The monitoring and support devices, including the right-sided chest\n tube are constant. The bilateral basal parenchymal opacities and the\n retrocardiac atelectasis are also unchanged. Unchanged size of the cardiac\n silhouette. The presence of small pleural effusion cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-17 00:00:00.000",
"description": "RP HUMERUS (AP & LAT) RIGHT PORT",
"row_id": 1205866,
"text": " 7:46 PM\n WRIST(3 + VIEWS) RIGHT PORT; ELBOW (AP, LAT & OBLIQUE) RIGHT Clip # \n HUMERUS (AP & LAT) RIGHT PORT\n Reason: ?fracture ?dislocation\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p fall with injury and tenderness on palpation\n REASON FOR THIS EXAMINATION:\n ?fracture ?dislocation\n ______________________________________________________________________________\n WET READ: NATg MON 8:26 PM\n comminuted ulnar olecranon fx, lateral epicondylar avulsion. There appears to\n be gas in the jointspace.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right wrist three views.\n\n CLINICAL HISTORY: 75-year-old man status post fall with injury and tenderness\n on palpitation.\n\n RIGHT HUMERUS: The humerus is intact without acute fractures. Mineralization\n is normal.\n\n RIGHT ELBOW: There is a fracture involving the olecranon with soft tissue gas\n and swelling. This may represent an open fracture. Please correlate\n clinically. There is calcification adjacent to the lateral epicondyle which\n can be seen with sequela of lateral epicondylitis, age indeterminate.\n\n RIGHT WRIST: Images of the right wrist show no signs for acute fractures or\n dislocations. There are degenerative changes of the first CMC and triscaphe\n joints. There is some mild irregularity seen of the distal ulna. There is\n irregularity seen of the head of the fifth metacarpal, which may be sequela of\n old trauma.\n\n IMPRESSION:\n 1. Fracture of the olecranon with gas and soft tissue swelling suggestive of\n an open fracture.\n 2. Calcification adjacent to the lateral epicondyle suggestive of previous\n lateral epicondylitis.\n 3. Degenerative changes of the first CMC and triscaphe joint.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205867,
"text": " 8:03 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?eval for interval change\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p intubation and chest tube placement\n REASON FOR THIS EXAMINATION:\n ?eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:02 P.M. ON \n\n HISTORY: Endotracheal and chest tube placements. Please assess.\n\n IMPRESSION: AP chest read in conjunction with chest and torso CTs earlier in\n the day. Previous moderate-sized right pneumothorax has probably decreased\n with the insertion of a second right apical pleural tube, though substantial\n volume of anteriorly collected pleural air could be present on the supine\n view. A considerable subcutaneous emphysema in the right neck and chest wall\n is comparable to the appearance on the torso CT five hours earlier.\n Pneumomediastinum is more evident on the cross-sectional study. There is no\n appreciable right pleural effusion, there is a moderate degree of right upper\n lobe atelectasis, revealed by upward retraction of the minor fissure below\n consolidated upper lobe. Left lower lobe atelectasis is more substantial.\n There is no appreciable left pleural effusion. Mediastinal assessment is more\n revealing on the recent torso CT, but there is no reason to suspect any\n interval change. Tip of the ET tube is partially obscured by the nasogastric\n tube, which is in standard placement, but it appears to be in standard\n placement as well. Left subclavian line ends in the upper right atrium.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1206783,
"text": " 10:10 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?tube placement\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p dobhoff placement\n REASON FOR THIS EXAMINATION:\n ?tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:10 A.M., \n\n HISTORY: Check Dobbhoff tube placement.\n\n IMPRESSION: AP chest compared to at 10:10 a.m.:\n\n What is probably the tip of the Dobbhoff feeding tube projects over the\n hypopharynx suggesting the tubing is coiled in the patient's mouth. A\n nasogastric drainage tube passes into the stomach and out of view. ET tube is\n in standard placement. Right subclavian line ends close to the superior\n cavoatrial junction. Greater consolidation at the left lung base and improved\n consolidation at the right are probably both areas of atelectasis. Upper\n lungs clear. Heart size top normal, unchanged. Pleural effusion is small, on\n the right. No pneumothorax. Right apical pleural drain in place. Right\n subclavian line ends in the region of the superior cavoatrial junction.\n\n Dr. was paged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1205906,
"text": " 8:01 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? progression of hemorrhage\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p fall with ICH\n REASON FOR THIS EXAMINATION:\n ? progression of hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post fall with ICH, evaluate progression of hemorrhage.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n COMPARISON: .\n\n FINDINGS: Compared to prior, there has been no appreciable change in the\n subarachnoid blood in the left sylvian fissure. Also unchanged is a small\n amount of hyperdense material in the atrium of the left lateral ventricle,\n posterior to the choroid plexus, which likely represents blood. No\n ventriculomegaly. A small area of encephalomalacia in the right frontal lobe,\n underlying a small surgical defect in the calvarium, is again seen.\n\n There is a slight increase in the size of the left parietal scalp soft tissue\n swelling.\n\n There is extensive sinus disease. There is near complete opacification of\n ethmoidal sinuses, mild mucosal thickening of the frontal sinuses and fluid\n levels with mucosal thickening in the maxillary sinuses. Sclerosis of the\n right maxillary sinus wall indicates chronic sinusitis. There is fluid in the\n nasopharynx and nasal cavity.\n\n There has been a decrease in subcutaneous emphysema in the imaged upper\n posterior neck.\n\n IMPRESSION:\n 1. No change in left subarachnoid hemorrhage. No change in apparent small\n focus of blood in the atrium of the left lateral ventricle.\n\n 2. Increased left parietal scalp soft tissue swelling.\n\n 3. Extensive sinus disease. Sclerosis of the right maxillary sinus wall\n indicates chronic sinusitis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1206060,
"text": " 4:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f pleural effusion, consolidation, change in size of pneum\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p polytruama after falling from RV. With high O2 requirement\n REASON FOR THIS EXAMINATION:\n e/f pleural effusion, consolidation, change in size of pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Polytrauma with high oxygen requirement, to assess for change in\n pneumothorax.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Right chest tube is again seen and there may be a\n tiny apical pneumothorax. Substantial subcutaneous emphysema is seen along\n the lower right chest and upper abdomen, along with multiple rib fractures.\n Relatively low lung volumes persist.\n\n There is increasing opacification at the right base. This could represent\n some combination of atelectasis and either pneumonia or pulmonary contusion or\n hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1206789,
"text": " 12:29 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? tube placement\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p dobhoff placement\n REASON FOR THIS EXAMINATION:\n ? tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male with recent fall. Evaluation status post\n repositioning of Dobbhoff tube.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Radiographs dated and .\n\n FINDINGS: A Dobbhoff tube has now been repositioned and courses inferior to\n the diaphragm with tip in the region of the gastric antrum. A second\n esophageal catheter is unchanged, coursing inferior to the diaphragm with tip\n out of view of the radiograph. Endotracheal tube is in standard position.\n Right-sided chest tube is in place. A right-sided subclavian catheter reaches\n the low SVC.\n\n Lung volumes remain low with bibasilar atelectasis. Small right pleural\n effusion is present. Effusion, if any, is trace on the left. No pneumothorax\n is seen. Multiple right rib fractures are present. Chest wall subcutaneous\n emphysema is decreased.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-23 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1206685,
"text": " 11:50 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for r subclavian\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p central line\n REASON FOR THIS EXAMINATION:\n eval for r subclavian\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post central line placement, followup.\n\n COMPARISON: , 5:38 a.m.\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n new right subclavian central venous access line. The course of the line is\n unremarkable, the tip of the line projects over the inflow tract of the right\n atrium, it could be pulled back by approximately 2 cm to ensure position in\n the vena cava.\n\n There is no evidence of complications, notably no pneumothorax. Otherwise, no\n relevant changes are seen. The other monitoring and support devices are in\n constant position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205899,
"text": " 5:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p intubation and NGT placement\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:18 A.M. ON \n\n HISTORY: Evaluate tube placement.\n\n IMPRESSION: AP chest compared to at 2:00 p.m.\n\n One right apical pleural tube remains. Any residual right pneumothorax is\n small. Subcutaneous emphysema in the right chest wall and neck has improved\n substantially, as have appearance of atelectasis in the right upper lobe, and\n left lower lobe. Atelectasis in the right lower lobe is new, comparable in\n severity to that on the left. ET tube is in standard placement, left\n subclavian line ends in the upper right atrium within 2 cm of the estimated\n location of the superior cavoatrial junction. Nasogastric tube passes far\n into the stomach and out of view. The multiple right rib fractures are only\n partially imaged. Healed left posterior rib fractures are noted in the upper\n hemithorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1206748,
"text": " 4:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?eval for acute change\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p fall with multiple injuries, not extubating\n REASON FOR THIS EXAMINATION:\n ?eval for acute change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:03 A.M. :\n\n HISTORY: Multiple injuries after a fall.\n\n IMPRESSION: AP chest compared to through 11:\n\n Compared to :55 a.m., moderate right basal atelectasis has\n improved, small right pleural effusion has decreased, but there is greater\n infrahilar opacification in the left lower lobe which could be either\n pneumonia or atelectasis. The upper lungs are clear. Cardiomediastinal and\n hilar silhouettes are unremarkable. ET tube is in standard placement,\n nasogastric tube passes below the diaphragm and out of view. Left central\n venous line has been removed. Right PIC line ends approximately 4.5 cm below\n the anticipated location of the superior cavoatrial junction. Right apical\n pleural tube unchanged in position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-18 00:00:00.000",
"description": "O ABD (SINGLE VIEW ONLY) IN O.R.",
"row_id": 1206015,
"text": " 5:42 PM\n ABD (SINGLE VIEW ONLY) IN O.R.; ABDOMINAL FLUORO WITHOUT RADIOLOGISTClip # \n Reason: ABDOMEN WASHOUT,CLOSURE AND IVC FILTER\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdomen washout, placement of IVC filter.\n\n COMPARISON: Scout abdominal radiographs taken during the procedure.\n\n FINDINGS: Two hard copies obtained during the procedure were sent to\n radiology for evaluation. A nasogastric tube is seen with the side port and\n the tip ending likely at the level of the stomach. Multiple surgical clips\n are seen overlying the midline, and a guide wire is seen tracking along the\n right aspect of the lumbar spine and the right pelvis, likely in the inferior\n vena cava. Degenerative changes of the spine are noted.\n\n IMPRESSION: No gross abnormalities are noted in these limited views obtained\n during the procedure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-17 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1205849,
"text": " 3:33 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: pls evaluate aortic arch\n Contrast: OPTIRAY Amt: 130CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with fall from roof, unequal BPs\n REASON FOR THIS EXAMINATION:\n pls evaluate aortic arch\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JEKh MON 4:50 PM\n chest:\n 1. 50% R anterior PTX w/ mediastinal shift and compressive effects on both\n lungs; R chest tube enters low and is oriented in posterior pleural space\n (away from PTX).\n 2. no L PTX.\n 3. no aortic or injury.\n 4. extensive R chest wall emphysema.\n 5. R posterolateral rib fx ; L posterolateral rib fx ; R clavicle fx.\n\n abdomen/pelvis:\n 1. worsening hepatic and splenic lacerations w/ growing perihepatic and\n perisplenic hematomas - active extrav around spleen; small amt blood tracking\n along B paracolic gutters.\n 2. prominent R adrenal gland - ? hematoma.\n 3. no free intraabdominal air.\n 4. extensive R abd/flank wall emphysema extending into R groin; early R flank\n hematoma.\n 5. no spine or pelvic fx.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old male with fall off roof of RV.\n\n STUDY: CT of the torso with contrast; 130 mL of Optiray intravenous contrast\n was given without adverse reaction or complication. Coronal and sagittal\n reformatted images were also generated.\n\n COMPARISON: Torso CT from , from an outside hospital at\n 1304.\n\n FINDINGS:\n\n CHEST: The patient is intubated with the tube terminating in the mid trachea.\n There is a pneumothorax involving 50% of the right hemithorax and is situated\n mostly anteriorly. A chest tube placed on the right exists in the posterior\n pleural space, but does not come in contact with this pneumothorax. There is\n severe mass effect on the right lung, mediastinum and left lung, consistent\n with tension pneumothorax. Additionally, extensive pneumomediastinum and\n pneumopericardium is noted. Both lungs demonstrate extensive atelectasis\n primarily in their lower lobes. The heart shows no pericardial effusion.\n There is no mediastinal hematoma. The aorta demonstrates no evidence of\n (Over)\n\n 3:33 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: pls evaluate aortic arch\n Contrast: OPTIRAY Amt: 130CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n dissection. There is no contrast extravasation. Extensive chest wall\n emphysema is demonstrated.\n\n ABDOMEN: Multiple liver lacerations are demonstrated in segments V, VI, VII\n and VIII with surrounding dense fluid around the liver and tracking along the\n right paracolic gutter. A single focus of peripheral contrast blush is\n demonstrated in segment VIII (2; 41), concerning for active extravasation.\n This appearance appears worse and has progressed from prior CT.\n\n Multiple splenic lacerations are demonstrated with a growing surrounding\n splenic hematoma. Additionally, multiple areas of contrast blush are noted,\n concerning for active extravasation. This fluid tracks along the left\n paracolic gutter. This too represents an increase from prior study.\n\n Thickening of the head of the right adrenal gland is compatible with hematoma.\n\n The kidneys enhance with and excrete contrast symmetrically. There are no\n perinephric fluid collections. Pancreas appears unremarkable. The small and\n large intestine show no evidence of obstruction or wall thickening. There is\n no free air. The abdominal aorta is intact.\n\n Continued subcutaneous emphysema and a developing right flank hematoma are\n demonstrated along the right abdominal wall.\n\n PELVIS: The bladder contains locules of gas and a Foley balloon. The\n prostate and rectum appear unremarkable. There is no free fluid or\n lymphadenopathy. Gas tracking along the right abdominal wall tracks down into\n the right groin.\n\n BONES: Multiple segmental fractures are demonstrated in the right\n posterolateral ribs from the third rib through the twelfth rib; there is\n additionally a fracture of the right clavicle. Multiple posterolateral rib\n fracture is also noted in the left ribs 9 through 12 although they appear to\n be older in age. No acute left rib fracture is seen. No spinal fracture is\n demonstrated. The sternum is intact. The pelvis is intact. A total hip\n arthroplasty on the left is in place without evidence of periprosthetic\n fracture or loosening.\n\n IMPRESSION:\n 1. Right tension pneumothorax; right chest tube and posterior pleural space,\n not evacuating this pneumothorax; mediastinal deviation and compression of the\n right and left lungs are concerning for tension pneumothorax.\n Pneumomediastinum and pneumopericardium is also present along with extensive\n right chest and abdominal wall subcutaneous emphysema extending into the\n groin.\n\n (Over)\n\n 3:33 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: pls evaluate aortic arch\n Contrast: OPTIRAY Amt: 130CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Extensive hepatic and splenic lacerations with growing perihepatic and\n perisplenic hematomas with areas concerning for active extravasation.\n\n Points 1 and 2 were called to OR 15 at the time of dictation to make the\n operating team aware.\n\n 3. Multiple segmental rib fractures on the right; the potential for flail\n chest exists. Right clavicular fracture.\n\n 4. Right adrenal hematoma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1205850,
"text": " 4:02 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval interval change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with trauma\n REASON FOR THIS EXAMINATION:\n Eval interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JEKh MON 4:35 PM\n 1. persisting L SAH and IVH, unchanged from OSH @ 12:52 pm; no herniation.\n 2. subcut gas in post neck soft tissues.\n 3. no acute fx.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old male with trauma.\n\n STUDY: CT of the head without contrast; coronal and sagittal reformatted\n images were also generated.\n\n COMPARISON: , at 12:52 p.m. from an outside hospital.\n\n FINDINGS: There continues to be a small amount of subarachnoid blood in the\n left sylvian fissure and sulci along the left hemisphere, similar in\n appearance to prior study. Additionally, there continues to be dense material\n laying in the occipital of the left lateral ventricle, similar in\n appearance to prior study. Encephalomalacia is noted in the right frontal\n lobe, compatible with prior infarct. Otherwise, there is no new area of\n intracranial hemorrhage. There is no edema or mass effect. There is no\n fracture. The visualized portion of the paranasal sinuses demonstrate\n thickened right maxillary sinus walls, and opacified right maxillary sinus,\n compatible with a chronic process. The mastoid air cells are clear. Gas\n tracking through the posterior right neck soft tissues is better evaluated on\n subsequent torso CT.\n\n IMPRESSION: Unchanged appearance of left subarachnoid blood and\n intraventricular hemorrhage without evidence of new hemorrhage or mass effect.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1206859,
"text": " 4:57 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: e/f pneumothorax\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with h/o right pneumothorax, set chest tube to water seal today\n REASON FOR THIS EXAMINATION:\n e/f pneumothorax\n ______________________________________________________________________________\n WET READ: AJy MON 7:28 PM\n\n no PTX with right chest tube on water seal. No change from study earlier the\n same day.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of right pneumothorax, chest tube on the waterseal.\n\n COMPARISON: , 1229.\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. No pneumothorax is visible in the right lung. The right chest tube\n is in unchanged position. Unchanged monitoring and support devices.\n Unchanged displaced right rib fractures.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1207754,
"text": " 4:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?eval for interval change\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p intubation\n REASON FOR THIS EXAMINATION:\n ?eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY.\n\n COMPARISON: .\n\n FINDINGS: Tip of endotracheal tube terminates 2.5 cm above the carina, and\n nasogastric tube and feeding tubes course below the diaphragms.\n Cardiomediastinal contours are unchanged. Persistent bilateral lower lobe\n opacities, left greater than right with adjacent moderate left and small right\n pleural effusions. Numerous right-sided rib fractures are again visualized,\n but there is no evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-09-01 00:00:00.000",
"description": "RP ELBOW (AP, LAT & OBLIQUE) RIGHT PORT",
"row_id": 1208156,
"text": " 12:41 PM\n ELBOW (AP, LAT & OBLIQUE) RIGHT PORT Clip # \n Reason: pls eval fracture age\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75M s/p R ORIF\n REASON FOR THIS EXAMINATION:\n pls eval fracture age\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT ELBOW\n\n CLINICAL HISTORY: Status post right open reduction internal fixation. Please\n evaluate fracture age.\n\n COMPARISON: .\n\n FINDINGS: There has been interval open reduction and internal fixation across\n the comminuted olecranon fracture with two K-wires and two figure-of-eight\n cerclage wires. The fragments are in near-anatomic alignment, with persistent\n 3-mm gap between the main fracture fragments. There has been interval\n resolution of the soft tissue gas. There is persistent soft tissue swelling\n about the elbow. There has been interval removal of the mineralization\n adjacent to the lateral epicondyle.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-09-04 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1208643,
"text": ", J. CC6A 1:56 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: R/O aspiration\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with TBI after fall plus multiple other injuries\n REASON FOR THIS EXAMINATION:\n R/O aspiration\n ______________________________________________________________________________\n PFI REPORT\n Aspiration with nectar thick and honey-thick liquids. Thinner preparations\n not attempted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1207988,
"text": " 2:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate dobhoff and line placement\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 M s/p fall from 15 feet now with non-operative SAH/IVH, bilateral rib\n fractures and hemoperitoneum s/p splenectomy and hepatorrhaphy course c/b ARD\n and now contained gastric perf s/p IR drainage\n REASON FOR THIS EXAMINATION:\n please evaluate dobhoff and line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate Dobbhoff tube and line placement.\n\n COMPARISON: .\n\n AP UPRIGHT VIEW OF THE CHEST: Endotracheal tube terminates 3.6 cm above the\n carina. Nasogastric tube follows a normal course on the left side port just\n below the GE junction. A drainage catheter projects in the left upper\n quadrant, unchanged. The Dobbhoff tube terminates in the mid abdomen,\n probably within the third portion of the duodenum. Right-sided subclavian\n central venous catheter terminates in the right atrium.\n\n There is no pneumothorax. Retrocardiac opacity is unchanged, probably\n atelectasis. New rounded right basilar opacity is concerning for developing\n pneumonia or aspiration. There are small bilateral pleural effusions. Right\n clavicular and multiple right-sided rib fractures are better evaluated on\n recent CT chest of . .\n\n IMPRESSION: Lines and tubes as above. Right basilar opacity concerning for\n developing pneumonia. Close interval follow up recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-09-08 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1209199,
"text": " 2:12 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval aspiration risk\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p fall, TBI\n REASON FOR THIS EXAMINATION:\n eval aspiration risk\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old man status post fall and traumatic brain injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in\n conjunction with the speech and swallow division. Multiple consistencies of\n barium were administered.\n\n FINDINGS: Barium passes freely through the oropharynx and esophagus without\n evidence of obstruction. There was minimal penetration of nectar thick and\n thick liquids with clearance upon coughing and swallowing. There was frank\n aspiration of thin liquids. For details, please refer to speech and swallow\n division note in OMR.\n\n IMPRESSION: Penetration with eventual clearance of nectar thick and thick\n consistencies. Frank aspiration of thin liquids.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-09-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1208321,
"text": " 11:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate NGT position\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with gastric perforation s/p clipping now s/p NGT placement\n REASON FOR THIS EXAMINATION:\n please evaluate NGT position\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Gastric perforation, NG tube placement.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n NG tube tip is in the right lower lobe bronchus and should be repositioned.\n Heart size and mediastinal silhouettes are unchanged. Bibasilar atelectasis\n are unchanged.\n\n Right central venous line tip is in the right atrium and should be pulled back\n approximately 3 cm to secure its position proximal to the cavoatrial junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-09-04 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1208642,
"text": " 1:56 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: R/O aspiration\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with TBI after fall plus multiple other injuries\n REASON FOR THIS EXAMINATION:\n R/O aspiration\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TXPb FRI 2:32 PM\n Aspiration with nectar thick and honey-thick liquids. Thinner preparations\n not attempted.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old man with traumatic brain injury after fall plus multiple\n other injuries. Rule out aspiration.\n\n COMPARISON: None.\n\n TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in\n conjunction with the speech and swallow division. Multiple consistencies of\n barium were administered.\n\n FINDINGS: Barium passes freely through the oropharynx and esophagus without\n evidence of obstruction. The barium was followed down to the GE junction and\n there was no gross evidence of stricture or leak. Initially, nectar thick was\n attempted and the patient aspirated. Then honey thick was attempted patient;\n the patient also aspirated this. The study was ceased at this point. For\n details, please refer to speech and swallow division note in OMR.\n\n IMPRESSION: Aspiration with nectar thick and honey-thick liquids. Thinner\n preparations not attempted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-25 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1207055,
"text": " 11:05 PM\n PORTABLE ABDOMEN Clip # \n Reason: please evaluate NGT and dobhoff position\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 M s/p fall from 15 feet now with non-operative SAH/IVH, bilateral rib\n fractures and hemoperitoneum s/p splenectomy and hepatorrhaphy now s/p packing\n removal and abdominal closure now with ARDS and GNR bacteremia and NGT in\n duodenum\n REASON FOR THIS EXAMINATION:\n please evaluate NGT and dobhoff position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 75-year-old man status post fall with multiple traumatic injuries\n with jejunal feeding tube and nasogastric tube in duodenum with obstructive\n picture. Please evaluate location of NG tube placement.\n\n COMPARISONS: Abdominal radiographs dated at 1647 hours.\n\n FINDINGS: The Dobbhoff tube is within the same location and the malrotated\n jejunum in the right lower quadrant. An additional tube seems to run along\n the tract of Dobbhoff and is presently being located with its tip in the\n stomach. The study is otherwise unchanged with incidentally noted skin\n staples in the right abdomen, a stable small right pleural effusion, and type\n G2 IVC filter in place.\n\n IMPRESSION: Dobbhoff tube unchanged in position, NG tube with tip in the\n stomach.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2189-08-17 00:00:00.000",
"description": "Report",
"row_id": 91765,
"text": "PATIENT/TEST INFORMATION:\nIndication: Right ventricular function.\nHeight: (in) 71\nWeight (lb): 181\nBSA (m2): 2.02 m2\nBP (mm Hg): 93/45\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 22:35\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPatient is on phenylephrine 0.5 mcg/kg/min\nLEFT ATRIUM: Mild LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Dilated RV cavity. Moderate global RV free wall hypokinesis.\nAbnormal septal motion/position consistent with RV pressure/volume overload.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal descending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. .\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Left pleural\neffusion.\n\nConclusions:\nThe left atrium is mildly dilated. The left atrium is elongated. No atrial\nseptal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses and cavity size are normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). The right ventricular cavity is dilated with\nmoderate global free wall hypokinesis. There is abnormal septal\nmotion/position consistent with right ventricular pressure/volume overload.\nThe aortic valve leaflets (3) are mildly thickened. There is no aortic valve\nstenosis. Trace aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. The pulmonary artery\nsystolic pressure could not be determined. There is no pericardial effusion.\n\n\nIMPRESSION: Preserved left ventricular systolic function. Dilated right\nventricle. Moderately depressed right ventricular systolic function\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-28 00:00:00.000",
"description": "DRAINAGE HEMATOMA/FLUID",
"row_id": 1207546,
"text": " 11:21 AM\n DRAINAGE HEMATOMA/FLUID; CT GUIDED NEEDLE PLACTMENT Clip # \n MOD SEDATION, FIRST 30 MIN.\n Reason: drainage of fluid in LUQ\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ********************************* CPT Codes ********************************\n * DRAINAGE HEMATOMA/FLUID CT GUIDED NEEDLE PLACTMENT *\n * MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p splenectomy w/ contained gastric leak\n REASON FOR THIS EXAMINATION:\n drainage of fluid in LUQ\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old man status post splenectomy with contained gastric\n leak, drainage of fluid within left upper quadrant.\n\n COMPARISON: Comparison is made to previous CT of .\n\n OPERATORS: Dr. (radiology fellow) and Dr. \n (attending radiologist) performed the procedure. Dr. , was\n present throughout the procedure.\n\n PROCEDURE: Following a discussion of the risks, benefits and alternatives to\n the procedure with the patient's wife informed consent was obtained by phone\n witnessed by Dr. . Following this, the patient was transported\n to the CT suite and placed in supine position. A limited CT scan was\n performed prior to drainage for localization purposes. A preprocedure timeout\n was performed using three patient identifiers. The patient was then turned so\n that his left side was slightly elevated.\n\n The left side of the abdomen was prepped and draped in usual sterile fashion.\n 10 mL of 1% lidocaine was infiltrated into the skin, subcutaneous tissue and\n into the peritoneum. An 18-gauge needle was advanced into the left\n side collection under CT guidance. A guidewire was then placed and an 8\n French pigtail catheter was advanced into the collection. Post-procedure CT\n showed that the pigtail catheter was in satisfactory position within the\n collection. 10 mL of dark brown bilious fluid was aspirated and sent for\n microbiological analysis. 60 mL of dilute nonionic contrast was injected into\n the collection. CT sinogram performed post-procedure demonstrated\n communication between the gastric fundus posterolaterally and the collection\n consistent with a gastric leak (5:14). A three way catheter and drainage bag\n were attached to the 8fr pigtail drain and 50mls of dark brown bile stained\n fluid drained out.\n\n Moderate sedation was provided by the patient's TSICU nurse. Please see\n separate nursing notes for medication details. The patient's hemodynamic\n parameters were monitored throughout. The patient remained hemodynamically\n stable throughout.\n\n (Over)\n\n 11:21 AM\n DRAINAGE HEMATOMA/FLUID; CT GUIDED NEEDLE PLACTMENT Clip # \n MOD SEDATION, FIRST 30 MIN.\n Reason: drainage of fluid in LUQ\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There were no immediate complications. The patient was transferred back to\n the floor in stable condition.\n\n CT FINDINGS: Limited non-contrast CT performed pre-drainage. There is\n bibasilar consolidation and bibasilar pleural effusions. The bilateral\n pleural effusions have increased slightly from previous CT.\n\n Persistent left upper quadrant collection within the splenectomy bed, which\n has not changed significantly in size measuring approximately 11 x 6 cm. No\n intra-abdominal free air noted. Previous cholecystectomy noted. Both\n kidneys, both adrenal glands and pancreas are unremarkable allowing for lack\n of oral and IV contrast and are better evaluated on the previous CT study. NG\n tube within the stomach. Unchanged appearance of lacerations within segment V\n and IVb. There is bibasilar consolidation and bibasilar pleural effusions.\n The pleural effusions have increased slightly from previous CT.\n\n POST-PROCEDURE CT SINOGRAM: CT performed following injection of 60 mL of\n dilute non-ionic contrast into the left upper quadrant collection. This shows\n communication between the collection and the fundus of the stomach\n posterolaterally(5:14).\n\n IMPRESSION: Technically successful CT-guided drainage of left upper quadrant\n collection with a 8fr drain inserted. A total of 60mls of dark brown bile\n stained fluid was drained initially. CT sinogram demonstrates communication\n between the gastric fundus and left upper quadrant collection consistent with\n a gastric leak. Findings were discussed with referring service at 15:45 on\n by phone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-09-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1208080,
"text": " 5:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubation\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with intubation\n REASON FOR THIS EXAMINATION:\n intubation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: 75-year-old man status post extubation.\n\n TECHNIQUE: Portable upright radiograph of chest. Comparisons were made with\n prior chest radiographs through with the most recent from\n .\n\n FINDINGS: Since , the endotracheal tube and orogastric\n tubes have been removed. Right central line ends at the cavoatrial junction.\n Bilateral lung volumes are low and since there is interval\n development of bilateral diffuse lung opacities and is likely moderate\n pulmonary edema. Increased retrocardiac density on the left side suggesting\n left lower lung atelectasis is overall unchanged. Presence of pleural\n effusion if any bilaterally is indeterminate due to diffuse bilateral opacity.\n Heart size is top normal and stable.\n\n IMPRESSION: Since appearance of bilateral diffuse lung\n opacities is likely moderate pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-25 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1207020,
"text": " 4:48 PM\n PORTABLE ABDOMEN Clip # \n Reason: please evaluate tube placement, evidence of obtructive patte\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 M s/p fall from 15 feet now with non-operative SAH/IVH, bilateral rib\n fractures and hemoperitoneum s/p splenectomy and hepatorrhaphy now s/p packing\n removal and abdominal closure now with ARDS and GNR bacteremia now with TF in\n NGT\n REASON FOR THIS EXAMINATION:\n please evaluate tube placement, evidence of obtructive pattern\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TXPb TUE 6:23 PM\n PFI: Dobbhoff tube and possible secondary nasointestinal tube with tip in the\n small bowel, unchanged in position from prior study.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old man status post fall with multiple traumatic injuries\n with evidence of obstructive pattern. Please evaluate NG tube position.\n\n COMPARISONS: Fluoroscopic nasointestinal tube placement dated , CT chest and abdomen dated .\n\n FINDINGS: Two supine AP views of the abdomen show the previously advanced\n nasointestinal tube in the same location as demonstrated in the fluoroscopic\n image from . The tip is in the jejunum which, due to the\n malrotation of the patient's small bowel lies in the right lower quadrant of\n the abdomen.\n\n IMPRESSION:\n Dobbhoff tube with tip in the small bowel, unchanged in position from prior\n study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-25 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1207021,
"text": ", J. TSICU 4:48 PM\n PORTABLE ABDOMEN Clip # \n Reason: please evaluate tube placement, evidence of obtructive patte\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 M s/p fall from 15 feet now with non-operative SAH/IVH, bilateral rib\n fractures and hemoperitoneum s/p splenectomy and hepatorrhaphy now s/p packing\n removal and abdominal closure now with ARDS and GNR bacteremia now with TF in\n NGT\n REASON FOR THIS EXAMINATION:\n please evaluate tube placement, evidence of obtructive pattern\n ______________________________________________________________________________\n PFI REPORT\n PFI: Dobbhoff tube and possible secondary nasointestinal tube with tip in the\n small bowel, unchanged in position from prior study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-26 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 1207151,
"text": " 1:17 PM\n DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: ?portal vein thrombosis\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with with elevated LFTs and increasingly elevated white count\n REASON FOR THIS EXAMINATION:\n ?portal vein thrombosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): WED 4:46 PM\n PFI:\n\n Dobbhoff tube unchanged in position, NG tube with tip in the stomach.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old man with elevated LFTs and increasing white count,\n evaluate for portal vein thrombosis.\n\n COMPARISON: Liver ultrasound, .\n\n FINDINGS: Note is made that a limited Doppler examination was performed to\n evaluate for portal vein thrombosis. The main, right, and left portal veins\n are patent and demonstrate hepatopetal flow.\n\n IMPRESSION: Patent portal veins.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-26 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 1207152,
"text": ", J. TSICU 1:17 PM\n DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: ?portal vein thrombosis\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with with elevated LFTs and increasingly elevated white count\n REASON FOR THIS EXAMINATION:\n ?portal vein thrombosis\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n Dobbhoff tube unchanged in position, NG tube with tip in the stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1207485,
"text": " 4:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumonia and pneumothorax\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p fall, course c/b pneumonia.\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia and pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male status post fall with hospital course\n complicated by pneumonia. Interval evaluation of the chest.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Multiple prior examinations, most recent dated .\n\n FINDINGS: Lung volumes remain low with bibasilar atelectasis which appears\n improved on the right. Increased on the left could represent atelectasis or\n infection. No pneumothorax is seen. Pleural effusions, if present at all,\n are minimal. The cardiomediastinal silhouette is unchanged. A right-sided\n central venous catheter tip enters the right atrium. An esophageal catheter\n courses inferior to the diaphragm with tip out of view of the radiograph. An\n endotracheal tube is in place with tip approximately 2.4 cm above the carina.\n Multiple right-sided rib fractures are present.\n\n IMPRESSION:\n 1. Increased opacity at the left base could represent atelectasis though\n infection is a possibility.\n\n 2. Right central venous catheter tip in right atrium. This would need to be\n withdrawn 4 cm to ensure positioning in the SVC.\n\n Findings discussed with Dr. at 1:00 pm .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-09-04 00:00:00.000",
"description": "UNILAT UP EXT VEINS US",
"row_id": 1208610,
"text": " 10:01 AM\n UNILAT UP EXT VEINS US Clip # \n Reason: SWELLING, PLEASE ASSESS RUE FOR DVT\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75M asymmetric UE swelling\n REASON FOR THIS EXAMINATION:\n please assess RUE for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Asymmetric upper extremity swelling in the right arm.\n\n COMPARISON: None available.\n\n TECHNIQUE: Upper extremity ultrasound with Doppler.\n\n FINDINGS: Grayscale and Doppler son of bilateral subclavian vein, right\n internal jugular, axillary, brachial, basilic and cephalic veins were\n performed. There is normal compressibility and flow.\n\n IMPRESSION: No evidence of DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1207702,
"text": " 3:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?eval for interval change\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p chest tube pull\n REASON FOR THIS EXAMINATION:\n ?eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: S/P removal of chest tube:\n\n The position of the various support lines and tubes is unchanged since the\n prior chest x-ray. An endotracheal tube is now present, which lies 4 cm from\n the carinal angle.\n\n A drainage catheter is seen in the region of the splenic fossa.\n\n No failure is seen. A right effusion is present. There is loss of the left\n hemidiaphragm suggesting the presence of atelectasis in the left lower lobe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-08-26 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1207200,
"text": " 5:20 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: ?abscess *is currently getting IV hydration for pre-treating\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with increasing WBC today to 35 s/p ex lap on antibiotics for\n board coverage and still spiking fevers\n REASON FOR THIS EXAMINATION:\n ?abscess *is currently getting IV hydration for pre-treating\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 6:49 PM\n 1. Extraluminal location of oral contrast adjacent to the fundus of stomach\n is concerning for a contained leak. No change in the size of a 6 x 10 cm\n splenic bed fluid collection but with new rim enhancement concerning for\n encapsulation. This is amenable to percutaneous drainage.\n\n 2. Multifocal ground-glass opacities could likely represent infection or\n inflammation, possibly related to aspiration.\n\n 3. Numerous right and left-sided rib fractures, right clavicular fracture are\n unchanged.\n\n 4. Decrease in the extent of two liver lacerations.\n\n 5. Appropriate position of an IVC filter and an NJ tube.\n WET READ VERSION #1 AJy WED 9:38 PM\n\n Chest: Right chest tube in place. no significant effusion. no PTX. Bilateral\n dependent lower lobe consolidation is c/w atelectasis. However, scattered\n parenchymal ground glass opacities are concerning for ongoing multifocal\n pneumonia and could account for fever. Heart and mediastinal structures are\n unremarkable. ETT, feeding/NG tubes and vasc caths in expected position.\n multiple right rib fx and right clavicle fx again noted.\n\n Abd/Pelvis: A fluid collection is again seen in the splenic bed. Thin\n peripheral enhancement is more conspicuous than on prior study, though the\n size is unchanged, and there is no air or other associated findings to\n specifically suggest superinfection. Thus, this could simply be\n postoperative, though it is impossible to exclude infection by imaging.\n Heterogeneous liver enhancement again c/w contusion. No focal fluid\n collection to suggest liver abscess. No biliary ductal dilation. s/p CCY.\n Pancreas, adrenals and kidneys unremarkable. No further focal fluid\n collections in the abdomen. Diverticulosis. IVC filter noted without\n associated clot identified.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old man with increasing white blood count up to 35 status\n post exploratory laparotomy on antibiotics for broad coverage and still\n spiking fevers, question abscess.\n\n (Over)\n\n 5:20 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: ?abscess *is currently getting IV hydration for pre-treating\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n COMPARISON: Multiple radiographs, the latest from and a CT\n of the abdomen and pelvis from .\n\n TECHNIQUE: MDCT images were acquired through the chest, abdomen and pelvis\n with IV and oral contrast. Multiplanar reformations were obtained and\n reviewed.\n\n CT OF THE CHEST WITH IV CONTRAST:\n The thyroid gland is unremarkable. There is no axillary or mediastinal\n lymphadenopathy by CT size criteria. A right clavicular fracture and punctate\n hyperdensity posterior to it (2:2) are likely related to recent trauma and\n essentially unchanged compared to the previous examination although the\n subcutaneous emphysema has decreased. The extent of subcutaneous emphysema\n has decreased. The heart and great vessels are unremarkable. There is no\n pericardial effusion present. An ET tube terminates in the mid thoracic\n trachea appropriately. A right subclavian approach central venous catheter\n terminates in the proximal right atrium. The lungs show moderate bibasilar\n atelectasis and a right-sided chest tube terminate in the apex. Mild\n ground-glass opacities in both upper lobes (2:24 and 26) are essentially\n unchanged compared to the previous examination. Peribronchovascular\n ground-glass opacities are also noted in both lower lobes. There are small\n nonhemorrhagic effusions bilaterally.\n\n CT OF THE ABDOMEN WITH IV CONTRAST:\n The liver lacerations, obvious as confluent areas of hypoattenuation in\n segment V and IVb, have decreased in size compared to the previous\n examination. The patient is status post splenectomy. A splenectomy bed fluid\n collection is low density, unchanged from the previous examination measuring 6\n x 10 cm, but shows a new area of rim enhancement likely representing mild\n capsulation. Small amount of oral contrast is noted adjacent to the fundus of\n the stomach. No abdominal free air is present. Both adrenals, both kidneys,\n pancreas are unremarkable. The patient has had a cholecystectomy. The small\n and large bowel loops are unremarkable. Note is made of uncomplicated\n mal-rotation with the fourth part of duodenum not extending up to the ligament\n of Trietz. An NJ tube terminates in the proximal jejunum.\n\n CT OF THE PELVIS WITH IV CONTRAST:\n The rectum, sigmoid colon (with diverticulosis), bladder with a Foley catheter\n in it and prostate gland are unremarkable. No pelvic or inguinal\n lymphadenopathy by CT size criteria is present. A small amount of fluid is\n noted in the left inguinal canal. No pelvic free fluid is present.\n\n OSSEOUS STRUCTURES:\n The visible osseous structures show multilevel degenerative disc and joint\n disease with intervertebral disc space narrowing at L5-S1, anterior osteophyte\n (Over)\n\n 5:20 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: ?abscess *is currently getting IV hydration for pre-treating\n Admitting Diagnosis: S/P FALL;PTX;RIB FRACTURE;SUBARACHNOID HEMATOMA\n Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n formation and subchondral cyst formation along L4-L5. Also noted is a left\n total hip prosthesis.\n\n Fractures of the right-sided ribs including the ninth to twelfth rib (with the\n twelfth rib having a 2-cm butterfly fragment), fractures of the right third,\n fourth, comminuted fracture of the right fifth, sixth, seventh, eighth,\n fracture of the right ninth with a large butterfly fragment are noted. Also\n noted are fractures of the left fourth, tenth and eleventh ribs.\n\n IMPRESSION:\n 1. Extraluminal location of oral contrast adjacent to the fundus of stomach\n is concerning for a contained leak. No change in the size of a 6 x 10 cm\n splenic bed fluid collection which is now better organized and has new rim\n enhancement concerning for abscess. This is amenable to percutaneous\n drainage.\n\n 2. Multifocal ground-glass opacities could likely represent infection or\n inflammation, possibly related to aspiration.\n\n 3. Numerous right and left-sided rib fractures, right clavicular fracture are\n unchanged.\n\n 4. Decrease in the extent of two liver lacerations.\n\n 5. Appropriate position of an IVC filter and an NJ tube.\n\n These findings including the change from the wet read were communicated to the\n surgical intern MD via telephone at 11:54 am on .\n\n\n"
}
] |
12,223 | 189,458 | Patient presented to OSH with anterior STEMI with peak CK 815, and was transferred to for cardiac catheterization, which was significant for the findings detailed above. In particular, it demonstrated LAD and RCA disease. Two Cypher DES were placed in the LAD with good angiographic results. The procedure was complicated by right iliac artery dissection which was successfully treated with stenting. A left iliac artery stent was also placed for iliac artery stenosis. She was admitted to the CCU post-procedure for monitoring. She did well, and was called out to a monitored bed on HD #2. Her medication regimen was optimized. She was continued on ASA and Plavix (started on presentation to OSH). Lopressor and captopril were added, with good control of her blood pressure. These were changed to once daily formulations (Toprol XL and lisinopril) prior to discharge. She was also started on a high dose statin, and lifestyle modification--including tobacco cessation--encourged. Transthoracic echocardiography during hospitalization was significant for an ejection fraction of 50%, with anteroseptal and apical akinesis / hypokinesis (results detailed above). On HD3, she was taken back to the cath lab for intervention on her RCA lesion. However, on access of the right iliac artery, the right iliac stent was noted to be underdeployed. This was dilated. However, on imaging of the coronary arteries, there was noted to be interval occlusion of the OM1 with fresh thrombus. The patient developed chest pain and ventricular bigeminy, and on retrospect, it was felt that thrombus that had developed on the lead wire had embolized to the OM1. Integrillin was started, and the lesion was balloon dilated with resolution of flow, and distal migration of residual thrombus to a very small lower pole OM1. The patient was continued on integrillin for 18 hours post-procedure with a peak CK of 1137 which resolved to 287 at time of discharge. She remained chest pain free following cath and was discharged in good condition. | Trivial mitral regurgitation is seen. DENIES C/O PAIN. There is mildregional left ventricular systolic dysfunction. There is mild symmetric left ventricularhypertrophy. Normal aortic arch diameter.AORTIC VALVE: No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild regional LVsystolic dysfunction. Trivial MR.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is normal in size. DENIES CHEST DISCOMFORT. The mitral valve leaflets are mildlythickened. S/p LAD stent.Height: (in) 64Weight (lb): 226BSA (m2): 2.06 m2BP (mm Hg): 130/70HR (bpm): 74Status: InpatientDate/Time: at 12:24Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH. THERAPEUTIC PTT. DENIES C/O SOB.GI: ABD OBESE, SOFT. There is atrivial/physiologic pericardial effusion. Doubt the presence of effusions on the supine study. Mildly depressed LVEF. The left ventricular cavity size is normal. IMPRESSION: WNL (allowing for supine positioning). DOES NOT FEEL SHE NEEDS IT AT THIS TIME.CV: HR 75 SR NO VEA NOTED. Normal LV cavity size. TVI E/e' >15, suggestingPCWP>18mmHg.LV WALL MOTION: Regional LV wall motion abnormalities include: midanteroseptal - akinetic; anterior apex - hypo; septal apex- akinetic; inferiorapex - hypo; lateral apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. Overall left ventricularsystolic function is mildly depressed. + BOWEL SOUNDS. Sinus rhythm. There is slight prominence of the superior mediastinum which may reflect supine positioning. RIGHT AND LEFT GROIN C%D, NO BLEEDING OR HEMATOMA. BP STABLE 108-109/ 59. COGESTED COUGH, LUNGS CLEAR. Sinus rhythmAnteroseptal infarct - probably acuteProbable lateral infarct - age undeterminedSince previous tracing of , suggestive of lateral myocardial infarct Sinus rhythmPremature ventricular contractionsAnteroseptal infarct - probably acuteLateral T wave changes may be due to myocardial ischemiaSince previous tracing of , ventricular premature complex seen and Qwaves in I and aVL absent Sinus rhythmAnterolateral infarct - age undeterminedSince previous tracing, no significant change Sinus rhythmAnterolateral infarct - age undeterminedSince previous tracing, no significant change AP SUPINE CHEST RADIOGRAPH: The heart size is within normal limits for technique. The pulmonary vascularity is normal without redistribution. Right ventricular chamber size and free wall motion are normal.There is no aortic valve stenosis. Resting regional wall motion abnormalities include mid todistal anteroseptal akinesis and apical akinesis/hypkinesis (apex not fullyvisualized). UPDATE PT. TOL CAPTOPRIL AND LOPRESSOR DOSES.RESP: ON ROOM AIR. Sinus rhythmAnteroseptal infarct - age undeterminedLateral T wave changes may be due to myocardial ischemiaSince previous tracing, more pronounced ST segment elevation in anterior leads- consider acute anteroseptal myocardial infarction NO BM OVERNIGHT. Sinus rhythmAnteroseptal infarct - age undeterminedLateral T wave changes may be due to myocardial ischemiaNo change from previous No changes. REFUSED NICOTINE PATCH. No focal consolidations on the visualized lung fields (left costophrenic angle excluded). FOOT WARM. URINE CLEAR YELLOW. PATIENT/TEST INFORMATION:Indication: STEMI. 45 YR OLD OBESE FEMALE C HTN,HIGH CHOL ,DEPRESSION ,NOW WITH ACUTE ANT MI,KISSING STENT TO LAD,BILATERAL STENTS TO ILIAC ARTERIES ,NEEDS STENT TO RCA MONDAY .HX SMOKER .HAD CP 11PM ,RELIEVED C FRIENDS SL NITRO .REOCCURED 230 AM WENT TO RECEIVED ASA,INTEGRILLIN,PLAVIX LOAD,HEPARIN ,LOPRESSER,NTP PASTE .SR NO ECTOPY .BP STABLE STARTED ON CAPTOPRIL AND LOPRESSER.1NTEGRILLIN 2MIC.BOTH GROINS ONLY MINOR OZZING ,BILATERAL PALP PULSES .BS CL SAT 98 RM AIR .POS BS ,NOT HUNGRY .NO STOOL .VOIDS QS .PT ON PAXIL,HEAVY SMOKER ,STATES NO FAMILY WILL CALL .COOPERATIVE SLEEPING IN NAPS .STABLE AT PRESENT POST AMI,STENT TO LAD,AWAITING INTERVENTION TO RCA SEEMINGLY S SUPPORT SYSTEM .SERIAL CKMONITOR FOR CP,BLEEDINGEMOTIONAL SUPPORT,WILL CONTACT WORK PALP PEDAL PULSES. DRINKING GINGERALE OVERNIGHT.GU: VOIDING ON COMMODE. NURSING PROGRESS NOTE 7P-7AS: "I WANT TO STAY IN THE CHAIR, IT HELPS MY BREATHING"O: NEURO: AWAKE AND ALERT, PLEASANT AND COOPERATIVE. No previous tracing available for comparison. O2 SAT 98%. ON PLAN OF CARE PER CCU TEAM. COMPARISON: There are no prior studies available for comparison. Tissue velocity imaging E/e' iselevated (>15) suggesting increased left ventricular filling pressure(PCWP>18mmHg). MONITOR GROIN FOR BLEEDING. HEPARIN AT 1650 UNITS/HR. ENCOURAGE PO INTAKE, FOLLOW UP WITH SOC SERVICE. MOVING ALL EXTREMITIES. 24 HR I/O (-) ~ 300 CC.A: S/P STEMI WITH KISSING STENTS TO LAD, ILIAC ART. WAITING FOR PCI TO RCA ON MONDAY .P: FOLLOW LYTES, CK, PTT. SITTING IN CHAIR ALL NIGHT, STATES SHE IS COMFORTABLE. | 11 | [
{
"category": "Echo",
"chartdate": "2147-02-10 00:00:00.000",
"description": "Report",
"row_id": 80275,
"text": "PATIENT/TEST INFORMATION:\nIndication: STEMI. S/p LAD stent.\nHeight: (in) 64\nWeight (lb): 226\nBSA (m2): 2.06 m2\nBP (mm Hg): 130/70\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 12:24\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV\nsystolic dysfunction. Mildly depressed LVEF. TVI E/e' >15, suggesting\nPCWP>18mmHg.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - akinetic; anterior apex - hypo; septal apex- akinetic; inferior\napex - hypo; lateral apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal aortic arch diameter.\n\nAORTIC VALVE: No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. There is mild\nregional left ventricular systolic dysfunction. Overall left ventricular\nsystolic function is mildly depressed. Tissue velocity imaging E/e' is\nelevated (>15) suggesting increased left ventricular filling pressure\n(PCWP>18mmHg). Resting regional wall motion abnormalities include mid to\ndistal anteroseptal akinesis and apical akinesis/hypkinesis (apex not fully\nvisualized). Right ventricular chamber size and free wall motion are normal.\nThere is no aortic valve stenosis. The mitral valve leaflets are mildly\nthickened. Trivial mitral regurgitation is seen. There is a\ntrivial/physiologic pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2147-02-14 00:00:00.000",
"description": "Report",
"row_id": 202937,
"text": "Sinus rhythm\nAnterolateral infarct - age undetermined\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2147-02-13 00:00:00.000",
"description": "Report",
"row_id": 202938,
"text": "Sinus rhythm\nAnteroseptal infarct - probably acute\nProbable lateral infarct - age undetermined\nSince previous tracing of , suggestive of lateral myocardial infarct\n\n"
},
{
"category": "ECG",
"chartdate": "2147-02-14 00:00:00.000",
"description": "Report",
"row_id": 202939,
"text": "Sinus rhythm\nPremature ventricular contractions\nAnteroseptal infarct - probably acute\nLateral T wave changes may be due to myocardial ischemia\nSince previous tracing of , ventricular premature complex seen and Q\nwaves in I and aVL absent\n\n"
},
{
"category": "ECG",
"chartdate": "2147-02-11 00:00:00.000",
"description": "Report",
"row_id": 202940,
"text": "Sinus rhythm\nAnteroseptal infarct - age undetermined\nLateral T wave changes may be due to myocardial ischemia\nSince previous tracing, more pronounced ST segment elevation in anterior leads\n- consider acute anteroseptal myocardial infarction\n\n\n"
},
{
"category": "ECG",
"chartdate": "2147-02-15 00:00:00.000",
"description": "Report",
"row_id": 202936,
"text": "Sinus rhythm\nAnterolateral infarct - age undetermined\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2147-02-12 00:00:00.000",
"description": "Report",
"row_id": 203168,
"text": "Sinus rhythm\nAnteroseptal infarct - age undetermined\nLateral T wave changes may be due to myocardial ischemia\nNo change from previous\n\n"
},
{
"category": "ECG",
"chartdate": "2147-02-10 00:00:00.000",
"description": "Report",
"row_id": 203169,
"text": "Sinus rhythm. No changes. No previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-02-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 902001,
"text": " 7:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?CHF\n Admitting Diagnosis: STEMI\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with STEMI and elevated filling pressures\n REASON FOR THIS EXAMINATION:\n ?CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Myocardial infarction with elevated filling pressures, evaluate for\n congestive heart failure.\n\n COMPARISON: There are no prior studies available for comparison.\n AP SUPINE CHEST RADIOGRAPH: The heart size is within normal limits for\n technique. The pulmonary vascularity is normal without redistribution. Doubt\n the presence of effusions on the supine study. No focal consolidations on the\n visualized lung fields (left costophrenic angle excluded). There is slight\n prominence of the superior mediastinum which may reflect supine positioning.\n\n IMPRESSION: WNL (allowing for supine positioning).\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-02-10 00:00:00.000",
"description": "Report",
"row_id": 1422682,
"text": "45 YR OLD OBESE FEMALE C HTN,HIGH CHOL ,DEPRESSION ,NOW WITH ACUTE ANT MI,KISSING STENT TO LAD,BILATERAL STENTS TO ILIAC ARTERIES ,NEEDS STENT TO RCA MONDAY .HX SMOKER .HAD CP 11PM ,RELIEVED C FRIENDS SL NITRO .REOCCURED 230 AM WENT TO RECEIVED ASA,INTEGRILLIN,PLAVIX LOAD,HEPARIN ,LOPRESSER,NTP PASTE .\n\nSR NO ECTOPY .BP STABLE STARTED ON CAPTOPRIL AND LOPRESSER.1NTEGRILLIN 2MIC.BOTH GROINS ONLY MINOR OZZING ,BILATERAL PALP PULSES .\n\nBS CL SAT 98 RM AIR .\n\nPOS BS ,NOT HUNGRY .NO STOOL .\n\nVOIDS QS .\n\nPT ON PAXIL,HEAVY SMOKER ,STATES NO FAMILY WILL CALL .COOPERATIVE SLEEPING IN NAPS .\n\nSTABLE AT PRESENT POST AMI,STENT TO LAD,AWAITING INTERVENTION TO RCA SEEMINGLY S SUPPORT SYSTEM .\n\nSERIAL CK\nMONITOR FOR CP,BLEEDING\nEMOTIONAL SUPPORT,WILL CONTACT WORK\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-02-11 00:00:00.000",
"description": "Report",
"row_id": 1422683,
"text": "NURSING PROGRESS NOTE 7P-7A\nS: \"I WANT TO STAY IN THE CHAIR, IT HELPS MY BREATHING\"\n\nO: NEURO: AWAKE AND ALERT, PLEASANT AND COOPERATIVE. MOVING ALL EXTREMITIES. SITTING IN CHAIR ALL NIGHT, STATES SHE IS COMFORTABLE. DENIES C/O PAIN. REFUSED NICOTINE PATCH. DOES NOT FEEL SHE NEEDS IT AT THIS TIME.\n\nCV: HR 75 SR NO VEA NOTED. BP STABLE 108-109/ 59. HEPARIN AT 1650 UNITS/HR. THERAPEUTIC PTT. RIGHT AND LEFT GROIN C%D, NO BLEEDING OR HEMATOMA. PALP PEDAL PULSES. FOOT WARM. DENIES CHEST DISCOMFORT. TOL CAPTOPRIL AND LOPRESSOR DOSES.\n\nRESP: ON ROOM AIR. COGESTED COUGH, LUNGS CLEAR. O2 SAT 98%. DENIES C/O SOB.\n\nGI: ABD OBESE, SOFT. + BOWEL SOUNDS. NO BM OVERNIGHT. DRINKING GINGERALE OVERNIGHT.\n\nGU: VOIDING ON COMMODE. URINE CLEAR YELLOW. 24 HR I/O (-) ~ 300 CC.\n\nA: S/P STEMI WITH KISSING STENTS TO LAD, ILIAC ART. WAITING FOR PCI TO RCA ON MONDAY .\n\nP: FOLLOW LYTES, CK, PTT. MONITOR GROIN FOR BLEEDING. ENCOURAGE PO INTAKE, FOLLOW UP WITH SOC SERVICE. UPDATE PT. ON PLAN OF CARE PER CCU TEAM.\n"
}
] |
29,631 | 159,670 | As mentioned in the HPI, Mr. presented to an OSH with a NSTEMI. He was medically managed and transferred to for further care. On he underwent a cardiac cath which revealed three vessel coronary artery disease and aortic stenosis. On he was brought to the operating room where he underwent a coronary artery bypass graft and aortic valve replacement. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Remained on Levophed, milrinone, and vasopressin drips which were slowly weaned over a few days. Within 25 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day four chest tubes were removed. Bedside swallowing eval. performed on post-op day five as he had some dysphagia with emesis along with altered mental status. He slowly developed worsening pulmonary edema despite aggressively pulmonary toilet. He required a right thoracentesis for an effusion on post-op day twelve. He also had thoracentesis on the left and his respiratory status improved. He was intermittently on BIPAP at night and no longer requires this. His mental status and respiratory status improved and he was discharged to rehab in stable condition on POD#15. | The patient is status post median sternotomy as before. The patient is status post median sternotomy, as before. An endotracheal tube and nasogastric tube have been withdrawn. An endotracheal tube and nasogastric tube have been withdrawn. Interval clearing of changes consistent with pulmonary vascular congestion. Expected post-operative appearance of the chest. Atherosclerotic disease is noted within the intrathoracic aorta with mediastinal and hilar contours otherwise within normal limits given portable technique. IMPRESSION: Slight prominence to the pulmonary vasculature without frank interstitial edema may reflect mild early fluid overload/CHF. Mild prominence of the pulmonary vasculature is noted, especially adjacent to the right heart border; however, no definite Kerley B lines are present. Median sternotomy wires and the most superior portion of midline surgical staple line are seen. A left chest tube, endotracheal tube, nasogastric tube and pulmonary arterial line remain in place. The patient is status post median sternotomy and mediastinal structures are unchanged. Clearing of pulmonary vascular congestion. FINDINGS: RIGHT SIDE: There is a mild plaque in the proximal internal carotid artery. The left-sided chest tube is in place. There is dense retrocardiac opacity, likely atelectasis. There is bilateral streaky density consistent with subsegmental atelectasis. Decrease in right pleural effusion, consistent with recent thoracentesis. Decrease in right pleural effusion, consistent with recent thoracentesis. Decreased right pleural effusion s/p thoracentesis. LS diminished and clear this am. hemithorax status post left thoracentesis. FINDINGS: There has been interval decrease in the extent of the right-sided pleural effusion consistent with the provided history. full wakeup not done yet r/t hemos.cv: vs/hemos as per flowsheet. She will be in today.A: Impaired resp status, improved on bipap and w/ lasix. on high dose pressors w/ volume requirements.neuro: remains sedated on propofol. edema PFI REPORT Grossly unchanged study. BIpap overnoc and prn. Lungs clear in upper airways, diminished bilaterally. FINDINGS: There is a new right IJ line, which replaces the previously visualized Cordis. FINDINGS: There are bilateral lung opacities which are most prominent in the right, and are grossly unchanged compared to the previous study. reversal meds given. IMPRESSION: Status post recent CABG without CHF or significant effusion. The appearance of the left hemithorax has improved, status post thoracentesis, with residual small effusion and no pneumothorax. Reassurances given.PULM: LSC with dim bases bilaterally per auscultation. BLE edema 1+. BS DIMINISHED BIBASILAR, EXPIRATORY WHEEZE UPPER. Strong non productive cough noted on assessment.CV: SR-ST per tele this shift, HR 80-95. Resp. Denies pain.Resp: BS clear, diminished in bases. KUB done, and Biscodyl suppository given PR. encouraged to cdb. foley to gravity good uop. PRN nebs given.GI/GU: + BS, small BM. spec sent for cdiff. ENDO: SSI X 1 . RECIEVED 1 UPC - REPEAT HCT PENDING. + BOWEL SOUNDS. Doppler pulses. CXR REVEALS + FLUID AND R+L PLEURAL EFFUSIONS PER DR. . +pp bilat. HISTORY: COPD and CHF, status post AVR. Lytes repleated prn. PP palpable. k+ repleted. denies pain.cv/skin: nsr->st w/ rare pac/pvc noted. LEFT PLEURAL CT DRAINING MIN. changed to atenolol. T max 98.8o.Resp-Lungs clear, decreased in the bases. NEURO: Pt confused, oriented to self only; re-oriented prn. Afebrile. Afebrile. MEDIASTINAL CT DC'D. HUO marginal, Lasix . Follows commands, MAE, PERRLA.CV-ST in the 100's all shift. Diurese & pulm toilet. EKG obtained to confirm rhythm and read by PA . given 40mEqs PO KCL for 3.8; repeat K 3.7. lopressor held d/t low SBP. Albuterol and atrovent neb's given with good effect. EKG/CXR DONE. LYTES REPLETED PRN. Lopressor PO tol well. Some PAC's noted, KCL, and Ca+ replaced as needed. Criticaid and dsd plased over HCT 31.5, WBC 16.9, Mg 2.5. .C/V: vss pt afebrile. ASSESS PULM.STATUS. Tolerating the Lopressor, Captopril, and Lasix. BS CLEAR OTHERWISE AND DIMINISHED BIBASILAR. Pulses by doppler.Resp: LS-CTA/Dim at bases with audible exp. PT ORIENTED TO SELF ONLY.RE-ORIENTED PRN. Neb tx's given prn. Pt lethargic in AM. Given Alb/Atrovent nebs x 3 for wheezing. ABG drawn by RT; 7.45/46/65/33/6. K >4.4, VASOPRESSIN OFF, MILRINONE CONTINUES AT .125MCQ WITH CI>2, MVO2 58%X2. Pt with pulses by doppler.Resp: LS- CTA/dim at bases with audible exp wheeze at times and neb given. ABG alkalotic, lasix gtt stopped; Diamox given, ABG slightly improving, pH 7.49. EXTRMEITIES SLIGHTLY COOL DOPP PP. MONITOR LYTES & U/O. Resp. Resp. LEVO ATTEMPTED TO WEAN TO .03MCQ RETURNED TO .04MCQ TO KEEP SBP>90. PT NPO TODAY EXCEPT MEDS.ABD SOFT. Taking stuff off, dsg, sat probe, n/c, ect. REPEAT ABG. ALTERED CARDIOVASCULAR STATUSS: "OOOOHHHH STOP THAT YOU DON'T HAVE TO DO THAT"O: CARDIAC: SR-ST WITH VEA. Pulmonary toilet, diurese as tolerated. CXR ordered for this am. denies pain, MAE, follows commands and assists minimally with turns.CV: Pt in NSR with PVCs & PACs noted; K+ repleated prn. Indeterminate PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Trivial MR. LV inflow pattern c/w impaired relaxation.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate regional LV systolic dysfunction. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is mildly dilated. Top normal/borderline dilated LV cavitysize. Lipomatous hypertrophy of theinteratrial septum.LEFT VENTRICLE: Normal LV wall thickness. Simple atheroma in aortic arch. The left ventricular cavity size is top normal/borderlinedilated. Normal ascending aortadiameter. There is a trivial/physiologic pericardial effusion. Normaldescending aorta diameter. There is mild symmetric left ventricularhypertrophy. Transmitral Doppler and TVI c/w Grade I (mild) LV diastolicdysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - akinetic; basal anteroseptal - hypo; mid anteroseptal -hypo; anterior apex - akinetic; septal apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Indeterminate PAsystolic pressure.GENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads orelectrodes. Trivial mitral regurgitation is seen. Mild-moderate regional LV systolic dysfunction. Normal aortic arch diameter. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No LV mass/thrombus.LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -hypo; mid anteroseptal - hypo; mid inferoseptal - normal; mid inferior -normal; anterior apex - hypo; septal apex - hypo; inferior apex - hypo;lateral apex - normal; apex - hypo; remaining LV segments contract normally.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. | 85 | [
{
"category": "Radiology",
"chartdate": "2180-10-03 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 1030244,
"text": " 11:06 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: Please assess for carotid stenosis\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with 3v CAD, preop for CABG\n REASON FOR THIS EXAMINATION:\n Please assess for carotid stenosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRc TUE 8:24 PM\n Less than 40% stenosis of the internal carotid arteries bilaterally.\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID ULTRASOUND\n\n INDICATION: Preoperative evaluation for CABG.\n\n FINDINGS: RIGHT SIDE: There is a mild plaque in the proximal internal\n carotid artery. The peak systolic velocity in the common carotid artery 60 cm\n cm/sec, proximal ICA 65 cm/sec, mid ICA 34 cm/sec, distal ICA 65 cm/sec and\n external carotid artery 150 cm/sec. ICA/CCA ratio 1.0. The flow in the\n vertebral artery is in antegrade direction. The patient is status post right\n carotid endarterectomy.\n\n LEFT SIDE: There is a mild plaque at the carotid bifurcation. The peak\n systolic velocity in the common carotid artery 91 cm/sec, proximal ICA 102\n cm/sec, mid ICA 65 cm/sec, distal ICA 46 cm/sec and external carotid artery\n 112 cm/sec. ICA/CCA ratio 1.1. The flow in the vertebral artery is in\n antegrade direction.\n\n IMPRESSION: Less than 40% stenosis of the internal carotid arteries\n bilaterally. This is a baseline examination at the .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-03 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 1030245,
"text": ", A. 11:06 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: Please assess for carotid stenosis\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with 3v CAD, preop for CABG\n REASON FOR THIS EXAMINATION:\n Please assess for carotid stenosis\n ______________________________________________________________________________\n PFI REPORT\n Less than 40% stenosis of the internal carotid arteries bilaterally.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-11 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1031731,
"text": " 12:08 AM\n PORTABLE ABDOMEN Clip # \n Reason: s/p CABG/AVR w/hopyactive bowel sounds and vomiting-r/o ileu\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n s/p CABG/AVR w/hopyactive bowel sounds and vomiting-r/o ileus\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl WED 9:40 AM\n Nonspecific bowel gas pattern.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old male status post CABG/AVR with hypoactive bowel sounds\n and vomiting. Rule out ileus.\n\n COMPARISON: None.\n\n FINDINGS: A single portable supine frontal view of the abdomen was obtained.\n Median sternotomy wires and the most superior portion of midline surgical\n staple line are seen. The stomach is air distended, and there are air-filled\n loops of transverse colon. There are no abnormally dilated loops of small\n bowel. Free air cannot be assessed for on this single supine view. Opacity\n of the left lung base is not fully evaluated on this study.\n\n IMPRESSION: Non-obstructive bowel gas pattern on this single supine view.\n Left basilar pulmonary opacity is not completely evaluated on this study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-03 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1030286,
"text": " 1:39 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CHEST PAIN\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with CAD, DM, AS a/w NSTEMI needs pre-op eval for CABG\n REASON FOR THIS EXAMINATION:\n please eval for acute cardiopulmonary disease\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old male with CAD, diabetes, aortic stenosis, pre-op for\n CABG.\n\n COMPARISON: Chest radiograph from one day prior.\n\n TWO VIEWS OF THE CHEST: There is no change in moderate prominence of the\n mediastinum with a left lateral tracheal indentation, likely consistent with\n goiter. There is no change in prominence of the pulmonary vasculature at the\n lung bases consistent with mild pulmonary edema. There are age indeterminant\n fractures of the fifth, sixth, and eighth right lateral ribs.\n\n IMPRESSION:\n 1. No change in prominence of vasculature at the bases indicative of\n pulmonary edema.\n 2. Age indeterminate right lateral rib fractures. Correlate clincailly with\n physical exam and history of recent trauma.\n 3. Indentation of the left lateral trachea consistent with thyroid goiter,\n not changed from the previous day.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031679,
"text": " 2:56 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?ptx after CT removal\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n ?ptx after CT removal\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 5:00 PM\n PFI: No pneumothorax after chest tube removal. Observed increasing heart\n size and more marked pulmonary congestive pattern, particular in comparison\n with study of .\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, AP PORTABLE SINGLE VIEW\n\n INDICATION: Status post left-sided chest tube removal, evaluate for possible\n pneumothorax.\n\n FINDINGS: AP single view of the chest obtained with patient in semi-upright\n position is analyzed in direct comparison with a preceding similar study\n obtained eight hours earlier during the same date. During the interval, the\n left-sided chest tube has been removed, and there is no evidence of any apical\n pneumothorax. Position of previously described Swan-Ganz catheter is\n unaltered. Noticed are an increased cardiac silhouette and a pulmonary\n vascular congestive pattern with increased perivascular haze on the bases and\n diffuse densities suggestive of some bilateral pleural effusions\n preferentially located posteriorly in the patient in semi-erect position.\n These findings are suggestive of increased left-sided CHF. The pattern is\n strikingly more marked on the two last examinations in comparison with the\n preceding chest examination of .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031680,
"text": ", W. CSURG CSRU 2:56 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?ptx after CT removal\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n ?ptx after CT removal\n ______________________________________________________________________________\n PFI REPORT\n PFI: No pneumothorax after chest tube removal. Observed increasing heart\n size and more marked pulmonary congestive pattern, particular in comparison\n with study of .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032145,
"text": " 6:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for effusions/infiltrates\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man s/p avr/cabg\n REASON FOR THIS EXAMINATION:\n assess for effusions/infiltrates\n ______________________________________________________________________________\n WET READ: 9:36 PM\n Increased patchy right and left lung opacities and diffuse lower lobe\n opacity/effusion have increased since at 15:10 and may represent\n worsening CHF, although underlying infection cannot be excluded. Reimaging\n after diuresis would help exclude underlying pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Patient S/P CABG, followup pulmonary edema.\n\n Comparison is made to prior study .\n\n Continual worsening in now moderate-to-severe pulmonary edema with bilateral\n small-to-moderate pleural effusions. Left lower lobe retrocardiac opacity is\n likely atelectasis. Post-operative cardiac silhouette is unchanged.\n Mediastinal widening is slightly increased, most likely due to vascular\n engorgement. A catheter sheath projects in the expected location of the left\n IJ vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031396,
"text": " 4:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CT placement.Pleural effusion.?Failure\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n CT placement.Pleural effusion.?Failure\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE\n\n HISTORY: Chest tube placement.\n\n One view. Comparison with . There is increased parenchymal density\n suggestive of mild vascular congestion. There is increased density in the\n retrocardiac area consistent with atelectasis or consolidation as before.\n There is bilateral streaky density consistent with subsegmental atelectasis.\n Hazy density at the left base consistent with pleural fluid appears improved.\n The patient is status post median sternotomy and mediastinal structures are\n unchanged. A left chest tube and Swan-Ganz catheter remain in place. An\n endotracheal tube and nasogastric tube have been withdrawn.\n\n IMPRESSION: Increased parenchymal density suggestive of pulmonary vascular\n congestion. Interval improvement in hazy density at the left base which may\n be due to change in patient position or decreased pleural fluid. No other\n significant change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031439,
"text": " 9:26 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: CT removal\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n CT removal\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRX MON 6:38 PM\n Improvement in vascular congestion.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Chest tube removal.\n\n One view. Interval clearing of changes consistent with pulmonary vascular\n congestion. Peak density consistent with subsegmental atelectasis persists.\n The patient is status post median sternotomy as before. Mediastinal\n structures are unchanged in appearance. An endotracheal tube and nasogastric\n tube have been withdrawn. A pulmonary arterial catheter remains in place.\n\n IMPRESSION:\n 1. Clearing of pulmonary vascular congestion.\n 2. No other significant change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031440,
"text": ", W. CSURG CSRU 9:26 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: CT removal\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n CT removal\n ______________________________________________________________________________\n PFI REPORT\n Improvement in vascular congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1029954,
"text": " 5:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrate/edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with chest pain\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate/edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest pain.\n\n PORTABLE CHEST RADIOGRAPH\n\n No priors.\n\n There is no pneumothorax or large pleural effusions; however, the right\n costophrenic angle is excluded from current radiograph. Mild prominence of\n the pulmonary vasculature is noted, especially adjacent to the right heart\n border; however, no definite Kerley B lines are present. Atherosclerotic\n disease is noted within the intrathoracic aorta with mediastinal and hilar\n contours otherwise within normal limits given portable technique.\n There is mild biapical pleural scarring and thickening of the minor fissure.\n Mediastinal prominence with tracheal deviation likley reflects thyroid\n enlargement.\n\n IMPRESSION:\n\n Slight prominence to the pulmonary vasculature without frank interstitial\n edema may reflect mild early fluid overload/CHF. Dedicated PA and lateral\n radiographs would be helpful for further assessment.\n\n Probable goiter\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1030963,
"text": ", W. CSURG CSRU 4:09 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p AVR/CABG\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n PFI REPORT\n Expected post-operative appearance of the chest, no pneumothorax. Support\n devices in the appropriate positions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-11 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1031732,
"text": ", W. CSURG CSRU 12:08 AM\n PORTABLE ABDOMEN Clip # \n Reason: s/p CABG/AVR w/hopyactive bowel sounds and vomiting-r/o ileu\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n s/p CABG/AVR w/hopyactive bowel sounds and vomiting-r/o ileus\n ______________________________________________________________________________\n PFI REPORT\n Nonspecific bowel gas pattern.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031124,
"text": " 7:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT/CT placement\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n ETT/CT placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRX SAT 9:14 AM\n No significant change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: ET tube and chest tube placement.\n\n One view. Comparison with the previous study done . The patient is\n status post median sternotomy, as before. Increased density in the\n retrocardiac area consistent with atelectasis or consolidation and hazy\n density at the left base consistent with pleural fluid persist. A left chest\n tube, endotracheal tube, nasogastric tube and pulmonary arterial line remain\n in place. There is no significant interval change.\n\n IMPRESSION: No significant change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031125,
"text": ", W. CSURG CSRU 7:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT/CT placement\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n ETT/CT placement\n ______________________________________________________________________________\n PFI REPORT\n No significant change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031554,
"text": " 7:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o inf, eff\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative.\n\n FINDINGS: In comparison with the study of , there is some increasing\n opacification at the left base silhouetting the hemidiaphragm medially. This\n is consistent with atelectatic change or possibly superimposed pneumonia.\n Indistinctness of pulmonary vessels is consistent with elevated pulmonary\n venous pressure.\n\n The left chest tube and Swan-Ganz catheter remain in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1030962,
"text": " 4:09 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p AVR/CABG\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf FRI 8:17 PM\n Expected post-operative appearance of the chest, no pneumothorax. Support\n devices in the appropriate positions.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 79-year-old man status post AVR and CABG.\n\n COMPARISON: Pre-operative radiograph dated .\n\n FINDINGS: The patient is now intubated, endotracheal tube in good position\n and 4.5 cm above the carina. Mediastinal drains are in place. The\n nasogastric tube ends in the proximal stomach. Swan-Ganz catheter is in the\n main right pulmonary artery. The left-sided chest tube is in place. Another\n catheter projects over the left upper abdomen/lung base. The degree of\n mediastinal widening is expected for immediate post-operative appearance.\n There is dense retrocardiac opacity, likely atelectasis. Small left effusion\n is present. Mild pulmonary vascular congestion is present.\n\n IMPRESSION: No pneumothorax. Support devices in the standard positions.\n\n Expected post-operative appearance of the chest.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033289,
"text": " 5:55 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? ptx s/p tap left\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n ? ptx s/p tap left\n ______________________________________________________________________________\n WET READ: JKPe WED 7:28 PM\n moderate lt effusion s/p ct removal with no ptx. very limited film to due\n positioning. Exact distal location of rt sheath unclear.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST dated \n\n HISTORY: 79-year-old man, status post CABG; ? hemithorax status post left\n thoracentesis.\n\n FINDINGS: Single bedside AP examination labeled \"upright with grid\" is\n compared with the similarly lordotically-positioned study obtained some two\n hours earlier. The appearance of the left hemithorax has improved, status\n post thoracentesis, with residual small effusion and no pneumothorax. The\n patient is status post recent CABG, with midline surgical staples in situ and\n eight intact sternal cerclage wires. There is unchanged left ventricular\n enlargement, but no edema or focal consolidation.\n\n IMPRESSION: Status post left thoracentesis with persistent small bilateral\n pleural effusions and associated basilar atelectasis, but no pneumothorax or\n other focal airspace process.\n\n A preliminary interpretation was furnished by Dr. .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032417,
"text": " 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Is CHF improving\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p AVR/CABG\n REASON FOR THIS EXAMINATION:\n Is CHF improving\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Followup CHF.\n\n REFERENCE EXAM: .\n\n FINDINGS: There is moderate right effusion with right lower lobe volume loss,\n perihilar haze and pulmonary vascular redistribution, all of which have\n increased compared to the study from the prior day. There is a left IJ line\n that initially does upward and then downward and it is unclear if this loop is\n within the patient or outside of the patient. The tip of the line is not well\n visualized and it is unclear if this crosses midline.\n\n IMPRESSION: Worsening CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1033164,
"text": ", W. CSURG CSRU 8:52 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for ? pna\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n evaluate for ? pna\n ______________________________________________________________________________\n PFI REPORT\n Grossly no change compared to . Left IJ removed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033264,
"text": " 3:36 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: s/p tap - rt for effusion ? ptx\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n s/p tap - rt for effusion ? ptx\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc WED 8:39 PM\n PFI:\n 1. No pneumothorax.\n 2. Decrease in right pleural effusion, consistent with recent thoracentesis.\n 3. No other significant change compared to study done earlier today.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PORTABLE AP CHEST RADIOGRAPH.\n\n HISTORY: 79-year-old man status post recent right-sided thoracentesis.\n\n COMPARISON: Comparison is made with chest radiograph done on at\n 8:57 a.m.\n\n FINDINGS: There has been interval decrease in the extent of the right-sided\n pleural effusion consistent with the provided history. There is no\n pneumothorax. Otherwise, there is no significant change from the study done\n earlier today.\n\n IMPRESSION:\n 1. Decreased right pleural effusion s/p thoracentesis. No pneumothorax.\n 2. Otherwise, unchanged compared to previous study.\n\n These results were discussed over the telephone with .\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033265,
"text": ", W. CSURG CSRU 3:36 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: s/p tap - rt for effusion ? ptx\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n s/p tap - rt for effusion ? ptx\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. No pneumothorax.\n 2. Decrease in right pleural effusion, consistent with recent thoracentesis.\n 3. No other significant change compared to study done earlier today.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1033163,
"text": " 8:52 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for ? pna\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n evaluate for ? pna\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf WED 12:49 PM\n Grossly no change compared to . Left IJ removed.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old man status post CABG. Please evaluate for pneumonia.\n\n TECHNIQUE: PA AND LATERAL CHEST RADIOGRAPH.\n\n COMPARISON: Comparison from chest x-ray from .\n\n FINDINGS: There are bilateral lung opacities which are most prominent in the\n right, and are grossly unchanged compared to the previous study. Left IJ was\n removed. The cardiac silhouette is unchanged. The visualized osseous and\n soft tissue structures are unchanged.\n\n IMPRESSION: Grossly unchanged study compared to the previous scan. Bilateral\n lung opacification and pleural effusion. This opacification might be related\n to pulmonary edema or pneumonia. Please evaluate clinically. Left IJ\n removed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032672,
"text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulm. edema\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man AVR/CABG\n REASON FOR THIS EXAMINATION:\n pulm. edema\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf MON 11:38 AM\n Grossly unchanged study. Slight minimal improvement in the opacification on\n the right. Tip of left IJ pulled back and is in the brachiocephalic vessel.\n Results communicated with nurse .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old man AVR/CABG. Please evaluate pulmonary edema.\n\n PORTABLE AP CHEST RADIOGRAPH\n\n COMPARISON: Chest x-ray from .\n\n FINDINGS: There are bilateral lung opacities more prominent on the right,\n grossly unchanged compared to the previous scan. There might be slight\n improvement in the lung opacification on the right. There is bilateral\n pleural effusion, unchanged from the previous scan. The heart silhouette is\n enlarged, and unchanged with compared to the previous scan. The tip of the\n left IJ is pulled back and appears it is in the brachiocephalic vessel as on\n the . The result was communicated with the nurse \n .\n\n IMPRESSION: Grossly unchanged study compared to previous scan. Bilateral\n lung opacification and pleural effusion unchanged from the previous scan.\n These opacification might be related to pulmonary edema or pneumonia. The tip\n of the left IJ is pulled back and it is in the brachiocephalic vessels.\n\n Results were communicated with nurse at 10:30 a.m.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032673,
"text": ", W. CSURG CSRU 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulm. edema\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man AVR/CABG\n REASON FOR THIS EXAMINATION:\n pulm. edema\n ______________________________________________________________________________\n PFI REPORT\n Grossly unchanged study. Slight minimal improvement in the opacification on\n the right. Tip of left IJ pulled back and is in the brachiocephalic vessel.\n Results communicated with nurse .\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033398,
"text": " 7:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusions\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n evaluate effusions\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 10:49 AM\n PFI: Status post CABG without CHF or significant effusion; right basilar\n subsegmental atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST \n\n HISTORY: 79-year-old man, status post CABG; evaluate effusions.\n\n FINDINGS: Single bedside AP examination labeled \"supine at 7:25 a.m.\" is\n compared with upright studies obtained the preceding day. The patient is\n status post recent CABG with midline surgical staples in situ and intact\n sternal cerclage wires. Allowing for the positioning, the overall appearance\n is not much changed. There is persistent LV enlargement without vascular\n congestion and only small bilateral pleural effusions. There is right more\n than left basilar subsegmental atelectasis, with no other airspace process.\n Atherosclerotic calcification of the thoracic aorta is redemonstrated.\n\n IMPRESSION: Status post recent CABG without CHF or significant effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033399,
"text": ", W. CSURG CSRU 7:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate effusions\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n evaluate effusions\n ______________________________________________________________________________\n PFI REPORT\n PFI: Status post CABG without CHF or significant effusion; right basilar\n subsegmental atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1032348,
"text": " 5:49 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o ptx, assess dlc placement\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man s/p avr/cabg and line change\n REASON FOR THIS EXAMINATION:\n r/o ptx, assess dlc placement\n ______________________________________________________________________________\n WET READ: MRGe FRI 10:41 PM\n Slight improvement in pulmonary edema. Bilateral small-to-moderate pleural\n effusions. Left lower lobe retrocardiac opacity is unchanged. Post-operative\n cardiac silhouette is unchanged. A CVL projects in the expected location of\n the left IJ vein with the tip at the brachiocephalic confluence.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Check line placement.\n\n REFERENCE EXAM: .\n\n FINDINGS: There is a new right IJ line, which replaces the previously\n visualized Cordis. The line initially goes up and then down, and it is\n unclear if this kink is within the patient or outside of the patient. The tip\n crosses midline and likely terminates in the superior vena cava. There is\n bilateral lower lobe volume loss with moderate bilateral effusions and\n perihilar haze likely representing CHF. An underlying infectious infiltrate\n cannot be excluded. There is no pneumothorax.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-06 00:00:00.000",
"description": "Report",
"row_id": 1645722,
"text": "Resp. Therapy note:\n1650 Patient up from the or this afternoon,\nstill intubated and placed on CMV.\\\ncurrent settings Fi02 80% VT 600x RR 14\n 10 cmh20 peep\nAppears to be ventilating smoothly\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-06 00:00:00.000",
"description": "Report",
"row_id": 1645723,
"text": "cvicu adm\npt adnm s/p cabg x3 and AVR. on high dose pressors w/ volume requirements.\n\nneuro: remains sedated on propofol. pupils equal, pinpoint. reversal meds given. full wakeup not done yet r/t hemos.\n\ncv: vs/hemos as per flowsheet. from OR on high dose pressors, tachy and receiving cellsaver. fluid boluses given and meds titrated as noted. goal pad to mid 20's. thermodilution CO low good mvo2.ficcks good, no acidosis w/ decreasing lactate. A+V wires present but not checked r/t tachycardia. min CT dng other than 200cc dump w/ turn in bed.. post-op hct 30. cont ST but slowing w/ volume resuscitation.\n\nresp: lungs clear. sx for min thick bld tinge secretions. pao2 improving-> fio2 wean. pt requiring \"glide scope\" for intubation.\n\ngi/gu: lg amt uop initially (lasix intra-op) now tapering to ~50cc/hr. abd soft. no bsp. insulin gtt per protocol.\n\nsocial: family in and updated, info booklet given.\n\nassess: significant pressor and fluid requirements\n\nplan: cont to monitor vs/hemos/labs closely. titrate meds, fluids per post op regime\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-18 00:00:00.000",
"description": "Report",
"row_id": 1645755,
"text": "npn 0700-1500;\nevents ;travelled for pa and lateral in xray\ncurrently having thorocentisis,\ns\" you know i think my wife is dead.\"\n\nros; neuro aoox1 mae to command in and oob to chair with max assist.\ncontinues to be confused and disorientated . reamins pleasant and cooperative.\n\nresp; lungs clear upper diminshed at bases with intermittent crackles lt side more diminished than rt.weak unproductive cough needs encouragement to c/db.\n\ncvs;tmax 98 po nsr with frequent ectopy bp stable tolerating lopressor.\n\ngu;passing small amounts of clear yellow urine via foley 15-20 mls/hr . aware.\n\ngi; belly soft pos bs taking small amount of diet tolerating ground and thick nectar but needs to be focused. bs covered on fixed and humalog\n\nskin; as prevously noted of concern is reddened area around lt knee incision s/ area not warm will follow.\n\na/p; continue with frequent orientation and encourage pt to focus on task in hand\ncontinue with pulmonary toilet\nencourage increased activity as tolerated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-18 00:00:00.000",
"description": "Report",
"row_id": 1645756,
"text": " 3pm-7pm\nNeuro: Pt awake, alert, oriented to self only. Follows commands. Swallows thickend liquids well. No verbalization of pain. Wrist restraints removed. Pt resting calmly at this time.\n\nCardio: SR in 70s. BP stable in high 90s, low 100s. UE pulses palpable, LEs with doppler.\n\nPulm: O2 @ 2l NC, sat 98 - 100%. Lungs clear in upper airways, diminished bilaterally. Thoracentesis completed bilaterally, approximately 1200ccs per lung. Pt unable to utilize IS due to confusion.\n\nGI: Abdomen obese, non-tender, bs present. No BM. Assisted with dinner.\n\nGU: Foley catheter draining clear yellow urine. Lasix IV given. Diuresed well.\n\nEndocrine: BS 125. Covered with regular SS per order.\n\nSocial: Wife in to visit. Pleasant. Concerned that husband isn't progressing fast enough. Encouragement provided and explained plan of care.\n\nPlan: Continue pulmonary toileting. Percussion may be needed. Bipap for overnight? Encouragement to CDB. Frequent orientation may be necessary. PT to see pt tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-17 00:00:00.000",
"description": "Report",
"row_id": 1645753,
"text": "Neuro:\nAOX1 only.Confused time and place.Pulls at O2.Needs frequent reminders and observation.Chair alarm and fall prevention initiated.Follows command.MAE.OOB to chair with 2 assist (Pivot and turn).Has difficulty following instructions.Strong grasp.\n\nCV:\nSR 80's with PVC's.Potassium repleated x2.BP 110-120's syst.Diamox d/c.Afebrile.\n\nResp:\nO2 5 l N/C.Sat >95.Does desat low 90's without O2.RR 20-32/min.SOB with minimal exersion.LS decreased bases.Non-productive cough.Was on BIPAP last night.\n\nGI/GU:\nFoley to gravity.Fair UO,>30 cc/hr.UCx sent.Purea diet.Total feed.No stool since .Supp.given with small BM.Passing gas.Positive BS.\n\nSkin:\nCoccyx intact.Left leg red area old incision.No drainage noted.NP M. notified.Non-tendor.\n\nEndo:\nSliding scale modified for High BS with daily lantus.\n\nPlan:\nMonitor electrolytes.Pulmonary hygiene.Safety/Fall prevention protocol.Total feed.Assess for BIPAP need overnight.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-18 00:00:00.000",
"description": "Report",
"row_id": 1645754,
"text": "CVICU NPN\nO: ROS\n\nNeuro: Alert, oriented x1 and restless. Cooperative and MAE, consistently follows commands. Denies pain. Oriented x2 and calm after sleeping comfortably on bipap overnoc.\n\nCV: HD stable. HR 70's nsr w/ occasional pvc's. Stable BP. Cont on po lopressor. Pedal pulses dopplerable.\n\nResp: Tacypneic 30's w/ labored breathing pattern and bibasilar crackles. 02sats dipped to 86% after turning w/ minimal recovery. Placed on Bipap at 2300 and fell asleep w/ regular breathing pattern and srr 20's. 20mg lasix also given. LS diminished and clear this am. Now back on 5lnp w/ 02sat 97% SRR 28.\n\nRenal: Low u/o 15-25cc/hr. 20mg lasix given w/ gd response. Body balance -400cc since mn. Bun/Cre 31/1.1. Na 148. K=3.6 and repleted.\n\nGI: Tol liquids and pills well. No difficulty swallowing. +bowel sounds, no stool overnoc.\n\nHeme: Hct stable 32.8.\n\nID: Tmax 97.6, wbc 15.1\n\nSkin: Reddened area on LLE around incision, no dnge, no increase in redness overnoc. Backside intact.\n\nSH: wife called and informed of pt status. Told he would rest on Bipap overnoc. She will be in today.\n\nA: Impaired resp status, improved on bipap and w/ lasix. Altered MS ?etiology.\n\nP: Cont to monitor. Reorient frequently. Pulm toilet. BIpap overnoc and prn. Diurese prn. Aspiration precautions. Monitor LLE incision sites. OOB to chair and increase activity as tolerated. Cont family support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-20 00:00:00.000",
"description": "Report",
"row_id": 1645760,
"text": "7P->7A\nNeuro- Pleasently confused. MAE, follows commands, but is pulling at things and has had soft limb restraints to BUE. No c/o pain all night.\n\nCV-NSR 80's-90's, some PVC's noted. No gtts, Lopressor held d/t decreased b/p at time due. SBP 100's/50's with mean > 60. Lasix this am, 20mg IV with good response. -750 at MN and currently -250. T max 98.8o.\n\nResp-Lungs clear, decreased in the bases. On 4L n/c O2 and then CPAP at MN on. Tolerated well without issues. Sats in mid to high 90's on CPAP. Good cough, non productive.\n\nGI/GU-Positive bowel sounds, stooled x 1, lg brown in bed. Heme -, colace and biscodyl held today. Foley to gravity, lasix 20mg IV helped with decreasing UOP.\n\nSocial-Wife called for update, will be in for visit today. Wants to know what the long term plan is.\n\nPlan-? floor with CPAP? Watch rhythm, ectopy, output, and hemodynamics. Encourge to do good pulmonary toilet, hourly.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-20 00:00:00.000",
"description": "Report",
"row_id": 1645761,
"text": "Resp Care\n\nPt was comfortably on BIPAP with full face overnight. Spo2 usually mid 90's but occasionally low 90s. pt using BIPAP I. Plan for tonight may include trial without use of BIPAP, check with team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-20 00:00:00.000",
"description": "Report",
"row_id": 1645762,
"text": "See and carevue for detailed documentation\n\nNeuro: Patient alert, oriented x1 -> 2. Can state he is intermittently, aware it is fall but unable to state correct date, year. Usually pleasant, cooperative. Sometimes becomes paranoid, verbally threatening to hit staff, but not making any threatening physical moves. OOB to chair good strength with standing. Transfer to commode x2, back to chair. Standing with good strength Sometime not fully cooperating, refusing to move feet. Denies pain.\n\nResp: BS clear, diminished in bases. Weaned to RA with SAT >95%. Uncooperative with I/S.\n\nCV: In NSR with BBB, rate 70-90. BP 90-100. Rec'd po lopressor with decreased BP to 80's, team aware. changed to atenolol. Potassium repleted po.\n\nGI/Endo: Ate breakfast well. Lunch fair. Taking pills well with nectar thickened liquids. Blood sugar treated per individual scale, am glargine with breakfast. Moderate soft BP on commode.\n\nGU: Foley to gravity with brown concentrated urien with sediment. Na now 141 from 148. Urine output dropped off this pm. Lasix given po.\n\nSocial: Wife updated by phone. Spoke with re: plan.\n\nPlan: Continue cardiopulmonary monitoring. Continue to reorient. Encourage activity. Screened for rehab. Transfer when bed available.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-21 00:00:00.000",
"description": "Report",
"row_id": 1645763,
"text": "Nursing Progress Note\nNeuro: alert, pleasantly confused. Oriented to self and occasionally hospital. Asking when we \"got into pig farming?\"\n\nCVS: vitals stable, pulses palp x 4 ext. Afebrile. Sternal dressing changed staples and sutures intact. Right piv in wrist wrapped due to patient picking at it.\n\nResp: ls clear in upper lobes diminished throughout bases. RA sats >93\n\nGI: abdomen distended soft, BM x 2. Poor PO overnight.\n\nGU: urine output sluggish approx 20 cc per hour of amber cloudy urine, team previously made aware.\n\nEndo: fs sb covered with scale.\n\nPain: denies\n\nSocial: wife called x 1 for update before bed.\n\nPlan: transfer to floor, no longer requiring ICU level care. Transfer to rehab when bed becomes available.\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-10-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032544,
"text": " 7:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pulmonary edema\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with COPD and CHF. s/p AVR\n REASON FOR THIS EXAMINATION:\n Pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON .\n\n HISTORY: COPD and CHF, status post AVR.\n\n REFERENCE EXAM: .\n\n FINDINGS: The right IJ line is unchanged. There is a large right effusion\n layering posteriorly that is increased compared to the film from the prior\n day. There are areas of consolidation in both lower lungs, right greater than\n left, that have also increased. The heart is moderately enlarged.\n\n IMPRESSION: Worsening infiltrate and effusion. It is unclear how much of\n this is fluid overload or if an underlying infectious infiltrate is present.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-19 00:00:00.000",
"description": "Report",
"row_id": 1645757,
"text": "NEURO:Pt remains oriented to self only. Pleasantly confused most of the shift. Did not tol BiPAP , pt had to be restrained. Denied pain. Re-oriented prn.\n\nCV: Pt in NSR 80s with PVCs. given 40mEqs PO KCL for 3.8; repeat K 3.7. lopressor held d/t low SBP. Lisinopril given when SBP 110s, however dipped to 80s systolic, ? D/C. Hct 33, pp palpable.\n\nRESP: Received pt on 2L NC with sats >98%. Placed on biPAP @ midnight per team to expand lungs. LS clear, dim in bases. Tapped previous shift (bil pleural effussions; 1100 R side; 1300 L side). weak non-productive cough and refuses IS.\n\nGI/GU: Pt eating pureed/soft/thickened liquids diet without difficulty. + BS, + flatus. HUO marginal, Lasix . BUN slightly bumped, creat wnl.\n\nENDO: BS @ 2200 high (214-tx per HISS, however rechecked per PA @ 0100 and retreated with 4 more units HISS for BS 145). ? need for ^ lantus or ^ custom SS.\n\nID/ACCESS: WBC 14.5, afebrile. old incisions remain pink. pt only has one peripheral which outdates today. stuck 2x for blood and 1 failed attempt at IV. need IV team for more access.\n\nPLAN: cont to monitor VS, resp status, neuro status. Labs, huo. Diurese & pulm toilet. ? transfer to floor afternoon. IV access! ^ Humalog SSI.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-19 00:00:00.000",
"description": "Report",
"row_id": 1645758,
"text": "Resp Care Note, Pt placed on bipap overnight with good results.Sats 100%.Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-19 00:00:00.000",
"description": "Report",
"row_id": 1645759,
"text": "npn 0700-1500\nneuro;aoo to self thinks that is president admits to not knowing month or year. confused and was verbally abuse to pt. but has remained pleasantly confused for most of shift.?hallucinating at times. in and oob with some difficulty today c/o of feeling very tired. attempted some time off restraints but pt piccking at lines and dsd so reapplied after new i.v inserted around 10 md.\n\nresp; lungs clear upper diminished at bases poor cough refusing to use i.s encouraged to cdb.rr 224-30 sats 96-98% on ra.\n\ncvs; tmax 97.1 ax nsr 80-90 with frequent pvc's bp dropped to 74 sys same in all limbs eventually returned to 100-118/44 by bp taken on lt leg per pa.\n\ngu u/o 20-25 mls /hr lasix at 4pm.via foley due\n\ngi; belly obese pos bs mod bm golden stoolx2.\n taking adequate diet took agood breakfast min lunch but took a health shake would prefer chocolate. bs covered on riss glargine increased from 20 to 25 units.in am. denies pain.\n\nsoc; wife called and updated on pts current condition\n\na/p continue to reorientate frequently encourage cdb.\ns/b pt poss ot consult page sent to case manager.\nIf pt stays of bipap tonight may go to floor to morrow.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-10 00:00:00.000",
"description": "Report",
"row_id": 1645734,
"text": "7a-7p\nNeuro: Pt alert and confused throughout shift. Pt hallucinating throughout most of shift and PA and PA aware. Pt started on haldol standing dose per team. Pt able to MAE's and constantly reoriented and redirected throughout shift.\n\nCV: HR- NSR/ST 90's-100's. EKG obtained to confirm rhythm and read by PA . Echo performed in AM as well. SBP 90's-120's. Pt weaned off of levophed drip in AM and milrinone drip shut off at 1300. Pt with CO's >4 and CI's >2.2 per thermodilution throughout shift. Pt started on lopressor and captopril per team with good response. Electrolytes monitored and repleted. Doppler pulses. Epicardial wires not checked due HR, attached to pt, but off.\n\nResp: LS-CTA/Dim at bases with audible upper expiratory wheezes. Albuterol and atrovent neb's given with good effect. Pt in respiratory distress at 0730 and given 80mg lasix IV per PA and chest X-ray obtained. ABG done, no changes from earlier abg. Resp status improved. Pt wheezy again at 1200 and neb txs given. Chest tube draining scant amount of serosang drainage and D/C'd per PA at 1400 and chest X-ray obtained.\n\nGI/GU: Abd. obese and +BS x4. Pt tolerating clears with no N/V. Foley intact draining adequate amounts of clear, yellow urine.\n\nEndo: Pt continuing on insulin drip and CVICU protocol followed.\n\nSkin: See flow sheet. OOB with and tolerated well.\n\nPlan: Assess neuro status. Resp. status and pulmonary toilet. Monitor CO's and CI's and possibly deline tonight or in AM. Monitor urine output. Advance diet and activity as tolerated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-11 00:00:00.000",
"description": "Report",
"row_id": 1645735,
"text": "7P->7A\nNeuro-Pleasently confused the whole shift. Attempted to reorientate without success. Follows commands, MAE, PERRLA.\n\nCV-ST in the 100's all shift. Lopressor, Lasix, Captopril all tolerated well. No gtts. Good UOP with Lasix 40mg IV. HCT 31.8, WBC 15.4 Lytes replaced all night per PRN replacements. Negative fluid balance.\n\nResp-Lungs coarse to Ins wheezing, diminished bibasular. When he keeps his O2 on his sats are in the upper 90's, with it off, he drifts down to the 80's. Good cough, nonproductive.\n\nGI/GU-Vomiting x 2, tonight. KUB done, and Biscodyl suppository given PR. PO's held the rest of the night. Hypo bowel sounds through the night. Foley to gravity with good UOP with Lasix.\n\nPlan-Continue to deintensify as much as possible d/t his confusion. He is trying to pull out everything he can. Watch lytes and rhythm. Monitor hemodynamics and resp status. Maintain restraints to keep lines and O2 on.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-17 00:00:00.000",
"description": "Report",
"row_id": 1645751,
"text": "RESP CARE: Pt placed on non-invasive Bipap 10/5 with 5lpm 02 bled in. Tol well overnight. Pulled mask off a few times. Otherwise pt on 5lpm nasal cannula with 02 sats 98%. Pts breathing remains paradoxical though has decreased since yesterday. Will await orders by PA/MD to continue Bipap.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-17 00:00:00.000",
"description": "Report",
"row_id": 1645752,
"text": "Neuro:Recieved lethargic arousing only to pain. Unable to take PO's too sleepy. Abg done to r/o increased c02. Placed on bipap forthe night and pt. eventually became more awake. Still confused but pleasant.Disoriented x3.\n\ncv/resp VSS afebrile. Bp and HR stable. Lungs diminished with bilat crackles in bases.\n\ngi/gu Npo till early this am due to lethargy . Given po K repletion 40 meq. swallows fine. foley to gravity good uop. Remains on diamox.\n\nInteg skin dry incision is healing on sternum Reddened and pink around staples.\n\ncentral line dc'd.\nPlan increase activity and diet. Pulmonary toilet and dieuresis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-14 00:00:00.000",
"description": "Report",
"row_id": 1645742,
"text": "1900-0700HR NOTE\nNEURO: Confused this shift. oriented to self. Following verbal commands and answering simple inquiries appropriately. Confused converstaion at times. Recognized family members with assistance. MAE's with active Rom. Reoriented frequently. Reassurances given.\nPULM: LSC with dim bases bilaterally per auscultation. 4L nc O2 sats 96%. Strong non productive cough noted on assessment.\nCV: SR-ST per tele this shift, HR 80-95. SBP 100-120mmHg per cuff . BLE edema 1+. Weak palpable PP bilaterally. Afebrile. Improved U/o with 0000hr lasix dose.\nGI/GU: Thickened fluids and pureed foods; swallowing precautions observed per nursing staff. Meds in applesauce this HS. Speech is clear after po intake. Active BS 4Q's. large soft BM this am. Incontinent of stool. Foley catheter draining clear yellow urine in good amounts.\nSKIN: Sternal DSD CDI. CT DSD is CDI. Back and buttocks intact. L-Thigh blister unchanged and previously documented. Lotion and criticare barrier applied.\nSOCIAL: Family visited.\nPLAN: Continue Pulm toilet. Reorient to surroundings. Increase activity as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-14 00:00:00.000",
"description": "Report",
"row_id": 1645743,
"text": "shift update:\n\nneuro: alert. oriented to self only. pleasant. mae. oob via tolerated well. denies pain.\n\ncv/skin: nsr->st w/ rare pac/pvc noted. bp stable. k+ repleted. +pp bilat. dsgs d&i.\n\nresp: lungs clear but dim in bases. labored resp noted at times. sat's drop to 90-91% on ra. encouraged to cdb. weak cough.\n\ngi/gu: abd soft distended. +bs. tolerating diet. inc lg amt stool. spec sent for cdiff. good diuresis after lasix, see flowsheet.\n\nendo: lantus given as ordered & fs treated w/ss humalog.\n\nid: afebrile.\n\nsocial: wife called for update & will be into visit in am.\n\nplan: reorient, frequent checks, wrist restraints to protect lines, o2 & drains. cont to monitor vs, i&o & labs. increase activity, pt consult.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-15 00:00:00.000",
"description": "Report",
"row_id": 1645744,
"text": "NEURO: Pt confused, oriented to self only; re-oriented prn. Pt denies pain, assists minimally with turning. Follows commands, & MAE.\n\nCV: NSR with PACs & PVCs noted. Lytes repleated prn. lopressor 25mg PO given and tol well. SBP 90s-110s. PP palpable. Hct 32.8.\n\nRESP: Pt on 4L NC with sats >94%. Pt occ looks labored in breating, however this is normal for pt. LS clear, dim in bases. Audible wheeze occ heard. Weak cough, non-productive. will not follow directions for IS use. PRN nebs given.\n\nGI/GU: + BS, small BM. Thickened liquids to swallow pills without difficulty. Lasix TID with + diuresis.\n\nENDO: BS tx per HISS.\n\nID/ACCESS: WBC 14.5, afebrile, blisters on L leg & incisions pink. no abx. Triple lumen catheter slightly out of skin, no change; MD in to evaluate, no changes or x-ray ordered, able to draw off line. ? d/c line . remains restrained d/t pt attempting to pull out lines & climb OOB.\n\nSOCIAL: No fmaily contact this shift.\n\nPLAN: monitor VS, neuro status, resp status & u/o, labs. re-orient prn & aggressive pulm toilet. PT Consult.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-09 00:00:00.000",
"description": "Report",
"row_id": 1645730,
"text": "Neuro:\nOriented to person only.Confused time and place.Good night sleep.Lethargic but easily arousable.MAE.Follows command.Cooperative and calm.Percocet elexir x1 for incisional pain.\n\nCV:\nSR 85-98 BBB.Rare PAC's.Short burst SVT x5 beats.Magnesium repleated.Sleeping at the time.Remains on Milrinone and Levo.CI>2.Last Mix venous 59.BP MAP>60.Syst low 85-90's when sleeping.Paced at ADemand 96 to see if rate would help UO.No effect on UO or BP.Afebrile.PAP 50-60 syst.CVP low 20's.\n\nResp:\nO2 5 lN/C.Sat>95%.Audible Exp Wheezing.SOB with minimal excertion. done this am to access failure and effusion.RR 16-24/min at rest.Strong cough.IS 500-550 ml.CT @20 cm suction.Minimal drainage.Lasix IV given x2 (40mg and 60mg).Increase in Bun/creat.ABG wnl.\n\nGI/GU:\nFoley to gravity.Poor UO overnight.MD aware.Increase Bun from 16 to 24/Creat from 0.9 to 1.4.K 4.0 this am.Repleated.Clear liquids.No BM.Denies abdominal discomfort.\n\nID:\nWBC low 20's.Afebrile.Antibiotic completed.\n\nEndo:\nWeaned off insulin drip this am.BS <120.\n\nPlan:\nMonitor renal function.Advance diet and activity as tolerated.Pain mananagment.Keep MAP>60 and sys >90.Pulmonary hygiene.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-09 00:00:00.000",
"description": "Report",
"row_id": 1645731,
"text": "ALTERED CARDIOVASCULAR STATUS\nS: \"NO YOU'RE NOT GOING TO DO THAT TO ME, I DON'T KNOW WHERE I AM\"\nO: CARDIAC: SR 90'S TO A PACED FOR HYPOTENSION, WITHOUT ATRIAL ARRYTHYMIAS, OCCASIONAL PVC. SBP REQUIRED ^ LEVO AT CHANGE OF SHIFT TO .06 TO KEEP SBP 100. LEVO ^ AT 1415 PER DR. . SBP 11O'S. RECIEVED 1 UPC - REPEAT HCT PENDING. CI>2. SVR 700-500'S. PAD'SHIGH 20'S TO LOW 30'S.CVP HIGH 20'S TO LOW 30'S. RECIEVED BUMEX 2 MG AT 0815 WITH 100 ML UO. MVO2 59.EXTREMITIES WARM AND DRY. MEDIASTINAL CT DC'D. LEFT PLEURAL CT DRAINING MIN. CXR REVEALS + FLUID AND R+L PLEURAL EFFUSIONS PER DR. . TTE BY INTENSIVIST REVEALS APICAL AKINESIS. CALCIUM REPLACED.MIRINONE DECREASED TO .06 PER DR. .\n RESP: AUDIBLE EXPIRATORY WHEEZE WORSE WITH EXERTION. BS DIMINISHED BIBASILAR, EXPIRATORY WHEEZE UPPER. NONPRODUCTIVE COUGH , IS 250-500. NO FURTHER CHEST TUBE LEAK NOTED. RR 20'S.\n NEURO: CONFUSED TO PLACE AND TIME, DOES NOT KNOW WHERE HE IS OR WHY, ASKING FOR . PERL, GRASPS STRONG AND EQUAL, MAE, FOLLOWS COMMANDS UNTIL WE TURN HIM THEN HE RESISTS. CALM OTHERWISE.\n GI: REFUSES PO'S HAD SMALL AMOUNT OF JELLO. DID TAKE PO MEDS. ABD SOFT. + BOWEL SOUNDS. NO STOOL,\n GU: UO <20, RECEIVED 2 MG BUMEX WITH 100ML UO, RECEIVED AN ADDITIONAL 2 MG BUMEX AFTER TRANSFUSION. >30 SINCE BUMEX. CREAT RISING 1.4.\n ENDO: SSI X 1 . INSULIN GTT RESTARTED AT 1415 FOR GLUCOSE 151.\n ID: TEMP 99.5, WBC 21.8 UP FROM 21.3\n PAIN:DENIES PAIN UNTIL HAS TO MOVE OR DEEP BREATHE.RECEIVED 5 ML OF PERCOCET ELIXIR FOR INCISIONAL DISCOMFORT WITH GOOD EFFECT.\n SOCIAL: DAUGHTER INTO VISIT ,PT MORE CONFUSED THAN PREVIOUS VISIT PER DAUGHTER.\nA: APICAL AKENESIS, DECREASED UO, LOW SVR, HYPOTENSION, CONFUSED,\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-CONTINUE LEVO,CI,MVO2,PADS,CVP, CT DRAINAGE, PP, DSGS, RESP STATUS-PULM TOILET, CHECK POST CT DC CXR, NEURO STATUS-REORIENTE PRN, I=O-UO-? LASIX GTT, LABS PENDING- HCT AT 1530/ GLUCOSE Q1HOUR. AS PER ORDERS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-09 00:00:00.000",
"description": "Report",
"row_id": 1645732,
"text": "Resp. Care Note: Albuterol/Atrovent\nunit dose treatment given to try and\ntreat wheezying and discomfort. Patient\nappears to have a long forced exhalation.\nNo change in RR, Breath sounds or level\nof comfort with treatment.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-15 00:00:00.000",
"description": "Report",
"row_id": 1645746,
"text": " PT ORIENTED TO SELF ONLY.RE-ORIENTED PRN. PLEASANT & COOPERATIVE WTIH CARE. NO ATTEMPTS TO CLIMB OOB.DENIES PAIN.\n\nCV- AFEBRILE . NSR WITH RARE PAC. LYTES REPLETED PRN. A-LINE PLACED THIS AM BY . LINE/CUFF PRESSSURES CONSISTANT. STARTED ON 2.5 LISINOPRIL TODAY.\n\nRESP-START OF SHIFT.PT TACHYPNEIC WITH LABORED RESP. LS DIM ALL FIELDS. SATS-90% ON 6LNC & 50% OFM. SKINN TONE GREY AND DIAPHORETIC. EKG/CXR DONE. PLACED ON BIPAP 50%X5/10.100MG LASIX IV X1 WITH GTT AT 3MG.HR. RESP STATUS IMPROVED GREATLY WITHIN 10MINS. REMAINED ON BIPAP FOR THIS SHIFT. ABG IMPROVING. LSC.SATS=97%.\n\n\nGI/GU- LASIX GTT @ 3MG /HR DIURESING WELL. PT NPO TODAY EXCEPT MEDS.\nABD SOFT. HYPOACTIVE BS.\n\nACCESS- RT ARTERIAL LINE PLACED BY . LT IJ TLC ERYTHEMATOUS & patent.\n\nPLAN-CONTINUE ON BIPAP UNTIL AM. ASSESS PULM.STATUS. REPEAT ABG. MONITOR LYTES & U/O.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-16 00:00:00.000",
"description": "Report",
"row_id": 1645747,
"text": "Respiratory note:\nPt received on mask ventilation. Started yesterday due to ^^WOB, low saturation. Pt remained on NIV overnight. Well tol, PS wean from 10 to 8. Improve ABG. Will continue to monitor respiratory status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-16 00:00:00.000",
"description": "Report",
"row_id": 1645748,
"text": "NEURO: Pt remains oriented only to self. denies pain, MAE, follows commands and assists minimally with turns.\n\nCV: Pt in NSR with PVCs & PACs noted; K+ repleated prn. Lopressor PO tol well. SBP 110s; lisinopril started yesterday. PP palpable. Hct 31.9.\n\nRESP: Pt remains on mask-ventilation 40% 8 PEEP & 5 PS. ABG alkalotic, lasix gtt stopped; Diamox given, ABG slightly improving, pH 7.49. LS clear, dim in bases. CXR ordered for this am. pt desats to high 80s when mask off (for meds or when he disconnects himself). Weak non-productive cough. Sats >98%, PaO2 102.\n\nGI/GU: NPO-mask ventilation; hypoactive BS; swallowing thickened liquids with meds no difficulty. Lasix gtt stopped d/t alkalosis worsening & 3360cc urine out last 24hr (-2.6 for day). NP ordered huo to remain >40cc when gtt stopped, pt did dip 25cc/hr, so gave 250cc NS fluid bolus with no improvement. Diamox 500mg ordered and given now. BUN 30, creat 1.1.\n\nENDO: BS tx per custom HISS.\n\nPLAN: Continue to monitor resp status/ABGs, huo>40cc, labs/lytes repleat prn. Monitor neuro status & VS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-10 00:00:00.000",
"description": "Report",
"row_id": 1645733,
"text": "7P->7A\nNeuro-Confused all shift, constantly reorientating without success. Pleasently confused, yelling out for wife. Taking stuff off, dsg, sat probe, n/c, ect. MAE =/strong. + gag and cough. Cooperative most of the time. No c/o pain all shift.\n\nCV-ST all shift in the 100's, initially A-paced but was competing with pacer and his own rate was in the 100's, sinus and it gave him a better b/p so left to his own rate. No ectopy noted, replaced Ca+ x 1. SBP 100->130's/60's->70's, on Norepi at 0.07, and Milrinone at 0.05. PAp about systemic. HCT 30.3, WBC 16.7, Na 132, MVsat 67->52 this am.\n\nResp-Insp wheezing with decreased bibasular, when patient wearing his O2 sats in mid to high 90's, when patient takes it off, drops into 80's. Given Alb/Atrovent nebs x 3 for wheezing. Good cough, nonproductive. Currently on .35% face tent with sats in mid to high 90's.\n\nGI/GU-Tolerating po fluids tonigh without problems, bowel sounds active, no stools. Abd soft, obese, non tender. Foley to gravity drainage. UOP slowly decreasing off. BUN 30, Cr 1.3.\n\nSkin-Sternal DSG changed x 2 d/t patient took it off and tried to pull the staples out too. Some bleeding at the site noted and dsg changed. Also tried to pull Swan out of L neck. Dsg reinforced and patient reoriented to person, place and time.\n\nSocial-No contact tonight. has been yelling out for his wife all night, on and off. Confused all night no matter how many times I try to reorient.\n\nPlan-wean Norepi, Milrinone per team, watch HR, B/P, and CO. Pulmonary toilet, diurese as tolerated. ? d/c CT's, evaluate rash, ? reaction.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-13 00:00:00.000",
"description": "Report",
"row_id": 1645740,
"text": "Neuro: pt remains confused following commands but only knows name. pt continues to pull on lines and tubes disconnecting himself from monitor or O2. Wrist restraints ordered and checked every 2 hours for placement, pt still manages to pull on things but to a less effect with restrainits.\nResp: O@ sats 06-98% on 4l NP, $0% face tent left on for most of night for humidity. Breath sounds clear but diminished in bases especially right side. Respiratory effect still appears labored with abdominal breathing. .\nC/V: vss pt afebrile. Blood pressure stable.\nGI: tolerateds liquids that have been thickened, does well swollowing pills.\nEndo: blood sugars have been elevated for the most part since coming off drip. 140's to 180's. pt receiving intermittent doses of insulin every 6 hours per protocol but no change in blood sugars have been seen. Scale increased last evening and pt being evaluate for possible lantus.\nGU: urine outputs low minimal response from lasix 40 mg earlier yesterday. Dose increased to 80mg of lasix with a good response pt putting out 100cc/hr for past 6hours sinse receiving it.\n\nPain: pt denies pain when asked.\nSkin: Incisions clean and dry no drainiag. pt has a open area on left upper leg possible caused by a blister from either tape or ace wrap. Criticaid and dsd plased over\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-13 00:00:00.000",
"description": "Report",
"row_id": 1645741,
"text": "7a-7p\nNeuro: Pt alert at times/ lethargic and sleepy at times. Pleasantly confused. Pt and follows commands. Pt continued to be restrained per PA . Pt c/o of no pain throughout the shift.\n\nCV: HR- NSR 80's-90's with PVC's and PAC's. SBP-90's-120's. Electrolytes monitored and repleted. Pt with pulses by doppler.\n\nResp: LS- CTA/dim at bases with audible exp wheeze at times and neb given. Pt lethargic in AM. ABG drawn in AM NP with no signifigant change and NP. Sats 94-98%. RR-20's-30's.\n\nGI/GU: Abd. soft with +BS. Pt with BM x1 with loose brown stool. Foley intact draining adequate amounts of clear, yellow urine. Continuing on lasix. Pt tolerating nectar thick liquids with ground meat with no N/V.\n\nEndo: Blood sugars poorly controlled 150's-250's. Pt started on lantus 20 units in AM and ISS adjusted. At 1500, BS 254 and pt given 15 units Humalog SC per PA .\n\nSkin: See flow sheet.\n\nActivity: OOB to chair with 2-3 person assist in afternoon.\n\nPlan: Monitor neuro status and keep pt safe. Monitor hemodynamics and pulmonary toilet. Monitor urine output. Monitor BS's and follow pt's own ISS protocol. Increase activity level.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-15 00:00:00.000",
"description": "Report",
"row_id": 1645745,
"text": "Addendum:\n\nPt extremely wheezey and WOB ^. Pt more lethargic and desating and staying 86-88% despite ^ O2; HR ^ 110s & pt more HTN than earlier. Pt ^ 6L NC and given continuous Nebs. ABG drawn by RT; 7.45/46/65/33/6. MD to notify of pt change, however awaiting his call. Pt remains on 6L NC & Neb tx @ time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-08 00:00:00.000",
"description": "Report",
"row_id": 1645728,
"text": "Neuro:\nOriented to person only.Confused in time and place.Wife tell me that he gets confused and somtimes aggressive when he is sick.Tries to take O2 off but cooperates with frequent redirection.Bed alarm on.Does not try to get out of bed or touch lines.Pupils equal and reactive.Percocet for incisional pain.\n\nCV:\nSR mid 90's BBB with PAC's rare.Remains on Milrinone,Vasopressin and levo.Levo weaned down slowly to keep MAP>60.CO and CI WNL per fick and thermodilution.2 units RBC given for hct 25.Repeat Hct 29.K repleated.Na low at 132.Epicardial wires off.Low grade temp.WBC>20.\n\nResp:\nO2 5 l N/C.LSC but diminished bases L>R.Left pleural effusion per CXRay .IS and DBC Q1-2 hrs.Dry non-productive cough.CT @20 cm.Minimal drainage.SOB noted with expiratory wheezing with repositioning.Short recooperation time with rest.\n\nGI/GU:\nFoley to gravity.Lasix 20 mg IV given for poor U/O.Good response.Hourly UO marginal.Abdomen soft.Takes clear liquids well.No BM.Denies naussea or discomfort.\n\nEndo:\nInsulin drip.Wean per protocol.\n\nPlan:\nWean pressors as tolerated.Pulmonary hygiene.Monitor mental status.Bed alarm with fall prevention.Increase activity and diet.Monitor labs.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-08 00:00:00.000",
"description": "Report",
"row_id": 1645729,
"text": "ALTERED CARDIOVASCULAR STATUS\nS: \"OOOOHHHH STOP THAT YOU DON'T HAVE TO DO THAT\"\nO: CARDIAC: SR-ST WITH VEA. K >4.4, VASOPRESSIN OFF, MILRINONE CONTINUES AT .125MCQ WITH CI>2, MVO2 58%X2. LEVO ATTEMPTED TO WEAN TO .03MCQ RETURNED TO .04MCQ TO KEEP SBP>90. UO <30 DR. AND DR. AWARE. RECEIVED 20 MG IV LASIX AT 1600. HCT 28. STERNAL DSG WITH OLD STAINING. CT MIN DRAINAGE. EXTRMEITIES SLIGHTLY COOL DOPP PP. CALCIUM REPLACED. PADS HIGH 20'S-LOW 30'S. CVP 18-24.\n RESP: AUDIBLE EXPIRATORY WHEEZING WITH EXERTION. BS CLEAR OTHERWISE AND DIMINISHED BIBASILAR. IS 500. NONPRODUCTIVE COUGH. + CT LEAK.\n NEURO: ORIENTED TO SELF, LATER IN DAY COULD TELL ME HOSPITAL\"\", GRASP STRONG AND EQUAL, MAE, FOLLOWS COMMANDS, PLEASANT AND CALM UNTIL MOVEMENT. PERL.\n GI: REFUSED JELLO WILL TRY AGAIN, TOOK MEDS WITH WATER. ABD SOFT, NONTENDER, + BOWEL SOUNDS. NO STOOL.\n GU: UO DROPPED TO 30 THEN <20, RECEIVED 20 MG IV LASIX AT 1600 WITH 100 ML DIURESIS SINCE. CREAT .9.\n ENDO: RESTARTED INSULIN GTT PRESENTLY AT 3 UNITS/HR.\n ID: RECEIVED VANCO 1 GM AT 0900.\\\n PAIN: DENIES PAIN UNTIL YOU MOVE HIM AND PAIN RESISTS MOVEMENT. RECEIVED 10 ML PERCOCET ELIXIR X 2 WITH GOOD EFFECT.\n SOCIAL: WIFE AND DAUGHTER INTO VISIT AND UPDATED.\nA: VASOPRESSIN OFF PER DR. , ATTEMPT TO WEAN LEVO UNSUCCESSFUL, DECREASED UO, REMAINS PLEASANTLY CONFUSED. NEEDS HIGHER SBP\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-WEAN LEVO- KEEP SBP>90 WITH MAP>55 PER DR. , CI, MVO2Q4 HOURS,PP, DSGS,CT DRAINAGE,RESP STATUS-PULM TOILET, NEURO STATUS-REORIENTE PRN, I+O-UO RESPONSE TO LASIX, LABS. AS PER ORDERS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-11 00:00:00.000",
"description": "Report",
"row_id": 1645736,
"text": "7a-7p\nNeuro: Pt confused throughout the shift. Pt alert at times and lethargic/sleepy throughout most of shift. Pt and follows simple commands. Pt with right pupil slightly larger than left. Briskly reacting. PA aware. Pt continually reoriented throughout the shift and continues to be restrained to upper extremities for safety per PA . Pt continues to attempt to pull at lines and tubes at this time.\n\nCV: HR-90's-110's. At 0830, pt with HR maintaining 110's and SBP 140's. Pt also with nausea and vomiting and reglan 10mg IV given and 5mg lopressor IV given per PA . Pt with good response and HR down to 90's and pt stating that nausea is gone at 1000 and tolerating sips of clears with pills. Pt also having PAC's and 2g magnesium sulfate IV given. SBP-90's-120's throughout most of shift. Pt with SBP 80's-90's when up in chair at 12. PA notified. A-line with no tracing due to line being kinked. New a-line placed in left radial by PA . Swan D/C'd at 1000 per PA . Epicardial wires pulled at approx. 1400 by PA . Electrolytes monitored and repleted. Pulses by doppler.\n\nResp: LS-CTA/Dim at bases with audible exp. wheezes. Neb tx's given prn. Pt on 3-4LO2 throughout the shift with sats 95-98% throughout the shift. ABG's with no changes at this time.\n\nGI/GU: Abd. obese with hypoactive BS. Pt tolerating clears throughout most of shift. Speech and swallow up to see pt and recommendations from S&S are nectar thick liquids with ground meat when pt awake and alert. Foley intact draining adequate amounts of urine.\n\nEndo: CVICU ISS protocol followed throughout the shift.\n\nSkin: See flow sheet.\n\nActivity: Pt up to chair with PT at 1100.\n\nPlan: Monitor and assess neuro status. Keep pt safe. Monitor hemodynamics and resp. status. Monitor blood sugars. Monitor urine output. Advance diet as tolerated and monitor for signs of aspiration. Increase activity level.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-12 00:00:00.000",
"description": "Report",
"row_id": 1645737,
"text": "7P->7A\nNeuro-Pleasently confused still, MAE, follows commands. PERRLA 3mm OU. Continiously needs reorientation to place and time. Continues to try and pull lines and tubes, soft wrist restraints remain. No pain, or nausea tonight. Has been pulling at everything from dsgs to lines to foley.\n\nCV-SR-ST, 90's->100's. Some PAC's noted, KCL, and Ca+ replaced as needed. Tolerating the Lopressor, Captopril, and Lasix. Good UOP with the 40mg IV of Lasix. Negative 1.7L at midnight, and currently 300 negative. T max 97.7o, BP 90-100's/60-70's, pulses by doppler, warm with good cap refill. HCT 31.5, WBC 16.9, Mg 2.5. K+/Ca+/Glucose have all been treated throughout the night\n\nResp-Lungs clear->coarse->insp wheeze and diminished bibasular. On 3L n/c O2 with sats in mid to high 90's, RR 20's-30's. Does get himself worked up in his manic fase and begins to wheeze. He also keeps taking off his N/C O2 not remembering what it is or why it's on him.\n\nGI/GU-Tolerating thick liquids well, does not like them. Says that they are \"sticky\" and justs wants \"water\", when told he has to have thick liquids, he is not happy. Glucose has been 90-150 requiring RISS coverage. Foley to gravity, working well with lasix. Bun and Cr remain the same.\n\nSocial-Wife called for update, given. Discussed with her how he is at home and she says that he is the same way he is here. Confused but not to this extreme.\n\nPlan-Watch resp status, rhythm, and hemodynamics. Replace electrolytes as needed. Encourage po intake, nectar thick with pureed consistancy on the solids. Deintensify d/t confusion and pulling of lines, removal of dsgs. Otherwise keep soft wrist restraints in place to keep lines and dsgs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-12 00:00:00.000",
"description": "Report",
"row_id": 1645738,
"text": "PATIENT CONTINUES TO BE OX1, NEEDS CONSTANT REORIENTATION TO PLACE AND TIME, HANDS POSEYED. WHEN SITTING IN CHAIR ATTEMPTING TO GET OUT. CHAIR ALARM ON..WHEN NOT RESTLESS, NEEDS LOTS OF STIMULI TO STAY AWAKE, VERY LETHARGIC. SEEMS LIKE HEIS EITHER RESTLESS, OR SLEEPING NO IN BETWEEN!!. SR 90'S WITH PACS, INCREASED LOPRESSOR 25MG , DCD CAPTOPRIL D/T SBP 90-100'S. ALINE DCD. U/O POOR INCREASED LASIX 40 MG TID. OOB IN CHAIR FOR 2HRS. BACK TO BED WITH 2MAN FULLASSIST. GI SEMIFORMED STOOL LARGE X2 INCONTINENT X2...FEEDING PATIENT, DID WELL WITH BREAKFAST, ATE ALL OF FRENCH TOAST, SOME FRUIT/OATMEAL, 120CC AJ THICKENED BS 155 RECEIVED 6REGULAR..PLAN CONTINUES TO REORIENT AS NEEDED. OOB TO CHAIR THIS PM. WIFE TO VISIT THIS PM..\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-12 00:00:00.000",
"description": "Report",
"row_id": 1645739,
"text": "A: RR labored, 36/min, o2sat dropped to 93%.\nA: NP increased to 6l/min, face mask added. Unsuccessfully attempted to suction. CXR done.\nR: Sats improved, pt more comfortable Starting to diurese from earlier dose of lasix.\nP: CXR results pending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-16 00:00:00.000",
"description": "Report",
"row_id": 1645749,
"text": "Neuro: oriented to self only. MAE. restrained, due to pulling at tubes, lines, anything within reach. requires orientation to surroundings, year and procedure he had performed. Yells @ staff at times, swearing and using ethnic slurs.\n\nPain: denies pain.\n\nCV: NSR HR 70's-80's PVC's and PAC's noted. sbp 110's. increased lisinopril dose to 5mg. pulses palpable bilaterally. left wrist IV placed \n\nResp: weaned off bipap to high flow, down to 6L NC, lung sounds clear, ABG's improving metabolic alkalosis. in upper lobes, crackles in bases.chest x-ray ' md. sats 90-100. non productive cough.\n\nGI/GU: bowelsounds hypoactive, no BM or flatus. foley draining, diamox written Q6H, 12 dose given, respnding adequately. diet advanced to ground and nectar thick liquids, no difficlty with eating or drinking.\n\nSkin: sternal and mediastinal dressings intact. coccyx pink, barrier cream applied. abrasions and blisters on legs, pink, non draining.\n\nAssessment: oob to chair in am. PT up @ 1500. restrained due to altred mental status.\n\nendo: following per unit protocol, 1400 bs 156, treated with 6 units regular\n\nsocial: wife called, lots of questions regarding status and oxygenation. questions answered.\n\nPlan: monitor oxygenation, replete lytes, remove cvl. pulmonary hygiene. monitor diet ?calorie count. monitor blood sugars\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-16 00:00:00.000",
"description": "Report",
"row_id": 1645750,
"text": "Resp. Care Note\nPt received in NIPPV with settings as per resp flowsheet. Pt taken off NIV this morning and placed on high flow neb initially at 95%. FiO2 weaned to 6LNP with pt maintaining adequate ABGs. Pt has prn nebulizer order but has not received Rxs this shift. BS with few crackles R base otherwise fairly clear.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-07 00:00:00.000",
"description": "Report",
"row_id": 1645724,
"text": "Neuro:\nSedated.Propofol drip @ 20mcg/kg/min.Daily wakeup done early evening.MAE.Nodes head to questions.Grimacing with mouth care and turns.Morphine for pain.Demorol x 1 for shivering with good effect.\n\nCV:\nST/SR 79-110.Rare to frequent PVC's.Milinone and vasopressin increased for low CI and SVO2.Fluid bolus for MAP<60 and syst<90.Epicardial pacemaker off/good sense and capture.Pulses doppler.UE and LE cool and pale.Acewrap left leg with hemovac intact.Remains on levophed at .07 mcg/kg/min.Low grade temp.Generalized edema.\n\nResp:\nIntubated via ETT (Difficult intubation in OR).AC/600/50%/rate 14/Peep 10.ABG WNL.CT @20 cm suction.Drainage mod to large with turn(sero-sanguinous).MD aware.Hg/Hct stable.No crepitis noted.LSC.Minimal bloodting secretions.\n\nGI/GU:\nFoley to gravity.Lasix x 2 for UO<30 cc/hr with fair response.BUN/Creat WNL.Abdomen soft with hypoactive BS.OG minimal bilious drainage.LWS.No BM.\n\nSkin:\nNo skin brakedown.Criticaid applied to coccyx.Repositioned Q2-3 hrs.\n\nEndo:\nInsulin drip per protocol.FS Q1 hr.\n\nPlan:\nMonitor hemodynamics.Adjust drip accordingly.Monitor labs.CXRay this am.Skin care.Insulin drip.UO>30 cc/hr with MAP>60.Wean from vent as tolerated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-07 00:00:00.000",
"description": "Report",
"row_id": 1645725,
"text": "Respiratory Therapy\nPt presents oraly intubated on full ventilatory support with PEEP of 10. Initial BS diffuse crackles which cleared after suctioning of sml amounts thick Blood tinged secretions. ABG WNL, no RSBI D/T high PEEP requirement. Plan: wean per protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-07 00:00:00.000",
"description": "Report",
"row_id": 1645726,
"text": "Resp.are Note: 7am- 11:30 am\nPatient weaned and extubated this shift.\nAnesthesia present for extubation,\nPatient extubated to 60% cool face tent,\nBreathing appears comfortable.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-07 00:00:00.000",
"description": "Report",
"row_id": 1645727,
"text": "cvicu npn\n\nneuro: pt initially on low dose propofol. sedation off. after extubation pt oriented to hospital, family. forgets he had \"heart surgery\" occas \"i have to get out of here\". pt stating \"help me, help me\" this afternoon. reassurance given, oriented to person only.\n\npain: pain level diff to assess. morphine 2 mg iv x2 this am. later in the day \"I hyrt\". percocet elix 5cc given.\n\ncv: vs/hemos as per flowsheet. SR w/ episodes pvc today. good thermo CO w/ CI ~2.2-2.5. milrinone wean to off today MD but unable to wean vasopressin or levophed. ~1600 pt w/ elevated pad (low 30's),cvp and hypotension. team aware. 500cc fluid bolus given. hct and svo2 sent=51. hct back at 24-> transfusion 1 unit prbc at present w/ pad 30 and cvp 19. diaphoretic. ekg done, seen by MD.\n\nresp: wean to extubation. MD cath for extubation, tol well. cong cough, occas productive thick blood tinge, BS coarse this afternoon. ofm most of shift, n/c 4l at presnt. o2 sat 99%.\n\ngi/gu: abd soft. ref po much of day. took couple sips h2o. no s+s of aspiration. rare bsp, denies nausea. uop as noted-drifting to teens this afternoon. fluids and prbc as above. insulin gtt cont per protocol.\n\nid: low grade temp.\n\nsocial: family into visit this afternoon.\n\nassess: vs/hemos improving at presnt w/ return of milrinone. transfusion and fluids.\n\nplan: cont to monitor vs/hemos closely. complete transfusion. titrate pressors as able. pulm hygiene.\n\n"
},
{
"category": "Echo",
"chartdate": "2180-10-10 00:00:00.000",
"description": "Report",
"row_id": 87408,
"text": "PATIENT/TEST INFORMATION:\nIndication: s/p CABG, AVR, decrease Urine output\nHeight: (in) 67\nWeight (lb): 211\nBSA (m2): 2.07 m2\nBP (mm Hg): 120/61\nHR (bpm): 113\nStatus: Inpatient\nDate/Time: at 11:26\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Symmetric LVH. Normal LV cavity size. Depressed LVEF. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Normal ascending aorta diameter.\n\nAORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). Normal AVR gradient. No\nAR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\nsystolic pressure.\n\nGENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or\nelectrodes. Suboptimal image quality as the patient was difficult to position.\nSuboptimal image quality - patient unable to cooperate.\n\nConclusions:\nThere is symmetric left ventricular hypertrophy. The left ventricular cavity\nsize is normal. LV systolic function appears depressed with probable\nanterior/anteroseptal and apical hypokinesis but views are technically\nsuboptimal for interpretation of regional wall motion (estimated LV ejection\nfraction ?30%). Cannot exclude LV thrombus. A bileaflet aortic valve\nprosthesis is present (not well seen). The transaortic gradient is normal for\nthis prosthesis. No aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. No mitral regurgitation is seen. The pulmonary artery\nsystolic pressure could not be determined.\n\nCompared to the prior study of (images reviewed) left ventricular\nsystolic function is probably more severely impaired but images are suboptimal\nfor comparison. Prosthetic aortic valve is now in place.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2180-10-06 00:00:00.000",
"description": "Report",
"row_id": 87409,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Chest pain. Coronary artery disease. Shortness of breath.\nStatus: Inpatient\nDate/Time: at 08:44\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes. No mass/thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous hypertrophy of the\ninteratrial septum.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. No LV\naneurysm. Moderate regional LV systolic dysfunction. No LV mass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - hypo; mid inferoseptal - normal; mid inferior -\nnormal; anterior apex - hypo; septal apex - hypo; inferior apex - hypo;\nlateral apex - normal; apex - hypo; remaining LV segments contract normally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal\ndescending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Trace AR.\nEccentric AR jet.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild thickening of mitral valve\nchordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope.\n\nConclusions:\nPre-CPB:\nThe left atrium and right atrium are normal in cavity size. No mass/thrombus\nis seen in the left atrium or left atrial appendage.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. No left ventricular aneurysm is seen. There is moderate regional\nleft ventricular systolic dysfunction with LVEF approximately 30-35%. . No\nmasses or thrombi are seen in the left ventricle. The remaining left\nventricular segments contract normally.\nRight ventricular chamber size and free wall motion are normal.\nThere are simple atheroma in the aortic arch. There are simple atheroma in the\ndescending thoracic aorta.\nThe aortic valve leaflets are severely thickened/deformed. There is severe\naortic stenosis. (~ 0.8-0.9 cm2) Trace aortic regurgitation is seen. The\naortic regurgitation jet is eccentric.\nThe mitral valve leaflets are structurally normal. Mild (1+) mitral\nregurgitation is seen.\nThere is no pericardial effusion.\n\n\nThe pt is receiving an infusion of milrinone at 0.15 uck/kg/min and\nnorepinephrine at 0.08 ucg/kg/min\nThere is preserved RV systolic. LV systolic function is mildly improved in the\nsetting of inotropes (Walls that contact well prebypass are more\nhyperdynamic/walls that were hypokinetic remain hypokinetic) There is a well\nseated bioprosthesis in the aortic position. There is a perivalvular AI jet\noriginating in the area outside and between the left and right coronary cusps\nof the prosthesis. The AI is moderate (2+) in quantity. The remaining study is\nunchanged from prebypass.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2180-10-03 00:00:00.000",
"description": "Report",
"row_id": 87410,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 67\nWeight (lb): 195\nBSA (m2): 2.00 m2\nBP (mm Hg): 137/85\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 08:58\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith >55% decrease during respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity\nsize. Mild-moderate regional LV systolic dysfunction. Cannot exclude LV\nmass/thrombus. Transmitral Doppler and TVI c/w Grade I (mild) LV diastolic\ndysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - akinetic; basal anteroseptal - hypo; mid anteroseptal -\nhypo; anterior apex - akinetic; septal apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Moderate-severe AS\n(area 0.8-1.0cm2). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Trivial MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Indeterminate PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is top normal/borderline\ndilated. There is mild to moderate regional left ventricular systolic\ndysfunction with anterior akinesis/hypokinesis, apical hypokinesis/akinesis,\nand anteroseptal hypokinesis. A left ventricular mass/thrombus cannot be\nexcluded. Transmitral Doppler and tissue velocity imaging are consistent with\nGrade I (mild) LV diastolic dysfunction. Right ventricular chamber size and\nfree wall motion are normal. The ascending aorta is mildly dilated. The aortic\nvalve leaflets are moderately thickened. There is moderate to severe aortic\nvalve stenosis (area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The\nleft ventricular inflow pattern suggests impaired relaxation. The tricuspid\nvalve leaflets are mildly thickened. The pulmonary artery systolic pressure\ncould not be determined. There is a trivial/physiologic pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-15 00:00:00.000",
"description": "Report",
"row_id": 222849,
"text": "Wide complex tachycardia. Sinus tachycardia is suggested. Compared to the\nprevious tracing of the rate has increased.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-10 00:00:00.000",
"description": "Report",
"row_id": 222850,
"text": "Sinus tachycardia. Left atrial enlargement. Left bundle-branch block.\nCompared to the previous tracing of left bundle-branch block has\nappeared.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-06 00:00:00.000",
"description": "Report",
"row_id": 222851,
"text": "Sinus tachycardia. Left axis deviation. Intraventricular conduction delay of\nleft bundle-branch block type. Since the previous tracing of the rate\nhas increased. The Q-T interval is shorter.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-05 00:00:00.000",
"description": "Report",
"row_id": 222852,
"text": "Sinus rhythm. Compared to the previous tracing of there are persistent\nST-T wave abnormalities raising consideration of acute myocardial ischemia.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-05 00:00:00.000",
"description": "Report",
"row_id": 222853,
"text": "Sinus rhythm\nLeft atrial abnormality\nIntraventricular conduction delay with left axis deviation - probable in part\nleft anterior fascicular block\nDelayed R wave progression - could be due to intraventricular conduction delay,\nleft ventricular hypertrophy or possible septal myocardial infarction, age\nindeterminate\nQ-T interval appears prolonged but is difficult to measure\nDiffuse ST-T wave abnormalities - suggest ischemia\nClinical correlation is suggested\nSince previous tracing of the same date, ectopy absent and delayed R wave\nprogression more prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-02 00:00:00.000",
"description": "Report",
"row_id": 223095,
"text": "Sinus rhythm\nConsider left atrial abnormality\nLeft anterior fascicular block\nDelayed R wave progression - could be due in part to left ventricular\nhypertrophy, left anterior fascicular block or possible prior anteroseptal\nmyocardial infarction\nQ-T interval appears prolonged but is difficult to measure\nU waves may be inverted - may be due to left ventricular hypertrophy and/or\nischemia\nDiffuse ST-T wave abnormalities - may be due in part to left ventricular\nhypertrophy but cannot exclude in part ischemia\nClinical correlation is suggested\nSince previous tracing of the same date, further ST-T wave changes and U waves\nappears inverted\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-02 00:00:00.000",
"description": "Report",
"row_id": 223096,
"text": "Sinus rhythm\nLeft anterior fascicular block\nLeft ventricular hypertrophy\nDiffuse ST-T wave abnormalities - may be due in part to left ventricular\nhypertrophy but cannot exclude in part ischemia\nClinical correlation is suggested\nSince previous tracing of the same date, delayed R wave progression less\nprominent\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-02 00:00:00.000",
"description": "Report",
"row_id": 223097,
"text": "Sinus rhythm. Left axis deviation. Left anterior fascicular block.\nProbable old septal myocardial infarction, age undetermined. ST segment\ndepressions and T wave inversions in the lateral precordial leads may indicate\nmyocardial injury/ischemia. Clinical correlation is suggested. No previous\ntracing available for comparison.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-05 00:00:00.000",
"description": "Report",
"row_id": 223092,
"text": "Sinus rhythm with atrial premature complexes (includes a triplet) and\nventricular premature complexes\nLeft atrial abnormality with left axis deviation - probably in part left\nanterior fascicular block\nProbable left ventricular hypertrophy\nQ-T interval appears prolonged but is difficult to measure\nDiffuse ST-T wave abnormalities - cannot exclude in part ischemia\nClinical correlation is suggested\nSince previous tracing of the same date, ectopy now present and further ST-T\nwave changes seen\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-05 00:00:00.000",
"description": "Report",
"row_id": 223093,
"text": "Sinus rhythm\nLeft atrial abnormality\nIntraventricular conduction delay with left axis deviation - probably in part\nleft anterior fascicular block\nProbable left ventricular hypertrophy\nQ-T interval appears prolonged but is difficult to measure\nDiffuse ST-T wave abnormalities - cannot exclude in part ischemia\nClinical correlation is suggested\nSince previous tracing of , rate faster, delayed R wave progression less\nprominent and further ST-T wave abnormalities present\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-03 00:00:00.000",
"description": "Report",
"row_id": 223094,
"text": "Sinus rhythm\nConsider left atrial abnormality\nLeft anterior fascicular block\nLeft ventricular hypertrophy\nDelayed R wave progression - could be due in part to left ventricular\nhypertrophy, left anterior fascicular block or possible prior septal myocardial\ninfarction\nQ-T interval appears prolonged but is difficult to measure\nU waves may be inverted - may be due to left ventricular hypertrophy and/or\nischemia\nDiffuse ST-T wave abnormalities - may be due in part to left ventricular\nhypertrophy but cannot exclude in part ischemia\nClinical correlation is suggested\nSince previous tracing of , further ST-T wave changes present\n\n"
}
] |
23,464 | 176,257 | A/P 44 yo M with h/o htn p/w with new chest pain, syncope, hypotension, in setting of prostatitis c/b urosepsis and same day change in beta-blocker dose. The stress of infection in addition to bradycardia from increased atenolol likely led to unstable angina and syncope. . #hypotension - the cause of patient's arrest was never clear. Our theory was that he was becoming septic from a urinary tract pathogen, possibly related to prostatitis. Pt likely had a bradycardic arrest in the setting of this septic picture plus the recent increased dose of his beta blocker. Pt's blood pressure was high-normal at discharge and he was able to tolerate the equivalent of 50 of lopressor. We felt this was a better drug than atenolol for this pt in light of his renal dysfunction (mild arf at presentation that cleared up with hydration). #urosepsis/prostatitis - positive U/A, likely related to prostatitis - STD ruled out by urethral swab. Pt probably became septic with foley insertion. Less likely from renal stone given nl CT abd. Will rx with 500 mg po levaquin for 4 weeks total for acute prostatitis. Abd/Pelvis CT negative for prostatic abscess. #bradycardia - probably has been going on for days as the patient has been feeling very fatigued x 3d. Brady likely from combination of increased atenolol plus vasovagal from the pain of the prostatitis. . #troponin leak -Pt had + troponin but negative CK at presentation which subsequently improved. It is unclear if related to the bradycardia or if from epinephrine during brady arrest or from CPR given in ER. No evidence of new coronary event on EKG. Pt. denies cocaine use, none seen in tox screen. Pt was seen by cardiology and had a negative stress mibi which also revealed normal ejection fraction. . #ARF - no known h/o renal failure. This was related to arrest vs hypotension of sepsis and dehydration. No hydronephrosis or perinephric abscess seen on abd/pelvic CT scan. Pt's renal fx improved with hydration. | Mild PAsystolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:1. IMPRESSION: Normal myocardial perfusion at the level of exerciese achieved. Mild (1+) mitral regurgitation is seen. /Positive troponin, bradycardic arrest.Height: (in) 66Weight (lb): 140BSA (m2): 1.72 m2BP (mm Hg): 130/80HR (bpm): 76Status: OutpatientDate/Time: at 08:09Test: TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). Mild (1+) aortic regurgitation is seen.3. TECHNIQUE: Noncontrast contiguous axial images were obtained from the level of the lung bases to the pubic symphysis. Mild (1+) AR.MITRAL VALVE: Normal mitral valve leaflets. In MICU pt weaned off levophed, sepsis protocol d/c'd. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. CT OF ABDOMEN WITH ORAL CONTRAST ONLY: Bilaterally, there are small pleural effusions with dependent atelectasis. Normal regional LV systolic function.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter.AORTIC VALVE: Normal aortic valve leaflets (3). No contraindications for IV contrast FINAL REPORT INDICATION: Sepsis and prostate pain, rule out perinephric or prostatic abscess. NSR 80s, no ectopy. 2) Small pocket of air in the bladder, which most likely is secondary to recent Foley catheter insertion. IMPRESSION: 1) No evidence of prostatic or perinephric abscess. CT OF PELVIS WITH ORAL CONTRAST ONLY: The rectum and sigmoid colon are unremarkable. ECG findings: no ECG changes. Cycling CKs.GI - Abd soft, +BS. The heart size and pulmonary vascularity are within normal limits. 12:44 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: does pt have perinephric or prostatic abscess. Left ventricular cavity size is normal. Resting blood pressure: 120/84. PATIENT/TEST INFORMATION:Indication: Syncope. (Over) 12:44 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: does pt have perinephric or prostatic abscess. There is a pocket of air demonstrated at the superior portion of the bladder. Rest and stress perfusion images reveal uniform tracer uptake throughout the myocardium with no areas of reversible perfusion defects. Resting perfusion images were obtained with Tl-201. Regional left ventricular wall motion is normal.2. Approved: MON 9:42 AM RADLINE ; A radiology consult service. /nkg , M.D. Sats high 90s 2L NC.CV - Arrived on levophed 0.03 mcg/k/min. Cardiology to see pt, pt to have echo in AM. SUPINE AP PORTABLE CHEST: A right internal jugular central venous access catheter has been inserted via the right internal jugular vein, and its tip ends in the superior right atrium. The lungs are free of focal opacities. This is most likely secondary to recent Foley catheter insertion. Reason exercise terminated: fatigue. Extremities W&D. Sinus rhythm. Sinus rhythm. Pain suprapubic with palpation.Resp - Lungs CTA. REASON FOR THIS EXAMINATION: does pt have perinephric or prostatic abscess. Cyckle CKs. Tylenol given and pt sleeping. Admitting Diagnosis: SEPSIS Field of view: 32 FINAL REPORT (Cont) 3) Small bilateral pleural effusions with dependent atelectasis. There is no free fluid or pelvic/inguinal lymphadenopathy. No mesenteric or retroperitoneal lymphadenopathy is present. No pleural effusion or pneumothorax is detected. IMPRESSION: Tip of right internal jugular line in superior right atrium. , M.D. The stomach, large bowel, and small bowel are unremarkable. The visualized osseous structures are unremarkable. Normal tracing. PATIENT CURRENTLY ON BETA BLOCKER MEDICATION. See FHP for adm data. The prostate is normal in size and density characteristics and demonstrates no surrounding stranding or localized fluid collection. The spleen is upper limits of normal in size, but otherwise normal. No consolidation or pulmonary nodules are identified. If there has been no Foley catheter placed, other considerations include air-producing organisms from urinary tract infection/cystitis. Please correlate clinically. The patient is currently on beta blocker medication. Peak blood pressure: 130/90. Taking liquids well.GU - UOP adequate. Able to wean off. COMPARISONS: None. BONE WINDOWS: Osseous structures are unremarkable and demonstrate no suspicious lytic or blastic lesions. COMPARISON: None. Also c/o sore throat. Resting heart rate: 44. Clinical correlation is suggested. The liver, gallbladder, pancreas, and adrenal glands are unremarkable. BP 100s/60s. Sycope/asystolic arrest likely d/t recent increased atenolol dose and urosepsis.Neuro - A&O x 3, MAE. EXERCISE MIBI Clip # Reason: 44 Y/O WITH H/O BRANDYCARDIC ARREST AND CHEST PAIN. Exercise images were obtained with Tc-m sestamibi. Peak heart rate: 96. UA positive, likely prostatitis. Additionally, there is no focal wall thickening or nodularity of the bladder mucosa or surrounding colon to suggest malignancy. Since the previous tracing of precordial T wave amplitudeis more prominent. This study was interpreted using the 17-segment myocardial perfusion model. The kidneys are also unremarkable and demonstrate no perinephric stranding or localized fluid collection to suggest abscess. MICU nursing adm notePt is 44 yo male adm from OSH S/P asystolic arrest, sepsis protocol. | 7 | [
{
"category": "Nursing/other",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Report",
"row_id": 1568830,
"text": "MICU nursing adm note\nPt is 44 yo male adm from OSH S/P asystolic arrest, sepsis protocol. See FHP for adm data. In MICU pt weaned off levophed, sepsis protocol d/c'd. UA positive, likely prostatitis. Sycope/asystolic arrest likely d/t recent increased atenolol dose and urosepsis.\n\nNeuro - A&O x 3, MAE. Pt c/o neck pain, chronic neck pain. Also c/o sore throat. Tylenol given and pt sleeping. Pain suprapubic with palpation.\n\nResp - Lungs CTA. Sats high 90s 2L NC.\n\nCV - Arrived on levophed 0.03 mcg/k/min. Able to wean off. BP 100s/60s. NSR 80s, no ectopy. Extremities W&D. Cycling CKs.\n\nGI - Abd soft, +BS. Taking liquids well.\n\nGU - UOP adequate. On Cipro for UTI.\n\nID - Afebrile.\n\nSocial - Pt is incarcerated. Prison guard at bedside, shackles on pts feet.\n\nPlan - Tx to floor. Cardiology to see pt, pt to have echo in AM. Cyckle CKs.\n"
},
{
"category": "Echo",
"chartdate": "2168-01-12 00:00:00.000",
"description": "Report",
"row_id": 78057,
"text": "PATIENT/TEST INFORMATION:\nIndication: Syncope. /Positive troponin, bradycardic arrest.\nHeight: (in) 66\nWeight (lb): 140\nBSA (m2): 1.72 m2\nBP (mm Hg): 130/80\nHR (bpm): 76\nStatus: Outpatient\nDate/Time: at 08:09\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). Mild (1+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n2. Mild (1+) aortic regurgitation is seen.\n3. Mild (1+) mitral regurgitation is seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-01-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 850736,
"text": " 8:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check line\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p RIJ\n REASON FOR THIS EXAMINATION:\n check line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right internal jugular line placement.\n\n COMPARISON: None.\n\n SUPINE AP PORTABLE CHEST: A right internal jugular central venous access\n catheter has been inserted via the right internal jugular vein, and its tip\n ends in the superior right atrium. The heart size and pulmonary vascularity\n are within normal limits. The lungs are free of focal opacities. No pleural\n effusion or pneumothorax is detected. The visualized osseous structures are\n unremarkable.\n\n IMPRESSION: Tip of right internal jugular line in superior right atrium.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-01-13 00:00:00.000",
"description": "EXERCISE MIBI",
"row_id": 851078,
"text": "EXERCISE MIBI Clip # \n Reason: 44 Y/O WITH H/O BRANDYCARDIC ARREST AND CHEST PAIN. PATIENT CURRENTLY ON BETA BLOCKER MEDICATION.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Forty-four year old with a history of bradycardic arrest and chest\n pain. The patient is currently on beta blocker medication.\n\n SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB:\n Exercise protocol: Modified .\n Resting heart rate: 44.\n Resting blood pressure: 120/84.\n Exercise duration: 9.45 minutes.\n Peak heart rate: 96.\n Percent maximum predicted heart rate obtained: 55%.\n Peak blood pressure: 130/90.\n Symptoms during exercise: atypical symptoms of lightheadedness with exercise.\n Reason exercise terminated: fatigue.\n ECG findings: no ECG changes.\n\n INTERPRETATION:\n Imaging Protocol: Gated SPECT.\n Resting perfusion images were obtained with Tl-201.\n Tracer was injected 15 minutes prior to obtaining the resting images.\n Exercise images were obtained with Tc-m sestamibi.\n This study was interpreted using the 17-segment myocardial perfusion model.\n\n Left ventricular cavity size is normal.\n Rest and stress perfusion images reveal uniform tracer uptake throughout the\n myocardium with no areas of reversible perfusion defects.\n\n Gated images reveal normal wall motion with a calculated LVEF of 65%.\n\n IMPRESSION: Normal myocardial perfusion at the level of exerciese achieved.\n Normal LV cavity size and function with a calculated LVEF of 65%.\n /nkg\n\n\n , M.D.\n , M.D. Approved: MON 9:42 AM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2168-01-11 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 850817,
"text": " 12:44 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: does pt have perinephric or prostatic abscess.\n Admitting Diagnosis: SEPSIS\n Field of view: 32\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with sepsis and prostate pain.\n REASON FOR THIS EXAMINATION:\n does pt have perinephric or prostatic abscess.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis and prostate pain, rule out perinephric or prostatic\n abscess.\n\n COMPARISONS: None.\n\n TECHNIQUE: Noncontrast contiguous axial images were obtained from the level of\n the lung bases to the pubic symphysis.\n\n CT OF ABDOMEN WITH ORAL CONTRAST ONLY: Bilaterally, there are small pleural\n effusions with dependent atelectasis. No consolidation or pulmonary nodules\n are identified. The liver, gallbladder, pancreas, and adrenal glands are\n unremarkable. The spleen is upper limits of normal in size, but otherwise\n normal. The kidneys are also unremarkable and demonstrate no perinephric\n stranding or localized fluid collection to suggest abscess. The stomach, large\n bowel, and small bowel are unremarkable. There is no free air or free fluid.\n No mesenteric or retroperitoneal lymphadenopathy is present.\n\n CT OF PELVIS WITH ORAL CONTRAST ONLY: The rectum and sigmoid colon are\n unremarkable. There is a pocket of air demonstrated at the superior portion\n of the bladder. This is most likely secondary to recent Foley catheter\n insertion. If there has been no Foley catheter placed, other considerations\n include air-producing organisms from urinary tract infection/cystitis. There\n is no radiographic evidence of an inflammatory process in the bladder or\n surrounding colon to correlate with this. Additionally, there is no focal\n wall thickening or nodularity of the bladder mucosa or surrounding colon to\n suggest malignancy. There is no evidence of enterovesicular fistula and no\n evidence of oral contrast entering the bladder. The prostate is normal in\n size and density characteristics and demonstrates no surrounding stranding or\n localized fluid collection. There is no free fluid or pelvic/inguinal\n lymphadenopathy.\n\n BONE WINDOWS: Osseous structures are unremarkable and demonstrate no\n suspicious lytic or blastic lesions. Reconstructions were not performed.\n\n IMPRESSION:\n 1) No evidence of prostatic or perinephric abscess.\n 2) Small pocket of air in the bladder, which most likely is secondary to\n recent Foley catheter insertion. No evidence of an inflammatory, infectious,\n or malignant process of the bladder or surrounding colon, and there is no\n evidence of an enterovesicular fistula. Please correlate clinically.\n (Over)\n\n 12:44 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: does pt have perinephric or prostatic abscess.\n Admitting Diagnosis: SEPSIS\n Field of view: 32\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3) Small bilateral pleural effusions with dependent atelectasis.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2168-01-12 00:00:00.000",
"description": "Report",
"row_id": 189550,
"text": "Sinus rhythm. Since the previous tracing of precordial T wave amplitude\nis more prominent. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2168-01-11 00:00:00.000",
"description": "Report",
"row_id": 189551,
"text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n"
}
] |
22,052 | 149,934 | This patient was admitted to on for symptoms concerning to C. Difficile colitis megacolon. A KUB showed massively dilated colon measuring up to 11 cm which given the history of C. difficile colitis is concerning for toxic megacolon. A CT scan showed diffuse wall thickening seen throughout the colon consistent with pancolitis, consistent with patient's known history of C. diff colitis. There is no evidence of pneumatosis, air in any mesenteric veins, portal venous air, or free air in the abdomen to suggest ischemic bowel. Her WBC was 26 but she was afevrile. She was admitted to the ICU and surgery was consulted. She recieved aggressive fluid resuscitation, IV Flagyl, and PO/PR Vancomycin. A CVL was placed to aid with ICU care. She was deemed unsafe for an operation at this point. She recieved serial abdominal examinations. On HD 3, TPN was started. Her recal tube was discontinued and she was transferred to the floor. She was on maintenance IV fluids. Her WBC was 19. Physical therapy saw her and rehab. On HD 6 she was started on sips. On HD 7 she tolerated clears. On HD 9 she was started on cholestyramine for diarrhea. She was started on Linezolid for a VRE UTI. On HD 13 she tolerated a regular diet. On HD 14 her WBC was 11. Her TPN was stopped. On HD 15 she was discharged to rehab. By the advice of the ID servce, she was off of all antibiotics except PO Vancomycin, which she is to take for 7 days. Flagyl and Linezolid were stopped. A urine culture from grew out Pseudomonas, but a UA from was negative so ID did not recommend any treatment. | Lungs clear/diminished at the bases. colon ischemia, pat. Mild mitral annularcalcification. Minimal medical hx: anemia, DM, HTN. :colonoscoopy and angio done-? + pulses to lower ext. LUNGS CTA BILAT, DIMINISHED AT THE BASES. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Noaortic regurgitation is seen.5.The mitral valve leaflets are mildly thickened. The transverse colon does appear mildly distended. Lungs R clear/crackles at the bases, L clear/diminished. Pancreas appears atrophic. IMPRESSION: Nonspecific thickening of the folds of the distal transverse colon. Probable small left pleural effusion. MEDICATED W/ DILAUDID MD'S ORDERS W/ EFFECT. AM ABG: 7.37/40/101/24/-1.CV: NSR without ectopy. AP PORTABLE UPRIGHT CHEST: There is a right-sided PICC line terminating within the proximal SVC. The rectum, sigmoid colon, descending colon, ascending colon, and cecum are of normal caliber and contour. There are linear opacities consistent with atelectasis as well as small bilateral pleural effusions with associated atelectasis. Hyperdynamic LVEF.AORTA: Moderately dilated aortic root.AORTIC VALVE: Aortic valve not well seen. Minimal edema. LUNGS CTA BILAT. NGT to R nare to LIWS draining scant amounts of bilious fluid. CONDITION UPDATEVSS. CONDITION UPDATEVSS. L knee remians with steri strips intact.GI/GU: Abd softly distended and + tenderness, hypo-absent BS. There is perihepatic ascites. DILAUDID GIVEN X1 MD'S ORDERS W/ GOOD EFECT. Rt radial aline intact-becoming positional. U/O QS VIA FOLEY. U/O QS VIA FOLEY. TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were obtained with and without IV contrast. IMPRESSION: Tubes and lines as described. No MR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:Suboptimal study. Pt continued with elevating WBC, temps, hypotension. There is mild aortic valve stenosis. Normal LV cavity size. Limited views obtained.1. Limited visualization of the colon demonstrates severe dilatation. The left atrium is moderately dilated.2. Pt renal status compromised with elevated CR:1.7 and poor UO. CTA done of Abd with po/IV contrast-? NGT to LIWS draining minimal amounts of bilious fluid. AFEBRILE. AFEBRILE. HR 90s, SBP 95-130, max temp 99.6 orally. NGT TO LWCS. STATUSD: ORIENTED X3..VERY ..FOLLOWS COMMANDSA: VSS..DECREASING DIARRHEA..CONTINUES ON VANCO ENEMA'S Q6 & PO VANCO..NPO EXCEPT FOR MEDS..SAT ON SIDE OF BED & STOOD WITH PT'S HELP CONTINUES TO BE WEAK..ADQUATE HUO'SR: STABLEP: TRANSFER TO FLOOR Left ventricular function.Height: (in) 70Weight (lb): 325BSA (m2): 2.57 m2BP (mm Hg): 140/61HR (bpm): 95Status: InpatientDate/Time: at 11:46Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.LEFT VENTRICLE: Normal LV wall thickness. Small amount of air is seen within the bladder, likely secondary to Foley catheterization. Incomplete visualization of severely dilated colon. PICC line to R AC which pt arrived with. Visualized loops of small bowel appear unremarkable. The splenic flexure appears unremarkable. R an PICC line intact, L SC central line.GI/GU:Abd softly distended, + BS, Pt stooling-fecal bag intact. No resp distress noted.Rt Radial aline intact with sharp waveform placed.AM ABG: 7.34/36/88/20/-5.CV: NSR with some unifocal PVCs noted early in PM. Pt remians NPO at this time. The left costophrenic sulcus is not completely visualized. CONT TO HAVE LOOSE STOOL. BOWEL SOUNDS PRESENT. A nasogastric tube terminates near the pylorus, possibly in the antrum of the stomach or proximal duodenum. See carevue for skin assess. A small amount of free fluid within the pelvis. CONT CURRENT ICU CARE AND ASSESSMENTS. CONT CURRENT ICU CARE AND ASSESSMENTS. to OR, medically treat?, conitnue fluids, Correct INR, Supportive care to pt and family. Pt follows commands well, MAEs and remains very coooperative. CVP 9-12, Max temp 99.0ax. determine ischema vs. colitis. HCT:26.9. REMAINS NPO. CONT ON LR AT 120/CC HR. ABD OBESE. Cholecystectomy clips are in the right upper quadrant. The left ventricularcavity size is normal. Left ventricular systolicfunction is hyperdynamic (EF>75%).3.The aortic root is moderately dilated.4.The aortic valve is not well seen. Left ventricular wall thicknesses are probably normal. PATIENT/TEST INFORMATION:Indication: Hypertension. There is a paucity of gas in the visualized portions of the stomach and small bowel. There may be a small left pleural effusion. WBC^24.5-continued on flayl IV. MIN C/O CRAMPING PAIN. Pt transfered to SICU from CC6 for worsening condition, ?to OR.Neuro: Pt awake, alert,oriented X3. ABDOMEN, SINGLE VIEW: This is a limited view of the abdomen which does not include the left lateral abdomen nor the upper quadrants. No normal colon is visualized. ABD SOFT, TENDER TO PALPITATION. There is suggestion of old trauma within the thoracic spine. CONT ON TPN. There is symmetric nonspecific thickening of the left side of the transverse colon, correlating with the findings on the recent CT scan. Suboptimaltechnical quality, a focal LV wall motion abnormality cannot be fullyexcluded. Since the recent study, a left subclavian vascular catheter has been placed, terminating in the superior vena cava. Pt remains having abd cramping at times. Mild AS. Heart size and mediastinal contours are unremarkable. vessels. HR 90s. See carevue for skin assessment. Patient is status post cholecystectomy. INDICATION: Line placement. NA:132, CR:1.6, BUN:26. Fluoroscopic images were obtained. The upper left lung is clear. -0700Pt admitted as direct admit to CC6 from OSH with c-diff colitis/toxic megacolon. O2 SAT ACCEPTABLE ON 2L NP. Multiplanar reformatted images confirm the axial findings. WBC:23.1, INR:1.3. + pulses to all ext. O2SAT ACCEPTABLE ON 2L NP. Pt states"I feel much better today". PAIN MANAGEMENT. PAIN MANAGEMENT. FIB PLACED. SBP 120-150. C/O CRAMPING PAIN. MOD AMT OF CLEAR DRAINAGE OUT.CONT TO MONITOR FOR S/S OF INFECTION, WORSENING DIARRHEA. NO C/O SOB. NO C/O SOB. COMPARISON: CT of the abdomen and pelvis from . The right lung is clear. 3X liquid stools. LR @ 120cc/hr. Noted is a large fat containing hernia in the anterior pelvis. No cough noted. FINDINGS: A tube was placed into the rectum, and barium was instilled into the colon. The spleen, adrenal glands, kidneys appear unremarkable. O2sat remain >99%. Multiple punctate calcific densities are seen within the liver, likely representing old granulomas. No neuro deficits noted.Resp: Pt with NC 2L, O2sat stable 95-99%, resp easy and regular with some episodes of tachypnia with anxiety or pain. | 12 | [
{
"category": "Nursing/other",
"chartdate": "2190-06-11 00:00:00.000",
"description": "Report",
"row_id": 1551647,
"text": "STATUS\nD: ORIENTED X3..VERY ..FOLLOWS COMMANDS\nA: VSS..DECREASING DIARRHEA..CONTINUES ON VANCO ENEMA'S Q6 & PO VANCO..NPO EXCEPT FOR MEDS..SAT ON SIDE OF BED & STOOD WITH PT'S HELP CONTINUES TO BE WEAK..ADQUATE HUO'S\nR: STABLE\nP: TRANSFER TO FLOOR\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-06-09 00:00:00.000",
"description": "Report",
"row_id": 1551642,
"text": "-0700\n\nPt admitted as direct admit to CC6 from OSH with c-diff colitis/toxic megacolon. Minimal medical hx: anemia, DM, HTN. Pt originally had L knee replacement at NEBH approx 4 weeks ago, since pt has had complicated course between rehab and readmittance to hosp. :colonoscoopy and angio done-? colon ischemia, pat. vessels. Pt continued with elevating WBC, temps, hypotension. Pt renal status compromised with elevated CR:1.7 and poor UO. Pt transfered to SICU from CC6 for worsening condition, ?to OR.\n\nNeuro: Pt awake, alert,oriented X3. Follows commands well. MAEs with some limited ROM due to deconditioning, discomfort and generalized weakness from illness. Speech clear and appropriate. Pupils are equal and reactive. No neuro deficits noted.\n\nResp: Pt with NC 2L, O2sat stable 95-99%, resp easy and regular with some episodes of tachypnia with anxiety or pain. Lungs R clear/crackles at the bases, L clear/diminished. No cough noted. No resp distress noted.Rt Radial aline intact with sharp waveform placed.\nAM ABG: 7.34/36/88/20/-5.\n\nCV: NSR with some unifocal PVCs noted early in PM. HR 90s, SBP 95-130, max temp 99.6 orally. CVP 12-14. + pulses to all ext. Minimal edema. See carevue for skin assessment. WBC^24.5-continued on flayl IV. HCT:26.9. INR^^ received 2 units FFP along with Vit K awaiting repeat INR results. PICC line to R AC which pt arrived with. L SC central line placed upon arrival. LR@200cc/hr for hydration. L knee remians with steri strips intact.\n\nGI/GU: Abd softly distended and + tenderness, hypo-absent BS. 3X liquid stools. NGT to R nare to LIWS draining scant amounts of bilious fluid. Pt remians NPO at this time. NA:132, CR:1.6, BUN:26. CTA done of Abd with po/IV contrast-? determine ischema vs. colitis. Not scheduled to go to OR at this point. Foley to BSD draining clear yellow urine. Approx 15-80cc/hr.\n\nEndo: RISS, fixed doses insulin cov.\n\nPlan: ? to OR, medically treat?, conitnue fluids, Correct INR, Supportive care to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-06-09 00:00:00.000",
"description": "Report",
"row_id": 1551643,
"text": "CONDITION UPDATE\nVSS. AFEBRILE. NO C/O SOB. LUNGS CTA BILAT, DIMINISHED AT THE BASES. O2 SAT ACCEPTABLE ON 2L NP. ABD SOFT, TENDER TO PALPITATION. C/O CRAMPING PAIN. MEDICATED W/ DILAUDID MD'S ORDERS W/ EFFECT. CONT TO HAVE LOOSE STOOL. FIB PLACED. U/O QS VIA FOLEY. CONT ON LR AT 120/CC HR. REMAINS NPO. NGT TO LWCS. MOD AMT OF CLEAR DRAINAGE OUT.\nCONT TO MONITOR FOR S/S OF INFECTION, WORSENING DIARRHEA. PAIN MANAGEMENT. PT/FAMILY TEACHING. CONT CURRENT ICU CARE AND ASSESSMENTS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-06-10 00:00:00.000",
"description": "Report",
"row_id": 1551644,
"text": "1900-0700\n\nNeuro: Pt awake, alert, oriented X3. Pt follows commands well, MAEs and remains very coooperative. Pt states\"I feel much better today\". Speech clear and appropriate. No neuro deficits noted. No seizure activity.\n\nResp: NC 2L on, resp easy and regular. O2sat remain >99%. No resp distress noted. Lungs clear/diminished at the bases. Pt practicing deep breathing and coughing exercises-requested IS for use. Rt radial aline intact-becoming positional. AM ABG: 7.37/40/101/24/-1.\n\nCV: NSR without ectopy. HR 90s. CVP 9-12, Max temp 99.0ax. SBP 120-150. Pt takes BP meds for HTN at home spoke to house officer about restart today. + pulses to lower ext. See carevue for skin assess. LR @ 120cc/hr. WBC:23.1, INR:1.3. R an PICC line intact, L SC central line.\n\nGI/GU:Abd softly distended, + BS, Pt stooling-fecal bag intact. NGT to LIWS draining minimal amounts of bilious fluid. Pt remains having abd cramping at times. Foley to BSD draining clear yellow urine, CR: 1.0, BUN:18.\n\nEndo: Humulog insulin scale with standing dose coverage.\n\nPlan: Supportive care, abx therapy\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-06-10 00:00:00.000",
"description": "Report",
"row_id": 1551645,
"text": "STATUS\nD: AWAKE ORIENTED X3 FOLLOWS COMMANDS\nA: STATES SHE'S FEELING MUCH BETTER TODAY WITH MIN CRAMPS..CONTINUES WITH LIQ BROWN STOOL..STARTED ON VANCO PO & ENEMAS..TOL WELL..PHYSICAL THERPY WORKING WITH PT ABLE TO GET HER OOB..VERY WEAK BUT ABLE TO STAND WITH WALKER FOR SHORT TIME AT SIDE OF BED..NG DC'D..STARTED ON TPN..ADQUATE HUO\nR: STABLE\nP: TRANSFER TO FLOOR WHEN BED AVAILABLE\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-06-11 00:00:00.000",
"description": "Report",
"row_id": 1551646,
"text": "CONDITION UPDATE\nVSS. AFEBRILE. A/OX3. NO C/O SOB. O2SAT ACCEPTABLE ON 2L NP. LUNGS CTA BILAT. ABD OBESE. BOWEL SOUNDS PRESENT. MIN C/O CRAMPING PAIN. DILAUDID GIVEN X1 MD'S ORDERS W/ GOOD EFECT. CONT ON TPN. U/O QS VIA FOLEY. MOD AMT OF STOOL OUT FIB.\nTRANSFER TO FLOOR WHEN BED AVAILABLE. MONITOR FOR S/S OF WORSENING INFECTION. PAIN MANAGEMENT. CONT CURRENT ICU CARE AND ASSESSMENTS.\n"
},
{
"category": "Echo",
"chartdate": "2190-06-09 00:00:00.000",
"description": "Report",
"row_id": 81632,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Left ventricular function.\nHeight: (in) 70\nWeight (lb): 325\nBSA (m2): 2.57 m2\nBP (mm Hg): 140/61\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 11:46\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Hyperdynamic LVEF.\n\nAORTA: Moderately dilated aortic root.\n\nAORTIC VALVE: Aortic valve not well seen. Mild AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. No MR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nSuboptimal study. Technically difficult study. Limited views obtained.\n\n1. The left atrium is moderately dilated.\n2. Left ventricular wall thicknesses are probably normal. The left ventricular\ncavity size is normal. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. Left ventricular systolic\nfunction is hyperdynamic (EF>75%).\n3.The aortic root is moderately dilated.\n4.The aortic valve is not well seen. There is mild aortic valve stenosis. No\naortic regurgitation is seen.\n5.The mitral valve leaflets are mildly thickened. No mitral regurgitation is\nseen.\n6.There is no pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-06-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 911284,
"text": " 5:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval for PICC/NGT placement, and look for free air under\n Admitting Diagnosis: ABDOMINAL PAIN;ACUTE DIVERTICULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with likely toxic megacolon, with PICC and NGT in place, just\n transferred\n REASON FOR THIS EXAMINATION:\n pls eval for PICC/NGT placement, and look for free air under diaphragm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old female status post PICC and nasogastric tube placement.\n\n AP PORTABLE UPRIGHT CHEST:\n\n There is a right-sided PICC line terminating within the proximal SVC. A\n nasogastric tube terminates near the pylorus, possibly in the antrum of the\n stomach or proximal duodenum. The right lung is clear. The left costophrenic\n sulcus is not completely visualized. There may be a small left pleural\n effusion. The upper left lung is clear. Heart size and mediastinal contours\n are unremarkable. There is a paucity of gas in the visualized portions of the\n stomach and small bowel. Limited visualization of the colon demonstrates\n severe dilatation. No free intraabdominal air is identified.\n\n IMPRESSION: Tubes and lines as described. Probable small left pleural\n effusion. Incomplete visualization of severely dilated colon.\n\n This was discussed with Dr. at 6:30 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-06-18 00:00:00.000",
"description": "COLON (BARIUM ENEMA)",
"row_id": 912633,
"text": " 4:12 PM\n COLON (BARIUM ENEMA) Clip # \n Reason: 63 year old woman with pancolitis r/o ischemic stricture\n Admitting Diagnosis: ABDOMINAL PAIN;ACUTE DIVERTICULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with pancolitis r/o ischemic stricture\n REASON FOR THIS EXAMINATION:\n 63 year old woman with pancolitis r/o ischemic stricture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: C. diff pancolitis, assess for ischemic stricture at the splenic\n flexure.\n\n COMPARISON: CT of the abdomen and pelvis from .\n\n FINDINGS: A tube was placed into the rectum, and barium was instilled into\n the colon. Fluoroscopic images were obtained. The rectum, sigmoid colon,\n descending colon, ascending colon, and cecum are of normal caliber and\n contour. There is symmetric nonspecific thickening of the left side of the\n transverse colon, correlating with the findings on the recent CT scan. The\n splenic flexure appears unremarkable. There is no extravasation of contrast\n outside of the colon. Lumbar spinal hardware is visualized.\n\n IMPRESSION: Nonspecific thickening of the folds of the distal transverse\n colon. These findings could be due to the patient's known C. difficile\n colitis; ischemia, however, cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-06-08 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 911288,
"text": " 5:41 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please assess for megacolon\n Admitting Diagnosis: ABDOMINAL PAIN;ACUTE DIVERTICULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman transferred from OSH with c. diff colitis and possible toxic\n megacolon\n REASON FOR THIS EXAMINATION:\n Please assess for megacolon\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old female with C. difficile colitis and concern for toxic\n megacolon.\n\n ABDOMEN, SINGLE VIEW: This is a limited view of the abdomen which does not\n include the left lateral abdomen nor the upper quadrants. In the included\n field of view, there is massively dilated colon measuring up to 11 cm in\n diameter. Given the history of C. difficile colitis, this is concerning for\n toxic megacolon. No normal colon is visualized. No dilated loops of small\n bowel are identified. No definite free intra-abdominal air is seen on this\n limited view. There is stabilization hardware of the lower lumbar spine.\n Cholecystectomy clips are in the right upper quadrant.\n\n IMPRESSION: Massively dilated colon measuring up to 11 cm which given the\n history of C. difficile colitis is concerning for toxic megacolon.\n\n This was discussed with Dr. at 6:30 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-06-08 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 911314,
"text": " 10:39 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Emergeant CT with PO and PR contrast63 year old woman with s\n Admitting Diagnosis: ABDOMINAL PAIN;ACUTE DIVERTICULITIS\n Field of view: 50 Contrast: OPTIRAY Amt: 140\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with severe CDIFF colitis / and episode of ischemic bowel at\n the splenic flexure - emergeant CT w/ PO and PR contrast\n REASON FOR THIS EXAMINATION:\n Emergeant CT with PO and PR contrast63 year old woman with severe CDIFF colitis\n / and episode of ischemic bowel at the splenic flexure - emergeant CT w/ PO and\n PR contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe C. diff colitis, question of ischemic bowel at splenic\n flexure.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were obtained\n with and without IV contrast. Multiplanar reformatted images were also\n displayed.\n\n CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: No focal consolidations are\n seen at the visualized lung bases. There are linear opacities consistent with\n atelectasis as well as small bilateral pleural effusions with associated\n atelectasis. Multiple punctate calcific densities are seen within the liver,\n likely representing old granulomas. Patient is status post cholecystectomy.\n The spleen, adrenal glands, kidneys appear unremarkable. Pancreas appears\n atrophic. There is perihepatic ascites. There is no evidence of free air\n within the abdomen. Visualized loops of small bowel appear unremarkable. The\n transverse colon does appear mildly distended. There is wall thickening\n throughout the colon. There is no evidence of pneumatosis. No air is seen\n within any mesenteric veins. There is no evidence of portal venous air within\n the liver.\n\n CT OF THE PELVIS WITH IV CONTRAST: Wall thickening is seen throughout the\n sigmoid. Small amount of air is seen within the bladder, likely secondary to\n Foley catheterization. A small amount of free fluid within the pelvis. Noted\n is a large fat containing hernia in the anterior pelvis.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions are identified. Severe\n degenerative changes are seen throughout the spine with grade II\n anterolisthesis of L4 on L5. Fixation hardware is seen at these levels within\n the lumbar spine. There is suggestion of old trauma within the thoracic\n spine.\n\n Multiplanar reformatted images confirm the axial findings.\n\n IMPRESSION: Diffuse wall thickening seen throughout the colon consistent with\n (Over)\n\n 10:39 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Emergeant CT with PO and PR contrast63 year old woman with s\n Admitting Diagnosis: ABDOMINAL PAIN;ACUTE DIVERTICULITIS\n Field of view: 50 Contrast: OPTIRAY Amt: 140\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pancolitis, consistent with patient's known history of C. diff colitis. There\n is no evidence of pneumatosis, air in any mesenteric veins, portal venous air,\n or free air in the abdomen to suggest ischemic bowel.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-06-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 911308,
"text": " 9:22 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 63 F s/p central line placement\n Admitting Diagnosis: ABDOMINAL PAIN;ACUTE DIVERTICULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 F s/p central line placement\n REASON FOR THIS EXAMINATION:\n 63 F s/p central line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY OF \n\n COMPARISON: at 17:27.\n\n INDICATION: Line placement.\n\n Since the recent study, a left subclavian vascular catheter has been placed,\n terminating in the superior vena cava. No pneumothorax is evident, but\n exclusion of the left costophrenic angle precludes full exclusion of\n pneumothorax on this supine radiograph. Repeat radiograph to include this\n region could be obtained at no additional charge to the patient.\n\n\n"
}
] |
4,184 | 114,845 | 55 y/o man with PMH significant for depression, type 2 diabetes mellitus, and HTN admitted through the ED with mental status changes and fever. . 1. Delirium: It is unclear why he would be having this. Included in the differential diagnosis are infection, overdose, serotonin syndrome, neuroleptic malignant syndrome, and hyperthyroidism. MRI did not show any reason for acute change in MS: no sign of HSV encephalitis; did show Tiny nonspecific elevated FLAIR signal intensity foci in the cerebral white matter and mid- pons. TSH was within normal limits. It is unlikely the pt's PNA alone would have caused his delirium as he is relatively young and healthy and the PNA does not seem abnormally severe. Most likely ethanol or withdrawal were the cause of his delirium. He denied drinking but was taking benzodiazepines and opioids that he has obtained on the street. He was given 110 mg of diazepam before significant decrease in his agitation making benzodiazepine or alcohol withdrawal the likely etiology. Urine tox screen was negative for amphetamines. Speaking with his wife, she had found two bottles of meds in his room at home but was not sure what they were as they had been placed in spare bottles. Pills were found to be ibuprofen 600mg, tramadol, and xanax 1mg. The patient's med list was obtained from his PCP's office on . no psychotropic medications are prescribed. the pharmacy also had no record of psychotropic medications being filled. His PCP confirmed /o substance abuse but the patient reported being clean at last visit on . Patient was treated with diazepam for CIWA>10. His agitation, hypertension and fever resolved by the morning after admission. He was alert and oriented but was still with pressured speech. Despite our recommendations he left the hospital against medical advice. 2. Pt found to have an infiltrate on CXR in addition to being febrile and having an elevated WBC count. Also concern for concurrent COPD exacerbation. He was treated with steroids, azithromycin and oxygen to maintain sats around 93 %. Ct scan was planned to further characterize this process. However, the patient left before this study could be completed. He was strongly advised to follow up with his PCP to follow up his chest x-ray abnormality. . 3. HTN- pharmacy was contact and it was found that he was taking lisinopril, carvedilol, Lipitor and niacin. These medications were continued during his hospital stay. . 4. Type 2 Pt takes insulin at home but his wife is unaware of the dose. Metformin and Humulin were held during admission. Fingersticks were well controlled with RISS. . | BS clear with intermittent per of I/E wheezes recieved Alb/atr Nebs with BC clear. IV access 1PIV L anticub. HE HAD A HEAD CT, WHICH WS NEG. Nbp 120's to 140's systolic. The heart size and mediastinal contours appear within normal limits. Noprevious tracing available for comparison. Peripheral pulses 3+ DP/DT Neg edema. Likely right cerebellar developmental venous anomaly. LS ARE DIMINSHED BILAT. GI/GU: Abdomen soft with + bs. HE IS STILL DIAPHORETIC. Note is made of a small, likely right cerebellar developmental venous anomaly, which appears to relate to the inferior vermian vein. The osseous structures appear within normal limits. The major vascular flow voids are preserved. recieved lisinopril and betablocker per routine with responding decrease HR/BP BP 162/79-118/63 MAPS>80. Denies discomfort at this time. HIS UA WAS + OPIATS.NEURO: THE PT WAS A/O X1. Ads soft nontender + BS NO N/V. Tiny nonspecific elevated FLAIR signal intensity foci in the cerebral white matter and mid- pons. FINDINGS: The left costophrenic angle is partially excluded from the radiograph. Minor non-specific repolarization changes. NOW HIS CIWA SCALE 7.RESP: LS I/E WHEEZING NOTED. Minimal mucosal thickening is demonstrated within both ethmoid sinuses. O2 4L/min NC. IN THE ED HE HAD A CXR, WHICH WAS NEG. Resp. TECHNIQUE: Single AP portable supine chest. Ivf d51/2ns at 100. d/c to floor tomm. Head mri completed this pm, unofficial report is that mri is negative. TECHNIQUE: Noncontrast head CT. HEAD CT WITHOUT IV CONTRAST: Study is limited by patient motion. HE IS ON A FACE MASK WITH O2 AT 98%, AND RR 22.CV: ST WITHOUT ECTOPY NOTED. There is focal consolidation within the lingula, obscuring a portion of the left heart border. Mediastinal veins are mildly dilated. ID: Continues on acyclovir and ceftriaxone. IMPRESSION: 1. Head mri completed. c/o mild h/a @ recieved tylenol with effect. AM chem pending.Heme: Hct 29.2 previous 32.9.Resp: RR 18-30 DOE, denies resp difficulty. Within the left lung base, there is a focal area of patchy opacity that could represent atelectasis versus early consolidation. CIWA score . +BS + FLEATUS NOTED. Sinus tachycardia, rate 130. No abnormal foci of susceptibility are seen. CV: Normal sinus rhythm with no ectopy noted, rate 70-90's. Minimal degenerative changes are seen within the spine. Smalll illdefined patchy opacity at left base could relate to atelectasis versus early consolidation/aspiration. INDICATION: Acute mental status changes. Integ: Skin is grossly intact. HE IS ON IV ABX. MRI OF THE BRAIN WITHOUT AND WITH CONTRAST: There are several tiny foci of nonspecific FLAIR increased signal intensity within the cerebral white matter and centrally within the pons. B/P 133/65 TO 164/84.GI/GU: NPO. HE HAD EXTREAM AGITATION, AND CONFUSION NOTED . Remaining visualized paranasal sinuses and mastoid air cells are clear. Events: Restraints d/c'd. No bm this shift. DFDdp Differentiation of and white matter appears preserved. IMPRESSION: AP chest compared to : Lung volumes are lower and borderline interstitial edema has developed. No hydrocephalus is demonstrated, and sulci are within normal limits. Advance diet as tolerated. IMPRESSION: Study limited by patient motion. approp. Has occ wheezes with exertion. Prominence of the upper zone pulmonary vasculature may relate to supine positioning. The ventricles and sulci are normal in size and symmetrical. No corresponding abnormal intracranial enhancement is found. Tolerating clear liquid diet at this time, can be advanced as tolerated. mass or CNS inection (HSV) REASON FOR THIS EXAMINATION: please eval for evidence of mass, focal abnormalities No contraindications for IV contrast FINAL REPORT PROCEDURE: MRI of the head without and with contrast. Heart is normal size. IV d51/2NS @ 100cc/hr. The remainder of the lungs are clear, and there are no pleural effusions. head MRI revealled venous anb can not r/o herpes encep.CV: HR 117-85 ST-SR no ectopy. MICU East 1900-0700 RN NoteNeuro: Awake alert oriented x3 follows commands MAE random equal strength. HR 102-114. no gross intracranial hemorrhage or mass effect FINAL REPORT HISTORY: Altered mental status and temperature of 103.8. COPD EXACERBATION: IV STEROIDS. PT HAD A INFILTRATE ON CXR. There are no areas of restricted diffusion to suggest recent infarction. AND A ELEVATED WBC. No valium required this shift. No pneumothorax. There is no shift of the normally midline structures. No tremors/siezures. calm/cooperative. FOLEY CATH 50-100CC/HR.ENDO: FS QID W/ RISS.POC: DELERIUM: QUESTION OF A MRI IN AM. The heart size is normal, and there is no mediastinal or hilar lymphadenopathy. The sulci and basal cisterns appear unremarkable. Pupils 3mm eqyal react brisk. freely. Surrounding osseous and soft tissue structures are unremarkable. No BMendo: FSBS Insulin coverage per protocol.GU: Foley u/o 100-600cc/hrSocial: fullcode status: no family cantact.Plan: called out to floor D/C foley HIS CIWA SCALE WAS 24. 3. ? Allowing for this, there is no gross intracranial hemorrhage or mass effect. Mr signed the AMA release form and was discharged with a prescription for levofloxacin. HIS TEMP 100.1 AX. COMPARISON: None. COMPARISON: None. No gross intracranial hemorrhage or mass effect. Able to stand and pivot, denies dizziness. MICU NURSING PROGRESS NOTE. HE WAS HAULLUCINATEING, DIAPHORETIC, AND THRSHING IN THE BED.VALIUM 110MG IV GIEN TOTAL. Able to assist with care. Healed left rib fractures are incidentally noted. There is no shift of midline structures. 2. O2 sat 94-97%. Plan: Continue to monitor per ciwa and medicate as required. The patient is status post left anterior maxillary wall surgery. | 10 | [
{
"category": "Nursing/other",
"chartdate": "2146-10-11 00:00:00.000",
"description": "Report",
"row_id": 1316781,
"text": "MICU/SICU NPN/AMA\nPlease see flowsheet for all assessment data. Pt has been anxious all day, pacing in hallway, frequently asking if he could go home. Pt stated that he had personal financial problems with other family members that need to be resolved. Pt has been transfer to a medical bed this PM and reported that he \"decided to just go home.\" Dr. was asked to meet with pt and pt informed her that he ws leaving the hospital. Mr signed the AMA release form and was discharged with a prescription for levofloxacin.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-10-10 00:00:00.000",
"description": "Report",
"row_id": 1316778,
"text": "ADMISSION NOTE 7P-7A:\n\nPT IS A 55Y/O MALE WHO WAS ADMITTED FROM THE ED WITH MENTAL STATUS CHANGE AND FEVERS. IN THE ED HE HAD A CXR, WHICH WAS NEG. HE HAD A HEAD CT, WHICH WS NEG. HIS UA WAS + OPIATS.\n\nNEURO: THE PT WAS A/O X1. HE HAD EXTREAM AGITATION, AND CONFUSION NOTED . HE WAS HAULLUCINATEING, DIAPHORETIC, AND THRSHING IN THE BED.\nVALIUM 110MG IV GIEN TOTAL. NOW THE PT IS SLEEPING. HE IS STILL DIAPHORETIC. HIS TEMP 100.1 AX. HIS CIWA SCALE WAS 24. NOW HIS CIWA SCALE 7.\n\nRESP: LS I/E WHEEZING NOTED. HHN GIVEN X3 ON TONIGHT. LS ARE DIMINSHED BILAT. HE IS ON A FACE MASK WITH O2 AT 98%, AND RR 22.\n\nCV: ST WITHOUT ECTOPY NOTED. HR 102-114. B/P 133/65 TO 164/84.\n\nGI/GU: NPO. +BS + FLEATUS NOTED. FOLEY CATH 50-100CC/HR.\n\nENDO: FS QID W/ RISS.\n\nPOC: DELERIUM: QUESTION OF A MRI IN AM. PT HAD A INFILTRATE ON CXR. AND A ELEVATED WBC. HE IS ON IV ABX. COPD EXACERBATION: IV STEROIDS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-10-10 00:00:00.000",
"description": "Report",
"row_id": 1316779,
"text": "MICU NURSING PROGRESS NOTE. 0700-1900\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Restraints d/c'd. No valium required this shift. Head mri completed.\n\n Neuro: Alert and oriented to person, place and time. Resp. approp. to questions and request. Reports feeling much better with every hour but is not sure of what has happened. Is moving all extrem. freely. Able to assist with care. Able to stand and pivot, denies dizziness. Denies discomfort at this time. Team reports overall pt has improved markedly since last pm. Head mri completed this pm, unofficial report is that mri is negative.\n\n Respiratory: Lung sounds are clear in upper fields, dimished in lower fields. Has occ wheezes with exertion. O2 saturation on 4l nc is 96-98%.\n\n CV: Normal sinus rhythm with no ectopy noted, rate 70-90's. Nbp 120's to 140's systolic. Ivf d51/2ns at 100. Iv in lt wrist d/c'd for pain at site. Repleated with 4 gms magnesium sulfate.\n\n GI/GU: Abdomen soft with + bs. No bm this shift. Tolerating clear liquid diet at this time, can be advanced as tolerated. Foley catheter patent and draining clear yellow urine 60-300cc/hr.\n\n ID: Continues on acyclovir and ceftriaxone.\n\n Integ: Skin is grossly intact.\n\n Plan: Continue to monitor per ciwa and medicate as required. Advance diet as tolerated. ? d/c to floor tomm.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-10-11 00:00:00.000",
"description": "Report",
"row_id": 1316780,
"text": "MICU East 1900-0700 RN Note\n\nNeuro: Awake alert oriented x3 follows commands MAE random equal strength. Pupils 3mm eqyal react brisk. No tremors/siezures. c/o mild h/a @ recieved tylenol with effect. CIWA score . restless insomnie recieved Ambien 5mg w/o effect by 0400 valium 10mg not able to sleep. calm/cooperative. head MRI revealled venous anb can not r/o herpes encep.\n\nCV: HR 117-85 ST-SR no ectopy. recieved lisinopril and betablocker per routine with responding decrease HR/BP BP 162/79-118/63 MAPS>80. IV access 1PIV L anticub. IV d51/2NS @ 100cc/hr. Peripheral pulses 3+ DP/DT Neg edema. AM chem pending.\n\nHeme: Hct 29.2 previous 32.9.\n\nResp: RR 18-30 DOE, denies resp difficulty. O2 4L/min NC. BS clear with intermittent per of I/E wheezes recieved Alb/atr Nebs with BC clear. O2 sat 94-97%. Congested prodi=uctive cough thick tan secretions CXR + PNA\nID: Afebrile T-Max 98.2 WBC 12.1 cont on triple abx.\n\nGI: diet adv to ate lg snack this pm. Ads soft nontender + BS NO N/V. No BM\n\nendo: FSBS Insulin coverage per protocol.\n\nGU: Foley u/o 100-600cc/hr\n\nSocial: fullcode status: no family cantact.\n\nPlan: called out to floor\n D/C foley\n"
},
{
"category": "Radiology",
"chartdate": "2146-10-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 889068,
"text": " 5:04 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with altered mental status temp 103.8\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDdp SUN 5:22 PM\n study limited by patient motion. no gross intracranial hemorrhage or mass\n effect\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Altered mental status and temperature of 103.8.\n\n COMPARISON: None.\n\n TECHNIQUE: Noncontrast head CT.\n\n HEAD CT WITHOUT IV CONTRAST: Study is limited by patient motion. Allowing\n for this, there is no gross intracranial hemorrhage or mass effect. There is\n no shift of midline structures. Differentiation of and white matter\n appears preserved. No hydrocephalus is demonstrated, and sulci are within\n normal limits. The sulci and basal cisterns appear unremarkable. Minimal\n mucosal thickening is demonstrated within both ethmoid sinuses. Additionally,\n small amount of mucosal thickening is also seen within the right maxillary\n sinus. The patient is status post left anterior maxillary wall surgery.\n Remaining visualized paranasal sinuses and mastoid air cells are clear.\n Surrounding osseous and soft tissue structures are unremarkable.\n\n IMPRESSION: Study limited by patient motion. No gross intracranial\n hemorrhage or mass effect.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 889065,
"text": " 4:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute infectious process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with temp 103.8, altered mental status\n REASON FOR THIS EXAMINATION:\n eval for acute infectious process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Temperature 103.8, altered mental status. Evaluate for acute\n infectious process.\n\n COMPARISON: None.\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: The left costophrenic angle is partially excluded from the\n radiograph. The heart size and mediastinal contours appear within normal\n limits. Prominence of the upper zone pulmonary vasculature may relate to\n supine positioning. Within the left lung base, there is a focal area of\n patchy opacity that could represent atelectasis versus early consolidation. No\n pleural effusion and no pneumothorax are identified. The osseous structures\n appear within normal limits.\n\n IMPRESSION:\n\n 1. Smalll illdefined patchy opacity at left base could relate to atelectasis\n versus early consolidation/aspiration.\n\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2146-10-09 00:00:00.000",
"description": "Report",
"row_id": 283719,
"text": "Sinus tachycardia, rate 130. Minor non-specific repolarization changes. No\nprevious tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-10-11 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 889322,
"text": " 10:39 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for PNA\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with resolving PNA\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST X-RAY, \n\n COMPARISON: \n\n INDICATION: Evaluate pneumonia.\n\n The heart size is normal, and there is no mediastinal or hilar\n lymphadenopathy. There is focal consolidation within the lingula, obscuring a\n portion of the left heart border. This appears slightly more prominent than\n on the initial chest radiograph of , and is in retrospect\n unchanged compared to but was more difficult to detect\n prospectively at that time due to lower lung volumes. The remainder of the\n lungs are clear, and there are no pleural effusions. Minimal degenerative\n changes are seen within the spine. Healed left rib fractures are incidentally\n noted.\n\n IMPRESSION: Evolving lingular pneumonia. Recommend follow-up radiographs in\n approximately four weeks after completion of antibiotic therapy to document\n complete resolution.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-10-10 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 889194,
"text": " 1:49 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: please eval for evidence of mass, focal abnormalities\n Admitting Diagnosis: FEVERS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with acute mental status changes, ? mass or CNS inection (HSV)\n REASON FOR THIS EXAMINATION:\n please eval for evidence of mass, focal abnormalities\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: MRI of the head without and with contrast.\n\n INDICATION: Acute mental status changes.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted MRI of the brain including post-\n gadolinium-enhanced T1-weighted images was performed.\n\n MRI OF THE BRAIN WITHOUT AND WITH CONTRAST: There are several tiny foci of\n nonspecific FLAIR increased signal intensity within the cerebral white matter\n and centrally within the pons. No corresponding abnormal intracranial\n enhancement is found. The major vascular flow voids are preserved. The\n ventricles and sulci are normal in size and symmetrical. There is no shift of\n the normally midline structures. No abnormal foci of susceptibility are seen.\n There are no areas of restricted diffusion to suggest recent infarction.\n\n Note is made of a small, likely right cerebellar developmental venous anomaly,\n which appears to relate to the inferior vermian vein.\n\n IMPRESSION:\n No evidence for recent infarction, mass lesion, or findings to suggest herpes\n simplex virus infection. However, lack of radiological evidence to support\n herpes encephalitis should not preclude treatment of this entity if there is\n high clinical suspicion, as the appearance of abnormalities, even on MRI, may\n be delayed.\n\n 2. Tiny nonspecific elevated FLAIR signal intensity foci in the cerebral\n white matter and mid- pons. Differential considerations include chronic\n microvascular ischemic infarction, post-inflammatory residua, including\n demyelinating disease, and residua of prior trauma.\n\n 3. Likely right cerebellar developmental venous anomaly.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-10-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 889122,
"text": " 6:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for increase in infiltrate\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with temp 103.8, altered mental status and concern for\n infiltrate on CXR.\n REASON FOR THIS EXAMINATION:\n Evaluate for increase in infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:48 A.M. on \n\n HISTORY: Fever.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes are lower and borderline interstitial edema has developed. There\n are no focal findings to suggest pneumonia. Heart is normal size.\n Mediastinal veins are mildly dilated. No pneumothorax.\n\n\n"
}
] |
31,054 | 102,945 | pt admitted cta - type b dissection admitted to CVICU bedrest / pain control / BP control BP meds adjusted multipple CTA - stable P BP under control DC in stable condition pt to have follow-up cta in one month f/u with PCP f/u with pulmonary for lung nodule arranged Medications on Admission: : Lisinopril 2.5 QD, ?inhaler | (Over) 12:01 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CT PELVIS W/CONTRAST Reason: progressionn of dissection Admitting Diagnosis: AORTIC DISSERCTION FINAL REPORT (REVISED) (Cont) Two 6 mm nodules in the right upper and left lower lobes are unchanged. 18 g piv in left ac patent with blood return.Resp: ls diminished at bases clear in upper lobes. Aorta remains tortuous, and there is a new left pleural effusion accompanied by adjacent left basilar atelectasis. (Over) 3:09 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: progression of dissection Admitting Diagnosis: AORTIC DISSERCTION Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: Visualized portions of the rectum, sigmoid colon, uterus, bilateral adnexa, urinary bladder are unremarkable. 1L D5W with 150 meq bicarb given at 150cc/hr for renal protection from CT contrast.GI: Abdomen soft, NT and nondistended. 4:16 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # Reason: please evaluate for aortic dissection, and PE. Unchanged appearance of the Tarlov's cyst in the left hemisacrum. Comparison to the more recent CT torso of confirms the presence of a left effusion and adjacent atelectasis. (Over) 12:01 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CT PELVIS W/CONTRAST Reason: progressionn of dissection Admitting Diagnosis: AORTIC DISSERCTION FINAL REPORT (REVISED) (Cont) As noted above bibasilar atelectasis and new left pleural effusion is noted. Captopril,lopressor, HCTZ and Norvasc as ordered. advance activity in am-clear with vascular surgery. (Over) 4:16 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # Reason: please evaluate for aortic dissection, and PE. There is mild aneurysmal dilatation of the suprarenal abdominal aorta that is not significantly changed and measures approximately 3.6 cm in maximum diameter. Incidental note is made of accessory left hepatic artery. MAE, strong, no defecits noted.CVS: temp 99.6, bp cuff 118/60 on nicardipine iv at 2.0 mcg/kg/min. Continues HTN at times despite Imdur, norvasc,lopressor, HCTZ and captopril-requiring resumption of nicardipine. A hemorrhagic component /rebleeding secondary to dissection cannot be excluded. 27-mm simple cyst of mid pole and 12-mm simple cyst of lower pole of the left kidney are visualized. The right and left renal arteries arise just distal to the end of the dissection flap and are patent. Borderline P-R interval prolongation. Borderline P-R interval prolongation. Borderline P-R interval prolongation. Borderline P-R interval prolongation. Zofran given. also treated for N/V with Zofran. PERRL. Pt. Pt. Pt. Pt. Wean nicardipine. with Dilaudid IV Q2-3. BS present. Early R waveprogression. Sinus rhythm. Sinus rhythm. T wave abnormalities. T wave abnormalities. ST-T wave abnormalities. Consider leftatrial abnormality. Foley cath. Sinus bradycardia. Sinus bradycardia. Sinus bradycardia. HCT STABLE. L RADIAL A LINE PLACED. PT HAS HER PERIOD. PIV x1. Left atrial abnormality.Non-diagnostic inferolateral Q waves. WOULD LIKE TO TITRATE OFF TODAY HR 70's SBP <120 on nicardipine gtt @2. MAE. Pulses palpable. Goal SBP <120. Follows commands. TYLENOL FOR ABD DISCOMFORT. IV ZOFRAN X1 FOR C/O NAUSEA. Since the previous tracing of the rate hasdecreased.TRACING #2 RESULT IS PROGRESSING TYPE B DISSECTION & L LOBE ATELECTASIS. admitted to CVICUB on Esmolol drip at 300mcq. T wave abnormalities.Compared to the previous tracing of the Q-T interval has shortened.TRACING #2 Nursing Progress Note:Neuro: AAO x3. Since theprevious tracing of no significant change.TRACING #1 No c/o SOBGI/GU: Emesis x2. C/o HA relieved with IV dilaudid.CV: SR without ectopy. NICARDIPINE CONTINUES AT MAX 3MCG/KG/MIN. See AFS for physical assessment. experiencing sternal pain that is described as tight; med. MULTIPLE ANTIHYPERTENSIVES & IV METOPROLOL FOR BP MANAGEMENT. Maintained on 2 mcq/min with HR in the 60's. CTA showed a Type B Aortic dissection. Since the previous tracingof probably no significant change. Switched to Nicardipine due to HR 50's. Abdomen soft, nondistended. No previous tracing available forcomparison.TRACING #1 Skin intact.Resp: LCTA Sats 97% on 3lnc. Good UO, clear yellow urine.Plan: SBP <120. transfer to floor tomorrow once BP is under control. PLAN PER VASCULAR TEAM IS BLOOD PRESSURE & MEDICAL MANAGEMENT. No surgical intervention for now as per Dr. . 3P-7P NPN:TRAVELED TO CT SCAN FOR REPEAT ABD/CHEST/TORSO SCAN. 0700-1500neuro: AAOx3, follows commands, moving all extremitescv: hr nsr, no ectopy, sbp 109-146, continues on nicardipine gtt to keep sbp 110-120, po lopressor/norvasc doses increased today, nicardipine now @ 3.0 mic/kg/min, pt c/o cp @ 1230 & sbp up @ that time, np aware, given po tylenol, narcotics dc'd today to assess pain, np in to see pt, 5 mg iv lopressor x 2, sbp down < 120 after lopressor given, pt sent to CTA @ 1500 to re-eval dissectionresp: on 3 l np, bs+ all lobes, clear, decreased to bases, sat 94-96, no c/o sob, no resp distress notedgi: on low NA+ diet, poor po due to nausea, vomited sm amt x 1 this am, medicated with iv zofran x 1 with relief, pt on ATC reglan, po protonixgu: foley patent, clear yellow urine, good uoother: family in to visist, am K+ 3.3 & repleated with 20 kcl x 1plan: continue to monitor in icu, wean nicardipine as tolerated keeping sbp 110-120, tylenol as needed for pain Speaks little English (Spanish speaking). 38 yo spanish speaking female admitted from ED with new onset epigastric pain. | 21 | [
{
"category": "Radiology",
"chartdate": "2132-04-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1006840,
"text": " 2:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: bleeding in chest\n Admitting Diagnosis: AORTIC DISSERCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with Type B Dissection\n REASON FOR THIS EXAMINATION:\n bleeding in chest\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: .\n\n INDICATION: Aortic dissection.\n\n Cardiac silhouette appears slightly larger compared to the previous\n examination, but this difference could potentially be due to the portable\n technique and lower lung volumes. Aorta remains tortuous, and there is a new\n left pleural effusion accompanied by adjacent left basilar atelectasis.\n Comparison to the more recent CT torso of confirms the presence\n of a left effusion and adjacent atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1006076,
"text": " 3:56 PM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for free air under diaphragm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with acute onset epigastric pain radiating to back this\n morning, ?h/o peptic ulcer.\n REASON FOR THIS EXAMINATION:\n please evaluate for free air under diaphragm\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST\n\n HISTORY: 80-year-old woman with acute-onset epigastric pain radiating to the\n back, with questionable history of peptic ulcer; evaluate for free air under\n the diaphragm.\n\n FINDINGS: Two views with no comparisons. There is rounded LV enlargement\n with some aortic tortuosity and unfolding, suggestive of underlying\n hypertension. There is no pulmonary vascular congestion, pleural effusion, or\n other evidence of CHF. The lungs are well-inflated and clear. The stomach is\n nondistended, and there is no evidence of free subdiaphragmatic air.\n\n IMPRESSION: No acute cardiopulmonary process, with evidence of underlying\n hypertension.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-16 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1006372,
"text": " 3:09 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: progression of dissection\n Admitting Diagnosis: AORTIC DISSERCTION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with new type B aortic dissection\n REASON FOR THIS EXAMINATION:\n progression of dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old woman with new type B aortic dissection. Evaluate\n for progression of dissection.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT-acquired contiguous axial slices were obtained from the top\n of the lungs to pubic symphysis after administration of intravenous and oral\n contrast. Multiplanar reformats were generated.\n\n CTA OF THE CHEST AND ABDOMEN WITH INTRAVENOUS CONTRAST: Previously noted type\n B aortic dissection demonstrates interval worsening with proximal migration,\n extending up to the level of the proximal aortic arch approximately 2 cm\n distal to the origin of the left subclavian artery. There is also development\n of a new left pleural effusion and evidence of contrast within the thrombus of\n the false lumen. Overall in light of these findings, an intimal leakage cannot\n be excluded. There is also development of bibasilar atelectasis, not seen on\n prior study. Distally the dissection extends about a centimeter proximal to\n the origin of the bilateral renal arteries. The celiac and superior\n mesenteric vessels still originate from the true lumen. The overall caliber\n of the false lumen has also increased in the interim. Again is noted mild\n aneurysmal dilation of the suprarenal abdominal aorta measuring 3 x 3 cm. The\n pulmonary arteries opacify well, there is no evidence of pulmonary embolism.\n The remainder of the heart and great vessels appear unremarkable. There is no\n pericardial effusion.\n\n CT OF THE CHEST WITH IV CONTRAST: A 6-mm pulmonary nodule is noted at the left\n lower lobe, unchanged compared to prior study. Another 6-mm nodule is noted\n in the right upper lobe, also unchanged compared to prior study. No\n pathologic mediastinal or axillary adenopathy is noted. As noted above\n bibasilar atelectasis and new left pleural effusion is noted.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, spleen, adrenals,\n pancreas, left kidney are normal. Unchanged appearance of two simple low-\n attenuating cystic lesions in the left kidney. The larger one is seen at the\n mid pole measuring approximately 3 cm. The stomach, intra-abdominal bowel\n loops are unremarkable. No pathologic mesenteric or retroperitoneal\n adenopathy is noted. There is no evidence of peritoneal free fluid or free\n air.\n\n (Over)\n\n 3:09 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: progression of dissection\n Admitting Diagnosis: AORTIC DISSERCTION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: Visualized portions of the\n rectum, sigmoid colon, uterus, bilateral adnexa, urinary bladder are\n unremarkable. There is no inguinal or pelvic adenopathy. There is no pelvic\n free fluid.\n\n OSSEOUS STRUCTURES: Again is noted a dense sclerotic focus in the left iliac\n crest, also seen on prior study. In the absence of known history of prior\n malignancy, this could represent a bone island. No other lytic or sclerotic\n osseous abnormalities are evident.\n\n IMPRESSION:\n 1. Interval progression of the type B aortic dissection with more proximal\n extension approximately the 2 cm inferior to the origin of the left subclavian\n artery. Evidence of new left pleural effusion with contrast opacification of\n the false lumen thrombus, an intimal leak cannot be excluded. These findings\n were discussed with the covering physician, ..\n\n 2. 6-mm left and right upper lobe pulmonary nodules; 6-12 months followup\n depending on patient history of risk factors criteria is\n recommended. Entered in critical results commununication system.\n\n 3. Unchanged appearance of two hypoattenuating cystic lesions of the left\n kidney, may represent renal cysts.\n\n 4. Unchanged appearance of the Tarlov's cyst in the left hemisacrum.\n\n 5. Isolated dense sclerotic focus in the left iliac , unchanged since\n prior study. In the absence of known history of malignancy, could represent a\n bone island.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-14 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1006078,
"text": " 4:16 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n Reason: please evaluate for aortic dissection, and PE.\n Contrast: OPTIRAY Amt: 145\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with h/o HTN, acute onset chest and epigastric pain radiating\n to back at 9AM, persistent, worse with inspiration.\n REASON FOR THIS EXAMINATION:\n please evaluate for aortic dissection, and PE.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FBr MON 5:08 PM\n Type B dissection with no involvement of major vessels. There is auto\n fenesteration above renal arteries.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old woman with history of hypertension and acute onset of\n chest and epigastric pain radiating to the back, please evaluate for aortic\n dissection or PE.\n\n No comparison is available.\n\n TECHNIQUE: Axial MDCT images were obtained from thoracic inlet to the pubic\n symphysis after administration of 90 cc of Optiray intravenously. No oral\n contrast was used. Sagittal and coronal reformatted images were then\n obtained.\n\n CTA OF THE CHEST: There is possibly acute type B dissection of the aorta\n which starts distal to the left subclavian artery (at the level, posterior to\n the left atrium), and extends into the abdomen, terminating just proximal to\n the renal arteries. The dissection shows prominent exit site (or \"auto-\n fenestration\") approx. 1 cm proximal to the right renal arterial origin. The\n dissection extends over approximately 16 cm in the craniocaudad dimension. The\n major splanchnic vessels including the celiac and superior mesenteric artery\n originate from the true lumen. However the intimal flap is only 6 mm distance\n from the origin of the celiac artery. The renal arteries originate distal to\n the dissection. There is apparent double flap/motion of flap at the\n diaphragmatic hiatus. There is aneurysmal dilatation of the immediately-distal\n suprarenal abdominal aorta measuring approximately 3.1 x 3.1 cm.\n\n CTA OF THE CHEST: No filling defect is noted within the main pulmonary artery\n and its branches to suggest pulmonary embolism. The heart is normal and the\n origin of the major coronary arteries are well opacified. The lung window\n does not demonstrate any pulmonary nodule, parenchymal opacification, or\n pleural effusion.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The liver, spleen, adrenal glands,\n pancreas, and the left kidney are normal and well perfused. 27-mm simple cyst\n of mid pole and 12-mm simple cyst of lower pole of the left kidney are\n visualized. The stomach, duodenum, and loops of small bowel and large bowel\n are well opacified. The aortic bifurcation and the iliac arteries are well\n opacified, and no other dissection is noted.\n (Over)\n\n 4:16 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n Reason: please evaluate for aortic dissection, and PE.\n Contrast: OPTIRAY Amt: 145\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: No concerning lytic or sclerotic lesions are identified.\n Incidental note is made of the large Tarlov (subperineurial) cyst on the left\n side of the sacrum which smoothly erodes the underlying bone.\n\n IMPRESSION:\n 1. Type B aortic dissection, commencing distal to the left subclavian artery\n and exiting immediately proximal to the origin of the renal arteries,\n extending over approximately 16cm ; its most-proximal portion may be\n partially- thrombosed (or, at least, poorly perfused). The celiac and superior\n mesenteric arteries originate from the true lumen with no evidence of\n dissection into these vessels or occlusion by the flap. The abdominal organs\n are well- perfused.\n\n 2. Two simple cysts are noted within the left kidney.\n\n 3. Large Tarlov cyst in left hemisacrum.\n\n COMMENT: Findings reviewed in person with Dr. (ED) and Vascular Surgery\n housestaff.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-04-18 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1006698,
"text": " 12:01 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CT PELVIS W/CONTRAST\n Reason: progressionn of dissection\n Admitting Diagnosis: AORTIC DISSERCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with dissection and increased pain\n REASON FOR THIS EXAMINATION:\n progressionn of dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n CT TORSO\n\n CLINICAL HISTORY: 38-year-old woman with dissection and increasing pain.\n Evaluate for progression of dissection.\n\n TECHNIQUE: MDCT-acquired axial images were initially obtained through the\n chest, abdomen and pelvis without contrast, followed by contrast-enhanced\n images through the chest, abdomen, and pelvis after administration of 80 cc of\n intravenous Optiray. Coronal and sagittal reformatted images were also\n obtained.\n\n COMPARISON: .\n\n CT OF THE ABDOMEN:\n\n Overall, there has been no significant interval change in extension of\n dissection flap, which still originate at the level of the subclavian artery\n origin. The ascending aorta remains normal in size and measures approximately\n 2.6 cm in greatest diameter.\n\n The dissection flap and descending thoracic aorta is overall unchanged in\n appearance. However, there appears to be slightly better opacification of\n some areas of the false lumen, which may be related to the rate of injection.\n The descending aorta measures approximately 2.9 cm at the level of the left\n main pulmonary artery, which is not significantly changed. The pulmonary\n arteries are normal in caliber.\n\n Note is made of prominent bilateral hilar lymph nodes. The largest right\n hilar lymph node measures 1.7 x 2.4 cm. The largest left hilar lymph node\n measures 1.5 x 1.1 cm. There is an enlarged precarinal lymph node that\n measures 1.3 cm in AP dimension x 1.3 cm in transverse dimension. No\n pathologically enlarged axillary lymph nodes are identified.\n\n There are small bilateral pleural effusions, left greater than right with\n associated atelectasis. The left pleural effusion has slightly increased in\n size. The left pleural effusion measures up to 25 Hounsfield units in density\n and underlying hemorrhagic component cannot be excluded.\n\n Evaluation of the lung windows.\n\n (Over)\n\n 12:01 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CT PELVIS W/CONTRAST\n Reason: progressionn of dissection\n Admitting Diagnosis: AORTIC DISSERCTION\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n Two 6 mm nodules in the right upper and left lower lobes are unchanged.\n\n The liver is normal in size and contour. There is no intrahepatic biliary\n dilatation. Incidental note is made of accessory left hepatic artery. The\n spleen, pancreas, and adrenal glands are unremarkable. The kidneys enhance\n symmetrically. There is no hydronephrosis. There is a 2.6 cm cyst in the\n interpolar region of the left kidney as well as additional multiple\n hypodensities that are too small to be accurately characterized.\n\n There is mild aneurysmal dilatation of the suprarenal abdominal aorta that is\n not significantly changed and measures approximately 3.6 cm in maximum\n diameter. The celiac and superior mesenteric arteries arise from the true\n lumen and are patent. The right and left renal arteries arise just distal to\n the end of the dissection flap and are patent. The common iliac, external\n iliac and internal iliac arteries are patent.\n\n CT OF THE PELVIS:\n\n The uterus and adnexal regions are unremarkable. The urinary bladder contains\n a Foley catheter and is collapsed. There is no significant free pelvic fluid.\n Evaluation of the anterior abdominal wall reveals a small hernia in the\n anterior abdominal wall containing a part of the lumen of one of the small\n bowel loops, consistent with a hernia. There is no associated bowel\n obstruction or pneumatosis. This is unchanged since the prior study.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. The\n Tarlov cyst is again noted in the sacrum.\n\n IMPRESSION:\n\n 1. No significant interval change in extent of dissection flap, which\n originates at the level of the proximal origin of the left subclavian artery.\n\n 2. Slight interval increase in size of a small left pleural effusion which\n measures up to 25 Hounsfield units in density. A hemorrhagic component\n /rebleeding secondary to dissection cannot be excluded. Diagnostic\n thoracentesis could be performed.\n\n 3. Hilar and mediastinal adenopathy of unclear etiology.\n\n 4. Two 6-mm pulmonary nodule. A followup in four to six months with\n dedicated chest CT is recommended to assess for stability.\n\n Slight interval increase in size of the pleural effusion was discussed with\n Dr. at 1 PM on .\n (Over)\n\n 12:01 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CT PELVIS W/CONTRAST\n Reason: progressionn of dissection\n Admitting Diagnosis: AORTIC DISSERCTION\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-18 00:00:00.000",
"description": "Report",
"row_id": 1659804,
"text": "NPN:\n\nNeuro: Alert and oreinted X3. Interpreters available to translate throughout day. Very weepy and emotional at times. Moves all extremities with equal strength. C/o feeling weak and tired today. Dangled on side of bed-did not want to sit in chair. Visited with husband. Social worker spoke with pt for support.\nID: Tmax 100.2 orally at 17pm. WBC-12.1\nCV: 60-80's SR with occassional PVC's noted. Continues HTN at times despite Imdur, norvasc,lopressor, HCTZ and captopril-requiring resumption of nicardipine. IV hydralazine given X2. Aline dampens at times-cuff @ 10-20pts lower at times but NP requesting following aline and attempting to keep SBP @ 110.\nHct 34.1. Palpable pedal pulses. Skin warm and dry. Repeat CT scan done r/t pt c/o Chest pain pressure after eating radiating to back. . Awaiting cardiology consult for assistance with BP control.\nResp: Lungs diminished in bases with atelectasis on Ct scan. Encouraged use if IS. Cough fair-nonproductive. Sats 95-98% on 3l nc O2.\nGU: Foley to gd with UO 40-200cc/hr. Creat-0.5. 1L D5W with 150 meq bicarb given at 150cc/hr for renal protection from CT contrast.\nGI: Abdomen soft, NT and nondistended. + bowel sounds and occassional belching after breakfast. Tolerated soup and fruit for lunch. Denies nausea or vomitting.\nEndo: Glucoses WNL.\nActivity: Independent moving in bed side to side. Dangled on side of bed-attempted OOB to cahir but pt emotional and c/o weakness and tiredness. Moves well.\nComfort: Hydromorphone .5 mg IV X2 for chest->back pain with good relief.\nA: Recurrent chest pain->back associated with uncontrolled HTN despite max med management.\nP: Awaiting cardiology input-continue to Keep SBP< 120. OOB to chair. Cont diet. Social work and case management involved.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-17 00:00:00.000",
"description": "Report",
"row_id": 1659802,
"text": "NPN:\n\nNeuro: Alert and oriented X3. Understands alot of english but primary language spanish. Moving all extremities with equal strength. No c/o back or abdominal pain like admission but c/o being uncomfortable in the bed.\nID: Tmax 99.1 orally. WBC-12.8.\nCV: 60-70's SR with occassional PVC's noted. Occassionally ^ HR to 80-90's with activity. K and Ca repleted. Continues on nicardipine gtt weaned from . Lopressor ^ 75mg tid and Captopril ^ 100mg tid. Cont on HCTZ 25mg and norvasc 10mg qd. Attempting to keep SBP <120's.\nPalpable pedal pulses. Hct 33.9.\nResp: Lungs diminished in bases L>R. Sats > 95% on 3l nc O2. Using IS to 1L.\nGU: Foley to gd with UO>30cc/hr. Diuresing at times UO>200cc/hr. Creat-0.6\nGI: Abdomen soft, NT, ND with + bowel sounds. Tolerating Regular diet without N/V today.\nGYN: Pt with menstrual period-c/o cramps in afternoon. Given tylenol X1.\nComfort: Denies pain. Tylenol and repositioning for cramps and generalized discomfort from bedrest.\nActivity: Pt moving independently in bed side to side. Dangled on side for short period. Remained on bedrest per Dr orders today.\nA: Attempting to wean nicardipine converting to increased lopressor and captopril doses\nP: Keep SBP @ 120. Replete lytes prn. Captopril,lopressor, HCTZ and Norvasc as ordered. Wean nicardipine. Social work and case management involvement re:no insurance. ? advance activity in am-clear with vascular surgery.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-18 00:00:00.000",
"description": "Report",
"row_id": 1659803,
"text": "NPN 1900-0700:\nNeuro: alert, oriented x3, c/o mild incisional pain, well controlled by Tylenol, ambulated out of bed with good tolerance.\n\nResp: Breathing regularly on O2 NC 3 LPM, sat 95-97%, LS CTA, denied any s/s of respiratory distress.\n\nCV: SB-NSR HR 54-82, BP 106-116/38-58, A-line positional, so NBP is the one followed for BP monitoring, still on Nicardipine drip, though weaned dwn to 0.5 mcg/kg/min, continued on Lopressor and captopril.\n\nGI/GU: tolerating liquids well, BS positive, no BM this shift, with foley cath U/O 150--300 cc/hr.\n\nInteg: Incisional dressing dry, clean, and intact, T max 98.9.\n\nPlan: continue antihypertensive drugs, wean narcidipine off as tolerated, once BP is stabilized, can be called out to a regular floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-19 00:00:00.000",
"description": "Report",
"row_id": 1659805,
"text": "N: A/O NO NEURO DEFICITS GETS OOB WITH NO ASSIST\n\nR: N/C 2L LUNGS CTA SATS WNL LOWER LOBE ATELECTASIS\n\nCV: KEEP SBP 110-120 AND GO BY ALINE ONLY \nLARGE QUANTITIES OF ANTIHYPERTENSIVE MEDS. ABLE TO WEAN OFF\nNICARDIPINE AT 2300. BP 100-115 BY ALINE\nALINE VERY POSITIONAL AT TIMES.\n\nGI/U F/C UOP ADEQ. ON HCTZ EATS WELL, +BS ABD SOFT NTND\n\nIV: SEVERAL PIV'S CDI\nFLUIDS: KVO\n\nPT IS HERE FROM GUATAMALA AS A IS HUSBAND.\nCT NEGATIVE FROM FRIDAY--DISSECTION IS NOT EXTENDING AND REMAINS STABLE.\n\nPLAN: MAINTAIN SBP 110-120 AND CONT. TO KEEP NICARDIPINE OFF.\nPT WILL BE RETURNING \"HOME\" SOCIAL SERVICES INVOLVED TO ASSIST WITH\nPRESCRIPTIONS ETC\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-15 00:00:00.000",
"description": "Report",
"row_id": 1659797,
"text": "Update\nNSR. SBP <120 on Nicardipine gtt. One episode of emesis (~400cc). Pt had swallowed evening lopressor and captopril within minutes of vomitting. Emesis reported to . Plan to watch VS carefully and repeat medication if necessary. Lorazapam given @hs (pt reported that she cannot sleep at night here.) C/o chest area pain, radiating to L upper/mid back. Dilaudid given IV plan to reassess. No solid food tonight. need return of hydrating IV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-16 00:00:00.000",
"description": "Report",
"row_id": 1659798,
"text": "Nursing Progress Note\nallergy penicillin, Bedrest, Spanish speaking\n\nNeuro: language barrier, no interpreter immediately available this shift. Following some simple commands with visual cueing. Understanding to straigten her arm when hearing the IV pump beep due to bent arm occlusion. MAE, strong, no defecits noted.\n\nCVS: temp 99.6, bp cuff 118/60 on nicardipine iv at 2.0 mcg/kg/min. SBP goal <120. hr 76 sr rare pvc/pac. skin warm dry intact. Pulses palp x 4 extremities. 18 g piv in left ac patent with blood return.\n\nResp: ls diminished at bases clear in upper lobes. nc at 2 L sat 89, increased to 4 l sats 94.\n\nGI: abdomen soft, obese, bs present.\n\nGU: foley cath draining concentrated yellow urine to gravity.\n\nPain: denies at this time.\n\nActivity: repositions self in bed, utilizes controls and modified call system appropriately.\n\nPlan: change nicardipine to po meds, transfer to floor when off iv meds and bp controlled on oral agents.\n\nSee carevue flowsheets and mars for further details and values\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-16 00:00:00.000",
"description": "Report",
"row_id": 1659799,
"text": "0700-1500\nneuro: AAOx3, follows commands, moving all extremites\n\ncv: hr nsr, no ectopy, sbp 109-146, continues on nicardipine gtt to keep sbp 110-120, po lopressor/norvasc doses increased today, nicardipine now @ 3.0 mic/kg/min, pt c/o cp @ 1230 & sbp up @ that time, np aware, given po tylenol, narcotics dc'd today to assess pain, np in to see pt, 5 mg iv lopressor x 2, sbp down < 120 after lopressor given, pt sent to CTA @ 1500 to re-eval dissection\n\nresp: on 3 l np, bs+ all lobes, clear, decreased to bases, sat 94-96, no c/o sob, no resp distress noted\n\ngi: on low NA+ diet, poor po due to nausea, vomited sm amt x 1 this am, medicated with iv zofran x 1 with relief, pt on ATC reglan, po protonix\n\ngu: foley patent, clear yellow urine, good uo\n\nother: family in to visist, am K+ 3.3 & repleated with 20 kcl x 1\n\nplan: continue to monitor in icu, wean nicardipine as tolerated keeping sbp 110-120, tylenol as needed for pain\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-16 00:00:00.000",
"description": "Report",
"row_id": 1659800,
"text": "3P-7P NPN:\n\nTRAVELED TO CT SCAN FOR REPEAT ABD/CHEST/TORSO SCAN. RESULT IS PROGRESSING TYPE B DISSECTION & L LOBE ATELECTASIS. PLAN PER VASCULAR TEAM IS BLOOD PRESSURE & MEDICAL MANAGEMENT. TYLENOL FOR ABD DISCOMFORT. NICARDIPINE CONTINUES AT MAX 3MCG/KG/MIN. MULTIPLE ANTIHYPERTENSIVES & IV METOPROLOL FOR BP MANAGEMENT. L RADIAL A LINE PLACED. HCT STABLE. PT HAS HER PERIOD. IV ZOFRAN X1 FOR C/O NAUSEA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-17 00:00:00.000",
"description": "Report",
"row_id": 1659801,
"text": "UPDATE:\n\nLOPRESSOR 5MG IVP AT 0300 FOR SBP 130'S SUSTAINED BY CUFF/ALINE.\nTYLENOL 650MG PO BACK PAIN.\nSLEPT ALL NIGHT/ NO COMPLAINTS\nNICARDIPINE CONT TO INFUSE. WOULD LIKE TO TITRATE OFF TODAY\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-15 00:00:00.000",
"description": "Report",
"row_id": 1659795,
"text": "38 yo spanish speaking female admitted from ED with new onset epigastric pain. CTA showed a Type B Aortic dissection. Pt. admitted to CVICUB on Esmolol drip at 300mcq. Switched to Nicardipine due to HR 50's. Maintained on 2 mcq/min with HR in the 60's. Pt. experiencing sternal pain that is described as tight; med. with Dilaudid IV Q2-3. Pt. also treated for N/V with Zofran. Goal SBP <120. No surgical intervention for now as per Dr. . See AFS for physical assessment. Pt. NPO except for a few ice chips.\nAllergic to PCN.\nPlan: BP control.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-04-15 00:00:00.000",
"description": "Report",
"row_id": 1659796,
"text": "Nursing Progress Note:\nNeuro: AAO x3. Speaks little English (Spanish speaking). MAE. Follows commands. PERRL. C/o HA relieved with IV dilaudid.\n\nCV: SR without ectopy. HR 70's SBP <120 on nicardipine gtt @2. PIV x1. Pulses palpable. Skin intact.\n\nResp: LCTA Sats 97% on 3lnc. No c/o SOB\n\nGI/GU: Emesis x2. Zofran given. Abdomen soft, nondistended. BS present. Foley cath. Good UO, clear yellow urine.\n\nPlan: SBP <120. Wean nicardipine. transfer to floor tomorrow once BP is under control.\n"
},
{
"category": "ECG",
"chartdate": "2132-04-22 00:00:00.000",
"description": "Report",
"row_id": 201476,
"text": "Sinus bradycardia. Borderline P-R interval prolongation. Consider left\natrial abnormality. ST-T wave abnormalities. Since the previous tracing\nof probably no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2132-04-21 00:00:00.000",
"description": "Report",
"row_id": 201477,
"text": "Sinus bradycardia. Since the previous tracing of the rate has\ndecreased.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2132-04-20 00:00:00.000",
"description": "Report",
"row_id": 201478,
"text": "Sinus rhythm. Borderline P-R interval prolongation. Left atrial abnormality.\nNon-diagnostic inferolateral Q waves. T wave abnormalities. Since the\nprevious tracing of no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2132-04-15 00:00:00.000",
"description": "Report",
"row_id": 201479,
"text": "Sinus rhythm. Borderline P-R interval prolongation. T wave abnormalities.\nCompared to the previous tracing of the Q-T interval has shortened.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2132-04-14 00:00:00.000",
"description": "Report",
"row_id": 201480,
"text": "Sinus bradycardia. Borderline P-R interval prolongation. Early R wave\nprogression. T wave abnormalities. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
}
] |
24,236 | 148,082 | The patient is admitted to this hospital through the Podiatry Service; however, the stress test showed multi-vessel disease. Podiatry continued to follow for evaluation of his left foot ulcer. At the time of discharge, he was having acetic acid wet-to-dry dressing changes, 0.25% q. day. Vascular Surgery was following at the same time and decided that bilateral iliac stenting would be the most optimum treatment currently and suggested that the patient should be worked up for cardiac disease prior to re-vascularization. Medicine was also consulted at that time for high blood pressure and for the biceps pain. While having angiography, he had a transient increase in his blood pressure and became diaphoretic and thus precipitated the evaluation for cardiac disease. Cardiology was consulted at that time to evaluate his heart. The patient was managed on the Medical Service for his drop in blood pressure and cardiac evaluation. He was also followed by Podiatry and Vascular Surgery. He was taken to the Cardiac Catheterization Laboratory which showed multi-vessel disease and Cardiothoracic Surgery was consulted. The patient was taken to the Operating Room on , where a coronary artery bypass graft times four was performed, left internal mammary artery to left anterior descending, saphenous vein graft to diagonal, saphenous vein graft to obtuse marginal and saphenous vein graft to PC by Dr. . The patient was transferred to the CSRU postoperatively where he did well. He was slowly weaned from his ventilator and was able to be extubated. The patient was able to be weaned to six liters nasal cannula after extubation, however, it was noted on chest x-ray that he had a small apical pneumothorax. A repeat chest x-ray showed resolution of that pneumothorax. The patient was continued on an insulin drip for his diabetes mellitus but continued to improve. His chest tube was in place for a high chest tube output. His Foley catheter was removed and the patient was transferred to the Floor. Physical Therapy was consulted in order to assess the patient's ambulation and mobility, however, with his foot infection and associated pain, it was difficult to assess at that time. After arriving on the Floor, the patient had an episode of rapid atrial fibrillation which was treated with amiodarone and Lopressor. The patient resolved, however, Lasix was also given due to some pulmonary edema and increasing oxygen need. The patient continued to have episodes of rapid atrial fibrillation while on the Floor, which required continued diuresis as well as intravenous Lopressor. His chest tube and Foley catheter were removed on postoperative day number three, and the patient had aggressive chest Physical Therapy and nebulizer treatments. His dressing changes for his foot continued per the Podiatry Service and his leg ulcer was noted to be slowly healing. The patient had multiple episodes of rapid atrial fibrillation which again required intravenous Lopressor. Amiodarone boluses were given and the patient was started on 400 three times a day of p.o. amiodarone, aggressive pulmonary toilet and continued diuresis was done, however, the patient continued to have respiratory difficulties when in rapid atrial fibrillation. The patient was evaluated on postoperative day number five and it was decided at that time that the patient should be transferred back to the Intensive Care Unit for respiratory difficulties. He was transferred back to the Surgical Intensive Care Unit where he was aggressively diuresed as well as his rate was controlled and chest Physical Therapy and nebulizer treatments were done. The patient improved slowly. Also, his white blood cell count was found to rise to 32.0; this was most likely due to a secondary infection of his foot and Zosyn was started. The patient continued to do well and his recurrent atrial fibrillation slowly improved; p.o. doses of Lopressor slowly increased to get better control of his rate and the patient was able to be controlled with a heart rate in the 50s to 60s with Lopressor. Following initiation of his Zosyn, the white count continued to improve and the patient was planned for a PICC line for long-term intravenous antibiotics. The patient was started on Lopressor 75 mg p.o. twice a day with good control with a heart rate of 50s to 60s. He is in sinus rhythm. He was also started on his preoperative medications of Amlodipine and Losartan with improvement of his blood pressure. The patient was also reduced to 400 mg q. day of amiodarone. Pulmonary was consulted at this time for this difficulty of diuresis and pulmonary edema. They continued to agree with the management of the patient and with aggressive pulmonary toilet as well as diuresis and nebulizer treatment. The patient was transferred back from the Intensive Care Unit on , and upon arriving on the floor, he continued to do well. Pulmonary toilet and aggressive chest Physical Therapy was continued and the patient was able to be weaned from his oxygen. Furthermore, his Foley catheter was removed and he was started on anti-coagulation for his episodes of atrial fibrillation. He had been started on heparin in the Intensive Care Unit and that was continued. Coumadin was then begun with a goal INR of 2.0 to 3.0. At that time he was stabilized from a cardiac perspective. Podiatry and Vascular Surgery were reconsulted to assess the patient's needs for revascularization and for his foot ulcer. It was decided at that time that the patient could be discharged in follow-up with Vascular Surgery for revascularization and Podiatry thereafter. On , the patient had a PICC line placed for a six week course of intravenous Zosyn for his foot ulcer and his Coumadin was also continued. The patient did well and was discharged to a rehabilitation facility at that time. His discharge date is pending. | There has been interval removal of a right-sided SG catheter. Patent distal left common iliac artery stent. IMPRESSION: 1) Persistent left retrocardiac atelectasis. Moderately diseased left peroneal artery reconstituting distal left anterior tibial artery and supplying patent plantar branches. The right common femoral artery catheter and sheath were removed and hemostasis was obtained. IMPRESSION: Persistent bibasilar atelectatic changes, with resolution of left-sided pneumothorax. Previously noted left apical pneumothorax has resolved. The right anterior tibial and posterior tibial arteries occluded. Again demonstrated is significant stenosis with proximal SFA and the region of previously placed stent. The catheter was repositioned within the right external iliac artery and serial right lower extremity arteriograms were obtained. There is moderate stenosis of the proximal posterior tibial artery and focal stenosis of the mid posterior tibial artery. As discussed Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) angiographic improvement of stenosis. There is bilateral, left greater than right, stenosis of the proximal common iliac arteries. nodular opacity in the right mid-zone, which could represent an EKG contact. The left anterior tibial artery is occluded proximally. The left common iliac artery stent is patent. Moderate disease of the left tibioperoneal trunk with stenosis demonstrated within the proximal and mid posterior tibial artery. Persistenet left pleural effusion. Cardiac enlargement is stagle. Occluded left proximal anterior tibial artery. Resting perfusion images were obtained with thallium. IMPRESSION: 1) Moderate, partially reversible perfusion defect within the inferior myocardial wall. Proximal right superficial femoral artery stent with extensive restenosis. The left peroneal artery reconstitutes a distal anterior tibial artery just above the ankle with moderate proximal stenosis and slow flow. FINDINGS: Again, the patient is S/P CABG with sternotomy wires and skin staples in place. Using a 0.035 guidewire, the Omniflush catheter was advanced such that the tip was within the left external iliac artery and serial left lower extremity arteriograms were performed. A left-sided chest tube and a mediastinal tube are identified. Bilateral, left greater than right, common iliac artery stenosis with significant pressure gradient demonstrated between the aorta and left common iliac artery. Right IJ PA catheter is seen terminating in the pulmonary trunk. Stress images show a moderate perfusion defect within the inferior myocardial wall. Previous angiogram on demonstrating significant stenosis of the left common iliac artery and within the stent placed within the right superficial femoral artery. The left peroneal artery is patent with moderate diffuse disease. There is worsening of perihilar haziness, and slight pulmonary vascular redistribution. A final chest x-ray demonstrates the tip to be at the SVC/right atrial junction. There is focal stenosis of the proximal left superficial femoral artery. A 0.35 was advanced under fluoroscopic guidance such that the tip is in the abdominal aorta. Abd distended, firm quiet but nontender upon palp.Gu status: bdline to qs amber urine/ hespan given x 1for low uop & ^.Neuro status: Initially anxious, restless & c/o pain med for same w mso4 and versed w gd results. LS diminished throughout, occas prod cough able to expectorate w/o diff. Bp bdline to adeq off neo.Distal pulses + w doppler x4 lt dp weak.Resp status: Slow to wake & wean from vent. T-SICU NURSING ADMIT NOTE(Continued): ABD OBESE, DISTENDED, (+)BOWEL SOUNDS. Remains on fluid restriction, on Lasix gtt presently infusing @5mg/hr, goal to keep negative 1liter per 24hr md. updateO: Pt s/p cab x 3 today w long standing hx of iddm & recent adm w foot ulcer lt heel.CV status: sr rare pvc noted. Strong productive cough.ID: afebrile, on piperacillin.GI: abdomen distended, firm, ++flatus, states has little appetiteHEME: heparin decreased to 1750 u/hr Hct low at 24ENDO: ss insulinSKIN: svg sites and sternal incision clean. PT OCCASIONALLY REMOVING O2 AND QUICKLY DESATS TO MID 80S. Hypertensive episodes controlled with lopressor and 1 x dose MS04.K repleated.RESP: Lung sounds initally clear but inspriratory wheezes developing throughout the day. REPEAT ANGIOPLASTY ON L ILIAC AND R SFA SUCCESSFULLY STENTED. ON INTERVENTION ON LEFT CIA STENOSIS AND RIGHT SFA STENT RESTENOSIS WAS STOPPED D/T PT'S C/O SHOULDER PAIN AND DIAPORESIS. Amniodarone 400mg tid.Labile BP 110's/60's - 180's/60'sAntihypertensives held until ectopy is resolved. breathsounds are decreased with rales bibasilar and upper airway wheezes.treated at 10am and 3pm. Remains in A Fib with a rate in the 120's despite multiple boluses of lopressor over the day. BASELINE CREATININE 1.4-1.7)S/P STENTING ONF L ILIAC AND R SFA LEFT BICEP PAIN (? PATIENT PLACED BACK ON IMV WITH IMPROVEMENT OF ABG'S. Tmax 100.1 orally. PT HAD CARDIAC CATH ON REVEALED CRITICAL LEFT MAIN DZ AND 2VD. Pt to maintain 02sats >90% per Dr. ,CV:Pt in afib hr 120-130-s this am despite amiodarone/lopressor po, unable to get oob secondardy to arrhythmia's..Lopressor 5mg IV ordered by MD with good effect. Sinus rhythmIntraventricular conduction defect, right bundle branch block typeConsider inferior infarct - age undeterminedSince previous tracing, QRS wider, intraventricular conduction delay ptternchanged 650mg tylenol given for generalized discomfort w/ good effect.Lytes replaced per standing orders. T. MAX 100.2SKIN: LEFT FOOT IN ACE WRAP, CHANGED BY PODIATRY THIS AM. Becomes SOBA: no ectopy, continues with O2 dependence and activity intoleranceP: ? RECEIVED IV LASIX AND NEBS WITH EFFECT. Another 2.5mg albuterol was given.Lungs were still decreased , had some upper airway wheezes. Packed with 1/4 strength Dakins solution. LYTES SENT, RESULTS PENDING.RESP: BREATH SOUNDS CLEAR IN UPPER LOBES WITH INTERMITTENT EXPIR WHEEZES. ON PT WAS WITH AMIODARONE AND AGAIN CONVERTED TO NSR. Followed by podiatry.OOB to CH with 2 max assist. ALSO DESATS WITH MINIMAL EXERTION (OOB TO CHAIR OR MOVING IN BED) TO 88-89% BUT QUICKLY RECOVERS.RENAL: PT RECEIVED IV LASIX ON 2 PRIOR TO TRANSFER, FOLEY PLACED WITH 220CC DRAINED IMMEDIATELY. | 36 | [
{
"category": "Radiology",
"chartdate": "2128-09-20 00:00:00.000",
"description": "L FOOT AP,LAT & OBL LEFT",
"row_id": 768569,
"text": " 9:37 PM\n FOOT AP,LAT & OBL LEFT Clip # \n Reason: Evaluate for osteomyelitis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with chronic left plantar midfoot ulcer; DM, HTN\n REASON FOR THIS EXAMINATION:\n Evaluate for osteomyelitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: History of chronic ulcer in diabetic. Evaluate for\n osteomyelitis.\n\n LEFT FOOT, THREE VIEWS: Soft tissue ulcer on plantar aspect of mid foot. No\n fracture, no evidence for osteomyelitis. Deformity and bone erosions involved\n the 2nd and 3rd metatars0- phalangeal joints with possible subluxation at the\n second metatarsal phalangeal joint.Similar changes may also be\n present in the tarso- metatarsal joint of the second digit and also involving\n the inter-metatarsal joints with possible anklyosis of the deformed navicular\n and cuneiform but no true lateral views are available. Previous studies for\n comparison.\n\n IMPRESSION: No fracture and no evidence for osteomyelitis. Neuroarthropathic\n changes as described.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-09-21 00:00:00.000",
"description": "ART EXT (REST ONLY)",
"row_id": 768601,
"text": " 8:28 AM\n ART EXT (REST ONLY) Clip # \n Reason: Evaluate for PVD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with DM, HTN, chronic L foot ulcer, claudication symptoms\n REASON FOR THIS EXAMINATION:\n Evaluate for PVD\n ______________________________________________________________________________\n FINAL REPORT\n REASON: Significant pain with walking in both calves. In addition to left heel\n ulcer.\n\n FINDINGS: Doppler evaluation was performed of both lower extermity arterial\n systems at rest.\n\n On the right Doppler tracings are triphasic at the femoral level only. They\n are monophasic below. An ankle-brachial index was recorded at 0.81. Pulse\n volume recordings show significant dropoff at the calf level and are\n essentially flat-line at the metatarsals.\n\n On the left Doppler tracings are triphasic at the femoral levels only. They\n are monophasic below. An ankle-brachial index is listed at 0.70. Pulse volume\n recordings also show significant dropoff at the calf level and approximately 4\n mm to the metatarsals.\n\n IMPRESSION: Significant bilateral superficial femoral artery and tibial artery\n disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-10-12 00:00:00.000",
"description": "CVL/PICC",
"row_id": 770275,
"text": " 2:53 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC FOR IV ABX, DM, LEFT FOOT ULCER\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man s/p CABG with foot infection\n REASON FOR THIS EXAMINATION:\n PICC for IV abx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68 year old man status post CABG with foot infection, requiring\n IV antibiotics.\n\n PROCEDURE/TECHNIQUE: The procedure was performed by Drs: and ,\n with Dr. being present and supervising. The patient's right upper arm\n was prepped and draped in the usual sterile fashion. Since no suitable\n superficial veins were visualized, ultrasound is used for localization. The\n right basilic vein was patent and compressible. After local anesthesia with 2\n cc of 1% Lidocaine, the right basilic vein was entered under ultrasonographic\n guidance with a 21 gauge needle. A .018 guidewire was advanced into the SVC\n under fluoroscopic guidance. The needle was then exchanged for a 4 FR sheath.\n A single lumen 4 FR catheter was advanced through the sheath and the sheath\n was removed and the catheter was flushed. A final chest x-ray demonstrates\n the tip to be at the SVC/right atrial junction.\n\n A Statlock was applied and the line was Heplock.\n\n IMPRESSION: Satisfactory placement of a 36 cm total length single lumen 4 FR\n PICC line with tip at the SVC/right atrial junction, ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-10-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 769770,
"text": " 10:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with postop cabg previous cxr elevated hemidiag. poss\n atelectasis- increase o2 requirement- readmit ICU resp distress\n REASON FOR THIS EXAMINATION:\n R/O PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old patient S/P CABG in respiratory distress.\n\n FINDINGS: AP portable chest radiograph. Comparison to AP portable chest\n radiograph of . The heart size is enlarged. Slight prominence of the\n pulmonary vascularity suggestive of mild cardiac failure. Previously noted\n left apical pneumothorax has resolved. Persistenet left pleural effusion.\n Bibasilar atelectasis. ? nodular opacity in the right mid-zone, which could\n represent an EKG contact.\n\n IMPRESSION: Bibasilar atelectasis. Mild cardiac failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 769404,
"text": " 7:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate pulmonary edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with postop cabg previous cxr elevated hemidiag. poss\n atelectasis\n REASON FOR THIS EXAMINATION:\n evaluate pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Postop of CABG, atelectasis, evaluate pulmonary edema.\n\n TECHNIQUE: Single portable AP view of the chest was compared to prior day.\n\n FINDINGS: There is a small left apical pneumothorax, which is unchanged in\n size. There are bilateral atelectatic changes, unchanged. There are low lung\n volumes. There has been interval removal of a right-sided SG catheter. The\n patient is status post sternotomy, and a left-sided chest tube is unchanged in\n position. The cardiomediastinal silhouette is unchanged. The left\n costophrenic angle is not visualized on this study.\n\n IMPRESSION:\n\n Status post removal of SG catheter, unchanged appearance of lungs, with\n unchanged pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-10-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 769899,
"text": " 10:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for worsening pulmonary edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with postop cabg previous cxr elevated hemidiag. poss\n atelectasis- increase o2 requirement\n REASON FOR THIS EXAMINATION:\n Evaluate for worsening pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P CABG, with worsening oxygen requirements and ? pulmonary\n edema.\n\n TECHNIQUE: Single portable AP view of the chest is compared with 1 day prior.\n\n FINDINGS: Again, the patient is S/P CABG with sternotomy wires and skin\n staples in place. There are multiple surgical clips overlying the\n mediastinum. There is worsening of perihilar haziness, and slight pulmonary\n vascular redistribution. Additionally, there is persistent left retrocardiac\n opacity. There is no other focal pulmonary opacities present. There may be a\n small left-sided pleural effusion. There is improvement in the right-sided\n atelectatic changes. No pneumothorax.\n\n IMPRESSION: 1) Persistent left retrocardiac atelectasis.\n 2) Cardiomegaly with mild pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-10-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 769541,
"text": " 10:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with postop cabg previous cxr elevated hemidiag. poss\n atelectasis\n REASON FOR THIS EXAMINATION:\n R/O PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post-op after CABG. Recent pneumothorax.\n\n AP CHEST: Comparison: CXR-.\n\n The left chest tube had been removed. The left apical pneumothorax is\n minimally enlarged. Cardiac enlargement is stagle. Multiple surgical clips\n and sternotomy wires are seen in the midline.\n Fluid is present within the minor fissure. Lung volumes are low and there\n are probable bilateral pleural effusions.\n\n IMPRESSION: Minimal increase in left apical pneumothorax with an otherwise\n unchanged appearance of the chest.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-09-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 769310,
"text": " 7:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: postop CABG low po2\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with postop cabg previous cxr elevated hemidiag. poss\n atelectasis\n REASON FOR THIS EXAMINATION:\n postop CABG low po2\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Postop CABG, low O2.\n\n COMPARISON STUDY: .\n\n CHEST, PORTABLE: Film is limited due to positioning. Patient is status post\n CABG. Right IJ PA catheter is seen terminating in the pulmonary trunk. There\n are small bilateral pleural effusions with associated bibasilar atelectasis.\n There is a small left apical pneumothorax. A left-sided chest tube and a\n mediastinal tube are identified.\n\n IMPRESSION:\n\n 1. Small left apical pneumothorax with left-sided chest tube. These findings\n were communicated to the ordering service.\n\n 2. Small bilateral pleural effusions with associated atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-10-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 769601,
"text": " 9:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with postop cabg previous cxr elevated hemidiag. poss\n atelectasis\n REASON FOR THIS EXAMINATION:\n pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Postoperative CABG, with pulmonary edema. ? change and\n atelectasis.\n\n TECHNIQUE: A single portable AP view of the chest is compared with .\n\n FINDINGS: The left-sided pneumothorax is no longer evident. There is left-\n sided apical thickening. There are sternotomy wires and skin staples\n overlying the mid chest. There is a stable size of the enlarged left\n ventricle. Again seen is bibasilar atelectatic changes. There is unchanged\n collapse of the right lower lobe with resultant elevation of the diaphragm.\n This is a poor inspiratory effort.\n\n IMPRESSION: Persistent bibasilar atelectatic changes, with resolution of\n left-sided pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-09-21 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 768654,
"text": " 10:33 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: INFECTED LEFT FOOT;DIABETES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with l foot ulcer. pre-op\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop study in patient with left foot ulcer.\n\n COMPARISON: None available.\n\n CHEST, PA AND LATERAL: The cardiac silhouette is normal for left ventricular\n configuration without overall enlargement. The mediastinal and hilar contours\n are unremarkable. The right hemidiaphragm is elevated and there is associated\n linear atelectasis in the right mid lung. On the lateral view, increased\n density is noted in the lower lungs overlying the vertebral bodies which\n likely represents atelectasis associated with elevated right hemidiaphragm.\n There are no pleural effusions. The pulmonary vasculature is unremarkable.\n\n IMPRESSION; Linear atelectasis in the right mid lung and increase in\n opacification seen on the lateral view in the lower lungs may likely\n represents atelectasis associated with elevated right hemidiaphragm.\n Underlying consolidation is unlikely. Clinical correlation is suggested.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-09-23 00:00:00.000",
"description": "PERSANTINE MIBI",
"row_id": 768739,
"text": "PERSANTINE MIBI Clip # \n Reason: OBS FOR SUSPECTED CV DISEASE.\n ______________________________________________________________________________\n FINAL REPORT\n SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB:\n Persantine was infused intravenously for approximately 4 minutes at a dose of\n approximately 0.142 mg/kg/min. No chest, neck, arm or back pain was reported by\n the patient. T wave inversion in leads V4-V6 were noted and reversed after the\n administration of aminophylline.\n\n HISTORY: Sixty-eight year old male with h/o diabetes mellitus and peripheral\n vascular disease who is awaiting avascular surgery and has been referred for\n preoperative evaluation.\n\n INTERPRETATION: One to three minutes after the cessation of Persantine\n infusion, MIBI was administered IV.\n\n Image Protocol: Gated SPECT.\n\n Resting perfusion images were obtained with thallium.\n Tracer was injected 15 minutes prior to obtaining the resting images.\n\n Stress images show a moderate perfusion defect within the inferior myocardial\n wall.\n\n Resting perfusion images show partial reversibility of this defect.\n\n Ejection fraction calculated from gated wall motion images obtained after\n Persantine administration shows a left ventricular ejection fraction of\n approximately 48%. There is hypokinesis of the inferior wall.\n\n IMPRESSION: 1) Moderate, partially reversible perfusion defect within the\n inferior myocardial wall. 2) Inferior wall hypokinesis with an ejection\n fraction of 48%. /nkg\n\n\n , M.D.\n , M.D. Approved: FRI 1:06 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2128-09-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 769197,
"text": " 4:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: INFECTED LEFT FOOT;DIABETES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with cad\n REASON FOR THIS EXAMINATION:\n preop\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Infected foot. Diabetes. Preoperative assessment.\n\n The heart size is normal. The aorta is slightly unfolded and the pulmonary\n vascularity is normal. There remains marked elevation of the right\n hemidiaphragm with adjacent linear opacity in the right lower lobe. There is\n slight thickening of the minor fissure which is also stable in the interval.\n\n IMPRESSION: Persistent elevation of right hemidiaphragm with linear\n atelectasis in the adjacent right lung base versus focal scarring. No\n significant change since recent study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-09-24 00:00:00.000",
"description": "PTA FEMORAL/POPLITEAL",
"row_id": 768839,
"text": " 8:01 AM\n ABDOMINAL AORTA Clip # \n Reason: stenting by Dr. based on angio results. As discussed\n Contrast: OPTIRAY Amt: 150\n ********************************* CPT Codes ********************************\n * PTA FEMORAL/POPLITEAL PTA ILIAC *\n * -51 MULTI-PROCEDURE SAME DAY INITAL 3RD ORDER ABD/PEL/LOWER *\n * -51 MULTI-PROCEDURE SAME DAY PTA PERIPHEREAL ARTERY *\n * PTA EACH ADD'L PERIPHERAL ARTE EXT BILAT A-GRAM *\n * -52 REDUCED SERVICES UD GUID FOR NEEDLE PLACMENT *\n * IV CONSCIOUTIOUS SEDATION PRO NON-IONIC 150 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with L LEG ischemia. Angio done. Dr. will stent Iliac\n and other vessels as necessary. As discussed with Dr. \n REASON FOR THIS EXAMINATION:\n stenting by Dr. based on angio results. As discussed w/ Dr. \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right superficial femoral artery stenting and left\n common iliac artery stenting at outside hospital. Left lower extremity\n ischemia with non-healing ulcer. Previous angiogram on demonstrating\n significant stenosis of the left common iliac artery and within the stent\n placed within the right superficial femoral artery.\n\n RADIOLOGIST: Procedure performed by Dr. and , staff radiologist\n present for and supervising the entire procedure.\n\n MEDICATION AND CONTRAST: 1.5 mg Versed, 50 mcg Fentanyl administered in\n divided doses with continuous hemodynamic monitoring for conscious sedation. 3\n cc 1% Lidocaine two inches nitropaste. 150 cc 30% nonionic contrast\n administered due to patient's generalized debilitation and cardiopulmonary and\n renal status.\n\n PROCEDURE/TECHNIQUE: The patient was informed of the details and the\n associated risks of the procedure and the patient was placed supine on the\n angiographic table. The left groin was sterilely prepped and draped in the\n usual fashion and 1% subcutaneous Lidocaine administered. Under\n ultrasonographic and fluoroscopic guidance, the left common femoral artery was\n accessed using a 19 gauge spinal puncture needle. A 0.35 was\n advanced under fluoroscopic guidance such that the tip is in the abdominal\n aorta. The needle was removed and exchanged for a 4 FR sheath. A 4 FR\n Omniflush catheter was advanced such that the tip at the infrarenal aorta and\n oblique and AP pelvic arteriograms are obtained. The 5 FR sheath is advanced\n under fluoroscopic guidance and a 4 FR Omniflush catheter is manipulated over\n a superstiff guidewire such that the tip is within the right common iliac\n artery and arteriogram of the proximal right lower extremity including stented\n SFA is obtained. Again demonstrated is significant stenosis with proximal SFA\n and the region of previously placed stent. A 6 mm power flex balloon catheter\n is advanced over 0.035 exchange wire such that its tip is within the proximal\n right superficial femoral. The 6 mm balloon is inflated distal mid and\n proximal portions of the stenosis. Subsequent arteriogram demonstrates good\n (Over)\n\n 8:01 AM\n ABDOMINAL AORTA Clip # \n Reason: stenting by Dr. based on angio results. As discussed\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n angiographic improvement of stenosis. The balloon catheter is withdrawn under\n fluoroscopic guidance and the 4 FR Omniflush catheter is withdrawn and\n arterial pressures are measured within the distal abdominal aorta and left\n common iliac artery. A significant pressure gradient, 30 to 60 mm Hg\n systolic. The 4 FR Omniflush catheter was removed and a 8 mm power flex\n balloon catheter was advanced over 035 wire through the 5 FR sheath such\n that the balloon traverses the proximal left iliac stenosis. Serial balloon\n angioplasty is obtained with an 8 mm balloon. Subsequent arteriogram\n demonstrates good angiographic result and there is no pressure gradient\n demonstrated within the aorta and common iliac following angioplasty. The\n catheters withdrawn. The sheath is withdrawn and hemostasis is obtained.\n\n While obtaining hemostasis, the patient complained of lower back pain somewhat\n relieved with Percocet. During in the process of obtaining hemostasis, the\n patient experienced bradycardia with heart rate down to 43 and became\n hypotensive. The previously placed nitropaste, due to hypertension during\n procedure was removed without significant improvement in good pressure and 0.5\n mg Atropine was administered. 500 cc lactated ringers was administered as a\n bolus. A 12 lead EKG was obtained with suggestion of mild ST elevation.\n Cardiac enzymes were drawn. The vascular surgery house staff were notified\n and decided to transfer patient to cardiology floor telemetry.\n\n IMPRESSION:\n\n 1. Successful angioplasty of proximal, stented, right superficial femoral\n artery with 6 mm balloon and resultant excellent angiographic result.\n\n 2. Successful angioplasty of proximal left common iliac artery with 8 mm\n balloon with resultant excellent angiographic result and no arterial pressure\n gradient demonstrated following angioplasty.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-09-22 00:00:00.000",
"description": "INITAL 2ND ORDER ABD/PEL/LOWER EXT A-GRAM",
"row_id": 768680,
"text": " 9:35 AM\n -LAT FEMORAL Clip # \n Reason: Evaluate for PVD. Please evaluate iliacs also.\n Contrast: OPTIRAY Amt: 230\n ********************************* CPT Codes ********************************\n * INITAL 2ND ORDER ABD/PEL/LOWER INTRO CFA/SFA/ILIAC/ GRAFT *\n * -59 DISTINCT PROCEDURAL SERVICE ABDOMINAL A-GRAM *\n * EXT BILAT A-GRAM IV CONSCIOUTIOUS SEDATION PRO *\n * NON-IONIC 200 CC SUPPLY NON-IONIC 30 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with h/o bilateral iliac stents , nonhealing L foot ulcer,\n DMx40yrs. NIAS shows bilat SFA and tibial dz.\n REASON FOR THIS EXAMINATION:\n Evaluate for PVD. Please evaluate iliacs also.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral iliac stents , nonhealing left foot ulcer, DM times\n 4 years. NIAS demonstrating bilateral SFA and tibial disease, chronic renal\n insufficiency, MI times 2.\n\n RADIOLOGIST: Procedure performed by Drs. , , and Dr. ,\n staff radiologist present and supervised the procedure.\n\n MEDICATION AND CONTRAST: .5 mg intravenous Versed, 75 mcg intravenous\n Fentanyl administered in divided doses under constant hemodynamic monitoring,\n 3 cc 1% subcutaneous Lidocaine. 230 cc 30% nonionic contrast administered due\n to patient's cardiac status. CO2 was utilized for aortography.\n\n TECHNIQUE: The patient was informed of the details and the associated risks\n of the procedure and written consent was obtained. The patient was placed\n supine on the angiographic table and the right groin was sterilely prepped and\n draped in the usual fashion. 3 cc of 1% subcutaneous Lidocaine was\n administered to the right groin. Under fluoroscopic guidance, the right\n common femoral artery was accessed using 19 gauge single wall puncture needle.\n A 0.035 wire was advanced under fluoroscopic guidance and the puncture\n needle was exchanged for a 4 FR sheath. A 4 FR Omniflush catheter was\n advanced over the 035 guidewire under fluoroscopic guidance such that the tip\n was at the level of the 1st lumbar vertebra and infrarenal aortogram was\n obtained using CO2 as contrast . The catheter was then positioned such\n that the tip was at the level of the iliac bifurcation and bilateral oblique\n pelvic arteriograms were obtained. Using a 0.035 guidewire, the Omniflush\n catheter was advanced such that the tip was within the left external iliac\n artery and serial left lower extremity arteriograms were performed. Arterial\n pressure was measured within the left external iliac, left common iliac, right\n common iliac and external iliac arteries as well as the aorta. A significant\n arterial pressure gradient was demonstrated within the aorta and the left\n common iliac artery. No significant pressure gradient was demonstrated\n between the aorta and the right common or external iliac artery. The catheter\n was repositioned within the right external iliac artery and serial right lower\n extremity arteriograms were obtained.\n\n (Over)\n\n 9:35 AM\n -LAT FEMORAL Clip # \n Reason: Evaluate for PVD. Please evaluate iliacs also.\n Contrast: OPTIRAY Amt: 230\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n During arteriograms of the right foot, the patient was complaining of left arm\n pain worsening over the course of the procedure and patient was noted to\n hypertensive with blood pressure 188/88. One inch nitroglycerin paste was\n applied without significant improvement of blood pressure or left arm pain.\n The patient's podiatry house staff and cardiology house staff were notified\n and it was decided to not proceed with intervention of the left iliac artery\n or right superficial femoral artery. The right common femoral artery catheter\n and sheath were removed and hemostasis was obtained. There were no other\n immediate complications.\n\n FINDINGS: There is extensive atherosclerotic disease of the infrarenal aorta.\n Bilateral single patent renal arteries are present. There is bilateral, left\n greater than right, stenosis of the proximal common iliac arteries. A\n significant pressure gradient is demonstrated between the aorta and the left\n common iliac artery, but demonstrated between the aorta and the right common\n iliac artery. The left common iliac artery stent is patent. There appears to\n be ulcerated plaque within the distal abdominal aorta just proximal to the\n common iliac artery bifurcation.\n\n There is focal stenosis of the proximal left superficial femoral artery. There\n is extensive atherosclerotic disease of the left popliteal artery with\n approximately 90% stenosis demonstrated distally. The left anterior tibial\n artery is occluded proximally. There is moderate disease of the tibioperoneal\n trunk. There is moderate stenosis of the proximal posterior tibial artery and\n focal stenosis of the mid posterior tibial artery. The left peroneal artery\n is patent with moderate diffuse disease. The left peroneal artery\n reconstitutes a distal anterior tibial artery just above the ankle with\n moderate proximal stenosis and slow flow. Patent plantar branches are present\n and the left dorsalis pedis is not well demonstrated.\n\n There is extensive restenosis within the stented proximal right superficial\n femoral artery. There is diffuse moderate disease of the right popliteal\n artery. There is occlusion of the left right trifurcation with reconstitution\n of the right peroneal artery at the mid calf. The right anterior tibial and\n posterior tibial arteries occluded. The right peroneal artery reconstitutes\n small plantar branches and the dorsal pedis artery.\n\n IMPRESSION:\n\n 1. Extensive infrarenal aortic atherosclerotic disease with ulcerated plaque\n just proximal to the common iliac bifurcation.\n\n 2. Bilateral, left greater than right, common iliac artery stenosis with\n significant pressure gradient demonstrated between the aorta and left common\n iliac artery.\n\n (Over)\n\n 9:35 AM\n -LAT FEMORAL Clip # \n Reason: Evaluate for PVD. Please evaluate iliacs also.\n Contrast: OPTIRAY Amt: 230\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Patent distal left common iliac artery stent.\n\n 4. Focal proximal stenosis of the left superficial femoral artery. Extensive\n left popliteal artery atherosclerotic disease with approximately 90% stenosis\n demonstrated distally.\n\n 5. Occluded left proximal anterior tibial artery.\n\n 6. Moderate disease of the left tibioperoneal trunk with stenosis\n demonstrated within the proximal and mid posterior tibial artery.\n\n 7. Moderately diseased left peroneal artery reconstituting distal left\n anterior tibial artery and supplying patent plantar branches.\n\n 8. Proximal right superficial femoral artery stent with extensive restenosis.\n\n 9. Moderately diseased right popliteal artery with occluded trifurcation and\n reconstitution of the right peroneal artery at the mid calf as the sole runoff\n vessel which reconstitutes small plantar branches and right dorsalis pedis\n artery.\n\n 10. Angioplasty of the left proximal common iliac artery and restenosed right\n superficial femoral artery can be obtained at a later date when cardiac\n evaluation is complete and additional dye load can be delivered. This was\n discussed with podiatry house staff at the time of the study.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-06 00:00:00.000",
"description": "Report",
"row_id": 1577991,
"text": "Insulin gtt started md order, will titrate for bloodsugars<120.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-07 00:00:00.000",
"description": "Report",
"row_id": 1577992,
"text": "NEURO- PERTL AT 3.0MM, CONSISTENTLY FOLLOWS COMMANDS, MAE, A&O\n\nCARDIAC- HR REGULAR RHYTHM, HAS BEEN SINUS BRADYCARDIAC ALL SHIFT- BP IS NOT AFFECTED, NO ECTOPY SEEN, NO A FIB TONIGHT, BP GOOD\n\nRESP- RIGHT LOBES ARE CLEAR, LEFT LOBES DIMINISHED, PRODUCTIVE COUGH, PO2 61 THIS NOTIFIED PT HAS BEEN ON 5L O2 VIA NC AND FACE TENT, SATS > 92%, USES IS WITH MUCH ENCOURAGEMENT DRAWING TV OF 750-800, RR 16 BPM\n\nGI-HYPERACTIVE BOWEL SOUNDS, NO BM FOR 7 DAYS, C/O ABDOMINAL PAIN AND NAUSEA-DOSS AND M.O.M GIVEN-PRODUCED LARGE, SOFT, THICK BM- MUCH RELIEF TO PT, HOWEVER ABD. STILL DISTENDED\n\nGU-FOLEY CATH, UOP TAPERING OFF, CLEAR AND YELLOW URINE, BUN 44, CREATININE 2.2-LASIX GTT OFF PER DR. \n\nENDO- FSBS HAVE SLOWLY DECREASED, CURRENTLY 90, INSULIN AT 0.5 U/HR MAINTENCE DOSE\n\nSKIN- NO TEMP, WARM AND DRY, LEFT FOOT IMPAIRED, INCISION TO RLE AND STERI-STRIPS TO CHEST SECONDARY CARDIAC SURGERY, NO BREAKDOWN ON BACK OR POSTERIOR AREA\n\nDIET- HOUSE DIET, ATE NOTHING OVERNIGHT\n\nHCT CONTINUES TO DECREASE CURRENTLY 23.7 DOWN FROM 25 LAST NIGHT-DR. NOTIFIED, HGB 7.7, REPLACED POTASSIUM PO, RECEIVING ZOSYN FOR INCREASED WBC\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-07 00:00:00.000",
"description": "Report",
"row_id": 1577993,
"text": "NEURO:Pt alert/oriented x3. C/O feeling \"fuzzy\" at x's. MAE's w/ generalized weakness.\n\nRESP:Ls much improved, faint crackles noted in bilat bases. Pt using i/s w/ much encouragmt. Pulling 750cc's, DOE during transfer to chair. O2sats 90-96% on 3.5-5L via NC. ABG's monitored. Po2 in the 60's, Team aware.\n\nCV:Pt remains in SB 50's, scant PVC's noted. No AFIB noted, recv'd scheduled dose of amiodarone, 50mg lopressor. Pt hypertensive this afternoon. Dr. aware. Pulses remain weak throughout.\n\nGI/GU:UO qs, bun/cr elevated HCTZ held, lasix gtt d/c'd. Bowel sounds noted, colace held secondary to 4 lg BM's.\n\n20meq's KCL po given per standing order, insulin adm sq per sliding scale. Pt remains on heparin gtt @1950u/hr scheduled for 5mg Coumadin this eve, coags q6hr. No changes made to heparin gtt today. Pt oob for several hrs this am, assisted back to bed this afternoon. Pt requiring 2 assists however, getting stronger. Pt s/b P.T. & S.W. Wife at bedside all questions encouraged/answered. Pt for tx to floor in am when bed avail per CT. Will cont w/ POC, ¬ify MD with significant changes in physical assmts.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-07 00:00:00.000",
"description": "Report",
"row_id": 1577994,
"text": "D Patients alert and oriented x3. Lungs clear anterior deminished at bases. posteriorly 2/3 up wheezy and markedly deminished. O2 Sat ,90 on 6lNC resp tx given with no effect. discussed with HO chest XRay done and Bun and Cre sent with lytes. L foot dsg done wound pink to dusky no granulosis noted W/D dsg done.\nA patient respitory staus is concerning\nR tx with FT and NC to maintain O2 Sat > 90. if Bun an CRE improved will tx with lasix. cont to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-09-30 00:00:00.000",
"description": "Report",
"row_id": 1577981,
"text": "update\nO: Pt s/p cab x 3 today w long standing hx of iddm & recent adm w foot ulcer lt heel.\nCV status: sr rare pvc noted. Bp bdline to adeq off neo.Distal pulses + w doppler x4 lt dp weak.\n\nResp status: Slow to wake & wean from vent. Currently on 5ps 5peep w bldine metab acidosis abg (unchanged from previous gases on simv.)BBS coarse to cl w distant brth snds lt base.Lavage/suct for sm amts thick white to pale yellow secretions.Chest tubes x 3 w sm amts ss drng.\n\nGi status: ogt to lws w bilious drng. Abd distended, firm quiet but nontender upon palp.\n\nGu status: bdline to qs amber urine/ hespan given x 1for low uop & ^.\n\nNeuro status: Initially anxious, restless & c/o pain med for same w mso4 and versed w gd results. Pt sleeping in naps, responds to voice and nodding to questions.\n\nLabs: insulin gtt for glucose mngment titrated ^ 8 u/hr w adeq bl gluc.\n\nA/P: post op cabg w metab acidosis. Extubate when more fully awake.Check am labs and rx per orders.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-04 00:00:00.000",
"description": "Report",
"row_id": 1577982,
"text": "patient given 2.5mg albuterol and .5mg atrovent via hhn.\nTolerated well, hr80's and stable. breathsounds are decreased with rales bibasilar and upper airway wheezes.\ntreated at 10am and 3pm. At 5:45 patient in a svt, hhn held at this time.\nwill cont to follow as needed.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-04 00:00:00.000",
"description": "Report",
"row_id": 1577983,
"text": "T-SICU NURSING ADMIT NOTE\nHPI: PT IS A 63 YO MALE WITH KNOWN CAD. HE WAS ORIGINALLY ADMITTED ON D/T A WORSENING LEFT FOOT ULCER (DEEP PROBING TO BONE). ON INTERVENTION ON LEFT CIA STENOSIS AND RIGHT SFA STENT RESTENOSIS WAS STOPPED D/T PT'S C/O SHOULDER PAIN AND DIAPORESIS. CARDIOLOGY CONSULTED FOR PRE-OP CLEARANCE FOR ANGIOPLASTY. P-MIBI ON REVEALED AN EF OF 48% AND MODERATELY REVERSIBLE INFERIOR DEFECT WITH INFERIOR HK. REPEAT ANGIOPLASTY ON L ILIAC AND R SFA SUCCESSFULLY STENTED. PT HAD CARDIAC CATH ON REVEALED CRITICAL LEFT MAIN DZ AND 2VD. S/P CABG X 4 ON , HE DID WELL POST-OPERATIVELY AND WAS TRANSFERRED TO FLOOR ON WHERE HE SUBSEQUENTLY DEVELOPED RAF, LOADED WITH AMIODARONE AND CONVERTED TO NSR. PT CONTINUED TO HAVE INTERMITTENT, NON-SUSTAINED EPISODES OF AF. ON PT WAS WITH AMIODARONE AND AGAIN CONVERTED TO NSR. AT THAT TIME PT WAS ALSO C/O INCREASED SOB, WAS WHEEZY AND HAD BILAT CRACKLES. RECEIVED IV LASIX AND NEBS WITH EFFECT. THIS AM, PT AGAIN IN/OUT OF AFIB, O2 SATS 89-92% ON 6LNC. PT TRANSFERRED TO T-SICU FOR FURTHER MANAGEMENT.\n\nPMHX:\nCAD--S/P MI ' AND '\nS/P BILAT ILIAC STENTS '\nHTN\nTYPE 2 DM (INSULIN DEPENDENT)\nHYPERCHOLESTEROLEMIA\nCRI (? BASELINE CREATININE 1.4-1.7)\nS/P STENTING ONF L ILIAC AND R SFA \nLEFT BICEP PAIN (? TENDONITIS)\n\nALLERGIES:\nNKDA\n\nPE:\nNEURO: ALERT AND ORIENTED X 3, SLEEPY AT TIMES BUT EASILY AROUSABLE. PT C/O LEFT SHOULDER DISCOMFORT SINCE ADMISSION, HOWEVER, PT HAS HAD INCREASING WEAKNESS OF LUE SINCE , UNABLE TO LIFT ARM ABOVE SHOULDER, STRENGTH 4/5 ON LUE, RUE. HEAD CT DONE ON , RESULTS NOT AVAILABLE AT THIS TIME. C/O STERNAL DISCOMFORT, RECEIVED PERCOCET FOR PAIN WITH EFFECT.\n\nCV: PT IN NSR ON ARRIVAL FROM 2. AT 12:15PM, PT BACK IN RAF WITH RATES UP TO 140-150 WITH 4-8 BEAT RUNS OF (PT RESTING IN BED AT THAT TIME). DENIES CP, INCREASED WHEEZING, SATS 91-92% BP WENT FROM 150/80S TO 120-130/80S. RECEIVED 5MG IV LOPRESSOR WHICH WAS REPEATED X 1 AND PT CONVERTED TO NSR. LYTES SENT, ALL WNL. PT DID WELL UNTIL 5:45PM WHEN HE AGAIN WENT INTO RAF RATE UP TO 150S. DR FROM CT ON UNIT AT THAT TIME, PT RECEIVED ANOTHER 10MG IV LOPRESSOR, IN/OUT OF AFIB FOR APPROXIMATELY 15 MINUTES, BP STABLE, THEN CONVERTED TO NSR AT 6:10PM. RECEIVED 150MG BOLUS OF AMIODARONE AND 2GMS MGS04 AND HAS REMAINED IN NSR SINCE THAT TIME. LYTES SENT, RESULTS PENDING.\n\nRESP: BREATH SOUNDS CLEAR IN UPPER LOBES WITH INTERMITTENT EXPIR WHEEZES. CRACKLES BILAT 2/3 UP ON RIGHT, 1/3 UP ON LEFT. (+)EGOPHONY BILAT. 02 AT 5LNC AND 70% FACE TENT, SATS 93-96%. PT OCCASIONALLY REMOVING O2 AND QUICKLY DESATS TO MID 80S. ALSO DESATS WITH MINIMAL EXERTION (OOB TO CHAIR OR MOVING IN BED) TO 88-89% BUT QUICKLY RECOVERS.\n\nRENAL: PT RECEIVED IV LASIX ON 2 PRIOR TO TRANSFER, FOLEY PLACED WITH 220CC DRAINED IMMEDIATELY. RECEIVED ANOTHER 20MG IV LASIX AT 2PM WITH NO RESPONSE UNTIL 4:30PM WHEN HE PUT OUT 360CC. LASIX GTT ORDERED. REPEAT LYTES SENT AT 6PM\n\nGI\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-04 00:00:00.000",
"description": "Report",
"row_id": 1577984,
"text": "T-SICU NURSING ADMIT NOTE\n(Continued)\n: ABD OBESE, DISTENDED, (+)BOWEL SOUNDS. (+)FLATUS. TOLERATING FULL LIQUID DIET. NO BM IN SEVERAL DAYS MOM GIVEN, RESULTS PENDING\n\nHEME: ?START HEPARIN GTT D/T PT IN/OUT OF RAF X 4 DAYS. WILL D/W CT SURGERY\n\nID: PT PREVIOUSLY ON IV ABX FOR LEFT FOOT ULCER, AWAITING RETURN CALL FROM PODIATRY IF PT STILL NEEDS ABX. T. MAX 100.2\n\nSKIN: LEFT FOOT IN ACE WRAP, CHANGED BY PODIATRY THIS AM. WILL CONTINUE ACETIC ACID DRESSING CHANGES.\n\nSOCIAL: WIFE IN TO VISIT, ANXIOUS D/T PT'S RETURN TO ICU, ALL QUESTIONS ANSWERED, SUPPORT PROVIDED.\n\nENDO: RECEIVED 3 UNITS REGULAR INSULIN FOR BLOOD SUGAR 136, WILL CONTINUE WITH SLIDING SCALE, ? RESTART PT'S HOME INSULIN DOSE IN AM IF TOLERATING POS\n\nA: READMISSION TO ICU FOR RESPIRATORY DISTRESS, CONTINUES WITH INTERMITTENT EPISODES OF RAF\n\nP: CONTINUE WITH CURRENT MANAGEMENT, F/U WITH PODIATRY REGARDING IV ABX COURSE FOR LEFT FOOT ULCER, CONTINUE PULMONARY TOILET\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-06 00:00:00.000",
"description": "Report",
"row_id": 1577989,
"text": " PT IS A&O, PERTL AT 3.0 MM, PUPILS BRISKLY REACTIVE, CONSISTENTLY FOLLOWS , \n\nCARDIAC- HR HAS BEEN VERY IRREGULAR, HAS BEEN SR AND A FIB ALL NIGHT, A FIB HAS BEEN HARD TO CONTROL, IV LOPRESSOR AND LABETALOL GIVEN WITH MINIMAL EFFECT, PT CONTINUES IN UNCONTROLLED A FIB, BP IS NOT AFFECTED BY HR, PULSES ALL PRESENT AND PALPABLE\n\nRESP- UPPER LOBES ARE CLEAR WITH A FEW WHEEZES, BASES WITH BILATERAL SCATTERED RHONCI, STRONG COUGH WHICH IS NON-PRODUCTIVE, O2 VIA FACE TENT AND 4L NC, SATS>94%\n\nGI- ABDOMEN IS SOFT BUT DISTENDED, HYPOACTIVE BOWEL SOUNDS, HAS NOT HAD BM IN 6 DAYS, HOWEVER IS PASSING GAS\n\nGU- UOP GOOD ON LASIX GTT, GOAL TO KEEP NET HOURLY UOP AT NEGATIVE 100-150, URINE CLEAR AND YELLOW\n\nENDO- FSBS HAVE BEEN HIGH, SS INSULIN GIVEN SQ\n\nSKIN- IMPAIRED AREA ON LEFT FOOT, DRSG \n\nNO TEMP LAST NIGHT, STILL ON INSULIN AND HEPARIN GTT, DID NOT SLEEP WELL LAST NIGHT\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-06 00:00:00.000",
"description": "Report",
"row_id": 1577990,
"text": "Neuro:Pt neurologically intact. No issues.\n\nResp: Pt wearing 5lnc accomp by 50%FT throughout most of the day, pt finally weaned to 5lnc O2 sats >93%. LS diminished throughout, occas prod cough able to expectorate w/o diff. Pt DOE, pt oob to chair w/ some resp difficulty. Self resolved w/o intervention. Pt to maintain 02sats >90% per Dr. ,\n\nCV:Pt in afib hr 120-130-s this am despite amiodarone/lopressor po, unable to get oob secondardy to arrhythmia's..Lopressor 5mg IV ordered by MD with good effect. Pt remains in sinus brady x several hours. BP stable throughout afib episodes via r radial art line. Pulses weak throughout. Pt remains on heparin gtt @1950u/hr. PTT 61 no changes made to gtt,\n\nGI/GU: Pt w/poor appetite, tolerating mostly liquid po's. Remains on fluid restriction, on Lasix gtt presently infusing @5mg/hr, goal to keep negative 1liter per 24hr md. , titrating Lasix gtt prn. Positive bowel sounds, no n/v.\n\nEndo: Pt requiring insulin coverage throughout , MD aware to resume insulin gtt to maintain therapeutic blood sugars.\n\nSkin: No skin breakdown noted, pt w/ healing sternum & rle secondary post cabg. LLE ulcer dsg changed per protocol.\nPt refusing \"heavy pain medication\" secondary to hallucinations. 650mg tylenol given for generalized discomfort w/ good effect.\nLytes replaced per standing orders. Will cont to encourage aggressive pulm toilet, check ptt's q6hr, adjust heparin gtt per standing order,.provide emotional support prn. Family called x2 full update given.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-09-29 00:00:00.000",
"description": "Report",
"row_id": 1577979,
"text": "WHITE MALE ADMITTED FROM OR AT 1336 S/P CABG X 4. INTUBATED AND SEDATED WITH IV PROPOFOL, NO OTHER GTT'S INFUSING. CT'S PATENT FOR MINIMAL DRAINAGE. PATIENT BEING AV PACED, PACER OFF AT ~1500, RYTHM NSR. FOLEY WITH CLEAR URINE. RT LEG WRAPPED, BILATERAL DOPPLERABLE PULSES. LT FOOT DSG DONE, MOADERATE SIZED OPEN WND IN BALL OF FOOT, W-D N/S DSG APPLIED. WIFE IN.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-09-29 00:00:00.000",
"description": "Report",
"row_id": 1577980,
"text": "UNABLE TO WEAN TO EXTUBATE, PH 7.30, PRESSURE SUPPORT ^ TO 15, PH DOWN TO 7.29. PATIENT PLACED BACK ON IMV WITH IMPROVEMENT OF ABG'S. WILL RETRY TO WEAN TO EXTUBATE LATER. SEDATED WITH IV MS.\nGLUCOSE AS PER LAB SHEET, INSULIN GTT NOW AT 4 UNITS QH. WILL CONTINUE TO FOLLOW PROTOCOL.\nNEURO: AWAKE APPEARS ALERT, FOLLOWS COMMANDS.\nCARDIAC: NSR WITHOUT, K+ REPLEATED. CT'S PATENT FOR MINIMAL SERO-SANG.\nGI: OG IN PLACE, PATENT FOR BILIOUS.\nGU: FOLEY, CLEAR YELLOW URINE.\nLT FOOT DSG D/I, DOPPERABLE PULSES.\nWIFE AND SON IN EARLIER, HAVE GONE HOME FOR THE NOC.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-05 00:00:00.000",
"description": "Report",
"row_id": 1577987,
"text": "TSICU NPN\nNEURO: Alert and Oriented X 3. Pupils 3mm/bsk. MAE. Denies numbness and tingling. Strength equal throughout. Has baseline lower extremity neuropathy secondary to long term diabetes.\n\nCV: HR frequently fluctuating between AF and NSR. Lopressor 5mg given X 4 with successful effect in converting to normal sinus. Remains on heparin gtt at 17.5 units/hr maintianing goal of Ptt 60-80. Amniodarone 400mg tid.\nLabile BP 110's/60's - 180's/60's\nAntihypertensives held until ectopy is resolved. Hypertensive episodes controlled with lopressor and 1 x dose MS04.\nK repleated.\n\nRESP: Lung sounds initally clear but inspriratory wheezes developing throughout the day. Multiple neb treatment administered. Lasix gtt increased and 10mg bolus given.\n\nGI: Abd soft nontender distended. +flatus. Denies nausea. Tol po's.\n\nGU: u/o 100-200cc hrly clear yellow urine. Lasix gtt. Started on fluid restriction 500cc/daily d/t inability to sustain goal status of negative 1 liter q 24 hrs.\n\nENDO: Glucose 200's covered with SSRI.\n\nID: Started on impericial iv Zosyn for an increased wbc 32. Tmax 100.1 orally. Pan cultutes . Sputum/Wound cx sent .\n\nSKIN/Mobility: Grossly intact. Sternal incision intact with irritated area at neck line secondary to face mask friction. Incision with staples. Approximated OTA. Without drainage. Left foot ulcer 5cm/8cm. Deep, granulating , pink. Minimal sero/sang stainging on packing. Packed with 1/4 strength Dakins solution. Followed by podiatry.\nOOB to CH with 2 max assist. STayed in chair for 3 hrs. Tolerated stand with walker with 2 max assistance BTB\n\nSOCIAL: Wife and sister into visit. Case Management following for rehab planning.\n\nA/P: Control rate, monitor fluid status, glucose control, electrolyte repleation, physical therapy.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-06 00:00:00.000",
"description": "Report",
"row_id": 1577988,
"text": "NSG NOTE PM\n PT. cont. with rhythm concerns. Remains in A Fib with a rate in the 120's despite multiple boluses of lopressor over the day. He remains on po amioderone as well as IV boluses earlier today. He has periodically converted to sinus but not sustained. He rcv'd additional lopressor IV 5 mg this evening abt 8 pm and by 9 pm had finally dropped his rate to the 60's and remained in sinus. He has also increased his po dose of lopressor from 50mg to 100mg . By 11pm rate started to vary somewhat again, presently his rate has dropped to the 50's in a sinus rhythm.\nRenal- U/O remains adequate but not able to significantly diurese this evening, to reach goal of 1 litre off today.\n Pt. c/o pain this evening and requested percocet for relief, rcv'd with gd effect per pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-08 00:00:00.000",
"description": "Report",
"row_id": 1577995,
"text": "T/SICU Nursing Progress Note\nS:\"I don't feel like smiling tonight\"\nO: Neuro: Awake, slept at intervals. C/o being uncomfortable in general and restless at times.\nCVS: sb, rate controlled, bp controlled, no ectopy\nRESP: on np plus face tent. Continues to be very SOB with exertion. Sats down to high 80's without oxygen. Strong productive cough.\nID: afebrile, on piperacillin.\nGI: abdomen distended, firm, ++flatus, states has little appetite\nHEME: heparin decreased to 1750 u/hr Hct low at 24\nENDO: ss insulin\nSKIN: svg sites and sternal incision clean. L foot continues with \ndressing changes.\nACTIVITY: OOB to chair with heavy assist of one. Becomes SOB\nA: no ectopy, continues with O2 dependence and activity intolerance\nP: ??transfer to floor today with telemetry\nContinue dsg changes to L foot. Reassure and support .\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-05 00:00:00.000",
"description": "Report",
"row_id": 1577985,
"text": "nsg note:\nneuro: pt intact coop. slightly confused as to time late evening but cleared completely overnight\nrresp: pt on 5 l np's and 100% face tent. with sats of 95 to 98. with any disruption of o2 sats drop to mid 80%. attempt to turn down face tent to 70% resulted in drop in sats also.\npt clear this am with decrease in bases. but with any exertion pt becomes very wheezy and complains of sob. wheezes are upper airway. getting nebs with rt. whcih do not seem to effect the wheezing. sats also drop with exertion then equillabrate with rest.\npt coughing up thick green creamy sputum. spec sent to lab.\npt has low grade temp 100.4 to 99.9. wbc elevated this am 2 blood cultures and a urine culture sent.\npt taking po's well. passing gas but no bm. abd softly distended.\nlasix gtt started at 9pm making 110 to120ccs per hr.\nheparin gtt started at 10pm at 3am ptt 80.8 checked with cardiovascular team. with in their therapuetic limits running at 1750units pr hr.\ngiven 9 units of reg insulin at 10pm.\ncv bp stable in nsr night with occasional apcs.\nat 630 pt went into rapid af. 5 lopressor given then an amiodarone bolus pt converted to nsr. he was hemodynamically stable through out.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-10-05 00:00:00.000",
"description": "Report",
"row_id": 1577986,
"text": "Patient given 2.5mg albuterol and .5mg atrovent via hhn at 1550.\ntolerated neb well, hr. 100-110 and stable\nlung are , fine rales in the bases, no wheezing at this time and no change in aeration after neb.\nwill cont. to follow on a q4prn bases.\n At 1645 patient became short of breath moving from chair to bed. Another 2.5mg albuterol was given.\nLungs were still decreased , had some upper airway wheezes. No change after neb.\nQuestion need for benefit of neb at this time\nwill cont. to follow on a prn bases.\n\n"
},
{
"category": "ECG",
"chartdate": "2128-09-29 00:00:00.000",
"description": "Report",
"row_id": 171485,
"text": "Sinus rhythm\nIntraventricular conduction defect, right bundle branch block type\nConsider inferior infarct - age undetermined\nSince previous tracing, QRS wider, intraventricular conduction delay pttern\nchanged\n\n"
},
{
"category": "ECG",
"chartdate": "2128-09-28 00:00:00.000",
"description": "Report",
"row_id": 171715,
"text": "Sinus bradycardia\nIntraventricular conduction defect\nPoor R wave progression\nConsider left atrial abnormality\nST-T wave abnormalities\n\n"
},
{
"category": "ECG",
"chartdate": "2128-09-25 00:00:00.000",
"description": "Report",
"row_id": 171716,
"text": "Sinus bradycardia\nIntraventricular conduction defect\nNondiagnostic lateral T wave changes may be due to myocardial ischemia\nProbable inferior myocardial infarction\nSince previous tracing, atrial ectopy not noted\n\n"
},
{
"category": "ECG",
"chartdate": "2128-09-22 00:00:00.000",
"description": "Report",
"row_id": 171717,
"text": "Sinus rhythm\nPossible inferior myocardial infarct - premature atrial contractions\nLong QTc interval\nLateral ST-T changes may be due to myocardial ischemia\nSince previous tracing ventricular premature complex is not present. Lateral T\nwave changes more pronounced\n\n"
},
{
"category": "ECG",
"chartdate": "2128-09-20 00:00:00.000",
"description": "Report",
"row_id": 171718,
"text": "Sinus arrhythmia\n- premature ventricular contractions\nLead(s) unsuitable for analysis:\nNondiagnostic T wave changes\nIntraventricular conduction delay\nNo previous tracing for comparison\n\n"
}
] |
15,951 | 108,970 | Infant has remained in room air throughout this hospitalization with oxygen saturations greater than 95 percent. Infant has not had any apnea or bradycardia this hospitalization. | Stable temp in isolette. P; cont currentfeeding plan.#2.Remains in R air, BBS clear, equal, mild subcostalretracions present,no spells thus far this shift. A. Toleratingfeeds. Alert,active with care, temp 97.7 in off isolette undersingle light, isolette turned on low air mode, nested insheepskin, Mae. Abd benign. Mild SC retractions notedduring cares. BP 67/31 (44).Wt 2110 (+25) on TFI 120 cc/kg/day BM/SC20, tolerating well. P; cont bili lights, bili onTuesday am. Bili today 10.1/ 0.3.Infant remains under single phototherapy with eye shields inplace. RESP RATE 34-48WITH MILD SC RETRACTIONS. RES: Infant remains in RA. NESTED W/BOUNDARIES.FONTANEL SOFT AND FLAT; SUTURES SMOOTHA:AGAP:CONTINUE TO MONITOR AND SUPPORT#4PARENTINGO:NO CONTACTA:UNABLE TO ASSESSP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE#6JAUNDICEO:UNDER SINGLE PHOTOTHERAPY WITH BILIMASK IN PLACE. ADDENDUM TO ABOVENNP NOTIFIED OF THIS AM BILI 10.1/0.3--NO NEW ORDERS P. Continue with current plan. NPN#1 S. O. Neonatology - NNP PRogress NoteInfant is active with good tone. Infant remains under single phototherapy with maskon. NO SPELLSA:STABLEP:CONTINUE TO MONITOR RESP STATUS#1F/E/NO:TF AT 100CC/KG SCF 20 36CC Q4HR PO/PG. BILI THIS AM 10.1/0.3A:HYPERBILIP:CONTINUE PHOTOTHERAPY, RECHECK AS ORDERED G&D: Infant is nested in an air isolette with stabletemperatures. Updated at bedside by this RN. A; P;cont update and teaching.#6.Mildly jaundiced, bili 10.2/0.3, placed under singlelights.A; Mildly jaundiced. NPN 0700-1. A; AGA P; cont dev support.#4. P. Monitorand document.#4 S. O. BS CLEAR. BP 63/36 (44).Wt 2085 (-5) on TFI 100 cc/kg/day BM20, tolerating well. The remainder of feed was givenng. She is tolerating po/pg feeds. 0200 feed given ng. ABDOMEN SOFT, FULL WITHGOOD BS. LS are clear andequal. Alternating oral and gavage. Active bowel sounds. abd soft, active bowel sounds, no loops, voiding and stooling. Plan: Continue to monitor respiratorystatus.3. R.R. She is pink, well perfused, no murmur auscultted. Plan:Continue to monitor G&D.4. DS 71. AFOF. BOTTLED 33CC X1TONIGHT; REMAINDER OF FEEDS GAVAGE. Voiding adn stooling. Mom to be discharged onTuesday. A. OCCASSIONALLYWAKING/FUSSY BUT CALMS WITH PACIFIER. MAE. Voiding qs and stooledx1, guaic negative. continues to require ng feeds. Breath sounds clear and equal. Breath sounds clear and equal. Neonatal NP-ExamSee Dr. note for details and plan of care as discussed in rounds this am.AFOF, sutures overriding. Familymeeting held. Bili today 8.4. Premature infant. He has good coordination with bottling.Abd is soft and round, no loops,+BS. Abd benign, no HSM. I have placed list of Early Intervention Programs and VNA's for d'c plans. Alert andactive during cares. Please refer to neonatology attending note for detailed plan. A.Hyperbilirubinemia. 30's to 40's.No desaturations noted. SKINSCHLERA JAUNDICED. Color jaundiced.Infant voiding and stooling. PAR: Mom up today. A; nospells.P; cont to monitor for spells.#3. Will cont to follow. Plan: Continue to keep Mom updated.6. FEN: TF currently at 120cc/kg/d of SC20/BM20. WT DOWN 5 GMA:TOLERATING FEEDS WELLP:CONTINUE TO MONITOR TOLERANCE TO FEEDS, FOLLOW WT AND DS,ENCOURAGE PO'S AS ABLE#3G&DO:IN AIR CONTROL ISOLETTE WITH STABLE TEMPERATURE.ACTIVE/MAE WITH CARES; SLEEPING WELL BETWEEN. 1900-0700 NPN#2 RESPIRATORYO:REMAINS IN RA WITH SATS 98-100%. Plan: Continue tomonitor for evidence of hyperbilirubinemia. RESP RATE 36-66WOITH MILD SC RETRACTIONS. Lytes 145/4.7/110,Attending aware. IV dereased.Dstick stable. #1RespLungs clear with mild retractions. Remains in RA with IC/SC retractions. NPNOteAddendum: Jaundice: mildly jaundiced, BILI 7.2/0.3 at 24hrs, Attending aware, A;bili in am. TB 10.1 (9.8/0.3) on . SWADDLED ANDNESTED. A; feeds tolerated.P; cont Tf=80cc/kg/day,advance feeds at 20cc/kg/day at 10+10 as advised by Dr..#2.Remains in R air, BBS clear, equal, mild subcostalretractions present, no spells thus far this shift.A;Stable. BP stable with means 36-44. Abd benign. No spits.DEVELOP: In isolette air mode. 0-4.8CCNONBILIOUS, PARTIALLY DIGESTED ASPIRATE. Abd soft, pink, BS+, girth stable, no loops. Temps 97.9-98.8. VOIDING WELL; LARGEMEC X1. NO SPELLS WITH SLEEP OR WITH POATTEMPTS.A:STABLEP:CONTINUE TO MONITOR#3G&DO:IN OFF ISOLETTE IWTH STABLE TEMPERATURE. No episodes apnea/brady/desat.CARDIAC: HR 130-190s, BP 67/31(44). Apgar scores 6 (1 min) 9 (5min). PNS O-/mom treated with Rhogam/Hep B neg/RPR NR/Rubella I. alert,active with care, blood culture negative thus far.A; asymptomatic. NOT YET WAKING TO EAT.A:AGAP;CONTINUE TO SUPPORT AND MONITOR#4PARENTINGNO CONTACT OVERNIGHT THUS FARA:UNABLE TO ASSESSP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE Tol feed so farP. ABDOMEN SOFT, SLROUND WITH GOOD BS. NPNOte#1. D10 infusing via peripheral IV at60cc/kg. Attending NOteDay of life 2 CGA 35in room air RR 30-60no spellsHR 110-160's no murmur mild jaundicebili 10.2/0.3weight 2090 down 70 grams on 80 cc/kg/day of SSC 20 cal/oz po/pgmax asp 4.8 cc spit oncevoiding and stoolingtaking minimal amounts poblood culture no growth to dateImp-making progresswill advance to 100 cc/kg/day total fluidswill begin single phototherapy BS CLEAR. No murmur, pink and well perfused.BILI: On phototherapy . TF=min 80cc/kg/day, offered po SC20 at 10am,po fed10cc,rest pg fed, po feeds at 55cc/kg/day,no spits, IVF D10infusing at PIV at 25cc/kg/day, BS+, no loops, voided, nostool thus far this shift.D'stix 73. Cont to monitor weight as well as feed tolerance#3DevWarmer off at 2200. BABY BOTTLED5-25CC OVERNIGHT WITH REMAINDER GAVAGE. cont to moniotr.#2FENBaby had been NPO. CBC and bl cx sent; no antibx started. BP 51/31 (41).WBC 9.1 (18 poly 2 bands) Not on antibiotics. Neonatal NP-Examsee Dr. note for details and plan of care as discussed in rounds this am.AFOF, sutures overriding. AppropriateP. MD note for maternal history. Initial DS at 46; increasing to 117 before making change. Culture negative.Hct 55Wt 2160 (-60) on TFI 60 cc/kg/day. 1900-0700 NPN#1F/E/NO:ADVANCED TO 75CC/KG SCF/BM 27CC Q4HR PO/PG. Cont to monitor#4Parentmom called for an update. P; cont to monitor.#3. At 0600, baby 20cc SC20. satin high 90's to 100. ACTIVE/MAEWITH CARES; SLEEPING WELL BETWEEN. FONTANEL SOFT AND FLAT; SUTURES SMOOTH. VSS upon admission. LS tight initially now with improved aeration after crying some. WT DOWN 70 GMA:TOLERATING FEEDS WELL; LEARNING TO POP:CONTINUE TO MONITOR TOLERANCE TO FEEDS, ENCOURAGE PO'S#2RESPIRATORYO:REMIANS IN RA WITH SATS >97%. 6 JaundiceREVISIONS TO PATHWAY: 6 Jaundice; added Start date: O2 sats high 90's. Active bowel sounds. Mom admitted at 25 2/7 weeks. RR 40's-70's. Baby cares given. trial infant to bottle formula; ? Please see Physician Note for complete maternal history.RESP: On RA, regular respirations 30-50s, O2 sats 97-100. | 22 | [
{
"category": "Nursing/other",
"chartdate": "2190-11-01 00:00:00.000",
"description": "Report",
"row_id": 1903390,
"text": "Social Work:\n\nPlease see sw note in sibling's chart.\n\nBriefly, mom declines sw support while babies are in NICU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-11-01 00:00:00.000",
"description": "Report",
"row_id": 1903391,
"text": "NPN 0700-\n\n\n1. FEN: TF currently at 120cc/kg/d of SC20/BM20. Infant\nbottled 10cc at 1000, gavaged the remainder. Then he bottled\n40cc/44cc at 1400. He has good coordination with bottling.\nAbd is soft and round, no loops,+BS. Voiding qs and stooled\nx1, guaic negative. No spits, no aspirates. Plan: Continue\nto monitor FEN.\n\n2. RES: Infant remains in RA. RR 30-60's. LS are clear and\nequal. O2 saturations 95-99%. Mild SC retractions noted\nduring cares. No episodes of apnea or bradycardia thus far\nduting this shift. Plan: Continue to monitor respiratory\nstatus.\n\n3. G&D: Infant is nested in an air isolette with stable\ntemperatures. Fontanels are soft and flat. MAE. Alert and\nactive during cares. Likes to suck on pacifier. Plan:\nContinue to monitor G&D.\n\n4. PAR: Mom up today. Updated at bedside by this RN. Family\nmeeting held. Mom interested in transfer to when\nbeds are available. Plan: Continue to keep Mom updated.\n\n6. BILI: Infant is slightly jaundiced. Bili today 10.1/ 0.3.\nInfant remains under single phototherapy with eye shields in\nplace. Infant given lab holiday tonight. Plan: Continue to\nmonitor for evidence of hyperbilirubinemia.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-11-02 00:00:00.000",
"description": "Report",
"row_id": 1903392,
"text": "NPN\n\n#1 S. O. Weight up 25 grams. Voiding and passing heme\nnegative green stools. Infant remains on 120cc/kg/day of\nbreast milk /special care 20 calorie. Infant took 5cc po\nfrom mom at the 2200 care. The remainder of feed was given\nng. 0200 feed given ng. No spits. A. Tolerating\nfeeds. continues to require ng feeds. P. Assess for\nbreast/po feeding.\n\n#2 S. O. Infant breathing in room air. R.R. 30's to 40's.\nNo desaturations noted. A. Premature infant. P. Monitor\nand document.\n\n#4 S. O. Mom in with friends. excited about holding\ntwins together at the same time.A. Mom to be discharged on\nTuesday. P. Check with regarding bed space .\n\n#6 S. O. Infant remains under single phototherapy with mask\non. Color jaundiced.Infant voiding and stooling. A.\nHyperbilirubinemia. P. Continue with current plan.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-11-02 00:00:00.000",
"description": "Report",
"row_id": 1903393,
"text": "Neonatology Attending\nDOL 4\n\nIn room air with no distress and no cardiorespiratory events.\n\nNo murmur. BP 67/31 (44).\n\nWt 2110 (+25) on TFI 120 cc/kg/day BM/SC20, tolerating well. Alternating oral and gavage. Abd benign. Voiding and stooling (guiac negative)\n\nUnder phototherapy with no new bilirubin today.\n\nTemp stable in air isolette.\n\nA&P\n34-5/7 week GA infant\n-Discontinue phototherapy today and repeat bilirubin in 24 hours\n-Transfer to MWMC today (d/w Dr. \n"
},
{
"category": "Nursing/other",
"chartdate": "2190-10-31 00:00:00.000",
"description": "Report",
"row_id": 1903383,
"text": "NPNOte\n\n\n#1.TF=80cc/kg/day,on Spc 20cal, po/pg fed tolerated, feeds\nincreased to 100cc/kg/day at 10am,BS+, no loops, voided,\nstooled, small mec.A; feeds tolerated. P; cont current\nfeeding plan.\n\n#2.Remains in R air, BBS clear, equal, mild subcostal\nretracions present,no spells thus far this shift. A; no\nspells.P; cont to monitor for spells.\n\n#3. Alert,active with care, temp 97.7 in off isolette under\nsingle light, isolette turned on low air mode, nested in\nsheepskin, Mae. A; AGA P; cont dev support.\n\n#4. Mom visited with maternal grand parents,asking app\nquestions.mom attempted to po feed the baby. A; P;\ncont update and teaching.\n\n#6.Mildly jaundiced, bili 10.2/0.3, placed under single\nlights.A; Mildly jaundiced. P; cont bili lights, bili on\nTuesday am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-10-31 00:00:00.000",
"description": "Report",
"row_id": 1903384,
"text": "Neonatology - NNP PRogress Note\n\nInfant is active with good tone. AFOF. She is pink, well perfused, no murmur auscultted. She is comfortable in room air. Breath sounds clear and equal. She is tolerating po/pg feeds. abd soft, active bowel sounds, no loops, voiding and stooling. Bili today 8.4. Stable temp in isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-11-01 00:00:00.000",
"description": "Report",
"row_id": 1903385,
"text": "1900-0700 NPN\n\n\n#2 RESPIRATORY\nO:REMAINS IN RA WITH SATS 98-100%. BS CLEAR. RESP RATE 34-48\nWITH MILD SC RETRACTIONS. NO SPELLS\nA:STABLE\nP:CONTINUE TO MONITOR RESP STATUS\n\n#1F/E/N\nO:TF AT 100CC/KG SCF 20 36CC Q4HR PO/PG. BOTTLED 33CC X1\nTONIGHT; REMAINDER OF FEEDS GAVAGE. ABDOMEN SOFT, FULL WITH\nGOOD BS. NO SPITS AND <1CC ASPIRATES. DS 71. VOIDING WELL;\nNO STOOL. WT DOWN 5 GM\nA:TOLERATING FEEDS WELL\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS, FOLLOW WT AND DS,\nENCOURAGE PO'S AS ABLE\n\n#3G&D\nO:IN AIR CONTROL ISOLETTE WITH STABLE TEMPERATURE.\nACTIVE/MAE WITH CARES; SLEEPING WELL BETWEEN. OCCASSIONALLY\nWAKING/FUSSY BUT CALMS WITH PACIFIER. NESTED W/BOUNDARIES.\nFONTANEL SOFT AND FLAT; SUTURES SMOOTH\nA:AGA\nP:CONTINUE TO MONITOR AND SUPPORT\n\n#4PARENTING\nO:NO CONTACT\nA:UNABLE TO ASSESS\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n#6JAUNDICE\nO:UNDER SINGLE PHOTOTHERAPY WITH BILIMASK IN PLACE. SKIN\nSCHLERA JAUNDICED. BILI THIS AM 10.1/0.3\nA:HYPERBILI\nP:CONTINUE PHOTOTHERAPY, RECHECK AS ORDERED\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-11-01 00:00:00.000",
"description": "Report",
"row_id": 1903386,
"text": "ADDENDUM TO ABOVE\nNNP NOTIFIED OF THIS AM BILI 10.1/0.3--NO NEW ORDERS\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-11-01 00:00:00.000",
"description": "Report",
"row_id": 1903387,
"text": "Neonatology Attending\nDOL 3\n\nIn room air with no cardiorespiratory events and no distress.\n\nNo murmur. BP 63/36 (44).\n\nWt 2085 (-5) on TFI 100 cc/kg/day BM20, tolerating well. Bottling with each feed, for partial up to full volumes. Voiding adn stooling. D-stick 71.\n\nBilirubin 10.1/0.3; under single phototherapy\n\nA&P\n34-5/7 week GA infant with feeding immaturity\n-Increase to TFI 120 cc/kg/day\n-No other changes in management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-11-01 00:00:00.000",
"description": "Report",
"row_id": 1903388,
"text": "Case Management Note\nChart has been reviewed to date. I have placed list of Early Intervention Programs and VNA's for d'c plans. I will be providing clinical updates to insurance. Will cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-11-01 00:00:00.000",
"description": "Report",
"row_id": 1903389,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF, sutures overriding. Breath sounds clear and equal. Nl S1S2, no audible murmur. Pink, jaundiced. Abd benign, no HSM. Active bowel sounds. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-10-30 00:00:00.000",
"description": "Report",
"row_id": 1903377,
"text": "Neonatology Attending\nDOL 1\n\nIn room air with no distress and no cardiorespiratory events.\n\nNo murmur. BP 51/31 (41).\n\nWBC 9.1 (18 poly 2 bands) Not on antibiotics. Culture negative.\n\nHct 55\n\nWt 2160 (-60) on TFI 60 cc/kg/day. Feeds started this morning SC20 at 20 cc/kg/day. Abd benign. Voiding and stooling. D-stick 77.\n\nTemp stable in off warmer\n\nA&P\n34-5/7 week GA twin\n-COntinue to monitor for respiratory maturity\n-Advance min TFI and continue to adjust IV as ad lib feeds progress\n-Lytes and bili pending\n-Parents visiting and up to date\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-10-30 00:00:00.000",
"description": "Report",
"row_id": 1903378,
"text": "NPNOte\n\n\n#1. TF=min 80cc/kg/day, offered po SC20 at 10am,po fed\n10cc,rest pg fed, po feeds at 55cc/kg/day,no spits, IVF D10\ninfusing at PIV at 25cc/kg/day, BS+, no loops, voided, no\nstool thus far this shift.D'stix 73. Lytes 145/4.7/110,\nAttending aware. A; feeds tolerated.P; cont Tf=80cc/kg/day,\nadvance feeds at 20cc/kg/day at 10+10 as advised by Dr.\n.\n\n#2.Remains in R air, BBS clear, equal, mild subcostal\nretractions present, no spells thus far this shift.A;\nStable. P; cont to monitor.\n\n#3. alert,active with care, temp stable on a off warmer bed,\nswaddled with blanket, mae. A; AGA P; cont dev support.\n\n#4.Mom visited, held the baby for the first time.grand\nparents visited,mom is planning to breast feed.A; loving P;\ncont update and teaching.\n\n#5. alert,active with care, blood culture negative thus far.\nA; asymptomatic. P; cont to monitor for s/s of sepsis.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-10-30 00:00:00.000",
"description": "Report",
"row_id": 1903379,
"text": "NPNOte\nAddendum: Jaundice: mildly jaundiced, BILI 7.2/0.3 at 24hrs, Attending aware, A;bili in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-10-31 00:00:00.000",
"description": "Report",
"row_id": 1903380,
"text": "1900-0700 NPN\n\n\n#1F/E/N\nO:ADVANCED TO 75CC/KG SCF/BM 27CC Q4HR PO/PG. BABY BOTTLED\n5-25CC OVERNIGHT WITH REMAINDER GAVAGE. ABDOMEN SOFT, SL\nROUND WITH GOOD BS. NO SPITS AND AG 24.5CM. 0-4.8CC\nNONBILIOUS, PARTIALLY DIGESTED ASPIRATE. VOIDING WELL; LARGE\nMEC X1. WT DOWN 70 GM\nA:TOLERATING FEEDS WELL; LEARNING TO PO\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS, ENCOURAGE PO'S\n\n#2RESPIRATORY\nO:REMIANS IN RA WITH SATS >97%. BS CLEAR. RESP RATE 36-66\nWOITH MILD SC RETRACTIONS. NO SPELLS WITH SLEEP OR WITH PO\nATTEMPTS.\nA:STABLE\nP:CONTINUE TO MONITOR\n\n#3G&D\nO:IN OFF ISOLETTE IWTH STABLE TEMPERATURE. SWADDLED AND\nNESTED. FONTANEL SOFT AND FLAT; SUTURES SMOOTH. ACTIVE/MAE\nWITH CARES; SLEEPING WELL BETWEEN. NOT YET WAKING TO EAT.\nA:AGA\nP;CONTINUE TO SUPPORT AND MONITOR\n\n#4PARENTING\nNO CONTACT OVERNIGHT THUS FAR\nA:UNABLE TO ASSESS\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-10-31 00:00:00.000",
"description": "Report",
"row_id": 1903381,
"text": "Attending NOte\nDay of life 2 CGA 35\nin room air RR 30-60\nno spells\nHR 110-160's no murmur mild jaundice\nbili 10.2/0.3\nweight 2090 down 70 grams on 80 cc/kg/day of SSC 20 cal/oz po/pg\nmax asp 4.8 cc spit once\nvoiding and stooling\ntaking minimal amounts po\nblood culture no growth to date\n\nImp-making progress\nwill advance to 100 cc/kg/day total fluids\nwill begin single phototherapy\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-10-31 00:00:00.000",
"description": "Report",
"row_id": 1903382,
"text": "6 Jaundice\n\nREVISIONS TO PATHWAY:\n\n 6 Jaundice; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-11-02 00:00:00.000",
"description": "Report",
"row_id": 1903394,
"text": "Nursing Discharge Note\nBaby boy is an ex 34 week twin born to 35 y/o G1 p0-now-1 Mom via c-section. Please see Physician Note for complete maternal history.\n\nRESP: On RA, regular respirations 30-50s, O2 sats 97-100. Lungs clear and equal. No episodes apnea/brady/desat.\n\nCARDIAC: HR 130-190s, BP 67/31(44). No murmur, pink and well perfused.\n\nBILI: On phototherapy . TB 10.1 (9.8/0.3) on . Phototx dc'd this mroning at 10AM with plan to check rebound in AM .\n\nFEN: BW 2185 current 2110(+25). On TF 120cc/kg/d full enteral feeds BM/SC20 via PO/NG (pump over 40 minutes). Breastfeeding when Mom present. Abd soft, pink, BS+, girth stable, no loops. Residuals minimal. No spits.\n\nDEVELOP: In isolette air mode. Temps 97.9-98.8. Development boundaries in place. Infant awake and active with care/ AGA.\n\nPARENTS: Mom is single (donor sperm), has very good family and friend support. Mom asks good/appropriate questions and participates well with care and feeds.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-10-29 00:00:00.000",
"description": "Report",
"row_id": 1903373,
"text": "Admission Note\nBaby boy is the 2185 gram product of a 34 week gestation born to a 35 you G3P0 mom with pregnancy complicated by twin gestation an cercial shortening. Mom admitted at 25 2/7 weeks. Mom has chronic hypertension and gestational diabetes. PNS O-/mom treated with Rhogam/Hep B neg/RPR NR/Rubella I. The infant for born by C-section for twin. Apgar scores 6 (1 min) 9 (5min). He was given PPV for several seconds.\n\nExam gen looking age appropriate\nweigh 2185 (50%) HC 32 (75%) length 46 cm (50%)\nTemp 97.7 HR 140 RR 58 Bp 58/25 mean 36 sat 98% D-stick 46\nnormocephalic atruamatic ant font open flat red reflex present bilaterally\nCV regular rate and rhythm no murmur femoral pulses 2+bilaterally\nAbd-soft with active bowel sounds no masses or distention\nGU nomal premature male testes in inguinal canal\nAnus patent\nSpine midline no sacral dimple\nHips stable\nClavicle intact\nExt warm well perfused brisk cap refill\nNeuro good tone minimal suck normal gag\n\nImp-overall doing well\nCV stable\nResp stable in room air\nFEN will begin IVF because of d-stick will consider feeds\nGI will check bili at 24 hours of life\nID will check CBC and blood culture will treat if CBC abnormal\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-10-29 00:00:00.000",
"description": "Report",
"row_id": 1903374,
"text": "NICU admit note:\n\nNewborn male twin #2 born via c/s at 34 5/7 weeks due to PROM with apgars of 6 and 9. MD note for maternal history. Infant placed on radiant wamer in servo mode. VSS upon admission. BP stable with means 36-44. Coloring initially acrocyanotic but transitioning to pink throughout. No murmur heard. Remains in RA with IC/SC retractions. LS tight initially now with improved aeration after crying some. O2 sats high 90's. RR 40's-70's. TF initially started at 80cc/kg, weaned down to 60cc/kg based on increasing DS. Initial DS at 46; increasing to 117 before making change. CBC and bl cx sent; no antibx started. Temp stable and infant active and alert with cares; opening eyes and looking around. Baby cares given. Mom in to visit but very sick; plans to BF when able. trial infant to bottle formula; ? need for NG tube later tonight if tires when bottling. Cont to monitor infant's resp status and follow DS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-10-30 00:00:00.000",
"description": "Report",
"row_id": 1903375,
"text": "Neonatal NP-Exam\n\nsee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF, sutures overriding. Breath sounds clear and equal. Nl S1S2, no audible murmur. Pink, ruddy and well perfused. Abd benign, no HSM. Active bowel sounds. Nl external male genitalia. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-10-30 00:00:00.000",
"description": "Report",
"row_id": 1903376,
"text": "#1Resp\nLungs clear with mild retractions. appears comfortable. sat\nin high 90's to 100. No spells\nA. Tol RA\nP. cont to moniotr.\n#2FEN\nBaby had been NPO. D10 infusing via peripheral IV at\n60cc/kg. At 0600, baby 20cc SC20. IV dereased.\nDstick stable. Void, one small stool.\nA. Tol feed so far\nP. Cont to monitor weight as well as feed tolerance\n#3Dev\nWarmer off at 2200. Temp stable on an off warmer with hat\nand blanket. Awake and alert with cares\nA. Appropriate\nP. Cont to monitor\n#4Parent\nmom called for an update. She would like to breast feed\ntoday.\nSepsis\nNo antibiotics. BC pending.\n\n\n"
}
] |
23,876 | 139,390 | 49 F with CAD s/p CABG and CHF (EF 35-40%) transferred from OSH with NSTEMI and CHF after a long hospital course. . # CAD: The pt's cardiac biomarkers were followed and they trended down. She underwent cardiac catheterization on the second hospital day with balloon angioplasty to a stenosis in the distal LAD and placement of a DES in the SVG-PDA graft. The patient required propofol sedation during the procedure and was monitored afterwards overnight in the CCU. She was continued on her home ASA, Plavix, beta blocker, pravastatin and ACEi. The patient arrived from the OSH on Coreg; this was continued instead of metoprolol . # Pump. The patient was previously known to have a depressed LVEF; repeat echo during this admission showed an EF of approximately 25%. She was felt to be mildly volume up and thus was gently diuresed. She was continued on her home digoxin (though this was decreased to every other day dosing), beta blocker and ACEi. She was started on spironolactone. Based on her EF assessment, the patient is likely a candidate for ICD implant in the future. . # PVD: The patient was continued ASA and Plavix. She was seen by vascular surgery who recommended avoiding groin access during cath. She will follow up in vascular clinic two weeks after discharge. . # ARF: The patient's creatinine reportedly peaked at 2.9 at the OSH. This renal failure appeared to have fully resolved by the time she was admitted to . Two days after cath, she again developed ARF that was felt to be contrast-associated. Nephrotoxic medications were held and this slowly improved. Peak Cr at was 2.2. . # PNA and bacteremia: The patient completed courses of vanc and ceftriaxone at the OSH. Repeat cultures at were negative and the patient did not have evidence of recurrent infection. Radiology advised a repeat CXR to evaluate for resolution of PNA as an outpt. . #. SOB: The pt complained of shortness of breath throughout her hospital stay. This was felt to be primarily due to volume overload and improved significantly with diuresis. Nevertheless, the pt did have some wheezes on exam and it was thought that she might have some airway reactivity. She noted good effect with fluticasone while in-house and was continued on this medication at the time of discharge. . # UTI: The patient had a positive UA at the time of admission but no urinary sxs. Her cultures growing only yeast. She did report some itching and erythema in her groin folds bilaterally. She was emperically treated with a three day course of Cipro as well as topical clotrimazol to the groin. . # Diarrhea: The patient was treated with flagyl at OSH even though C. Diff studies were negative. Her C. Diff at the was again negative x 2 and the patient did not complain of diarrhea. . # Anemia: The patient was started on iron at the OSH based on iron studies performed there. She also receieved one unit pRBCs at the OSH. Iron supplementation was continued. . # DM: The patient was continued on Lantus and a sliding scale. An A1c was checked and found to be elevated. The service was consulted and assisted with her managment, though no major changes were recommended for her regimen. | Moderate to severe(3+) MR. Uninterpretable LV inflow pattern due to MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. False LV tendon (normal variant). No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annularcalcification. There is moderate pulmonary artery systolichypertension. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is dilated. The aortic valve leaflets (3) are mildly thickened butaortic stenosis is not present. Normal ascending aortadiameter. Bed alarm on/ side rails up.CV: sr some pvc's, sbp 130's, dopplerable pulses, absent pulse to right tibial, vascular team aware. Sinus tachycardiaConsider left atrial abnormalityLow limb lead QRS voltages - is nonspecificAnterior myocardial infarct, age indeterminateDiffuse ST-T wave abnormalities - cannot exclude in part ischemia - clinicalcorrelation is suggestedSince previous tracing of , sinus tachycardia present and further ST-Twave changes seen Theleft ventricular cavity is mildly dilated. There is no pericardial effusion.Compared with the prior study (images reviewed) of , left ventricularsystolic function is more depressed. Mildly dilated LV cavity. Mild thickening of mitral valve chordae. Moderate to severe (3+) mitralregurgitation is seen. Coronary artery disease.Height: (in) 67Weight (lb): 128BSA (m2): 1.67 m2BP (mm Hg): 130/70HR (bpm): 82Status: InpatientDate/Time: at 11:47Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. left brachial sheath d/ by md . Severeglobal LV hypokinesis. [Intrinsic left ventricular systolicfunction is likely more depressed given the severity of valvularregurgitation.] No 2D or Doppler evidence of distal arch coarctation.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild [1+] TR. [Intrinsic LVsystolic function likely depressed given the severity of valvularregurgitation.] No resting LVOTgradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. 0.5mg iv push ativan given md. c-diff +, @ osh was negative, 2 negative samples her at , c-diff sent./ pending.Endo: humalog sliding scale/ lantus given at hsSkin: see flow sheetSocial: no calls this shiftPlan: Transfer to 3 when bed available, bs control, wound care, safety precautions, pulmoanry toilet. Possible prior anterior myocardial infarction. Probable sinus rhythm. 7p-7aNeuro: pt arrived from cath lab, arousable but sleepy. Right ventricular chamber size and free wallmotion are normal. Left ventricular wall thicknesses are normal. Tissue Doppler imaging suggests an increased left ventricularfilling pressure (PCWP>18mmHg). Diffusenon-specific ST-T wave changes. pt had 4 loose bm's, very mucous like, ? The mitralvalve leaflets are mildly thickened. Compared to the previous tracingof there is no significant change other than the tracing quality. palpable radial pulses. no hematoma bleeding controlled dsd intact. Significant baseline artifact makes interpretationdifficult. PATIENT/TEST INFORMATION:Indication: Congestive heart failure. The degree of mitral regurgitation andpulmonary artery hypertension have increased. sats remain 96%.GI/GU: foley to gravity draining adequate amouts of urine. There is severe global leftventricular hypokinesis (LVEF = 25 %). mae's follows commands, alert, confused. Pt c/o not being able to breathe when she lies flat, team aware. arm board on / kept straight until 0730.Resp: ls clear with crackles at bases, nebs given 96% on 3lnc. No AS. TDI E/e' >15, suggesting PCWP>18mmHg. aware of act before pulling. No aortic regurgitation is seen. dsg changed twice due to serosang drainage, pressure held for 2 minutes/ md called and made aware. | 4 | [
{
"category": "Nursing/other",
"chartdate": "2181-01-19 00:00:00.000",
"description": "Report",
"row_id": 1574441,
"text": "7p-7a\nNeuro: pt arrived from cath lab, arousable but sleepy. mae's follows commands, alert, confused. Pt became more oriented thoughout night, but would awake from sleep yelling, wanting to get out of bed, c/o being claustrophobic/ feeling anxious. 0.5mg iv push ativan given md. Bed alarm on/ side rails up.\n\nCV: sr some pvc's, sbp 130's, dopplerable pulses, absent pulse to right tibial, vascular team aware. left brachial sheath d/ by md . palpable radial pulses. aware of act before pulling. dsg changed twice due to serosang drainage, pressure held for 2 minutes/ md called and made aware. no hematoma bleeding controlled dsd intact. arm board on / kept straight until 0730.\n\nResp: ls clear with crackles at bases, nebs given 96% on 3lnc. Pt c/o not being able to breathe when she lies flat, team aware. sats remain 96%.\n\nGI/GU: foley to gravity draining adequate amouts of urine. pt had 4 loose bm's, very mucous like, ? c-diff +, @ osh was negative, 2 negative samples her at , c-diff sent./ pending.\n\nEndo: humalog sliding scale/ lantus given at hs\n\nSkin: see flow sheet\n\nSocial: no calls this shift\n\nPlan: Transfer to 3 when bed available, bs control, wound care, safety precautions, pulmoanry toilet.\n"
},
{
"category": "Echo",
"chartdate": "2181-01-17 00:00:00.000",
"description": "Report",
"row_id": 64575,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease.\nHeight: (in) 67\nWeight (lb): 128\nBSA (m2): 1.67 m2\nBP (mm Hg): 130/70\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 11:47\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Severe\nglobal LV hypokinesis. False LV tendon (normal variant). [Intrinsic LV\nsystolic function likely depressed given the severity of valvular\nregurgitation.] TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Moderate to severe\n(3+) MR. Uninterpretable LV inflow pattern due to MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. Left ventricular wall thicknesses are normal. The\nleft ventricular cavity is mildly dilated. There is severe global left\nventricular hypokinesis (LVEF = 25 %). [Intrinsic left ventricular systolic\nfunction is likely more depressed given the severity of valvular\nregurgitation.] Tissue Doppler imaging suggests an increased left ventricular\nfilling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Moderate to severe (3+) mitral\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , left ventricular\nsystolic function is more depressed. The degree of mitral regurgitation and\npulmonary artery hypertension have increased.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2181-01-18 00:00:00.000",
"description": "Report",
"row_id": 132072,
"text": "Probable sinus rhythm. Significant baseline artifact makes interpretation\ndifficult. Possible prior anterior myocardial infarction. Diffuse\nnon-specific ST-T wave changes. Compared to the previous tracing\nof there is no significant change other than the tracing quality.\n\n"
},
{
"category": "ECG",
"chartdate": "2181-01-16 00:00:00.000",
"description": "Report",
"row_id": 132073,
"text": "Sinus tachycardia\nConsider left atrial abnormality\nLow limb lead QRS voltages - is nonspecific\nAnterior myocardial infarct, age indeterminate\nDiffuse ST-T wave abnormalities - cannot exclude in part ischemia - clinical\ncorrelation is suggested\nSince previous tracing of , sinus tachycardia present and further ST-T\nwave changes seen\n\n"
}
] |
3,855 | 128,805 | The patient was admitted and underwent an ex-lap with extensive lysis of adhesions, ileocolonic resection with ileocolonic anastomosis, Hartmann procedure with end colostomy, takedown splenic flexure, and component separation technique for incisional hernia repair which she tolerated well. She was started empirically on Vancomycin, ceftriaxone, and flagyl. On post-op day 3, the patient had an acute onset of hypoxia (SaO2 to 70%) and tachycardia. The patient complained of shortness of breath without chest pain. On exam, the patient was tachypneic, anxious appearing, and had coarse breath sounds bilaterally. ECG revealed ST depression in leads V2 and V3. The patient was given aspirin, nitro, and lopressor which resulted in slowing of her heart rate to 100s, her BP was normotensive, and SaO2 was in the 80s. On transfer to the ICU, ABG revealed pO2 of 47. The patient was intubated with improvement of her SaO2. An NG tube was placed. Cardiac enzymes were negative. A chest CT showed no evidence of pulmonary embolus. However, there were massive bilateral pneumonic airspace consolidations, worst in both upper lobes, but with additional areas of consolidation in the aerated portions of both lower lobes and bibasilar atelectasis. This suggested that an aspiration event precipitated the patient's hypoxic episode. Bronchoscopy revealed thick, yellow secretions in the right upper and left lower lobes. Cultures from the bronchoalveolar lavage did not have growth. Follow up chest x-ray showed improvement in the bilateral pulmonary infiltrates with almost complete resolution of the right upper and left upper lobes with still present consolidation and pleural effusion in the left lower lobe. This rapid improvement of massive consolidation suggested aspiration rather than infectious cause of her hypoxia. In the ICU, the patient was started on a phenylephrine drip for hypotension. On post-op day 5, the patient was able to be weaned from the ventilator and she was extubated. Her antibiotics were discontinued as there were no growth from her cultures. The patient's bowel function eventually returned and her diet was gradually advanced. The patient was tolerating a regular diet on discharge. On post-op day 6, the patient was transfused a unit of packed red blood cells for a Hct of 21.4. The patient was remained stable clinically and was transferred out of the unit on post-op day 7. Physical therapy was consulted and cleared the patient for home discharge. The patient was discharged in stable condition with pain well-controlled and able to ambulate without assistance. | K repleted.Resp: LS clear/diminished. EKG done for brief ST wave inversion that subsequently resolved. Dilaudid prn pain with mod. Dr. aware and ok to give Vanco before trough available. Enzymes cycled and negative.resp: ls clear/diminished, suctioned for scant amts. Respiratory Care:Pt. Sputum cx sent. Abd incision, sutures intact erythematous, area outlined. D/C CVL per primary team. Verified by CXR. JP 1 draining serous fluid. A-line monitoring dc'd, CVP 8-10. s/p 1U PRBCs for Hct 21.4, post-transfusion HCT 28.0. ABDOMINAL INCISION SLIGHTLY ECCHYMOTIC, STAPLES IN PLACE. Quad lumen L subclavian placed. Fent&Midaz titrated to appropiate sedation. BS with improved aeration t/o. Rate WNL. Afebrile.CV: NSR. Titrate Fent and Midaz to adequate sedation. Bronched this am. updated by Dr. and Dr. . 1.5liter LR bolus for hypotension. NPNplease see carevue for further detailsN: Propofol gtt changed to Fent and Midaz gtt. to cpap. A-line dampening. pt tol well. Coronal and sagittal reformatted images were made. IV ABX, FOLLOW TEMPS & WBC COUNT. Pt c/o abd. Colostomy outputs liquid in moderate amounts, frequent flatus. is tender, +bs, abd. JPS X 2 WITH SEROSANG DRAINAGE.PLAN: RSBI & SPONTANEOUS BREATHING TRIAL THIS AM, POSSIBLE EXTUBATION. REASON FOR THIS EXAMINATION: r/o PE No contraindications for IV contrast FINAL REPORT INDICATIONS: Worsening tachypnea and hypoxia. IMPRESSION: AP chest compared to . Mucomyst and bicarb started to renal protection after CTA contrast.ENDO: SSRI.ID: Pan cultured. incision noted for erythema - not extending beyond the marked lines. Sinus rhythm. Sinus rhythm. ls clear with dim. Cardiac enzymes sent- negative. updateplease see Carevue for specificsNeuro: A&O x 3. PERRL. 2BALs obtained and sent during bronch. Neo titrated off to keep map >60, received lr bolus x's 1 for hypotension with improvement. Dr. aware. Bibasilar atelectasis. AFEBRILE. VSS, afebrile. Fentynal/midaz. NGT TO SUCTION, MINIMAL OUTPUT. See CareVue for details. Modest non-specific inferior ST-T wave changes. BS present. Monitor ABGS and hemodynamics. Pt tachypnic to 32, HR 130s, BP120/80. Resp CarePt intubated this am for resp distress and hypoxia with 7.5 ETT 214 @ lip. The ascending and descending aorta are normal in caliber. Nsg.progress notes:See flow sheet for specific:Neuro: on fentanyl & versed gtt,titrated to keep the pt sedated,now fentanyl 100mcg/hr & versed 2mg/hr with prn dilaudid with good effect,PERL,follows commands.MAE.CV: NSR,HR 83-110,no ectopy noted,SBP 90-113,neo still at 0.5mcg/kg/mt.went up with neo to 1mcg for 2hrs as BP low but back to 0.5 again by 5am.T max 99.8,IVF LR 100ml/hr,K+ 2.9 repleted with 80mmol kcl,rptd K+ 3.7,po4 2.5 K phos to replete,Fluid bal of +2L by MN,CVP 9cm,HCT 24.7 team aware.Resp: remains on vent,vent changes per ABG @ AM Fio2 40% RR-18,peep 8cm,LS clear & diminished at bases,SXN thick white secretions,O2 sat wnl,ABG acceptable.GI: NPO,abd soft.+ BS,colostomy pink,draining greenish liq stool sm amt only,abd dressing changed wound clean no drains,with erythema around same like day,no cahnge,SICU md aware.JP's draining ss drain.GU: foley cath patent with yellow clear urine,adq amt.ID : T max 99.8,on anbx.endo: BS q6h on ssri,doesn't need any coverage.Act: bed fast,turned & position changed,skin ,Plan: cont current plan,titrate Neo to keep MAP >60,wean off fentanyl if tolerates,PS trial,pulm hygiene,wean off vent as tolerates.support to pt & family COLOSTOMY WITH DUSKY AREAS (NOTED PREVIOUSLY). Denies SOB.GI: Abd soft. ABGS monitored. Bilateral, predominantly right upper lobe and diffuse left-sided pulmonary consolidation as previously demonstrated on prior study of same date. CVP 10-15.R: Chest CTA this a.m to r/o PE. Left subclavian CV line has tip located in mid to distal SVC. JP 2 draining serosang fluid. Pt. The left subclavian line tip is in mid SVC. NODDING "YES" TO PAIN, RELIEVED WITH DILAUDID. There is bilateral lower lobe atelectasis. PATIENT TOLERATING CPAP + 7 PS & 5 PEEP, ABG WITHIN NORMAL RANGE. There is a small left pleural effusion which appears to layer freely posteriorly. CXR done x 2. A/C currently at PEEP 10, Fi02 50 sats 96-100. SICU team notified and primary team aware. HISTORY: Acute desaturation. MAE.C: NS with rare PVCs. IMPRESSION: 1. ET tube tip is at the thoracic inlet. CONTINUE WITH CURRENT NURSING CARE & TREATMENT. Modest non-specific ST-T wave changes. Neo titrated to MAP>60, BP 80-100s, +PP. Nasogastric tube is looped in the hypopharynx and ends in the upper stomach. provide emotional support to pt. Small left pleural effusion. is tender - dr. aware and at bedside to evaluate. Cough . Follows commands. COMPARISON: Chest radiograph from . APPROPRIATE & FOLLOWING COMMANDS. affect.cv: sinus 90's- 100's, no ectopy, K+/phos/mag repleted. Nsg.progress notes:see flow sheet for specific:neuro: pleasant AOx3,MAE,follow commands,helping in self care.c/o pain abd,percoset & oxycontin with good effect.easily getting anxious with all care & sourroundings.CV: NSR HR 70-95, no ectopy noted.SBP 80-100,lopressor held,denies CP.ResP: spont breathing on RA,LS clear & diminished at bases,O2 sat wnl,weak productive cough.GI: tolerated, soft diet & liq,abd softly distended,+ BS,colostomy draining brown liq stool,stoma pink with dark greenish edges,primary team aware,s/b ostomy nurse during day & care done.GU: foley cath patent with yellow clear urine adq amtEndo: BS Q6H on SSRI.ID: afebrile.act: turned & position changed with pt's help,pt is able to turn herself.,skin .Plan: cont current plan,pulm hygiene,encourage deep breath & cough,ambulate as tolerates.ostomy & wound care,assurance to pt & family,transfer to floor when bed available. Tip of NG tube is in fundus of stomach. Plan is to extubate today. CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: There are marked areas of airspace consolidation in both upper lobes, right greater than left. Pts diet progressed to full liquids, toelrating in small amts well. Tip of the left subclavian line projects over the SVC. REASON FOR THIS EXAMINATION: confirm NGT placement and infiltrate cjange FINAL REPORT CHEST, SINGLE AP FILM For NG tube placement. | 20 | [
{
"category": "Nursing/other",
"chartdate": "2172-11-20 00:00:00.000",
"description": "Report",
"row_id": 1311936,
"text": "Nsg.progress notes:\nsee flow sheet for specific:\nneuro: pleasant AOx3,MAE,follow commands,helping in self care.c/o pain abd,percoset & oxycontin with good effect.easily getting anxious with all care & sourroundings.\nCV: NSR HR 70-95, no ectopy noted.SBP 80-100,lopressor held,denies CP.\nResP: spont breathing on RA,LS clear & diminished at bases,O2 sat wnl,weak productive cough.\nGI: tolerated, soft diet & liq,abd softly distended,+ BS,colostomy draining brown liq stool,stoma pink with dark greenish edges,primary team aware,s/b ostomy nurse during day & care done.\nGU: foley cath patent with yellow clear urine adq amt\nEndo: BS Q6H on SSRI.\nID: afebrile.\nact: turned & position changed with pt's help,pt is able to turn herself.,skin .\n\nPlan: cont current plan,pulm hygiene,encourage deep breath & cough,ambulate as tolerates.ostomy & wound care,assurance to pt & family,transfer to floor when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-17 00:00:00.000",
"description": "Report",
"row_id": 1311929,
"text": "condition update\nneuro: alert, following commands, nodding and attempting to mouth words. Pt intermittently agitated during the day, tearful at times. Fentynal/midaz. gtt weaned off per sicu team to wean vent. to cpap. Pt c/o abd. pain, abd. is tender - dr. aware and at bedside to evaluate. Dilaudid prn pain with mod. affect.\ncv: sinus 90's- 100's, no ectopy, K+/phos/mag repleted. Neo titrated off to keep map >60, received lr bolus x's 1 for hypotension with improvement. Enzymes cycled and negative.\nresp: ls clear/diminished, suctioned for scant amts. thick tan sputum. Unable to wean to cpap throughout the day as pt having apneic periods, successfully weaned to CPAP this evening as pt is more awake.\ngu: foley draining adequate amts. clear yellow urine.\ngi: npo, ngt to lws, draining small amts. bilious drainage. abd. is tender, +bs, abd. incision noted for erythema - not extending beyond the marked lines. stoma is pink with dusky areas, unchanged from yesterday.\nendo: no ssri coverage necessary.\nplan: continue cpap overnight, sbt in am, wean to extubate. pain management, emotional support, pulmonary toileting, monitor bp.\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-17 00:00:00.000",
"description": "Report",
"row_id": 1311930,
"text": "Respiratory Care:\nPt. had been on A/C most of the day and was failing multiple spontanious BT's. Late this PM the sedation was removed and she started breathing. I then tried a SBT and RSBI and she did well. RSBI = 34. To rest she is now on PSV 7/5 @ 40% and looks good! Plan: tomorrow RSBI and SBT followed by extubation if all goes well. See CareVue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-16 00:00:00.000",
"description": "Report",
"row_id": 1311925,
"text": "Resp Care\nPt intubated this am for resp distress and hypoxia with 7.5 ETT 214 @ lip. BLBS very course and wheezy pt suctioned for copious amt of thick tan secretions and alb MDI started Q4. Pt taken to CT to r/o PE bronch done post extubation and BAL sample sent to lab. Pt was having trouble oxygenating this am but improved this afternoon fio2 was able to weaned to 40% peep at 10. plan at this time is to continue to monitor ABGs and maintain adequate oxygenation and ventilation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-16 00:00:00.000",
"description": "Report",
"row_id": 1311926,
"text": "npn\n7-11pm.\nneuro: pt sedated on fent 150mcg and versed 2mg. pt easily arousable, follows commands, very argumentative with turning ? pain issue or anxiety issue, pt given vistaril 25mg im prior to turning.\n\npain: exp pain at 2230 ? anxiety also pt given vistaril and then bolus of 3cc fent with turn due to pt fighting and being non compliant.\n\ncad: nsr 70 to 80's no ectopy noted, abp 97/532 to 113/67, neo gtt titrated down to .5mcg with map 78. map to be greater than 60. md aware of neo gtt titration.\n\nresP: no changes in vent settings, check abg at mn. ls clear with dim. bases. sats 99-98 % on 40% fio2.\n\ngi: abd drsg , + ngt to lcws.\n\ngi: uo >50cc/hr of pale yellow urine. eve K+ 2.9 repletion started with 40 meq another 20 meq needed.\n\nid: temp max 99.8 rectal vanco random needs to be drawn at 6am\n\nsocial: husband into visit on eves.\n\nplan: wean neo as tolerated to maintain map >60 , wean fent down to 100 mcg if tolerated. provide emotional support to pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-18 00:00:00.000",
"description": "Report",
"row_id": 1311931,
"text": "CONDITION UPDATE\nASSESSMENT:\n PATIENT SLEEPING ON/OFF MOST OF THE NIGHT. APPROPRIATE & FOLLOWING COMMANDS. OCCASIONALLY ANXIOUS WHEN ATTEMPTING TO MOUTH WORDS. NODDING \"YES\" TO PAIN, RELIEVED WITH DILAUDID.\n HEART RATE 90'S NORMAL SINUS, NO ECTOPY. MAP > 60 OVERNIGHT. MAKING ADEQUATE HOURLY URINE AND CVP ~ 10. AFEBRILE. LUNG SOUNDS CLEAR. PATIENT TOLERATING CPAP + 7 PS & 5 PEEP, ABG WITHIN NORMAL RANGE. SECRETIONS MINIMAL, BUT THICK AND YELLOW.\n ABDOMEN SOFT, NONDISTENDED. NGT TO SUCTION, MINIMAL OUTPUT. COLOSTOMY WITH DUSKY AREAS (NOTED PREVIOUSLY). LIQUID GREEN STOOL FROM OSTOMY, APPLIANCE . ABDOMINAL INCISION SLIGHTLY ECCHYMOTIC, STAPLES IN PLACE. JPS X 2 WITH SEROSANG DRAINAGE.\nPLAN:\n RSBI & SPONTANEOUS BREATHING TRIAL THIS AM, POSSIBLE EXTUBATION. CONTINUE WITH CURRENT NURSING CARE & TREATMENT. IV ABX, FOLLOW TEMPS & WBC COUNT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-18 00:00:00.000",
"description": "Report",
"row_id": 1311932,
"text": "rsep care\n\nPt is currently on PSV 5/+5, 40%. ABG on 7/+5 were very good, RSBI was also in range of extubation. Pt has mod to large amts thk secretion, strong cough. Plan is to extubate today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-18 00:00:00.000",
"description": "Report",
"row_id": 1311933,
"text": "Respiratory Care:\n\nPt successfully extubated this AM after PSV all noc without difficulties. SBT and RSBI were completed with result of 40.\nDoing OK @ present (1510 )\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-17 00:00:00.000",
"description": "Report",
"row_id": 1311927,
"text": "Respiratory Care Note:\n Patient continues on A/C mode with much improved blood gases today. BS with improved aeration t/o. Suctioned for small amounts of greyish-white sputum. Combivent MDI started at 4am. Patient without spontaneous respirations at 4:30, s/p pain meds. Wean held at this time, but rate was decreased slightly and PEEP was weaned to 8.\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-17 00:00:00.000",
"description": "Report",
"row_id": 1311928,
"text": "Nsg.progress notes:\nSee flow sheet for specific:\nNeuro: on fentanyl & versed gtt,titrated to keep the pt sedated,now fentanyl 100mcg/hr & versed 2mg/hr with prn dilaudid with good effect,PERL,follows commands.MAE.\nCV: NSR,HR 83-110,no ectopy noted,SBP 90-113,neo still at 0.5mcg/kg/mt.went up with neo to 1mcg for 2hrs as BP low but back to 0.5 again by 5am.T max 99.8,IVF LR 100ml/hr,K+ 2.9 repleted with 80mmol kcl,rptd K+ 3.7,po4 2.5 K phos to replete,Fluid bal of +2L by MN,CVP 9cm,HCT 24.7 team aware.\nResp: remains on vent,vent changes per ABG @ AM Fio2 40% RR-18,peep 8cm,LS clear & diminished at bases,SXN thick white secretions,O2 sat wnl,ABG acceptable.\nGI: NPO,abd soft.+ BS,colostomy pink,draining greenish liq stool sm amt only,abd dressing changed wound clean no drains,with erythema around same like day,no cahnge,SICU md aware.JP's draining ss drain.\nGU: foley cath patent with yellow clear urine,adq amt.\nID : T max 99.8,on anbx.\nendo: BS q6h on ssri,doesn't need any coverage.\nAct: bed fast,turned & position changed,skin ,\nPlan: cont current plan,titrate Neo to keep MAP >60,wean off fentanyl if tolerates,PS trial,pulm hygiene,wean off vent as tolerates.support to pt & family\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-16 00:00:00.000",
"description": "Report",
"row_id": 1311924,
"text": "NPN\nplease see carevue for further details\nN: Propofol gtt changed to Fent and Midaz gtt. Fent&Midaz titrated to appropiate sedation. Currently opens eyes spontaneously, arousable to voice. PERRL 4mm. Follows commands. MAE.\n\nC: NS with rare PVCs. HR 100-70s. Neo titrated to MAP>60, BP 80-100s, +PP. 1.5liter LR bolus for hypotension. Cardiac enzymes sent- negative. EKG done for brief ST wave inversion that subsequently resolved. SICU team aware. Quad lumen L subclavian placed. Verified by CXR. CVP 10-15.\n\nR: Chest CTA this a.m to r/o PE. CXR done x 2. Sputum cx sent. Bronched this am. 2BALs obtained and sent during bronch. pt tol well. ABGS monitored. A/C currently at PEEP 10, Fi02 50 sats 96-100. RR 16-20. tachypneic with increased agitation or pain. Suctioned for thick tan secretions copious amounts.\n\nGI: Abd soft appropiately tender. + BS x4. Abd incision, sutures intact erythematous, area outlined. Dr. aware. Stoma producing dark black/green loose stool. this afternoon stoma noted to be dusky from o'clock. Stoma this am was pink. SICU team notified and primary team aware. NGT placed in R nare, placement verified via CXR and auscultation.\n\nGU: Foley draining clear yellow urine adq amounts. Mucomyst and bicarb started to renal protection after CTA contrast.\n\nENDO: SSRI.\n\nID: Pan cultured. Unable to obtain Vanco trough level. Multiple phone calls to lab- stated there was a problem with analyzer. Dr. aware and ok to give Vanco before trough available. Tmax 100.6 ax, diaphoretic at times.\n\nSOCIAL: family at bedside. updated by Dr. and Dr. .\n Spokesperson will be sister as per family request.\n\nPLAN: Wean fi02 as tolerated. Aggressive pulmonary toileting. Monitor ABGS and hemodynamics. Titrate Neo to MAP>60. Titrate Fent and Midaz to adequate sedation. Monitor cardiac enzymes q6. Provide comfort and support.\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-19 00:00:00.000",
"description": "Report",
"row_id": 1311934,
"text": "update\nplease see Carevue for specifics\n\nNeuro: A&O x 3. Motor strength weak but OOB to chair with assistance. PERRL. Cough . Afebrile.\n\nCV: NSR. No ectopy noted. SBP 75-85, pt's baseline. A-line dampening. K repleted.\n\nResp: LS clear/diminished. Rate WNL. O2 sat 95-100% on 2L NC. Denies SOB.\n\nGI: Abd soft. BS present. JP 1 draining serous fluid. JP 2 draining serosang fluid. Colostomy draining green-brown liquid. Abdominal incision sutures clean, dry, no drainage. DSD changed & .\n\nGU: Foley draining c/y/u.\n\nPsychosocial: Family by bedside early evening. Pt talked with husband on phone at length. Pt. expressed concern & insecurity to the RN related to colostomy bag.\n\nPlan: Cont to monitor and treat pain. Provide emotional support and education concerning colostomy. Transfer to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-11-19 00:00:00.000",
"description": "Report",
"row_id": 1311935,
"text": "FOCUSED NURSING NOTE\nPlease see carevue flowsheet for further details\n\n Pt progressing on post-op course as expected. No resp distress or signs of decompensation. VSS, afebrile. A-line monitoring dc'd, CVP 8-10. s/p 1U PRBCs for Hct 21.4, post-transfusion HCT 28.0. Excellent pain control achieved with oxycontin 20mg , medicated for BTP x 1 prior to ambulation. Colostomy outputs liquid in moderate amounts, frequent flatus. Ostomy RN at bedside today for teaching and stoma care- stoma pink, slight edema, 25% green mucosal tissue. Pts diet progressed to full liquids, toelrating in small amts well. Activity level increased to ambulation today, also tolerated very well. PT consult pending. Coping well, emotional support and education ongoing.\n\nPLAN OF CARE: Monitor resp status, pulmonary hygiene. Monitor fluid balance closely. Monitor for sx infection, bleeding, wound closure. Emotional support and ostomy teaching ongoing. Monitor pain control. Transfer to floor pending bed availability. labs in am. D/C CVL per primary team.\n"
},
{
"category": "ECG",
"chartdate": "2172-11-16 00:00:00.000",
"description": "Report",
"row_id": 154743,
"text": "Sinus rhythm. Modest non-specific ST-T wave changes. Compared to the previous\ntracing of no significant diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2172-11-09 00:00:00.000",
"description": "Report",
"row_id": 154744,
"text": "Sinus rhythm. Modest non-specific inferior ST-T wave changes. Compared to the\nprevious tracing of no significant diagnostic change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-11-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 939746,
"text": " 5:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change\n Admitting Diagnosis: CROHN'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with acute desaturation POD 3 s/p ECF resection, now POD 5\n with slowly improving resp status\n REASON FOR THIS EXAMINATION:\n please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with known bilateral pulmonary\n infiltrates.\n\n COMPARISON: Chest radiograph from .\n\n IMPRESSION: The ET tube tip is 6.5 cm above the carina. The left subclavian\n line tip is in mid SVC. The NG tube tip is in the stomach.\n\n There is additional improvement in the bilateral pulmonary infiltrates with\n almost complete resolution of the right upper and left upper lobes with still\n present consolidation and pleural effusion in the left lower lobe. This rapid\n improvement of massive consolidation during 48 hours suggests aspiration\n rather than infectious cause of this finding.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-11-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 939541,
"text": " 3:11 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: confirm NGT placement and infiltrate cjange\n Admitting Diagnosis: CROHN'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with acute desaturation POD 3 s/p ECF resection.\n\n REASON FOR THIS EXAMINATION:\n confirm NGT placement and infiltrate cjange\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n For NG tube placement.\n\n Tip of NG tube is in fundus of stomach. Left subclavian CV line has tip\n located in mid to distal SVC. Endotracheal tube 6 cm above carina.\n Bilateral, predominantly right upper lobe and diffuse left-sided pulmonary\n consolidation as previously demonstrated on prior study of same date.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-11-16 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 939460,
"text": " 6:09 AM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: DESAT TO 70% WITH INCREASE TO 75% ON NONREBREATHER MASK, TACHYPNIC TO 32, HR 130S BP 120/80, EVAL FOR PE\n Admitting Diagnosis: CROHN'S DISEASE/SDA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman POD 3 s/p ECF resection with desat to 70% with increase to\n 75% on nonrebreather mask. Pt tachypnic to 32, HR 130s, BP120/80.\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Worsening tachypnea and hypoxia. Assess for pulmonary embolus.\n\n TECHNIQUE: Volumetric CT imaging of the chest was performed before and after\n administration of 100 cc of Optiray IV contrast. Coronal and sagittal\n reformatted images were made.\n\n COMPARISON: Chest radiographs from earlier the same day.\n\n CHEST CTA: The pulmonary arteries are well opacified with IV contrast and\n show no intraluminal filling defects to suggest emboli. Assessment in areas\n of severely consolidated lung is difficult. There is no evidence of emboli\n within these vessels. The ascending and descending aorta are normal in\n caliber. There is no intramural/periaortic hematoma, dissection, or evidence\n of active extravasation.\n\n CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: There are marked areas of\n airspace consolidation in both upper lobes, right greater than left. Patchy\n areas of consolidation are also seen in the aerated portions of the left lower\n lobe and right lower lobe. There is bilateral lower lobe atelectasis. There\n is a small left pleural effusion which appears to layer freely posteriorly.\n Multiple likely reactive mediastinal lymph nodes are present. There is no\n pericardial effusion. Limited assessment of the upper abdomen shows a normal\n left adrenal gland and no diagnostic abnormality in the imaged portions of the\n liver and spleen.\n\n BONE WINDOWS: No lytic or sclerotic osseous lesions are identified.\n\n CT RECONSTRUCTIONS: Coronal and sagittal reformatted images show no evidence\n of pulmonary embolus.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolus.\n 2. Massive bilateral pneumonic airspace consolidations, worst in both upper\n lobes, but with additional areas of consolidation in the aerated portions of\n both lower lobes. Bibasilar atelectasis.\n 3. Small left pleural effusion. Whether the effusion is transudative or\n exudative cannot be determined by this study.\n\n (Over)\n\n 6:09 AM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: DESAT TO 70% WITH INCREASE TO 75% ON NONREBREATHER MASK, TACHYPNIC TO 32, HR 130S BP 120/80, EVAL FOR PE\n Admitting Diagnosis: CROHN'S DISEASE/SDA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-11-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 939599,
"text": " 4:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate progression\n Admitting Diagnosis: CROHN'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with acute desaturation POD 3 s/p ECF resection.\n\n REASON FOR THIS EXAMINATION:\n ?infiltrate progression\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:48 A.M, .\n\n HISTORY: Acute desaturation.\n\n IMPRESSION: AP chest compared to .\n\n Bilateral pulmonary consolidation is improving consistent with improving\n pneumonia. Nasogastric tube is looped in the hypopharynx and ends in the\n upper stomach. ET tube tip is at the thoracic inlet. Tip of the left\n subclavian line projects over the SVC. No pneumothorax or appreciable pleural\n effusion. The heart is normal size. Dr. and I discussed these\n findings, at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-11-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 939456,
"text": " 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: STAT CXR - acute desat\n Admitting Diagnosis: CROHN'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with acute desaturation POD 3 s/p ECF resection.\n REASON FOR THIS EXAMINATION:\n STAT CXR - acute desat\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST , 5:30 A.M.\n\n HISTORY: Acute desaturation postoperative date 3.\n\n IMPRESSION: AP chest compared to :\n\n Severe bilateral pulmonary consolidation is most likely due to multifocal\n pneumonia. Elevation of the left hemidiaphragm indicates an element of\n atelectasis, though this could be due to gaseous distention of the stomach,\n rather than primary loss of lung volume. There is also quite likely a small\n right pleural effusion. Heart is not enlarged. There is no pneumothorax.\n\n Dr covering for Dr was paged to report these findings, at the time\n of dictation.\n\n\n"
}
] |
9,008 | 137,638 | Assessment and Plan: Pleasant yo woman with MMP, now admitted for hypotension in the setting of bilateral LE ulcers, new consolidation on CXR, and positive C. Diff assay. . 1. Hypotension: There was concern for septic shock given her history of infection, positive C. Diff assay, LE ulcers, and new consolidation on CXR. The patient, however had no fever, cough, or sputum production, which made PNA less likey. Given her cardiac history, there was concern for cardiogenic shock, however there were no sxs to suggest recent MI, EKG is unchanged and no edema on CXR. There was a low suspicion for PE, however if with UE edema some concern for clot which may have propogated. The patient patient was confirmed DNR/DNI, and no additional lines were placed. She was given IVF in addition to antibiotic coverage for presumed sepsis, but she remained persistently hypotensive. The family was notified that she would require additional access for IV fluids. The family reiterated there request for no additional lines, and she was placed on comfort measures. The patient passed comfortably just before midnight at approximately 11:56 on . . # ARF: Her creatinine was elevated in the setting of a urine sodium of less than 10. She was most likely pre-renal in the setting hypotension. She was given fluids, through her lines, but remained persistently hypotensive. . # Abd pain: She had mild pain, with mild distension. Her white count was elevated and her c. diff was positive, which was the most likely etiology for her pain and clinical presentation of sepsis. . # LE ulcers: A small 1 cm circumscribed ucler was noted on the foot which expressed small amounts of puss. Foot x-rays were not suggestive of osteo. . # Hyponatremia: Her low sodium was liklely secondary to poor PO intake, and she appeared dry on admission. Fluids were started as soon as she arrived. . # LUE edema: concerning for DVT vs thrombophlebitis, however no hx of recent line in the LUE. A LUE US was inconclusive. . # GERD: She was placed on an H2 blocker since she was also taking plavix. | There is a moderate soft tissue edema in the left arm; unable to see cepahlic and basilic vein. The right mastoid air cells are slightly underpneumatized. TECHNIQUE: Left upper extremity venous ultrasound, portable. There are focal areas of hypoattenuation within the left corona radiata and cerebellum, which appear chronic. The left hemidiaphragm is slightly ill-defined compared to prior, which likely reflects the presence of small pleural effusion and atelectasis though pneumonia cannot be entirely excluded. IMPRESSION: Small left pleural effusion with left basilar atelectasis -- cannot exclude pneumonia. Ventricles and sulci are mildly prominent, reflective of diffuse cortical atrophy. Atrial fibrillation with moderate ventricular response and demand pacing.Left axis deviation consistent with left anterior hemiblock. Non-specific ST-T wave abnormalities.Compared to tracing #1 no diagnostic change.TRACING #2 Soft tissue induration and calcification about the first metatarsophalangeal joint with hallux valgus deformity. There is underlying soft tissue induration, but no soft tissue gas is identified. There is pronounced scoliosis, similar to prior. The first metatarsophalangeal joint is markedly abnormal, with hallux valgus deformity, joint space narrowing, and extensive surrounding soft tissue induration. Normal compressibility seen in the left interal jugular vein, axillary, and brachials veins. Unable to see the cephalic and basilic vein. Compared to the previous tracingof less of the rhythm is now paced and atrial fibrillation may be new.Suggest clinical correlation and repeat tracing.TRACING #1 Left axis deviationconsistent with left anterior hemiblock. Diffusenon-specific ST-T wave abnormalities. TECHNIQUE: MDCT-acquired axial images of the head were obtained without the use of IV contrast. IMPRESSION: No acute intracranial process. Otherwise, the radiograph is unchanged. Calcified/osseous bodies are noted about the joint, possibly representing either osteophyte formation or calcified tophi, though there are no erosions to further support a diagnosis of gout. FINDINGS: As compared to the previous radiograph, a right-sided PICC line has been placed. There is also relative hypodensity of the periventricular white matter, reflective of chronic microvascular ischemic disease. FINDINGS: Suboptimal and inconclusive study. FINDINGS: There is a left pacemaker, in appropriate position. There is moderate soft tissue edema in the left arm. No definite evidence of osteomyelitis. There is normal compressibility in the left internal jugular vein, axillary vein, and brachial veins. Patient weak, uncomfortable, and difficult to cooperate with arm positioning. Low lung volumes. Unable to obtain diagnostic images of the subclavian vein due to arm positioning. Unable to obtain diagnostic images of subclavian vein, and unable to obtain diagnositic flow images of subclavian and axillary vein. No acute fracture is seen. Hilar and mediastinal silhouette stable. The patient is weak, uncomfortable and difficult to cooperate with arm positioning. Tarsal-metatarsal alignments are normal. FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass, mass effect, or large vascular territorial infarct. Dense mucus is present within the right sphenoid sinus. TECHNIQUE: Portable AP chest radiograph, single view. The heart size is difficult to assess. RIGHT FOOT, THREE VIEWS: There is bandage material overlying the first metatarsophalangeal joint. Right lung appears clear. Evaluate for osteomyelitis. There is no underlying periostitis or cortical erosion to suggest osteomyelitis radiographically. COMPARISON: No prior. Probable atrial fibrillation with demand pacing. There is no evidence of acute intracranial hemorrhage or mass effect. Clinical correlation is advised. Degenerative spurring is noted in the mid foot, as well as a large plantar and dorsal calcaneal spur. The tip of the line projects over the junction of the brachiocephalic vein and the superior vena cava. While this most likely reflects degenerative change, tophaceous gout cannot be excluded, though the lack of erosion argues against this. There is no evidence of complications, notably no pneumothorax. If there has been clinical concern, consider MRI for further evaluation. No comparison studies available. IMPRESSION: 1. Middle ear cavities are clear. There are no fractures. COMPARISON: . COMPARISON: . COMPARISON: . Consider lateral view to better assess. There are extensive vascular calcifications. 2:31 PM CT HEAD W/O CONTRAST Clip # Reason: Eval bleed MEDICAL CONDITION: year old woman with mental status changes REASON FOR THIS EXAMINATION: Eval bleed No contraindications for IV contrast WET READ: LLTc SUN 4:44 PM no acute intracranial process FINAL REPORT INDICATION: Mental status change. 2. 2:05 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for PICC placement (please shoot CXR to R-side, Admitting Diagnosis: HYPOTENSION MEDICAL CONDITION: year old woman with hypotension REASON FOR THIS EXAMINATION: Please eval for PICC placement (please shoot CXR to R-side, unable to visualize PICC on last film) FINAL REPORT CHEST RADIOGRAPH INDICATION: Hypotension, evaluation for PICC line placement. 7:25 PM UNILAT UP EXT VEINS US LEFT Clip # Reason: Please evaluate for clot Admitting Diagnosis: HYPOTENSION MEDICAL CONDITION: year old woman with hypotension concerning for sepsis, LUE edema REASON FOR THIS EXAMINATION: Please evaluate for clot WET READ: IPf SUN 10:52 PM Suboptimal and inconclusive study. | 7 | [
{
"category": "Radiology",
"chartdate": "2199-06-30 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 1147083,
"text": " 7:25 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: Please evaluate for clot\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hypotension concerning for sepsis, LUE edema\n REASON FOR THIS EXAMINATION:\n Please evaluate for clot\n ______________________________________________________________________________\n WET READ: IPf SUN 10:52 PM\n Suboptimal and inconclusive study.\n Patient weak, uncomfortable, and difficult to cooperate with arm positioning.\n\n Normal compressibility seen in the left interal jugular vein, axillary, and\n brachials veins.\n\n Unable to obtain diagnostic images of subclavian vein, and unable to obtain\n diagnositic flow images of subclavian and axillary vein.\n There is a moderate soft tissue edema in the left arm; unable to see cepahlic\n and basilic vein.\n\n D/w Dr. while on the floor doing the portable, and decided study\n can be repeated in the morning, if patient able to cooperate with arm\n positioning.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old woman with hypotension concerning for sepsis and left\n upper extremity edema.\n\n TECHNIQUE: Left upper extremity venous ultrasound, portable.\n\n COMPARISON: No prior.\n\n FINDINGS: Suboptimal and inconclusive study. The patient is weak,\n uncomfortable and difficult to cooperate with arm positioning. There is normal\n compressibility in the left internal jugular vein, axillary vein, and brachial\n veins. Unable to obtain diagnostic images of the subclavian vein due to arm\n positioning. Unable to see the cephalic and basilic vein. There is moderate\n soft tissue edema in the left arm.\n\n Discussed with Dr. while on the floor during the portable\n ultrasound; study can be repeated in the morning if patient able to cooperate\n with arm positioning.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-01 00:00:00.000",
"description": "RP FOOT AP,LAT & OBL RIGHT PORT",
"row_id": 1147135,
"text": " 9:29 AM\n FOOT AP,LAT & OBL RIGHT PORT Clip # \n Reason: Please evaluate for osteomyelitis\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with R 1st toe ulcer\n REASON FOR THIS EXAMINATION:\n Please evaluate for osteomyelitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old female with right first toe ulcer. Evaluate for\n osteomyelitis.\n\n COMPARISON: .\n\n RIGHT FOOT, THREE VIEWS:\n\n There is bandage material overlying the first metatarsophalangeal joint.\n There is underlying soft tissue induration, but no soft tissue gas is\n identified. There is no underlying periostitis or cortical erosion to suggest\n osteomyelitis radiographically.\n\n The first metatarsophalangeal joint is markedly abnormal, with hallux valgus\n deformity, joint space narrowing, and extensive surrounding soft tissue\n induration. Calcified/osseous bodies are noted about the joint, possibly\n representing either osteophyte formation or calcified tophi, though there are\n no erosions to further support a diagnosis of gout.\n\n There are no fractures. Tarsal-metatarsal alignments are normal. There are\n extensive vascular calcifications. Degenerative spurring is noted in the mid\n foot, as well as a large plantar and dorsal calcaneal spur.\n\n IMPRESSION:\n 1. No definite evidence of osteomyelitis. If there has been clinical\n concern, consider MRI for further evaluation.\n 2. Soft tissue induration and calcification about the first\n metatarsophalangeal joint with hallux valgus deformity. While this most\n likely reflects degenerative change, tophaceous gout cannot be excluded,\n though the lack of erosion argues against this. Clinical correlation is\n advised.\n\n"
},
{
"category": "ECG",
"chartdate": "2199-06-30 00:00:00.000",
"description": "Report",
"row_id": 307344,
"text": "Probable atrial fibrillation with demand pacing. Left axis deviation\nconsistent with left anterior hemiblock. Non-specific ST-T wave abnormalities.\nCompared to tracing #1 no diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2199-06-30 00:00:00.000",
"description": "Report",
"row_id": 307345,
"text": "Atrial fibrillation with moderate ventricular response and demand pacing.\nLeft axis deviation consistent with left anterior hemiblock. Diffuse\nnon-specific ST-T wave abnormalities. Compared to the previous tracing\nof less of the rhythm is now paced and atrial fibrillation may be new.\nSuggest clinical correlation and repeat tracing.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-06-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1147064,
"text": " 2:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with change mental status\n REASON FOR THIS EXAMINATION:\n Eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old woman with change in mental status.\n\n TECHNIQUE: Portable AP chest radiograph, single view.\n\n COMPARISON: .\n\n FINDINGS: There is a left pacemaker, in appropriate position. Low lung\n volumes. The left hemidiaphragm is slightly ill-defined compared to prior,\n which likely reflects the presence of small pleural effusion and atelectasis\n though pneumonia cannot be entirely excluded. Right lung appears clear. The\n heart size is difficult to assess. Hilar and mediastinal silhouette stable.\n There is pronounced scoliosis, similar to prior.\n\n IMPRESSION: Small left pleural effusion with left basilar atelectasis --\n cannot exclude pneumonia. Consider lateral view to better assess.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-06-30 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1147063,
"text": " 2:31 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with mental status changes\n REASON FOR THIS EXAMINATION:\n Eval bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc SUN 4:44 PM\n no acute intracranial process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status change.\n\n No comparison studies available.\n\n TECHNIQUE: MDCT-acquired axial images of the head were obtained without the\n use of IV contrast.\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass,\n mass effect, or large vascular territorial infarct. There are focal areas of\n hypoattenuation within the left corona radiata and cerebellum, which appear\n chronic. There is also relative hypodensity of the periventricular white\n matter, reflective of chronic microvascular ischemic disease. Ventricles and\n sulci are mildly prominent, reflective of diffuse cortical atrophy. There is\n no evidence of acute intracranial hemorrhage or mass effect. No acute\n fracture is seen. The right mastoid air cells are slightly underpneumatized.\n Middle ear cavities are clear. Dense mucus is present within the right\n sphenoid sinus.\n\n IMPRESSION: No acute intracranial process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1147101,
"text": " 2:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for PICC placement (please shoot CXR to R-side,\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hypotension\n REASON FOR THIS EXAMINATION:\n Please eval for PICC placement (please shoot CXR to R-side, unable to visualize\n PICC on last film)\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hypotension, evaluation for PICC line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, a right-sided PICC line has\n been placed. The tip of the line projects over the junction of the\n brachiocephalic vein and the superior vena cava. To ensure proper\n positioning, the line should be advanced by approximately 3-4 cm.\n\n There is no evidence of complications, notably no pneumothorax.\n\n Otherwise, the radiograph is unchanged.\n\n\n"
}
] |
15,416 | 119,851 | Postoperatively, the patient did well and had no acute issues. There were no desaturations. The patient tolerated his trache well. The patient does have a history of type 2 diabetes mellitus and postoperatively his fingersticks were monitored, however, they were always within the 100-150 range and no coverage was necessary. He also has a history of depression and psychotic disorders, however, these were not a problem during the hospitalization. On postop day 2, it was noted that the nurses that some food was suctioned out of his trache and therefore a speech and swallowing consult was obtained. Speech and swallowing technologists noted that there was traces of aspiration, with maneuvers of chin tucking and pureed thickened liquids no aspirations occurred. He was, therefore, started on a clear liquid diet alternating with pureed thickened solids and tolerated that well. The patient's electrolytes were also followed during the stay and there were no abnormalities. The patient had no problems with urinary or excretory functions. On postop day 5, the patient's trache was changed to a #7 Portex thereby downsizing it. The patient will, therefore, be ideally set up with a skilled nursing facility to help him care for this new trache and get comfortable with its daily routine as well as to transition him from the hospital stay to home. He was evaluated by radiation therapy and oncology during the stay and treatment plans are still in their planning stages. He will follow up with Dr. 1 week after discharge in his clinic. | Following administration, pharyngeal transit time and pharyngoesophageal sphincter relaxation were within normal limits. Site is bleeding slightly and pt is requiring tracheal suctioning Q1-2Hr while in PACU.Pt arrives alert, oriented, cooperative. Tracheostomy tube in standard placement. 4 ICU nursing progress note: Respiratory: #7 portex in place. There is mild reduction of laryngeal elevation and laryngeal valve closure. Pt denies pain..slight discomfort.Suctioned q3-4hrs for thick tan-yellow secretions. The oral phase was within normal limits for bolus formation, mastication, bolus control and oral transit time. last temp 99.9. compression boots on.GU: pt requires freq voiding with incontinence noted, able to use urinal. There is possible trace aspiration after one trial of thin liquids. UO adequate (see careview).GI: pos bowel sounds, previous RN pt took eve PO meds but with difficulty r/t pain. Resp CarePt. IMPRESSION: Moderate pharyngeal aphasia secondary to large mass at the lingual space. LS coarse upper, diminished lower bases.CV: HR 93-99 SR no ectopy, BP 120-145/67-80. Bolus propulsion was mildly impaired and there was some residue on the posterior pharyngeal wall. follows commands, pt c/o of some mild discomfort at trach site r/t thight sutures. Dressing reinforced.GI: Abdomen is large obese faint positive bowel sounds heard.GU: Pt reportedly voids in urinal without difficulty. rr 18-20 Cardiac: HR 80-=90sr..BP 110-130/60-70 GI: Diet advanced to liquids...tolerating well.. GU: Using urinal..voiding in small amts. CHEST, ONE VIEW: Comparison with . There was penetration following the swallow as a result of residue remaining in the valleculae. Moderate residue within the valleculae. There is a moderate amount of residue within the valleculae and piriform sinuses. Dispo: Per ENT..pt to have continues o2 sat monitoring thru the noc..? nonverbal comm r/t trach, appears oriented. Initial biopsy done today showed Adeno CA. There is moderate impairment of anterior-posterior tongue movement. Tracheostomy tube in place. CXR done in PACU showed left lower lobe atelectasis and bilateral pleural effusions. slept well overnight.Resp: #7 portex trach intact, site pink with sm amt serous drainage noted. Bronchoscopy was done which showed the large supraglotal mass. Mild mediastinal vascular engorgement is function of low lung volumes and likely volume overload. Small amt of serous drainage..site looks good. Portex trach #7 is in place. Sutures intact. Able to swallow, mouth care done. MICU NPN Admit to MICU:72y.o. Lungs coarse with deminished breath sounds throughout. 5:34 AM CHEST (PORTABLE AP) Clip # Reason: Assess new trach placement. pos distal pulses.GU: pt keeps urinal at bedside, voids frequently in sm amts, see careview for totals.GI: pos bowel sounds, tolerating clear liquids and PO meds well.Skin: skin dry and intact.IV: 20g PIV r arm WNL.Plan: cont to monitor resp status, vitals. There is a small amount of penetration seen with thin liquids, nectar thick liquids, and puree consistency solids. expectorating bloody secreations.Plan:Follow/protocol. Slight motion mars images, however, left lower lobe atelectasis is apparent; bilateral pleural effusions, if present, are small. He had recent onset hoarse voice and his psychiatrist noted this. Tolerated well. Pt has biopsy done of large lingular mass. moves extremities well. Endo: Has not required insulin..however now taking liquids..on ssri. provide updates on POC to pt as appropriate, assessment ongoing. Possible trace aspiration as described above. comfort level. IMPRESSION: AP chest compared to : Lung volumes remain low and left lower lobe atelectasis has worsened. FINAL REPORT AP CHEST, 5:30 . afebrile. sats 96-98 on 0.50 trach collar. HISTORY: Supraglottic mass and new tracheostomy. ID: Afebrile..last dose of antibiotics this evening. psych meds restarted this evening.Resp: pt trached with #7 portex, suctioned x 2 for sm amt bloody, freq dressing changes, pt remains on 50% trach collar, sats 97. HR 80 NSR Denies chest pain. VSSPMH: HTN, DM, High cholesterol, Schizoeffective DOAllergies: NKANeuro: Pt c/o slight abdominal discomfort on transfer and c/o slight neck pain at trach site. no BM.IV: 20g PIV x 1 WNL, D5 1/2 NS @ 100/hr.Skin: skin dry and intact.Social: no contact from family overnight.Plan: continue to monitor airway patency and resp status, cont to asses pain and medicate as needed per order. pt. For further details, please refer to the speech and language pathology report from the same date. trached yesterday with #7 Portex (epiglottic mass).Came to -4 for overnight observation. Has strong cough and encouraged to do so. Upper lungs are grossly clear. LS coarse and diminished. Nursing Note: 1900-0700 pt full codeNeuro: pt awake and alert, sleeping at present. Resp CarePt remains trached on cool aerosol trach mask with FIO2 set @ 50%.Pt has productive cough, no other changes noted. Has not voided yet in MICU.ID: afebrileSocial: brother and wife are next of There may be a small volume of pleural fluid on either side of the chest. Very low lung volumes. Family aware. Neuro: Pt is alert and orientated..oob to chair with assist of 2. REASON FOR THIS EXAMINATION: Assess new trach placement. Gas filled loops of bowel are present. Various consistencies of barium including thin liquid, nectar-thickened liquid, puree, and a cookie coated with barium were administered. no suctioning done overnight, pt has strong cough, cleared some brown thick secretions overnight infrequently.CV: HR 75-90 SR no ectopy, NBP 100-140/60-70. Airway patent, cuff inflated with pressure of 30cm.50% TM with SPo2 96-100%.Bs: clear bilat. asessment ongoing. The heart is normal size. Pneumoboots on.Resp: Pt arrived on 50% trach collar. Epiglottic deflection was absent secondary to a large mass in that area. 2:02 PM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: rule out aspiration Admitting Diagnosis: SUPRAGLOTTIC MASS/SDA MEDICAL CONDITION: 72 year old man s/p tracheotomy, with cough on bedside swallowing evaluation REASON FOR THIS EXAMINATION: rule out aspiration FINAL REPORT STUDY: Video oropharyngeal swallowing evaluation. | 10 | [
{
"category": "Radiology",
"chartdate": "2200-05-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 963939,
"text": " 5:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess new trach placement.\n Admitting Diagnosis: SUPRAGLOTTIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with supraglottic mass and a new trach placed on .\n\n REASON FOR THIS EXAMINATION:\n Assess new trach placement.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:30 .\n\n HISTORY: Supraglottic mass and new tracheostomy.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes remain low and left lower lobe atelectasis has worsened. Upper\n lungs are grossly clear. There may be a small volume of pleural fluid on\n either side of the chest. The heart is normal size. Mild mediastinal\n vascular engorgement is function of low lung volumes and likely volume\n overload. Tracheostomy tube in standard placement. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-05-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 963854,
"text": " 1:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: New Trach - please evaluate position of tip and eval for pne\n Admitting Diagnosis: SUPRAGLOTTIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with supraglottic mass and a new trach\n REASON FOR THIS EXAMINATION:\n New Trach - please evaluate position of tip and eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New tracheostomy.\n\n CHEST, ONE VIEW: Comparison with . Very low lung volumes.\n Tracheostomy tube in place. Slight motion mars images, however, left lower\n lobe atelectasis is apparent; bilateral pleural effusions, if present, are\n small. Gas filled loops of bowel are present. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-05-29 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 964336,
"text": " 2:02 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: rule out aspiration\n Admitting Diagnosis: SUPRAGLOTTIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p tracheotomy, with cough on bedside swallowing evaluation\n REASON FOR THIS EXAMINATION:\n rule out aspiration\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Video oropharyngeal swallowing evaluation.\n\n INDICATION: 72-year-old male status post tracheostomy, presenting with\n coughing. Question aspiration.\n\n ORAL AND PHARYNGEAL VIDEO FLUOROSCOPIC EXAMINATION: An oral and pharyngeal\n video fluoroscopic swallowing evaluation was performed in collaboration with\n the speech and language pathology division. Various consistencies of barium\n including thin liquid, nectar-thickened liquid, puree, and a cookie coated\n with barium were administered.\n\n The oral phase was within normal limits for bolus formation, mastication,\n bolus control and oral transit time. There is moderate impairment of\n anterior-posterior tongue movement. There is no oral residue present within\n the oral cavity or premature spillover.\n\n There is mild reduction of laryngeal elevation and laryngeal valve closure.\n Epiglottic deflection was absent secondary to a large mass in that area.\n Following administration, pharyngeal transit time and pharyngoesophageal\n sphincter relaxation were within normal limits. There is a moderate amount of\n residue within the valleculae and piriform sinuses. Bolus propulsion was\n mildly impaired and there was some residue on the posterior pharyngeal wall.\n\n There is a small amount of penetration seen with thin liquids, nectar thick\n liquids, and puree consistency solids. There was penetration following the\n swallow as a result of residue remaining in the valleculae. There is possible\n trace aspiration after one trial of thin liquids.\n\n IMPRESSION: Moderate pharyngeal aphasia secondary to large mass at the\n lingual space. Moderate residue within the valleculae. Possible trace\n aspiration as described above.\n\n For further details, please refer to the speech and language pathology report\n from the same date.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-05-27 00:00:00.000",
"description": "Report",
"row_id": 1462449,
"text": "Nursing Note: 1900-0700 pt full code\n\nNeuro: pt awake and alert, sleeping at present. nonverbal comm r/t trach, appears oriented. moves extremities well. c/o incisional pain at trach site overnight, 2mg IV morphine prn given. psych meds restarted this evening.\n\nResp: pt trached with #7 portex, suctioned x 2 for sm amt bloody, freq dressing changes, pt remains on 50% trach collar, sats 97. LS coarse upper, diminished lower bases.\n\nCV: HR 93-99 SR no ectopy, BP 120-145/67-80. last temp 99.9. compression boots on.\n\nGU: pt requires freq voiding with incontinence noted, able to use urinal. UO adequate (see careview).\n\nGI: pos bowel sounds, previous RN pt took eve PO meds but with difficulty r/t pain. no BM.\n\nIV: 20g PIV x 1 WNL, D5 1/2 NS @ 100/hr.\n\nSkin: skin dry and intact.\n\nSocial: no contact from family overnight.\n\nPlan: continue to monitor airway patency and resp status, cont to asses pain and medicate as needed per order. cont to monitor vitals, labs. provide updates on POC to pt as appropriate, assessment ongoing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-05-27 00:00:00.000",
"description": "Report",
"row_id": 1462450,
"text": "Resp Care\nPt. trached yesterday with #7 Portex (epiglottic mass).Came to -4 for overnight observation. Airway patent, cuff inflated with pressure of 30cm.50% TM with SPo2 96-100%.\nBs: clear bilat. pt. expectorating bloody secreations.\nPlan:Follow/protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-05-27 00:00:00.000",
"description": "Report",
"row_id": 1462451,
"text": "Nursing Note:\n\nunable to drawn AM labs via venipuncture x4 attempts, multiple RN's attempted, will notify MD, assessment ongoing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-05-27 00:00:00.000",
"description": "Report",
"row_id": 1462452,
"text": " 4 ICU nursing progress note:\n Respiratory: #7 portex in place. Small amt of serous drainage..site looks good. Sutures intact. Pt denies pain..slight discomfort.\nSuctioned q3-4hrs for thick tan-yellow secretions. Has strong cough and encouraged to do so. Wearing 50% cn..sats 95-98%. rr 18-20\n Cardiac: HR 80-=90sr..BP 110-130/60-70\n GI: Diet advanced to liquids...tolerating well..\n GU: Using urinal..voiding in small amts.\n Endo: Has not required insulin..however now taking liquids..on ssri.\n ID: Afebrile..last dose of antibiotics this evening.\n Social: Brother in and updated. He also spoke with social service.\n Dispo: Per ENT..pt to have continues o2 sat monitoring thru the noc..??dc to floor tomorrow. Family aware.\n Neuro: Pt is alert and orientated..oob to chair with assist of 2. Tolerated well.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-05-27 00:00:00.000",
"description": "Report",
"row_id": 1462453,
"text": "Resp Care\nPt remains trached on cool aerosol trach mask with FIO2 set @ 50%.\nPt has productive cough, no other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-05-28 00:00:00.000",
"description": "Report",
"row_id": 1462454,
"text": "Nursing Note: 1900-0700 pt full code\n\nNeuro: pt 3, ambulated well from chair to bed earlier in evening. follows commands, pt c/o of some mild discomfort at trach site r/t thight sutures. slept well overnight.\n\nResp: #7 portex trach intact, site pink with sm amt serous drainage noted. sats 96-98 on 0.50 trach collar. LS coarse and diminished. no suctioning done overnight, pt has strong cough, cleared some brown thick secretions overnight infrequently.\n\nCV: HR 75-90 SR no ectopy, NBP 100-140/60-70. afebrile. pos distal pulses.\n\nGU: pt keeps urinal at bedside, voids frequently in sm amts, see careview for totals.\n\nGI: pos bowel sounds, tolerating clear liquids and PO meds well.\n\nSkin: skin dry and intact.\n\nIV: 20g PIV r arm WNL.\n\nPlan: cont to monitor resp status, vitals. comfort level. ? C/O to floor tomorrow. asessment ongoing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-05-26 00:00:00.000",
"description": "Report",
"row_id": 1462448,
"text": "MICU NPN Admit to MICU:\n72y.o. male transferred from PACU for overnight observation. Pt has biopsy done of large lingular mass. Pt lives alone at home. He had recent onset hoarse voice and his psychiatrist noted this. Bronchoscopy was done which showed the large supraglotal mass. Initial biopsy done today showed Adeno CA. Portex trach #7 is in place. Site is bleeding slightly and pt is requiring tracheal suctioning Q1-2Hr while in PACU.\n\nPt arrives alert, oriented, cooperative. VSS\n\nPMH: HTN, DM, High cholesterol, Schizoeffective DO\n\nAllergies: NKA\n\nNeuro: Pt c/o slight abdominal discomfort on transfer and c/o slight neck pain at trach site. MAE alert and oriented. Able to swallow, mouth care done. Pt reports that he normally takes his psych meds at night. Team needs to check with Surgeon to see if it is OK to give him his meds PO.\n\nCV: BP 140's/60. HR 80 NSR Denies chest pain. Pneumoboots on.\n\nResp: Pt arrived on 50% trach collar. Lungs coarse with deminished breath sounds throughout. CXR done in PACU showed left lower lobe atelectasis and bilateral pleural effusions. RR 20-30. Trach dressing completely stained with blood. Dressing reinforced.\n\nGI: Abdomen is large obese faint positive bowel sounds heard.\n\nGU: Pt reportedly voids in urinal without difficulty. Has not voided yet in MICU.\n\nID: afebrile\n\nSocial: brother and wife are next of \n"
}
] |
84,998 | 164,945 | IMPRESSION/PLAN: Ms. is a 78yo woman with a PMHx significant only for HTN who presented after having been found down, with new onset atrial fibrillation initially with RVR. Imaging consistent with L MCA stroke with dense L MCA on imaging. Etiology of stroke either cardioembolic due to new onset afib vs. artery-to-artery embolus given apparent history of HL with the questionable use of statin. She was very likely to have significant ongoing neurological deficits and her prognosis was felt to be rather poor. After family discussion, pt transitioned to with plan for dispo to home with hospice. # CODE/CONTACT: ; daughters: : , : | The cardiac, mediastinal and hilar contours are unchanged, with calcification of the thoracic aorta. SUPINE AP VIEW OF THE CHEST: The endotracheal tube has moved distally compared to the prior study, with the tip approaching the ostia of the right main stem bronchus. Occasional atrial premature beats. Sinus rhythm. There are no acute osseous findings. IMPRESSION: Endotracheal tube tip approaches the ostia of the right main stem bronchus, and should be retracted. COMPARISON: at 19:17 from Hospital. No previous tracing availablefor comparison. DFDdp No pleural effusion or pneumothorax is seen. Nasogastric tube tip is within the stomach. Lungs are clear. 9:39 PM CHEST (PORTABLE AP) Clip # Reason: confirmed tube placement MEDICAL CONDITION: 78 year old woman with intubated at outside hospital REASON FOR THIS EXAMINATION: confirmed tube placement FINAL REPORT INDICATION: Intubated at outside hospital. | 2 | [
{
"category": "Radiology",
"chartdate": "2182-11-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1216962,
"text": " 9:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirmed tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with intubated at outside hospital\n REASON FOR THIS EXAMINATION:\n confirmed tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubated at outside hospital.\n\n COMPARISON: at 19:17 from Hospital.\n\n SUPINE AP VIEW OF THE CHEST: The endotracheal tube has moved distally\n compared to the prior study, with the tip approaching the ostia of the right\n main stem bronchus. Nasogastric tube tip is within the stomach. The cardiac,\n mediastinal and hilar contours are unchanged, with calcification of the\n thoracic aorta. Lungs are clear. No pleural effusion or pneumothorax is\n seen. There are no acute osseous findings.\n\n IMPRESSION: Endotracheal tube tip approaches the ostia of the right main stem\n bronchus, and should be retracted. Findings discussed by phone with Dr.\n at 9:56 p.m., .\n DFDdp\n\n"
},
{
"category": "ECG",
"chartdate": "2182-11-20 00:00:00.000",
"description": "Report",
"row_id": 249798,
"text": "Sinus rhythm. Occasional atrial premature beats. No previous tracing available\nfor comparison.\n\n"
}
] |
27,380 | 148,848 | He was admitted to the Trauma Service. Neurosurgery, Orthopedics, Plastics and Urology were consulted given his multiple injuries. He was taken to the operating room for washout and repair of his scrotal tear and for repair of and debridement open right femur fractures; intramedullary rod fixation right femur fracture; debridement and closure of a laceration of the hand. He was taken to the Trauma ICU postoperatively where he remained for several days. He was later taken back to the operating room by Orthopedics for washout and debridement, open femoral fracture wound down to bone, repair patellar tendon disruption, open reduction, internal fixation right patella fracture and open reduction, internal fixation right distal radius and ulnar fractures. There were no intraoperative complications. Eventually he was weaned and extubated and was transferred to the regular nursing unit. He was taken to the operating by Plastics on for placement of arch bars and maxillomandibular fixation, ORIF of right zygomatic fracture and ORIF of right mandibular fracture. He has a Penrose drain which will remain in place until follow up in clinic in 1 week. Because his jaws are wired a Nutrition consult was placed; Ensure Plus supplements were started. He will need to adhere to a soft/liquid diet and will be able to use straws to drink the liquid. Physical and Occupational therapy were consulted and have recommended acute rehab after hospital stay. Social work was consulted early during his hospital stay for emotional support for patient and family. | TLS and c-spine cleared. EKG done, nsr. pt lavaged and sxn'd-lrg tan clot sxn'd and resolved pt's resp distress. Resp Care,Pt.remains intubated overnoc on A/C. ls clear bilat upper lobes and dim bilat lower lobes.GI: abd soft, ND, present BM. corneals impaired.CV-SR. Aline w/ adequate waveform. Hct 31.1 Generalized edema. Bowel regimen ordered. ogt now to low cont sxn-draining bilious. Injured extremities elevated on pillows.Compression boot to LLE; lovenox therapy started .Back & coccyx remain intact without evidence of pressure areas.RLE remains in extension with brace applied. lavaged ogt and cleared up slightly. H2 Blocker for prophylaxis. Scrotom with sutures intact, OTA and elevated. Compression boot on LLE. respiratory carept on the vent changes made tol well. PERRL & brisk at 2-4mm; corneals intact; increasing scleraedema. When light from sedation, patient MAE's & follows commands. Pepcid continues.ID- afebrile; kefzol dosing discontinued now that bolt is out. Maintain SBP<150Pulm-cpap 5/5/.30. RUE splint/ace. 1:28 PM DUP EXTEXT BIL (MAP/DVT); ART DUP EXT UP UNI OR LMTD Clip # Reason: R/O DVT BOTH GROINS PRE IVC FILTER, ? serous fluid as noted. dissection of flap of right subclavian artery, Hct continues low despite transfusions, CT of orbits showing right orbital roof is displaced concerning for right optic nerve compression. Slight resp acidosis noted, vent changes made.GI/GU- Foley with amber/brown urine output, 30-60/hr. right hip aquacel just once a shift. Vented and adeq oxygenation. Hct stable but trending down, now 26.8. mag this am 1.7-repleted with 2gms of magnesium sulfate.RESP: MMV mode 600/5/5/30%-tolerating well. Discussed with MD.Plan- CT head, face and cspine in am, follow ICP and BP. Some sclera edema noted. Moderate serosanginous drainage from left upper, inner thigh abraision and right upper outer thigh incisions. ABG resp. Coccyx/pressure points intact.Pt. tmax 100.4-clindamycin continues for fx's. Hct stable. Foley patent with adeq UO. RLE ace/knee immobilizer. Open fracture site on right outer thigh has vac dressing intact with s/s drainage. Comminuted right patellar fracture and lipohemarthrosis. FINDINGS: Compared to , the right subclavian central venous catheter has been removed. There is displaced left proximal clavicle fracture. COMPARISONS: CT sinus from , CT head from . T/SICU NSG NOTE0700>>EVENTS: S/P ORIF right radial & ulnar fractures S/P ORIF right patella fracture; brace applied. There is a right mandibular fracture and a fracture through the right temporomandibular joint better characterized on sinus CT. There is a comminuted fracture through the right zygomatic arch. The fracture through the right orbital roof is displaced and concerning for right optic nerve compression. Left epidural hematomas. PFI REPORT PFI: Malpositioned right subclavian IV catheter. Surgical bolt in the right temporal lobe with a small focus of associated intraparenchymal hemorrhage and surrounding soft tissue edema. There is a right mandibular fracture and fracture of the right temporomandibular joint, which is better visualized on sinus CT. 3. Left proximal clavicle fracture. COMPARISONS: CT C-spine from and CT sinus/facial from , . Distal aspect of right femoral intramedullary rod is incompletely evaluated. Right mandibular and maxillary fractures. Severely comminuted fracture of the right patella is seen with an inferiorly displaced inferior pole patellar fracture fragment. There is a fracture of the right zygomatic arch. REASON FOR THIS EXAMINATION: Eval SDH No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 1:31 PM Two left-sided frontal epidural hematomas, right frontal subdural hematoma, bilateral frontal pneumocephalus, right frontal fracture, left frontal bone fracture which is depressed and comminuted, numerous right and left orbital and maxillary fractures. Displaced and comminuted fracture of the right frontal bone with associated pneumocephalus and right subdural hematoma. FINDINGS: A series of two intraoperative radiographs demonstrates an obliquely oriented fracture of the distal right radial shaft and a severely comminuted fracture of the distal right ulna. RSC introducer was rewired with MLC but was found to position in head vessel; decision was made to remove central access and not replace at this time as patient has PIV x2 taht were patent. On a single image (2:12), there is an obliquely oriented linear filling defect within the proximal left subclavian artery. Re- demonstrated is a medial clavicular fracture. There is an unchanged small parenchymal hemorrhage with surrounding edema in the right frontal lobe, along the path of a previously present ICP monitor. INDICATION: Status post MVC with right hand laceration. Additionally, there is ground- glass opacity in the medial aspect of the right lower lobe (2:29). The previously noted fracture of the maxillary sinus involving the anterior wall has been internally fixed. Left retrocardiac opacity, compatible with atelectasis. Unchanged left epidural hematomas, right subdural hematoma, and right frontal parenchymal hematoma. FINDINGS: New right subclavian intravenous catheter has been placed, which travels superiorly, probably in the right internal jugular vein, the tip is out of the view. Mild subcutaneous emphysema on the right side appears to be postoperative in nature. There is a focal consolidation of the right lower lobe (2:35), and hazy, ill-defined ground-glass opacity of the peripheral aspect of the left upper and lower lobe (2:28 and 330). A central venous catheter terminates at the medial aspect of the right brachiocephalic vein. There has been interval removal of a surgical bolt. There has been interval removal of a surgical bolt. IMPRESSION: Postoperative changes with internal fixation of mandibular fracture as well as the anterior wall right maxillary sinus fractures. There is hardware within the right proximal femur, and a small focus of gas (2:121), and inflammatory stranding within the subcutaneous tissues of the lateral aspect of the right thigh. Overall alignment is slightly changed compared to the intraoperative radiographs, with slightly worsened foreshortening, improved radial displacement, and worsened palmar angulation of the distal radial fracture fragment. Distal ulna fx fragment is inferiorly displaced. FINDINGS: Previously noted left frontal epidural hematomas and right frontal subdural hematoma are unchanged in size and density. A linear filling defect on a single image within the left subclavian artery may represent a dissection flap. | 52 | [
{
"category": "Radiology",
"chartdate": "2145-07-20 00:00:00.000",
"description": "VEN DUP EXTEXT BIL (MAP/DVT)",
"row_id": 1027254,
"text": " 1:28 PM\n DUP EXTEXT BIL (MAP/DVT); ART DUP EXT UP UNI OR LMTD Clip # \n Reason: R/O DVT BOTH GROINS PRE IVC FILTER, ? LEFT SUBCLAVIAN A DISSECTION\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with multiple fractures\n REASON FOR THIS EXAMINATION:\n r/o groin DVTs for IVC filter placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRc WED 1:36 PM\n 1. No left subclavian artery dissection.\n 2. No DVT at the common femoral veins bilaterally.\n ______________________________________________________________________________\n FINAL REPORT\n VENOUS ULTRASOUND\n\n INDICATION: Status post trauma with multiple fractures. Leg swelling.\n\n FINDINGS: Limited evaluation of the subclavian artery was performed. There\n is no evidence of dissection.\n\n Both common femoral arteries were examined and there is no evidence of\n intraluminal thrombus. Both common femoral veins are easily compressible and\n demonstrate good flow.\n\n IMPRESSION:\n 1. No evidence of left subclavian artery dissection on a limited study.\n 2. No DVT at the common femoral veins bilaterally.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-18 00:00:00.000",
"description": "Report",
"row_id": 1620409,
"text": "21yr male s/p MVA with telephone pole. Unclear if passenger or driver. Other occupant killed. Multipe cranial fractures with small L SDH. Other fractures include R femur and clavicle. Also major laceration of L testicle. Femur and testicle repaired in OR. ICP bolt placed at OSH. 7.5 ET, 24 @ lip. BS essentially CTAB. Minimal secretions. Continue to monitor neuro status and wean vent as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-18 00:00:00.000",
"description": "Report",
"row_id": 1620410,
"text": "Admission Note\n Pt is a 22yo male driver in MVC, passenger pronouced dead at scene, ETOH involved. Pt was intially brought to Hospital scanned then transferred to .\nIntial report of injuries included:\nR open femur fx\nR patella fx\nR wrist fx\nL clavicle fx\nEvulsed scrotum with exposed testicle\nMultiple facial fxs\nR temporal depressed skull fx\nL frontal SDH with pnemocephalus\n\n Pt went to OR from ED and arrived in ICU post-op at 1600. He received multiple units of blood and FFP from OSH (6u PRBCs), ED (2u FFP) and OR (4u PRBCs and 2u FFP). Not reversed from anesthesia and remained on propofol with PRN pain med. Neuro check done off propofol at 1830 and pt consistently FCs, MAEs and squeezing hands for yes/no answers appropriately. + racoon eyes and marked swelling, unable to open to assess pupillary response. Bolt in place with ICP 5-8 and CCP>70.\n Vented and adeq oxygenation. Lungs clear. SR with no ectopy, adeq BP. Repeat HCT stable at 33. afebrile. Vac dressing to R thigh, DSD to multiple abrasions on LLE, cast to R wrist, DSD to scrotum. Abd soft, - BS, NGT to LWS with thick old blood out in small amts. Foley patent with adeq UO.\n Family in at bedside updated on injuries, explained POC and ICU enviroment. They were present for neuro exam and very relieved to see pt FCs and communicate with hand . police called and will be in to arrest pt in day or two, family aware.\n\nPlan- CT scans in am of head, Cspine and face. Need for future OR with time TBD by specific teams. Keep sedated overnight with freq neuro checks and adeq pain meds. Needs hinge brace fro R knee form ortho tech in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-19 00:00:00.000",
"description": "Report",
"row_id": 1620411,
"text": "Resp Care,\nPt.remains intubated overnoc on A/C. ABG resp. alkolosis, RR decreased. Not overbreathing vent. Plan C-Scan this am. BS=, clear. No RSBI due to ICP. Maintain current vent settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-19 00:00:00.000",
"description": "Report",
"row_id": 1620412,
"text": "T/SICU Nursing Progress Note\n1900-0700\n\nPlease see Carevue for exact data.\n\nReview of Systems:\n Pt sedated on Propofol. Fentanyl IVP PRN for pain with good effect. bolt in place. Transduced, ICP 10-18, Goal <20. Cpp's remained greater than 70. Neuro checks q 1 hour, initially ordered for q2 till requested change by nsurg. PERL 3mm/3mm briskly reactive. Consistently following commands, nodding yes and no appropriately. Cough/gag/corneals intact. Some sclera edema noted. Moves LE on bed, lifts and holds UE as tolerated with injuries. + rhinorrhea-> Serous drainage. Dr and nsurg resident aware and in to eval. Pt on bedrest. Logroll. J collar in place ATC. Right knee immobilizer in place, sling on left arm. No suggested order for dilantin. Pt ordered for CT of head and face today per Dr. .\n\nCV- HR 80's, nsr. BP 110-130's/60-70's goal SBP < 140. EKG done, nsr. Hct 31.1 Generalized edema. Cycling CPK's for possible rhabdo. Lab values trending upward. Next CPK at 10 am. 500cc NS bolus given x2 for dropping urine output. 18g L Hand, R SC Trauma Line, L Radial Art Line. NS @ 150. Repleated with Magnesium and Calcium Gluconate. All pulses palpable, ext's warm, cap refill intact.\n\nResp- #7.5 ETT, 24@LL. CMV TV 600, Peep 5, Rate 14, FiO2 40%. LS ctab, diminished at bases. Thin, bloody secretions suctioned from mouth, Min on deep suction. Sats 100%. Slight resp acidosis noted, vent changes made.\n\nGI/GU- Foley with amber/brown urine output, 30-60/hr. Goal ~ 100cc/hr per Dr. for possible rhabdo. Abd soft, absent bs at this time. H2 Blocker for prophylaxis. Bolused with 500cc NS x 2.\n\nSkin- bolt wrapped with gauze and tegaderm. CDI. Left Lower arm in sling, right lower arm in splint. Scrotom with sutures intact, OTA and elevated. Right upper leg (outer aspect of thigh) closed with wound vac dressing. right lateral knee incision ota with staples intact. Multiple abrasions around right knee and one on left inner thigh dressed with vaseline gauze and dsd.\n\nEndo: Bld sugars 90-130, no sliding scale ordered\n\nID- wbc 9, afebrile. Pt on cefazolin q8 hrs.\n\nLytes: Lyte repletion as tolerated\n\nHct: Stable\n\n Mom , step-dad and in to visit overnight. Discussed with MD.\n\nPlan- CT head, face and cspine in am, follow ICP and BP. Goals ICP <20, SBP <140, urine output ~100. Cont to provide pt and family with emotional support, continue to update on .\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-19 00:00:00.000",
"description": "Report",
"row_id": 1620413,
"text": "Addendum: Note written by RN reviewed and signed by preceptor RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-19 00:00:00.000",
"description": "Report",
"row_id": 1620414,
"text": "Respiratory Care\npatient remains on ventilatory support. ABG's drawn to monitor progress.\nAll settings documented in Carevue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-19 00:00:00.000",
"description": "Report",
"row_id": 1620415,
"text": "T/SICU NSG NOTE\n0700>>\n\nEVENTS: CT scans: head, c-spine; CTA of torso.\n TLS and c-spine cleared.\n bolt removed.\n Tube feedings started.\n Serial HCT checks scheduled.\n **Pre-op for tomorrow with orthopedics to repair right patella and right ulnar/radial fractures.(?also plastics to assess right hand wound.)\n Ophthamology toassess orbital injuries d/t fractures.\n\n\nNEURO- sedated with propofol; fentanyl infusion added for analgesia- patient sedate and calm with infusions running.\n PERRL & brisk at 2-4mm; corneals intact; increasing scleraedema. When light from sedation, patient MAE's & follows commands. He is purposeful & reaches consistently for ETT. +cough, impaired gag. Exam is more delayed- less brisk since fentanyl infusion\nbegan. bolt removed by neurosurgical team today.\nPatient able to nod head in response to pain this am; appears comfortable on current dose of fentanyl(150mcg/hour): vital signs are steady & stable and patient tolerates activity without griamcing.\nFacial and crainial swelling persists; HOB now @ 30 degrees.\nNasal drainage has slowed; continues with thick old sanginous fluid.\n\nCVS- see careview; stable vitals. Goal bp >100 and <150 systolic. Blood pressure limits set for questionable left SC dissection flap as seen in one view on CTA of torso. prn dose hydralizine provided x1 prior to fentanyl infusion start.\nRSC introducer has NOT been exchanged for MLC yet.\n\nRESP- vent mode has been changed to PSV 10cm, PEEP 5cm and fio2 remains 30%. ABG with adequate gas exchange. Saturations maintained 98-100%. Breaths sounds are clear throughout; secretions are small mounts of thick old bloody sputum.\n\nRENAL- IVF increased to 200cc/hour with improved hourly output; clear & yellow now. Potassium and calcium repleted.\n\nGI- tube feedings started via OGT; replete w/fiber with goal of 80cc/hour. Abd is soft with hypoactive bowel sounds. Bowel regimen ordered. Pepcid continues.\n\nID- afebrile; kefzol dosing discontinued now that bolt is out.\n wbc wnl\n\nHEME- drifting HCT, 31>>28>>24. Patient is to receive 2 units PRBC's tonight pre-op.\n\nENDO- no issues\n\nSKIN- see careview for details:\n RUE hand wound is covered with primary surgical dressing; site not assessed today. Also splint is present on RUE to stabilize radial & ulnar fractures. Exposed fingers are swollen, but warm with capillary refill <3seconds. Arm remains elevated.\n Right outer thigh incision is covered w/priamry surgical dressing and remains dry & intact.\n Open fracture site on right outer thigh has vac dressing intact with s/s drainage.\n Right lower anterior shin(just below knee) has 3 abraisions that are superficial, red, dry, and covered with xeroform guaze and dry dressing.\n Left scrotal laceration remains sutured, OTA, clean & dry & with minimal edema noted.\n Extremities are warm with easily palpable pulses. Compression boot on LLE.\n NO pressure areas detected; posterior skin surface\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-21 00:00:00.000",
"description": "Report",
"row_id": 1620426,
"text": "Nursing Note 7a-7p\nPt went for repeat head CT-essentially, unchanged. Hct remains @ 26. Placed on cpap-tol well.\n\nNeuro off prop for 10 min-opens eyes spont. mae on bed. no follow. localizes only. strong coug, weak gag. corneals impaired.\n\nCV-SR. Aline w/ adequate waveform. Maintain SBP<150\n\nPulm-cpap 5/5/.30. lungs coarse bilat. dim RLL. suctioned for scant white secretions.\n\nGI-OGT to LCS 750 ml out. remains NPO for PEG. no bm\n\nGU-mobilizing fluids. clear/yellow via foley\n\nInteg-L inner thigh drsg ~q6hr aquacel drsg . right hip aquacel just once a shift. RLE ace/knee immobilizer. RUE splint/ace. RSC old introducer site drsg c/d/i\n\nIV-PIV X2- LR decreased to 75 ml/hr\n\nEndocrine-no ssi required.\n\nI/D-WBC wnl, afebrile\n\nPlan-PEG tomorrow. monitor neuros, Hct. Maintain SBP <150. possible extubation tomorrow. Still needs LUE immobilizer for clavicle fx, when more awake.\n\n, dad, girlfriend visiting. someone on premesis at all times.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-22 00:00:00.000",
"description": "Report",
"row_id": 1620427,
"text": "Nursing Progress Note\nReview of Systems: see carevue for specific data:\n\nNeuro: propofol gtt @ 80mcg/kg/min, when off sedation-pt mae's left side stronger than right-moves spontaneously but not to command.opens eyes and lifts head off of pillow.pupils equal and reactive bilat. impaired corneal on right, intact on left.impaired gag, intact cough.sclera edema decreased in the last 24 hours.\n\nCV: HR 80's-90's-NSR, no ectopy noted. SBP goal is less than 180, maintained throughout night. tmax 100.6. lovenox started last night-hold am dose for OR today. LR @ 75cc/hr. p boot on lle.\n\nRESP: on cpap 5/5/ 30% -tolerated well most of night. around 0330 pt's volumes went down, rr up. psox down to low 90's. sounded very congested, earlier changed to heated circuit. pt lavaged and sxn'd-lrg tan clot sxn'd and resolved pt's resp distress. most of night pt's psox >95% and eupneic. normally sxning scant amt of white/thin sputum. LS coarse bilat upper lobes and dim bilat lower lobes. ABG this am-before incident showed pa02 of 74-will resend new abg.rotated ett tube last night.\n\nGI: abd soft, nd,present BS. npo due to OR today for PEG and possibly trach. ogt most of night draining green bilious and then changed to brown-Dr. aware. lavaged ogt and cleared up slightly. Hct stable. and pt is on a H2B.no BM this shift-on senna and colace.\n\nGU: foley cath draining clear,yellow urine-sometimes with a green tinge. adequate amt of urine an hour.\n\nPain: pt appeared to get uncomfortable at times, arching back. uncomfortable with repositioning. given prn fentanyl with good effect.\n\nEndo: no coverage needed per RISS\n\nSocial: father stayed the night last night in the waiting area.\n\nLabs: hct stable at 27.0, I Ca 1.06-repleted with 2gms of Ca gluconate,K 3.7, Mag 1.9, cpk down to 7053.\n\nPlan: OR for PEG,?trach vs trial extubation?\n hold am lovenox for OR\n pain control\n pulmonary toileting\n assess resp status for any changes, check new abg results\n pain management\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-22 00:00:00.000",
"description": "Report",
"row_id": 1620428,
"text": "resp care\n\nPt had an abrupt ^ in secretions this shift. Very tick, tenacious and pluggy . He was changed over to humidified system but oyxgenation fell and pt required suctioning until finally a moderate sized, green-brown plug was removed from airway. Pt may go for trach and peg today or may get trial extubation first.Since pluggy secretions have newly presented, humidification of airway for a whole shift may be helpful to pt before extubation trial. ABG GOOD OXYGENATION with metabolic alkalosis. RSBI was 97 today\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-22 00:00:00.000",
"description": "Report",
"row_id": 1620429,
"text": "T/SICU SNG NOTE\n0700>>1900\n\nEVENTS: precedex infusion used for wean.\n extubated without event.\n improved neuro exam awake: following.\n successful swallow evaluation; ground diet ordered.\n PT evaluation done; activity advanced.\n\nNEURO- now alert & oriented; appropriate & cooperative. Speech is clear. MAE's and now consistently following commands: see careview assesment. Pt states some 'pins & needles' sensation in RUE, but positive sensation all 4 extremities. +cough & gag. Pupils pre exam: equal & reactive to light @ 3mm/brisk; dilated from ophthomology exam. Precedex infusion was used for wean to extubation with success. Patient now ordered for clonidine patch.\nPatient states pain level is , aching and includes RUR,RLU, back and scrotal areas. Patient is receiving dilaudid .25-.5mg ivp prn with effect; also positive sedation from dilaudid. Tylenol added to analgesic options.\n\nCVS- see careview; stable vitals with appropriate elevations in BP/HR with ativity and discomfort.\n\nRENAL- increasing hourly urine output: auto-diuresing. IVF infusing at 75cc/hour until po diet is tolerated.\n\nRESP- weaned and extubated; now tolerating Face Tent @ 40% without distress. Saturations maintained greater than 95% with varying respiratory rate: low teens to 30. Strong cough that is productive of thick blood tinged sputum; patient requires assistance to clear secretions from mouth. Breath sounds are clear; patient able to take deep breaths on command.\n\nGI- passes swallow evaluation- see note. Ground regular diet with ensure supplements ordered. Pepcid continues. Abd soft with bowel sounds; no stool; bowel regimen continues. Rectal exam this am without evidence of impaction.\n\nID- temp max 100.6; remains on clindamycin for facial fractures; wbc wnl.\n\nENDO- no issues.\n\nSKIN- no new issues: see careview assesment 2 for details. Moderate serosanginous drainage from left upper, inner thigh abraision and right upper outer thigh incisions. Extremties remain warm with palpable pulses. Injured extremities elevated on pillows.\nCompression boot to LLE; lovenox therapy started .\nBack & coccyx remain intact without evidence of pressure areas.\nRLE remains in extension with brace applied. Multipodus bots applied today.\nPT evaluations doone; patient dangled at bedside and transferred to chair with max assist; pad in place for return to bed activity.\n\nSOCIAL- multiple family memebers visiting today; frequent updates and explanations provided & questions answered. Family is pleased with patient's progress espescially now that he is extubated and talking appropriately.\n\nA/P: extubated\n diet started; probable no PEG at this time pending success of po diet.\n activity advanced- OOB\n probable plastic surgery next week for facial fracture repair.\n family aware of all plans.\n assess for transfer to floor in am.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-23 00:00:00.000",
"description": "Report",
"row_id": 1620430,
"text": "Nursing (1900-0700)\nPt. groggy, appropriate, oriented. Speech slurred last eve ?narcotic related, clearer this a.m. No recall of accident. He stated last eve that he had \"blurry vision\", but this has improved this a.m. It is still difficult for him to see the tv clearly. Pt. MAE with some weakness/difficulty due to fractures in all but LLE. Pain as noted, not utilizing PCA very much, prn dilaudid supplemented.\n\nSkin warm, dry. Pt. with ace wraps to right leg and arm. Femur fx fixation site oozing large amts. serous fluid as noted. Otherwise few scattered mild abrasions noted. Coccyx/pressure points intact.\n\nPt. tolerating thin liquids this shift. Abd. benign. Diet per speech/swallow yesterday - pureed solids.\n\nPt. remained in chair until 9pm and was hoyered back to bed due to fatigue. Sleeping in long naps without difficutly.\n\nNo further clinical problems noted, see flowsheet for assessment.\nA/P: Pt. s/p mvc, multiple orthopedic injuries - all fixed but facial fx's. Neurosurgical issues resolved. Pt. stable.\n?Transfer to floor today. Pulmonary toilet. Continue to optimize mobility, comfort, safety.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-21 00:00:00.000",
"description": "Report",
"row_id": 1620423,
"text": "Nursing Progress Note\nReview of Systems:See carevue for specific data\n\nNeuro: on propofol gtt @ 60mcg/kg/min.off propofol pt not follow commands,pupils 3mm and brisk bilat,impaired corneal-bilat sclera edema, pt unable to open eye, edema?,most seen is left eye open a small amt. impaired gag and intact cough. moves all extremities on bed, stronger on left than right. pt gets agitated when off propofol too long, lift head off pillow and starts coughing uncontrollably.\n\nCV: HR 80's-90's,NSR with no ectopy noted. goal SBP is < 150's, maintained throughout night while on the propofol and prn fentanyl. tmax 100.4-clindamycin continues for fx's. LR @ 250cc/hr. CPK trending down-now 11,950. Hct stable but trending down, now 26.8. mag this am 1.7-repleted with 2gms of magnesium sulfate.\n\nRESP: MMV mode 600/5/5/30%-tolerating well. rr and psox wnl. sxning small amt of white/thick sputum. rotated ett. ls clear bilat upper lobes and dim bilat lower lobes.\n\nGI: abd soft, ND, present BM. started on senna and colace. no BM today. made npo after midnight for OR today to place PEG. ogt now to low cont sxn-draining bilious. tf was replete with fiber and goal should be 80cc/hr.\n\nGU: foley cath draining clear,yellow , and adequate amt of urine an hour.\n\nPain: given prn fentanyl with turns and repostioning-positive effect on pt, HR and BP trend down after a dose.\n\nSocial: family in visiting last evening. mother and fiance stayed in waiting area last night. someone is suppose to come with a supina for pt's chart today to make a copy.\n\nPlan: OR today for PEG\n ? extubate after OR\n ? IVC filter or anticoagulation to be started\n assess neuro status for any changes\n maintain SBP < 150\n trend Hct's and CPK's\n when more awake needs splint for lue for clavicle fx for comfort\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-21 00:00:00.000",
"description": "Report",
"row_id": 1620424,
"text": "Resp care\n\nPt remained in MMV mode overnight ( .6Lx7BPM=4.2 L MMV ). However, breathing remaiined active all night and only PSV/CPAP portion of mode was used by patient. He had surgery for his leg yesterday, today he will return to OR again as he still needs a PEG and facial bone reconstruction over several OR visits.RSBI 35, ABG showing compensated resp acidosis . Pt sx for small to mod amt secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-21 00:00:00.000",
"description": "Report",
"row_id": 1620425,
"text": "respiratory care\npt on the vent changes made tol well. see respiratory page of carevue for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-19 00:00:00.000",
"description": "Report",
"row_id": 1620416,
"text": "T/SICU NSG NOTE\n(Continued)\ns intact.\nSOCIAL- multiple family memebers present throughout the day. Frequent progress and plan of care updates provided. Social service support provided- see note.\n\nASSESS: 21 yo male s/p high speed MVC with multi-trauma- see admit note.\n > possible new injury identified per CTA of torso: dissection flap of R subclavian artery. Also noted: grade 1 renal injury.\n > stable & consistent neuro exam\n > remains intubated for OR in am to repair remaining ortho injuries.\n > repair of facial injuries at later date when facial swelling is less.\n\nPLAN- pre-op for tomorrow\n keep sedated overnight with Q2 hour neuro checks\n hold tube feeds at midnight\n transfuse 2units PC pre-op; continue with serial CHT checks.\n consider wean to extubate post-op if patient stable and tolerated SBT and has cuff leak.\n continue assessment of LUE for neurovascular change indicated LSC vascular changes related to dissection. Maintain BP <150/\n continue with family/patient support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-20 00:00:00.000",
"description": "Report",
"row_id": 1620417,
"text": "Neuro patient on propofol 50mcg/kg/min, and fentanyl 150mcg/hr neuro exam done off propofol continued on fentanyl. Patient arousable with loud talking and sternal rub moves all extremities sometime inconsistent with following commands, pupils equal and reactive, corneal impaired, scleraedema OD>OS, natural tears given opthm consult done unable to dilate eyes per team need to do neuro exam, +gag\nResp 30% PS 10 peep 5 TV 500 resp rate 12-16 lungs clear abg7.38/48/116/29/2 o2 sats >97% sx for min white secretions\nGI npo after mn for OR today abd soft nontender no stool hypo active bowel sounds given colace and senna\nGU u/o 30-120 copper color IVF NS at 200cc maintained given 500cc fluid bolus for low u/o min effect yesterday +5liter yest BUN 13 cr .8\nCVS Hct 25.6 after 2uprbc INR 1.2 on unit PRBC BP 119/56-157/ given hydralazine 20mg IV x1, Mag 1.8 tx. Skin w+D pp+ +radial pulses cap refill both arms <3 sec\nendo not requiring ss insulin coverage\nskin RUE hand wound covered with primary surgical dressing with splint and ace wrap +radial and +ulnar fx exposed finger edematous with + capillary refill <3sec\nright outer thigh incision is covered w/primary dressing D+I, right outer thigh with vac dressing intact serosang drainage. right lower ant shin 3 abrasions clean and dry.\nleft scrotal lacerations remains sutured OTA clean and dry +edema\nleft arm in sling to protect lt clavicle fx\nsocial family in slept outside of unit\naccess RT SC trauma line, 18g lt hand peripheral, right radial aline\na. 21 yo mva with fatality at scene ? dissection of flap of right subclavian artery, Hct continues low despite transfusions, CT of orbits showing right orbital roof is displaced concerning for right optic nerve compression. ? Rhabdo with elevated ck and brownish urine\nP. to OR in am transfuse to a total of 4u prbc check hct post, maintain bp < 150/, see opthm note possibly dilate eyes today, continue to support family and patient, keep pt hydrated goal of 100cc qhr urine, monitor lytes and renal cr and bun closely replete lytes prn, continue to asscess LUE for neurovascular changes related to possible dissection flap of Rt subxlavian artery\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-20 00:00:00.000",
"description": "Report",
"row_id": 1620418,
"text": "Resp Care\n\nPt is to be returning to OR today for repair of orthopedic injury ( ? leg ). He is alert although his eyes are closed. ABG mostly compensated respiratory acidosis and good oxygenation. Pt is on PSV/CPAP. Spont RSBI is 43. ICP bolt pilled yesterday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-20 00:00:00.000",
"description": "Report",
"row_id": 1620419,
"text": "respiratory care\npr on the vent changes made tol well. see respiratory page of carevue for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-20 00:00:00.000",
"description": "Report",
"row_id": 1620420,
"text": "T/SICU NSG NOTE\n0700>>\n\nEVENTS: S/P ORIF right radial & ulnar fractures\n S/P ORIF right patella fracture; brace applied.\n Removal of VAC dressing on right outer thigh wound; site sutured closed.\n Ultrasound of LLE and left subclavian vessles to assess ? dissection- reports pending.\n Failed rewiring of LSC central line; access discontinued.\n Returned to PSC/CPAP mode\n\nNEURO- patient in OR 0730 to 1200; returned from OR with paralytic med on board and shivering..required propofol & fentanyl boluses to settle. Pupils remained equal and briskly reactive to light at 3mm.(right pupils at times appears irregular in shape.) Sedation not suspended for exam until 1445 due to various procedures occurring: central line change, ultrasound, xray. Patient slow to wake and respond; fentanyl infusion continued @ 100mcg/hour for analgesia post-op. Patient with intermittent and brief periods of response to vigorous stimulation and voice prompts. Inconsistent following commands, but moving spontaneoulsy at pre-op level: wiggling both feet, bending left leg, lift & holding both upper extemities off bed, and spontaneous right hand grasp to hand being held. Intact cough and impaired gag; impaired right corneal, intact left corneal; head turning toward voice, and lifting head & shoulders off bed. No movement of right fingers noted but warm with normal capillary refill. Attempts to open eyes noted; swelling persists. Patient localizes to nailbed pressure. Fentanyl reduced to 50mcg/hour in attempt to lighten sedation further and was stopped at ~1800. By 1830, patient was moving more vigorously and frequently in bed with attempts to shift position; his cough & gag reflexes were stronger and patient became distressed due to retained secretions- biting & choking on ETT and attempting to reach ETT with left hand. Propofol was restarted @ 1830 and fentanyl infusion was suspended with prn dosing resummed. PAtietn settled without further event.\n\nCVS- see careview for details. Goal BP remains < 150 systolic; no hydralizine required this shift. Vitals respond to propofol & fentanyl administration. Rare PVC noted. Mg++, Ca+, K+ all repleted.\n RSC introducer was rewired with MLC but was found to position in head vessel; decision was made to remove central access and not replace at this time as patient has PIV x2 taht were patent.\n LLE ultrasound was done to assess for clot.\n LSC ultrasound was done to assess ? dissceted area seen on CTA ...results pending on both tests.\n\nRESP- vent mode changed to MMV with back-up mode available as needed due to ongoing sedation. PSV & CPAP settings are . Patient has maintained a spontaneous MV of 6.5 liters with ABG revealing acceptable gas exchange(tolerating PCO2 of 51 at this time).\nBreath sounds remain clear with slightly diminished RLL; mild congestion appreciated and scant to small amount of thick tan(old blood) secretions cleared with suctioning. NO plan to extubate today.\nVAP prevention prot\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-20 00:00:00.000",
"description": "Report",
"row_id": 1620421,
"text": "T/SICU NSG NOTE\n(Continued)\nocol in effect.\n\nRENAL- adequate hourly urine output; drainage is postional. IVF changed to LR at 250cc/hour- clear & yellow.\n\nGI- OGT in place; pepcid ongoing. Tube feedings resummed post-op. Abd is soft with hypoactive bowel sounds. Bowel regimen to be resummed.\nPossible PEG placement tomorrow to provide adequate nutrition pending repair of facial fractures with jaw wiring within next 5-7 days. Unable to place NG access due to nasal & skull fractures and + pneumoocephalus.\n\nHEME- received total 4 units PRBCs pre-op and 1 unit intra-op; post-op HCT of 33; INR wnl; platelets remain ~ 75K.\n Plan to follow HCT checks.\n\nID- tmax 99.4 post-op. Clindamycin dosing started per plastics team request. WBC wnl.\n\nENDO- no issue\n\nSKIN- see careview assessment area 2 for specifics.\n NEW incisions today: right ulnar & radial sies and right knee- all sites are covered with surgical dressing and are unable to be assessed by nursing at this time.\n RUE has new splint & ace wrap. RLE has ace wrap covering all incisions and impaired sites. brace was fitted by ortho tech today & is positioned & locked in full extension. Both upper extremities are nonweight bearing; RLE is touch down only per ortho. PT/OT consults ordered and are pending visits when appropriate.\n Left testicular suture line is C&D; scrotum is notable for increased swelling and bruising discoloration today.\n Left upper inner thigh abraision site is draining small amounts of serous fluid.\n Right outer thigh and flank incision (from surgery), are OTA and are draining serous fluid- aquacel and DSD applied to sites.\n Back & buttocks remain intact without pressure areas; coccyx slightly pink post-op..side to side turning resummed.\n Compression boot to LLE continues; no anticoagulatin ordered as yet.\n\nSOCIAL- multiple family members visiting throughout the day. Progress updates provided in depth with changes in plan of care made known with understanding acknowledged. Family with many questions regarding patient's course of recovery- timming and sequencing of plans.. information provided as able. Family remains outwardly calm and appropriate with acknowledgment of progress patient has made and awareness of future procedures required.\n\nASSESS- tolerated ORIF of fractures to RU & RL extemities.\n increased sedation and delayed waking post-op requiring adjustment to sedation and analgesic therapy.\n deferring extubation until PEG can be placed for continued adequate nutritional support during jaw wiring period and due to inability to use nasal access.\n\nPLAN- adjust sedation/analgesia to allow for quicker waking and improved neuro response. Assess analgesia requirements.\n monitor hct post-op\n monitor for signs of infections post-trauma & post-op\n wean vent as tolerated but delay extubation pending PEG placement- TBD- possibly .\n continue to assess effected extremities(RU,,RL for compromise\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-07-20 00:00:00.000",
"description": "Report",
"row_id": 1620422,
"text": "T/SICU NSG NOTE\n(Continued)\npost-injury and post-op.\n monitor for pulmonary compromise related to potential LE clot or fat emboli- desaturation and increased respiratory work &/or distress.\n continue with family support & communication.\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026966,
"text": " 9:01 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for tube/CVL placement, interval change\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man intubated with R CVL, s/p MVC with pulm contusions\n REASON FOR THIS EXAMINATION:\n eval for tube/CVL placement, interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after right central venous line\n insertion.\n\n Portable AP chest radiograph was reviewed with no prior studies available for\n comparison.\n\n The ET tube tip is 5 cm above the carina. The NG tube tip is in the stomach.\n The right subclavian line is not clearly seen and might terminate at the\n junction of the subclavian vein and brachiocephalic vein, although it should\n be assessed clinically. A repeated radiograph with no obscuring devices is\n recommended.\n\n The cardiomediastinal silhouette is unremarkable. Bibasilar opacities are\n consistent with atelectasis. Left pleural effusion is demonstrated with\n accompanying fracture of the second rib. The mediastinal contour is\n indistinct with no clear contour of the aortic arch; thus, evaluation with\n chest CTA is highly recommended to exclude the possibility of aortic injury.\n\n Findings were discussed with Dr over the phone by Dr on\n at 9 am approximately.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-18 00:00:00.000",
"description": "R FEMUR (AP & LAT) RIGHT",
"row_id": 1026952,
"text": " 7:56 PM\n FEMUR (AP & LAT) RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # \n Reason: FX REPAIR\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT FEMUR, 10 VIEWS\n\n INDICATION: Fracture repair.\n\n FINDINGS: A series of 10 intraoperative radiographs demonstrates\n intramedullary rod fixation of a transversely oriented fracture of the right\n humeral diaphysis. Comminuted fracture of the patella is also seen. There is\n gas in the soft tissues adjacent to the fracture line suggestive of a\n laceration. Please refer to operative report for full details.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-18 00:00:00.000",
"description": "R HAND, AP & LAT. VIEWS RIGHT",
"row_id": 1026953,
"text": " 8:01 PM\n HAND, AP & LAT. VIEWS RIGHT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT\n Reason: REDUCTION IN THE OR\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT WRIST, TWO VIEWS.\n\n INDICATION: Reduction in the OR.\n\n FINDINGS: A series of two intraoperative radiographs demonstrates an\n obliquely oriented fracture of the distal right radial shaft and a severely\n comminuted fracture of the distal right ulna. Provided views demonstrate\n dorsal and radial displacement of the distal fracture fragment at the radial\n fracture line and severe comminution of the distal ulnar fracture. Please\n refer to operative report for full details.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1027026,
"text": " 8:57 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval SDH\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with MVC, SDH.\n REASON FOR THIS EXAMINATION:\n Eval SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 1:31 PM\n Two left-sided frontal epidural hematomas, right frontal subdural hematoma,\n bilateral frontal pneumocephalus, right frontal fracture, left frontal bone\n fracture which is depressed and comminuted, numerous right and left orbital\n and maxillary fractures.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 21-year-old man with motor vehicle collision, subdural hematoma.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n COMPARISONS: CT C-spine from and CT sinus/facial from , .\n\n FINDINGS: Along the superior portion of the frontal lobe, there are two\n epidural hematomas with associated pneumocephalus. Along the right frontal\n lobe, there is an acute subdural hematoma with associated pneumocephalus.\n\n There is a 5-mm depressed and comminuted fracture of the right frontal bone\n with associated pneumocephalus. There is significant bilateral soft tissue\n swelling with subcutaneous emphysema and bilateral subgleal hematomas.\n\n There is a surgically placed bolt in the right frontal lobe. At the\n termination of the bolt within the right frontal lobe, there is a 6 x 5 mm\n area of hyperintensity with a surrounding area of hypointensity. This is\n consistent with a small area of intraparenchymal bleed with associated soft\n tissue edema.\n\n There is bilateral frontal sinus opacification with an air-fluid level present\n within the left frontal sinus. There is a fracture of the right zygomatic\n arch. There is a fracture of the anterior portion of the right frontal\n bone, with extension of the fracture into the right frontal sinus with\n fracture of the posterior wall. There are extensive fractures of the left and\n right orbits and nasal bones, which are better characterized on the sinus CT\n examination.\n\n The ventricles are bilaterally symmetric, and there is no mass effect. The\n small ventricles and lack of prominent sulci could be characteristic for a\n patient of this age.\n\n IMPRESSION:\n (Over)\n\n 8:57 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval SDH\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Left-sided frontal lobe epidural hematomas. Right-sided frontal subdural\n hematoma. There is associated pneumocephalus with these areas of hemorrhage.\n 2. Surgical bolt in the right temporal lobe with a small focus of associated\n intraparenchymal hemorrhage and surrounding soft tissue edema.\n 3. Right frontal bone fracture which is depressed and comminuted.\n 4. Left frontal bone fracture with extension through the posterior wall of\n the left frontal sinus.\n 5. Multiple fractures of bilateral orbits and nasal bones which are better\n characterized on facial CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-18 00:00:00.000",
"description": "TRAUMA #3 (PORT CHEST ONLY)",
"row_id": 1026899,
"text": " 9:53 AM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n TRAUMA CHEST XRAY\n\n COMPARISON: CT Chest same day.\n\n HISTORY: Trauma.\n\n FINDINGS: The exam is somewhat limited due to overlying trauma board. An\n endotracheal tube is seen 5.1 cm above the carina. There is no evidence of\n pneumothorax, frank consolidation, or effusion. The cardiomediastinal\n silhouette is unremarkable. There is displaced left proximal clavicle\n fracture.\n\n IMPRESSION: ET tube 5.1 cm above carina. No evidence of pneumothorax. Left\n proximal clavicle fracture. Please refer to CT chest performed prior to this\n study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1027027,
"text": ", F. TSICU 8:57 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval SDH\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with MVC, SDH.\n REASON FOR THIS EXAMINATION:\n Eval SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Two left-sided frontal epidural hematomas, right frontal subdural hematoma,\n bilateral frontal pneumocephalus, right frontal fracture, left frontal bone\n fracture which is depressed and comminuted, numerous right and left orbital\n and maxillary fractures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-19 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1027028,
"text": " 8:57 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fx, dislocation\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with skull and facial fx s/p high-speed MVC with inadequate\n c-spine films from OSH\n REASON FOR THIS EXAMINATION:\n eval for fx, dislocation\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 1:56 PM\n There is no cervical spinal fracture and there is normal alignment of the\n cervical spine.\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 21-year-old man with skull and facial fractures status post\n high speed motor vehicle collision with inadequate C-spine films from outside\n hospital. Evaluate for fracture and dislocation.\n\n TECHNIQUE: Contiguous axial non-contrast images of the cervical spine were\n obtained without IV contrast. Sagittal and coronal reconstructions were\n obtained.\n\n COMPARISONS: CT sinus from , CT head from .\n\n FINDINGS: There are no disc, vertebral or paraspinal abnormalities seen.\n There is no sign of fracture or abnormal alignment. However, CT is not able\n to provide intrathecal detail comparable to MRI. Visualized outline of thecal\n sac appears unremarkable.\n\n There is a fracture of the right first rib and a fracture of the left second\n rib. There is a right mandibular fracture and a fracture through the right\n temporomandibular joint better characterized on sinus CT.\n\n There is fluid within the sphenoid sinuses.\n\n The patient is intubated; however, the tip of the endotracheal tube is not\n visualized in this study.\n\n IMPRESSION:\n 1. There is no cervical spine fracture and there is normal alignment of\n osseous structures.\n 2. There is a right mandibular fracture and fracture of the right\n temporomandibular joint, which is better visualized on sinus CT.\n 3. Right-sided first rib fracture and left-sided second rib fracture.\n\n\n (Over)\n\n 8:57 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fx, dislocation\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-19 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1027029,
"text": ", F. TSICU 8:57 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fx, dislocation\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with skull and facial fx s/p high-speed MVC with inadequate\n c-spine films from OSH\n REASON FOR THIS EXAMINATION:\n eval for fx, dislocation\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n There is no cervical spinal fracture and there is normal alignment of the\n cervical spine.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-19 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 1027030,
"text": " 8:58 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: evaluate for fx\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with skull and facial fx s/p high-speed MVC with inadequate\n c-spine films from OSH\n REASON FOR THIS EXAMINATION:\n evaluate for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 1:47 PM\n PFI: Multiple skull, orbital, nasal fractures. Depressed fracture through\n the right orbital roof raises concern for optic nerve compression.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 21-year-old man with skull and facial fractures status post high-\n speed motor vehicle collision with inadequate C-spine films from outside\n hospital, evaluate for fracture.\n\n TECHNIQUE: Contiguous axial images were acquired through the paranasal\n sinuses. Coronal reformatted images were prepared.\n\n FINDINGS: There is a 5-mm depressed and comminuted fracture through the right\n frontal bone which was seen on prior CT and is associated with pneumocephalus\n and a right-sided subdural hematoma.\n\n There is a fracture through the anterior portion of the left frontal bone,\n which extends obliquely through the posterior wall of the frontal sinus and is\n associated with adjacent pneumocephalus and a right-sided epidural hematoma.\n This fracture crosses through the cribriform plate and extends into the\n ethmoid sinus.\n\n There is a 2-mm depressed fracture through roof of the left orbit and a non-\n displaced fracture of the left inferior orbital rim.\n\n There is a depressed and angulated fracture of the roof of the right orbit.\n This displaced fracture extends inferiorly and may compromise the optic nerve.\n There is a 2-mm medially displaced fracture of the right medial orbital rim.\n\n There is a fracture through the body of the right mandible as well as the\n right maxilla. There is a fracture through the lateral portion of the glenoid\n fossa of the right temporomandibular joint.\n\n There is a fracture through the pterygoid plate and a fracture through the\n sphenoid sinus.\n\n The right maxillary sinus is opacified and there is an air-fluid level present\n within the left maxillary sinus.\n\n There is a comminuted fracture through the right zygomatic arch.\n\n (Over)\n\n 8:58 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: evaluate for fx\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The patient is intubated with an endotracheal tube and a nasogastric tube;\n however, the tip of the endotracheal tube is not visualized on this study.\n\n IMPRESSION:\n 1. Multiple fractures through the right and left orbits. The fracture\n through the right orbital roof is displaced and concerning for right optic\n nerve compression.\n 2. Fracture through the left frontal bone extending to the posterior wall of\n the frontal sinus raises the possibility for intracerebral infection.\n 3. Displaced and comminuted fracture of the right frontal bone with\n associated pneumocephalus and right subdural hematoma.\n 4. Left epidural hematomas.\n 5. Right mandibular and maxillary fractures.\n 6. Opacifications of bilateral maxillary sinuses.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-19 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 1027031,
"text": ", F. TSICU 8:58 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: evaluate for fx\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with skull and facial fx s/p high-speed MVC with inadequate\n c-spine films from OSH\n REASON FOR THIS EXAMINATION:\n evaluate for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Multiple skull, orbital, nasal fractures. Depressed fracture through\n the right orbital roof raises concern for optic nerve compression.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1027412,
"text": " 5:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with fever, s/p intubation\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MPSc WED 11:48 AM\n Increased bibasilar atelectasis. Superimposed pneumonia or aspiration cannot\n be excluded. Right subclavian catheter removal without pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Fever with intubation, right central venous catheter\n removal.\n\n STUDY: Semi-upright portable frontal chest x-ray.\n\n FINDINGS:\n\n Compared to , the right subclavian central venous catheter has been\n removed. No pneumothorax. Endotracheal and NG tube are in expected and\n unaltered positions. There is increased bibasilar opacity consistent with\n worsened atelectasis, with near complete collapse of the left lower lobe.\n Other superimposed aspiration or pneumonia cannot be excluded. Heart size and\n mediastinal contour are unchanged. As before, there is a left clavicle\n fracture and left second rib fracture.\n\n IMPRESSION:\n Worsening bibasilar atelectasis with near complete collapse of the left lower\n lobe. Superimposed pneumonia or aspiration cannot be excluded.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1027313,
"text": ", F. TSICU 1:28 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check line placement, right sc-tlc. r/o ptx.\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with multiple trauma, intubated.\n REASON FOR THIS EXAMINATION:\n check line placement, right sc-tlc. r/o ptx.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Malpositioned right subclavian IV catheter. Left retrocardiac\n atelectasis, otherwise no significant change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-18 00:00:00.000",
"description": "R KNEE( (SINGLE VIEW) RIGHT",
"row_id": 1026949,
"text": " 7:49 PM\n KNEE( (SINGLE VIEW) RIGHT; -76 BY SAME PHYSICIAN # \n Reason: eval patella fx\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with MVC R patella fx seen on fluoro\n REASON FOR THIS EXAMINATION:\n eval patella fx\n ______________________________________________________________________________\n WET READ: SBNa SUN 8:40 PM\n Single view demonstrates comminuted patellar fracture with inferior\n displacement of distal fx fragments. +Lipohemarthrosis in knee joint. Pt is\n s/p ORIF of femur.\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT KNEE, TWO VIEWS.\n\n INDICATION: Evaluate patellar fracture.\n\n FINDINGS: Distal aspect of an intramedullary rod of the right femur is seen\n with two distal interlocking screws. Severely comminuted fracture of the\n right patella is seen with an inferiorly displaced inferior pole patellar\n fracture fragment. There is lipohemarthrosis. Lucency within the tibia may\n reflect the site of previous external fixator device.\n\n IMPRESSION:\n\n 1. Comminuted right patellar fracture and lipohemarthrosis.\n\n 2. Distal aspect of right femoral intramedullary rod is incompletely\n evaluated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-20 00:00:00.000",
"description": "VEN DUP EXTEXT BIL (MAP/DVT)",
"row_id": 1027255,
"text": ", F. TSICU 1:28 PM\n DUP EXTEXT BIL (MAP/DVT); ART DUP EXT UP UNI OR LMTD Clip # \n Reason: R/O DVT BOTH GROINS PRE IVC FILTER, ? LEFT SUBCLAVIAN A DISSECTION\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with multiple fractures\n REASON FOR THIS EXAMINATION:\n r/o groin DVTs for IVC filter placement\n ______________________________________________________________________________\n PFI REPORT\n 1. No left subclavian artery dissection.\n 2. No DVT at the common femoral veins bilaterally.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1027610,
"text": ", F. TSICU 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with increasing secretions\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n PFI REPORT\n Improved bibasilar atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-18 00:00:00.000",
"description": "RP HAND (AP, LAT & OBLIQUE) RIGHT PORT",
"row_id": 1026948,
"text": " 7:46 PM\n HAND (AP, LAT & OBLIQUE) RIGHT PORT Clip # \n Reason: see below\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with MVC R hand lac, eval for fx\n REASON FOR THIS EXAMINATION:\n see below\n ______________________________________________________________________________\n WET READ: SBNa SUN 8:44 PM\n Transverse comminuted fractures of the distal radius and ulna with\n displacement and volar angulation of fx fragments. Distal radius fx fragment\n is superiorly displaced and overrides the proximal fx fragment by approx 2 cm.\n Distal ulna fx fragment is inferiorly displaced. Overlying cast material\n limits exam.\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT WRIST, THREE VIEWS.\n\n INDICATION: Status post MVC with right hand laceration. Evaluate for\n fracture.\n\n FINDINGS: Comparison to the previous study from at 3:36 p.m. Again\n noted is an obliquely oriented fracture of the distal right radial shaft.\n There is dorsal displacement greater than one shaft width, slight radial\n subluxation, palmar angulation, and foreshortening of the radius at the site\n of the radial fracture. Severely comminuted fracture of the distal ulna is\n seen with radial angulation, radial displacement, and palmar angulation and\n displacement of the distal fracture fragment. The distal ulna appears\n dorsally subluxed with respect to the distal radius and the carpus. No\n definite carpal fracture is seen. A cast is in place that obscures fine bony\n detail. Overall alignment is slightly changed compared to the intraoperative\n radiographs, with slightly worsened foreshortening, improved radial\n displacement, and worsened palmar angulation of the distal radial fracture\n fragment. Severe soft tissue swelling is seen.\n\n IMPRESSION:\n\n Displaced and angulated fractures of the distal right radial shaft and the\n distal right ulna as described.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-28 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 1028857,
"text": " 9:49 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: Assess for alignment of fracture fragments. Please do 3d rec\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man s/p multiple facial trauma now s/p repair\n REASON FOR THIS EXAMINATION:\n Assess for alignment of fracture fragments. Please do 3d reconstructions\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE SINUSES\n\n CLINICAL INFORMATION: Patient with multiple facial fractures status post\n surgery.\n\n TECHNIQUE: Axial images of the sinuses were obtained with coronal reformats.\n Comparison was made with the previous CT examination of \n\n FINDINGS: Again multiple facial fractures are identified involving the right\n maxillary sinus, mandible on the right side and the left frontal bone. Since\n the previous study, there has been post-surgical fixation of the mandibular\n fracture. The fracture fragments are now better aligned and apposition.\n Fracture of the ramus of the mandible is also visualized. Additional\n fractures of the pterygoid plates are seen as well as the right zygomatic\n arch.\n\n The previously noted fracture of the maxillary sinus involving the anterior\n wall has been internally fixed. The previously noted gap at the fracture site\n has reduced. The lateral fracture is again identified with mild depression.\n Again, extensive sinus soft tissue changes are identified involving maxillary,\n ethmoid, frontal, and sphenoid sinuses. Partially visualized are extra-axial\n hematomas in both frontal region. Mild subcutaneous emphysema on the right\n side appears to be postoperative in nature.\n\n IMPRESSION: Postoperative changes with internal fixation of mandibular\n fracture as well as the anterior wall right maxillary sinus fractures.\n Extensive sinus soft tissue changes and other fractures involving the\n bilateral frontal bone, right zygomatic arch, pterygoid plates are again\n visualized.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-19 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1027034,
"text": " 9:12 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for aortic and other traumatic injury\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with ? aortic injury s/p high speed MVC\n REASON FOR THIS EXAMINATION:\n eval for aortic and other traumatic injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl MON 1:35 PM\n 1. No evidence of acute traumatic aortic injury.\n 2. Obliquely oriented linear filling defect within the proximal subclavian\n artery may represent a dissection flap.\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO WITH INTRAVENOUS CONTRAST\n\n HISTORY: 21-year-old male status post high speed motor vehicle collision.\n Evaluate for aortic and other traumatic injury.\n\n COMPARISON: No prior studies are available for comparison at this time.\n\n TECHNIQUE: MDCT-acquired axial images were obtained from the lung apices to\n the pubic symphysis with 5 mm slice thickness, following intravenous\n administration of 130 cc of Optiray contrast. Coronal and sagittal\n reformatted images were created.\n\n FINDINGS:\n CHEST: There is no evidence of acute traumatic aortic injury. On a single\n image (2:12), there is an obliquely oriented linear filling defect within the\n proximal left subclavian artery. This may represent a dissection flap.\n\n The central pulmonary arteries opacify normally, without evidence of some\n central pulmonary embolism. However, the study is not optimally timed for\n evaluation of the smaller segmental and subsegmental pulmonary emboli.\n\n There is no mediastinal hematoma.\n\n There is dependent atelectasis within the lung bases bilaterally. There is a\n focal consolidation of the right lower lobe (2:35), and hazy, ill-defined\n ground-glass opacity of the peripheral aspect of the left upper and lower lobe\n (2:28 and 330). This is a nonspecific CT appearance, and may represent\n pulmonary contusion in the setting of trauma. Additionally, there is ground-\n glass opacity in the medial aspect of the right lower lobe (2:29). There is\n segmental collapse of the medial left lower lobe (2:28). There is no\n pericardial effusion.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, gallbladder and\n spleen are normal on arterial phase imaging. The right kidney is normal.\n (Over)\n\n 9:12 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for aortic and other traumatic injury\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Adjacent to the posterior aspect of the interpolar region of the left kidney,\n is a crescentic-shaped fluid collection that measures 1 cm in transverse\n dimension and is consistent with a grade 1 renal injury. There is associated\n fluid tracking along the left paracolic gutter (2:67 and 2:79). There is\n normal symmetric contrast enhancement of the kidneys. The renal collecting\n systems are normal. Within the right kidney, is a cortically based too small\n to characterize 6-mm hypodense lesion. There is no surrounding fluid to\n suggest traumatic injury, and this statistically most likely represent a renal\n cyst.\n\n The pancreas is normal.\n\n There is no free air within the abdomen. Contusion of the right int. obl.\n muscle is noted.\n\n There is no mesenteric or retroperitoneal lymphadenopathy.\n\n Evaluation of the bowel is limited without the wall thickened without the use\n of oral contrast. The small bowel and colon are normal in caliber. There is\n a Foley catheter within the urinary bladder, and intravenous contrast layering\n dependently within the urinary bladder. There is significant amount of air\n within the non-dependent portion of the urinary bladder, consistent with\n catheterization. The prostate and seminal vesicles are normal. There is no\n pelvic or inguinal lymphadenopathy. There is a small amount of free fluid\n within the pelvis (2:17 and 300B:39).\n\n LINES AND TUBES: The endotracheal tube terminates above the carina. A\n central venous catheter terminates at the medial aspect of the right\n brachiocephalic vein. Nasogastric tube is present. The tip is located within\n the stomach.\n\n OSSEOUS STRUCTURES: There is a fracture of the medial one-third of the left\n clavicle, with distraction of 6 mm of the fracture fragment, and inferior\n displacement of the distal clavicular fracture fragment in relation to the\n proximal clavicle. No vertebral fracture is identified. There is hardware\n within the right proximal femur, and a small focus of gas (2:121), and\n inflammatory stranding within the subcutaneous tissues of the lateral aspect\n of the right thigh.\n\n Not completely imaged, there is edema of the left scrotum and subtle edema\n within the medial musculature of the left upper thigh.\n\n IMPRESSION:\n 1. No acute traumatic aortic injury is identified.\n (Over)\n\n 9:12 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for aortic and other traumatic injury\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. A linear filling defect on a single image within the left subclavian\n artery may represent a dissection flap.\n 3. Grade 1 left kidney injury.\n 4. Fracture of the left clavicle.\n 5. Segmental atelectasis of the left lung and consolidation ground-glass\n opacities at the lungs bilaterally, which may represent contusion in the\n setting of trauma.\n\n Findings regarding the possible dissection flap of left subclavian artery and\n of the left kidney injury were discussed with Dr. at 12 p.m. on\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-19 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1027035,
"text": ", F. TSICU 9:12 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for aortic and other traumatic injury\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with ? aortic injury s/p high speed MVC\n REASON FOR THIS EXAMINATION:\n eval for aortic and other traumatic injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. No evidence of acute traumatic aortic injury.\n 2. Obliquely oriented linear filling defect within the proximal subclavian\n artery may represent a dissection flap.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1027312,
"text": " 1:28 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check line placement, right sc-tlc. r/o ptx.\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with multiple trauma, intubated.\n REASON FOR THIS EXAMINATION:\n check line placement, right sc-tlc. r/o ptx.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 3:56 PM\n PFI: Malpositioned right subclavian IV catheter. Left retrocardiac\n atelectasis, otherwise no significant change.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 21-year-old man with right subclavian IV catheter placed.\n\n COMPARISON: .\n\n FINDINGS: New right subclavian intravenous catheter has been placed, which\n travels superiorly, probably in the right internal jugular vein, the tip is\n out of the view.\n\n The endotracheal tube terminates 5 cm above the carina. Nasogastric tube ends\n in the stomach. Cardiomediastinal silhouette is stable. There is no focal\n consolidation or pneumothorax. Left retrocardiac density has developed,\n likely secondary to atelectasis. Pulmonary vascularity is not increased. Re-\n demonstrated is a medial clavicular fracture.\n\n IMPRESSION:\n\n 1. Malpositioned right subclavian venous catheter.\n\n 2. Left retrocardiac opacity, compatible with atelectasis.\n\n Findings were discussed with Dr. at 3:20 p.m. on ,\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1027609,
"text": " 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with increasing secretions\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:10 AM\n Improved bibasilar atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 21-year-old man with increasing secretions.\n\n COMPARISON: .\n\n AP SEMI-UPRIGHT CHEST: An endotracheal tube terminates 4.3 cm above the\n carina. -intestinal tube is in unchanged position below the\n hemidiaphragm. The cardiac and mediastinal contours are stable. There\n remains a small amount of opacity in the retrocardiac left lower lobe, and to\n a lesser extent in the right base medially, which are improved. The remainder\n of the lungs continue to be clear. The visualized pulmonary vascularity is\n within normal limits.\n\n IMPRESSION: Improved lower lobe opacities without new consolidation,\n probably atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1027482,
"text": " 11:36 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with SDH, epidural decreasing responsiveness\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw WED 2:52 PM\n PFI: No significant interval change in two left-sided frontal epidural\n hematomas, a right-sided frontal subdural hematoma and a right-sided\n intraparenchymal hemorrhage. There has been interval removal of a surgical\n bolt. -white matter differentiation is preserved. There are no new areas\n of hemorrhage. There are multiple skull and facial fractures that appear\n stable compared to prior CTs.\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 21-year-old man with subdural hematoma, abnormal hematoma\n with decreasing responsiveness, evaluate for interval change.\n\n TECHNIQUE: Head CT contiguous axial images were obtained through the brain.\n No contrast was administered.\n\n COMPARISONS: Head CT from .\n\n FINDINGS: Previously noted left frontal epidural hematomas and right frontal\n subdural hematoma are unchanged in size and density. There is an unchanged\n small parenchymal hemorrhage with surrounding edema in the right frontal lobe,\n along the path of a previously present ICP monitor. There is preservation of\n -white matter differentiation. The ventricles are stable in size.\n\n Multiple facial and skull fractures are again seen. Blood products are again\n seen in the sinuses. There has been a slight interval decrease in bilateral\n subgaleal hematomas.\n\n IMPRESSION:\n 1. Unchanged left epidural hematomas, right subdural hematoma, and right\n frontal parenchymal hematoma.\n 2. No evidence of new cerebral edema.\n\n The findings were discussed with Dr. at the time of the study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-20 00:00:00.000",
"description": "RO FOREARM (AP & LAT) RIGHT IN O.R.",
"row_id": 1027241,
"text": " 8:29 AM\n FOREARM (AP & LAT) RIGHT IN O.R.; UPPER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # \n Reason: ORIF RT RADIUS FX\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n\n FIFTEEN FLUOROSCOPIC VIEWS OF THE RIGHT FOREARM\n\n INDICATION: ORIF right radius fracture.\n\n FINDINGS: Comparison is made with priors from . Fifteen\n fluoroscopic views were obtained in the OR without radiologist which show\n progressive plating of distal radius and ulnar fractures. For more details,\n please see the intraoperative report.\n\n IMPRESSION: Intraoperative views of ORIF of right radius and ulnar fractures.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-20 00:00:00.000",
"description": "R KNEE (2 VIEWS) RIGHT",
"row_id": 1027242,
"text": " 8:31 AM\n KNEE (2 VIEWS) RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: ORIF RT PATELLA\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT PATELLA, EIGHT VIEWS\n\n INDICATION: ORIF.\n\n FINDINGS: A series of eight intraoperative radiographs of the right patella\n demonstrate ORIF of the patella in progress. No immediate hardware-related\n complication is seen. Please refer to operative report for full details.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1027483,
"text": ", F. TSICU 11:36 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with SDH, epidural decreasing responsiveness\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No significant interval change in two left-sided frontal epidural\n hematomas, a right-sided frontal subdural hematoma and a right-sided\n intraparenchymal hemorrhage. There has been interval removal of a surgical\n bolt. -white matter differentiation is preserved. There are no new areas\n of hemorrhage. There are multiple skull and facial fractures that appear\n stable compared to prior CTs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-18 00:00:00.000",
"description": "R KNEE( (SINGLE VIEW) RIGHT",
"row_id": 1026911,
"text": " 10:52 AM\n HIP 1 VIEW; KNEE( (SINGLE VIEW) RIGHT Clip # \n ANKLE 1 VIEW RIGHT\n Reason: please eval for fx / dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with right open femur fracture\n REASON FOR THIS EXAMINATION:\n please eval for fx / dislocation\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT HIP, FEMUR, KNEE, AP views.\n\n FINDINGS:\n\n RIGHT HIP: No evidence of acute fracture, dislocation or degenerative changes.\n\n RIGHT FEMUR: There is a open fracture of the right mid-distal femoral shaft\n with medial displacement of the distal fracture fragment by approximately 4\n cm. Multiple small fracture fragments are identified adjacent to this area.\n Overlying soft tissue swelling and subcutaneous air is noted.\n\n RIGHT KNEE: There appears to be a lucent line through the superior aspect of\n the patella, suggesting a fracture though incompletely visualized on this\n single AP view. There is no evidence of dislocation or degenerative changes.\n The medial and lateral compartment are unremarkable. Tiny radiodensities\n noted overlying the knee, may represent superficial debris or foreign bodies.\n\n RIGHT ANKLE: There is a medial malleable plate transfixed with three screws to\n the distal tibia. There is no evidence of hardware loosening. The ankle\n mortises appears to be intact. Degenerative changes at the tibiotalar\n joint are noted.\n\n IMPRESSION:\n LIMITED STUDY.\n 1. Open fracture of the right mid-distal femoral shaft.\n 2. Probable patellar fracture, and dedicated knee views are recommended.\n 3. Possible tiny foreign bodies in the soft tissues of the knee.\n 4. Old fracture status post ORIF at the right ankle with evidence of early\n degenerative changes at the tibiotalar joint.\n\n These findings were discussed with Dr. at 11:15 a.m. via\n telephone.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-07-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1027413,
"text": ", F. TSICU 5:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n Admitting Diagnosis: S/P MOTOR VEHICLE ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 21 year old man with fever, s/p intubation\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n PFI REPORT\n Increased bibasilar atelectasis. Superimposed pneumonia or aspiration cannot\n be excluded. Right subclavian catheter removal without pneumothorax.\n\n"
},
{
"category": "ECG",
"chartdate": "2145-07-18 00:00:00.000",
"description": "Report",
"row_id": 221619,
"text": "Sinus rhythm. Early repolarization pattern. Compared to the previous tracing\nof no diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2145-07-18 00:00:00.000",
"description": "Report",
"row_id": 221620,
"text": "Sinus rhythm. Diffuse ST segment elevation most consistent with early\nrepolarization pattern, given patient's age. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
}
] |
23,336 | 151,609 | 1. Ileus: Upon admission, a rectal tube was placed and intravenous fluids was while the patient was kept nothing by mouth. She was put on a good bowel regimen of Colace, Dulcolax, lactulose and enemas to help move her bowels. However, this medication regimen did not help and so a prokinetic metoclopramide was then started. The patient began moving her bowels initially with the rectal tube and later after the rectal tube was discontinued. On serial KUBs, there was some decrease in distention of the small bowel and colon. A virtual colonoscopy was done on the patient and was reviewed showing that there was no mass or obstruction. Therefore, given the patient's history of esophageal dysmotility it is most likely that she also has dysmotility of the gut leading to this ileus. She is to continue on her prokinetic medication with metoclopramide in order to continue to move her bowels. Once she was on the metoclopramide, other stool softener such as Colace and Dulcolax could be discontinued. 2. Pulmonary, left lower lobe pneumonia: After one week of being in the hospital, the patient's left lower lobe pneumonia did become worse. Though she was alright on her prophylactic dose of Augmentin for aspiration pneumonia, the Augmentin was discontinued so that levofloxacin and Flagyl could be started. Chest x-ray revealed increasing opacity now of both the left lower lobe and left upper lobe. Therefore, a CT chest was obtained showing that there is elevation in the left diaphragm, left pleural effusion, left apical nodule that was unchanged, patchy ground glass opacity in the left upper lobe that was new, a round glass nodule in the left lower lobe that had increased in size from 7 to 10 mm and obstruction with fluid level in the left main stem that was more consistent with mucous plugging rather than a mass. The patient then subsequently went for a bronchoscopy on which showed no obstructive mass. However, during the procedure there was a complication of bleeding into the bronchial tree and the patient's O2 saturation required increase leading to intubation for airway protection. The patient was then transferred to the Medical Intensive Care Unit where she then had a repeat bronchoscopy on for removal of the blood clot. She was extubated on with O2 saturation of 92 to 95% on room air. Given that the patient continued to have some low grade fever while in the Medical Intensive Care Unit, it was established that she should switch over to levofloxacin and Zosyn for better anti pseudomonal coverage despite the fact that no pseudomonas grew in any of the lung biopsy that was obtained. From the specimen obtained on the bronchoscopy, no organism did grow. Patient then was called out to the medical floor where she is to complete 14 weeks of levofloxacin and Flagyl. The Zosyn was discontinued given that it was not giving her any additional benefit. 3. Cardiovascular: Patient does have coronary artery disease. She continued to have on and off chest pain during the hospital course. She was ruled out with cardiac enzyme on two separate occasions. There was no evidence on telemetry except for questionable atrial flutter in both her electrocardiogram and telemetry. Though it was never clarified whether she was truly in atrial flutter, she was however not a candidate for anticoagulation given prior falls in her history. However, to maintain her heart rate, in less than 100 beats per minute, she was started on low dose beta blocker. A transthoracic echo was done revealing moderate left atrial enlargement, moderate right atrial enlargement, ejection fraction of greater than 75%, right ventricular hypertrophy, 1+ aortic regurgitation, 1+ mitral regurgitation, 2+ tricuspid regurgitation and moderate pulmonary hypertension. For coronary artery disease, she cannot be given aspirin and she refused nitroglycerin which she says drops her blood pressure too low. She refused any nitrates since it causes her significant hypertension. Given her malnutrition state, it was felt that it was not of any benefit to start a statin. As for her other regimen for the coronary artery disease, she is to continue on her ACE inhibitor. 4. Hematology: The patient did have a bleeding diathesis based on laboratory values of the PTT and INR. She was given one dose of vitamin K and 2 units of fresh frozen plasma without any response in her bleeding diathesis. However, when she was called out to the medical floor, it was shown that her coagulation laboratory values were not too far off from the normal except for an INR of 1.8. She was then given vitamin K 5 mg po qd x3 days. This bleeding diathesis is likely due to the fact that she is quite malnutritioned, hence not having enough vitamin K to have a low INR. Therefore she should be supplemented with vitamin K as needed. | There is diffuse osteopenia. Appearances are compatible with ileus or pseudoobstruction, however, multiple fluid levels are present. There is prominence of the proximal pulmonary arteries and indistinctness of the pulmonary vasculature consistent with mild failure/volume overload. FINDINGS: The endotracheal tube has been removed. There is persistent left retrocardiac infiltrate. There is a persistent left retrocardiac and left basilar and midlung zone opacity, unchanged from prior study. Buttox injection granulomas are noted. There are calcifications of the aorta, iliacs. There appears to be a component of volume loss present as well, with elevation of the left hemidiaphragm and some slight shift of the mediastinum towards the left. Gallbladder wall edema is identified, however, this is also seen in low albuminic states. There is calcification of the aorta with marked calcification of the iliac vessels. Persistent left lower lobe consolidation on chest radiograph. Areas of enhancing lung are intermixed with areas of extensive low attenuation. The rectum and sigmoid are dilated and fluid-filled and demonstrate mild wall enhancement, which is a nonspecific. There is edema in the gallbladder wall, but the patient is hypoalbuminic. Incidental note is made of residual bleed overlying the left upper quadrant, presumably residual pacer lead. Rectal prolapse is seen. There is a large area of oral contrast opacification which likely represents a dilated sigmoid colon. extravasation of contrast from the sigmoid- Delayed images FINAL REPORT (Cont) Left pleural effusion. There is a small right pleural effusion with associated atelectatic changes, but the right lung is otherwise clear. New in the interval are areas of patchy ground-glass attenuation and small airways disease involving the left upper (Over) 4:46 PM CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # Reason: is there an obstructive neoplasm explaining worsening left l Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) lobe and superior segment of the left lower lobe. There is an ovoid opacity noted overlying the right iliac bone which may represent a injection granuloma. The right lung and left upper lung visualized portions are clear however this study is limited by patient position and severe scoliosis. TECHNIQUE: Non-contrast images of the delayed pelvis, following p.o. pt with elevated LFT's and INR.. RUQ US done, no cholecyctitis evident. Moderate [2+] tricuspid regurgitation isseen. Mild (1+) aortic regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Mild (1+) mitralregurgitation is seen. Indeterminate regular supraventricular rhythm with baseline artifact. Compared to the previous tracing of the rhytnm nowappears to be a sinus mechanism. Stat CXR done. Pt given 1mg MS04 with decrease of pain to . CXR done and kub done. Right ventricular systolic function appearsdepressed. There is a mild resting left ventricular outflow tractobstruction.RIGHT VENTRICLE: The right ventricular free wall is hypertrophied. There is a mild resting left ventricular outflow tractobstruction. Right ventricular systolic function appearsdepressed.AORTA: The aortic root is normal in diameter. Compared to theprevious tracing of the rhythm appears to have changed from atrialflutter to coarse atrial fibrillation. CV: Pt with low grade temp (tmax = 99.0). There is nomitral valve prolapse. is AAO x 3, MAE, assists with care.Resp: Lungs are coarse T/O. There is mild mitral annular calcification. was briefly trialed on PS and did fine-then placed on T-piece- abg on this with a RR of ~30 was 166/36/7.47/27/3.she was then bronced again for a smaller amt of clot, sats still 100%-pt looks comfortable.HEME-hct stable at 30ish. Mild (1+) aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. continues to exhibit a low grade temp.C.V: Pt. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are normal. Pt in afib (controlled rate), no ectopy. Lungs essentially clear--occasional rhonchi that clear with suction. BILATERAL CHEST EXPANSION NOTED.GI: ABD IS SOFT, NON-DISTENDED AND NON-TENDER. The tips of the papillary musclesare calcified. Left ventricularhypertrophy by voltage. No ectopy.GI/GU: Patent foley in place and belly soft with + BS. integ: stage 1 decube to coccyx. Votlagecriteria for left ventricular hypertrophy have appeared. TMAX OF 99.9 AS PER RECTAL. Past history of ASD repair.Height: (in) 64Weight (lb): 92BSA (m2): 1.41 m2BP (mm Hg): 110/58HR (bpm): 100Status: InpatientDate/Time: at 09:54Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is moderately dilated. Prolonged Q-T interval. GI: Pt cachetic. + good peripheral pulses.GI: + BS x 4, abd. The right ventricular free wall is hypertrophied. Probableleft ventricular hypertrophy. CT shows min improvement in her LLLconsolidation. pt repositioned freq side-side. Compared to the previoustracing of cardiac rhythm is now regularized. If pt returns to MICU after procedure will place OGT. asking for fluids, so attempted small amts. Plan for bronch and hopeful extubation today. Significant pulmonicregurgitation is seen. Significant pulmonicregurgitation is seen. The inferior vena cava is dilated (>2.5 cm), with minimalrespiratory variation consistent with a right atrial pressure >20 mmHg.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. Possible right ventricular hypertrophy. Possible right ventricular hypertrophy. has remained afib in a controlled rate. There are focal calcificationsin the aortic root. There are focalcalcifications in the ascending aorta.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but notstenotic. | 40 | [
{
"category": "Radiology",
"chartdate": "2142-05-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 786405,
"text": " 6:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: effusions, infiltrate, ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with acute chest pain\n REASON FOR THIS EXAMINATION:\n effusions, infiltrate, ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP:\n\n INDICATION: Acute onset chest pain. Evaluate for effusions, infiltrate or\n pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: Allowing for marked patient rotation to the left, the position of\n the ETT is unchanged. The right lung is clear. There is persistent left\n perihilar and basal consolidation. This appears largely unchanged since prior\n study. No pneumothorax. There may be a tiny left basal effusion.\n\n IMPRESSION: Appearances largely unchanged since prior study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 786500,
"text": " 10:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/o infiltrate, aspiration (witnessed)\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman recently extubated with probable aspiration, increased\n fremitus at right base\n REASON FOR THIS EXAMINATION:\n R/o infiltrate, aspiration (witnessed)\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Extubated with probable aspiration.crackles at the right base\n reference exam .\n\n FINDINGS: The endotracheal tube has been removed. There is continued\n consolidation/volume loss in the left lower lobe and retrocardiac region. The\n right lung and left upper lung visualized portions are clear however this\n study is limited by patient position and severe scoliosis. Again noted is a\n low position of the humeral head which is unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-19 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 786508,
"text": " 12:41 PM\n PORTABLE ABDOMEN Clip # \n Reason: s/p dopov placement. pls also do portable supine and erect\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p dopov placement. pls also do portable supine and erect if possible for\n eval for sbo/ileus\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post Dopoff placement.\n\n FINDINGS: There is a feeding tube with tip in the stomach. The film is\n obscured by motion. There is increased retrocardiac opacity consistent with\n volume loss/infiltrate.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-19 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 786522,
"text": " 4:40 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ABD PAIN, ELEV LFT'S, EVAL FOR SIGNS OF CHOLECYSTITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with fever, abdominal pain and elevated LFTs.\n REASON FOR THIS EXAMINATION:\n plesae eval for signs of cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73 year old woman with abdominal pain and elevated LFT's.\n\n FINDINGS: The liver is of normal echogenicity. No gallstones are identified.\n The gallbladder is not fully distended, and wall thickness measures 6 mm,\n however, the gallbladder is not fully distended. There is edema in the\n gallbladder wall, but the patient is hypoalbuminic. The common bile duct\n measures 5 mm in diameter. Negative son sign. There is\n hepatomegaly.\n\n IMPRESSION:\n\n 1. No common bile duct or intrahepatic ductal dilatation. No gallstones.\n 2. Gallbladder wall edema is identified, however, this is also seen in low\n albuminic states.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-20 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 786564,
"text": " 1:02 PM\n CT ABDOMEN W/CONTRAST; CT CHEST W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: Rule out mesenteric ischemia\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p colonoscopy . Presents with increasing abdominal\n pain, elevated lactate\n REASON FOR THIS EXAMINATION:\n Rule out mesenteric ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 73 year old female with increasing abdominal pain and\n elevated lactate. Assess for mesenteric ischemia.\n\n TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet\n through the pubic symphysis following the administration of 150 cc of Optiray\n given due to patient debility.\n\n COMPARISON: .\n\n CT OF THE CHEST WITH IV CONTRAST: The right atrium, right ventricle, and\n pulmonary arteries are enlarged, consistent with pulmomary arterial\n hypertension and right-sided cor pulmonale. There is no significant\n mediastinal, hilar, or axillary lymphadenopathy. Lung windows demonstrate a\n marked progression of the previously evident left lower lobe density, with\n near- complete consolidation of the left lower lobe. There is a small right\n pleural effusion with associated atelectatic changes, but the right lung is\n otherwise clear.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The liver appears normal. There is\n pericholecystic fluid but no gallstones or wall thickening to suggest\n cholecystitis. The spleen, pancreas, kidneys, and adrenal glands appear\n grossly normal. Small cysts are present in both kidneys. Again seen is\n dilatation of the colonic loops, which is not significantly changed in the\n interval. The rectum and sigmoid are dilated and fluid-filled and demonstrate\n mild wall enhancement, which is a nonspecific. There is a large area of oral\n contrast opacification which likely represents a dilated sigmoid colon.\n However, extravasation and pooling of contrast cannot be excluded. A delayed\n examination is recommended. There is no free air, bowel wall thickening, or\n stranding to suggest possible mesenteric ischemia. The SMA demonstrates\n approximately 50% narrowing but is patent. There are calcifications of the\n aorta, iliacs. and origin of the renal arteries.\n\n IMPRESSION:\n\n 1) No definite evidence of mesenteric ischemia.\n\n 2) Persistent dilation of the colon.\n\n 3) Progression of left lower lobe consolidation.\n (Over)\n\n 1:02 PM\n CT ABDOMEN W/CONTRAST; CT CHEST W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: Rule out mesenteric ischemia\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 4) Pooling of contrast within the pelvis which most likely represents a\n contrast-filled sigmoid. A delayed examination is recommended to exclude\n extravasation of contrast.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-20 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 786602,
"text": " 10:44 PM\n CT PELVIS W/O CONTRAST Clip # \n Reason: ? extravasation of contrast from the sigmoid- Delayed images\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p colonoscopy . Presents with increasing abdominal\n pain, elevated lactate\n REASON FOR THIS EXAMINATION:\n ? extravasation of contrast from the sigmoid- Delayed images to be obtained\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n CT OF THE PELVIS WITHOUT CONTRAST.\n\n INDICATION: This is a followup examination to a previous examination earlier\n the same day, to evaluate for possible extravasation of oral contrast within\n the bowel loops of the pelvis. As a result, these are delayed images devoted\n to the pelvis and are read in conjunction with the earlier study done at 1312\n hours of .\n\n TECHNIQUE: Non-contrast images of the delayed pelvis, following p.o. contrast\n administration were performed.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: Contrast is now seen to reach the\n rectum and demonstrates no evidence of contrast extravasation. Prominent\n pelvic bowel loops with air fluid levels are again noted but are otherwise\n unchanged and normal in appearance without evidence for ishemia. Rectal\n prolapse is seen. Buttox injection granulomas are noted. A Foley balloon\n catheter tip is seen within the bladder which appears normal. Bone windows\n demonstrate non suspicious lytic or sclerotic lesions.\n\n IMPRESSION: Followup examination reveals contrast to reach the rectum with no\n evidence of extraluminal extravasation. Unchanged appearance to prominent\n pelvic loops consistent with ilues pattern.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n (Over)\n\n 10:44 PM\n CT PELVIS W/O CONTRAST Clip # \n Reason: ? extravasation of contrast from the sigmoid- Delayed images\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 786666,
"text": " 11:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p left PICC placed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n see above\n REASON FOR THIS EXAMINATION:\n s/p left PICC placed\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable chest of compared two days earlier.\n\n INDICATION: PICC line placement.\n\n Examination is limited due to marked kyphoscoliosis of the patient as well as\n additional rotation. A left PICC line is present. After coursing through a\n tortuous left brachiocephalic vein into the superior vena cava, it makes an\n unusual right lateral and superior turn. This turn occurs in the region of\n the right tracheobronchial angle and may be within the azygos vein.\n\n A feeding tube terminates within the body of the stomach.\n\n The patient is status post median sternotomy. The cardiac and mediastinal\n contours allowing for marked leftward rotation of the patient. Increased\n opacity is seen throughout most of the left lung with only a small amount of\n aerated lung present at the left apex. There is also probably a small left\n pleural effusion. The right lung remains grossly clear.\n\n IMPRESSION:\n\n 1. Unusual position of right PICC line, possibly coursing into the azygos\n vein, although an extravascular location cannot be excluded. Findings have\n been discussed with the IV nurse caring for the patient.\n\n 2. Interval worsening opacity in the left mid and lower lung zones, with\n associated volume loss. This suggest progressive collapse. Underlying\n infectious process is not excluded.\n\n 3. Small left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-06-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 787653,
"text": " 9:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for position of og tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 yo female with no gag reflex and recurrent aspiration pneumonia is getting\n products but needs meds via og tube\n REASON FOR THIS EXAMINATION:\n please assess for position of og tube\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST compared to 6 days earlier\n\n CLINICAL INDICATION: OG tube placement.\n\n An OG tube is unchanged in position terminating within the proximal to mid-\n stomach. The patient is rotated towards the left. There is improved\n visualization of the left hilum and left heart border. There remains dense\n opacification of the left retrocardiac region and there is persistent blunting\n of the left costophrenic sulcus. The right lung appears clear.\n\n IMPRESSION:\n 1) Feeding tube terminates within the stomach.\n 2) Improving aeration in the left mid-lung zone, likely due to a combination\n of improving pleural effusion and improving atelectasis. There remains dense\n opacification in the left retrocardiac area which may be due to a combination\n of atelectasis and pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-26 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 787111,
"text": " 3:05 PM\n CHEST (PA & LAT) Clip # \n Reason: is there persistent pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with esphogeal dysmotility and aspiration risk\n\n REASON FOR THIS EXAMINATION:\n is there persistent pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Esophageal dysmotility and aspiration risk, evaluate for\n persistent pneumonia.\n\n COMPARISON: .\n\n PA & LATERAL CHEST: This is a redictation of a lost report. There is dense\n increased opacity in the left mid and lower lung zones. There is an abrupt cut\n off of a left sided bronchus. This overall appearance is consistent with\n lingular and left lower lobe atelectasis. There is also a left pleural\n effusion. The right lung is clear. The feeding tube is in place. The patient\n is s/p sternotomy.\n\n IMPRESSION: Atelectasis of the lingula and left lower lobe. Abrupt cut-off of\n left bronchus suggests mucoid impaction as the etiology. Left pleural\n effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-29 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 787368,
"text": " 2:50 PM\n CT CHEST W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: has the pneumoia on the left improved when compared with las\n Field of view: 30\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with esophageal dysmotility and aspiration problems with\n persistent fevers\n REASON FOR THIS EXAMINATION:\n has the pneumoia on the left improved when compared with last ct chest\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Esophageal dysmotility and aspiration problems, persistent\n fevers.\n\n TECHNIQUE: Contiguous axial images were obtained through the chest using a\n high resolution technique without intravenous contrast.\n\n COMPARISON: .\n\n CT CHEST WITHOUT CONTRAST: There is stable cardiomegaly. The pulmonary\n artery is prominent. There are bilateral small pleural effusions. The left\n effusion is slightly larger on the current study. There is no significant\n axillary, mediastinal or hilar lymphadenopathy.\n\n Limited evaluation of the upper abdomen reveals no focal abnormalities.\n\n The lung windows demonstrate dense consolidation in the left lower lobe, which\n is slightly improved from the prior study. There is stable\n scarring/atelectasis of the right middle lobe. There is a new area of\n consolidation in the posterior segment of the left upper lobe. This may\n represent new aspiration or a new focus of pneumonia. The appearance of\n consolidation in the lingula is slightly better. The airways appear to be\n patent. The appearance of secretions in the left upper lobe and lingular\n bronchi has improved in the interval. There is no evidence for air trapping\n on the expiratory images.\n\n Bone windows demonstrate no suspicious lytic or sclerotic abnormalities.\n\n The above findings were confirmed with the coronal reformations.\n\n IMPRESSION: Slight interval improvement in left lower lobe consolidation.\n There has also been interval improvement in the lingular consolidation.\n These findings are consistent with improving pneumonia.\n\n There is a new small area of consolidation in the posterior segment of the\n left upper lobe, which may represent a focus of aspiration or a new focus of\n pneumonia.\n\n\n (Over)\n\n 2:50 PM\n CT CHEST W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: has the pneumoia on the left improved when compared with las\n Field of view: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 786072,
"text": " 1:08 PM\n CHEST (PA & LAT) Clip # \n Reason: is there a pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with esphogeal dysmotility and aspiration risk\n REASON FOR THIS EXAMINATION:\n is there a pna\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST, :\n\n CLINICAL INDICATION: Aspiration risk. Clinical suspicion for pneumonia.\n\n Comparison is made to .\n\n There has been interval development of dense consolidation in the left lower\n lobe, completely obliterating the left hemidiaphragm contour and resulting in\n homogeneous increased opacity behind the heart. There appears to be a\n component of volume loss present as well, with elevation of the left\n hemidiaphragm and some slight shift of the mediastinum towards the left. The\n left heart border is partially obscured. The other visible mediastinal\n contours are stable in the interval. There remains marked enlargement of the\n main pulmonary artery contour.\n\n The right lung appears clear, and there is no evidence of right pleural\n effusion.\n\n The skeletal structures reveal diffuse demineralization and compression\n deformities are noted within the spine. Scoliosis is also present.\n\n More recent chest radiographs from and are not currently\n available for comparison but described similar findings.\n\n IMPRESSION: Extensive consolidation within the left lower lobe, which is\n associated with volume loss. Considering persistence of this finding over\n several months and the presence of volume loss, a post obstructive pneumonia\n from a central neoplasm should be considered. Alternatively, a chronic\n alveolar process such as bronchiolalveolar cell carcinoma or lipoid pneumonia\n are additional considerations. CT is suggested for further assessment if\n clinically warranted.\n\n An addendum will also be issued to this report once the more recent chest\n radiographs have become local on PACS for comparison purposes.\n\n ADDENDUM:\n\n Prior chest radiographs of and have become\n available. As compared to the previous studies, the degree of left lower lobe\n opacification has significantly increased and the associated volume loss has\n increased as well. Although possibly due to recurrent aspiration pneumonia\n with mucous plugging, a post obstructive process should be considered and CT\n would be helpful for further assessment.\n (Over)\n\n 1:08 PM\n CHEST (PA & LAT) Clip # \n Reason: is there a pna\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 786337,
"text": " 9:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p bronch with transbronchial biopsy, r/o pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p bronch with transbronchial biopsy, r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old woman status post bronchoscopy and transbronchial\n biopsy.\n\n PORTABLE AP VIEW OF THE CHEST: Comparison . Patient is status\n post median sternotomy. An endotracheal tube is present with its tip\n approximately 3 cm above the carina. There is a persistent left retrocardiac\n and left basilar and midlung zone opacity, unchanged from prior study. There\n is prominence of the proximal pulmonary arteries and indistinctness of the\n pulmonary vasculature consistent with mild failure/volume overload. The right\n lung is otherwise clear.\n\n IMPRESSION: No pneumothorax. Left lower lobe consolidation. Mild failure\n and/or volume overload.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-12 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 785928,
"text": " 2:56 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: assess for obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with chronic constipation and ileus vs. pseudoobstruction\n REASON FOR THIS EXAMINATION:\n assess for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chronic constipation and ileus vs, pseudo-obstruction.\n\n There are multiple loops of air filled bowel, with multiple fluid levels. The\n colon is not dilated, though it would be difficult to exclude the presence of\n some dilated loops of small bowel. No free intraperitoneal air is detected.\n multiple rounded calcifications are seen over the abdomen -- some, but not in\n all of these are thought to represent phleboliths. The others are of\n indeterminate etiology. Incidental note is made of residual bleed overlying\n the left upper quadrant, presumably residual pacer lead. No free\n intraabdominal air is identified.\n\n IMPRESSION:\n\n Multiple air filled loops of bowel. Overall appearances are similar to those\n on the abdominal films from 3 days earlier. Appearances are compatible with\n ileus or pseudoobstruction, however, multiple fluid levels are present.\n\n Some of the rounded calcifications may correspond to injection granuloma as\n described on the CT scan.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-14 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 786102,
"text": " 4:46 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: is there an obstructive neoplasm explaining worsening left l\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with esophageal dysmotility and aspiration problems\n REASON FOR THIS EXAMINATION:\n is there an obstructive neoplasm explaining worsening left lower lobe\n consolidation and volume loss?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT THORAX, :\n\n CLINICAL INDICATION: Esophageal dysmotility and history of aspiration.\n Persistent left lower lobe consolidation on chest radiograph. CT is requested\n to exclude obstructing endobronchial lesion as a cause for this finding.\n Comparison is made to a prior chest CT dated .\n\n Helical CT of the thorax was performed following IV administration of 100 cc\n of Optiray. Nonionic contrast was administered due to the debilitated status\n of the patient. Images were acquired with 5 mm collimation and reconstructed\n at 5 mm intervals.\n\n Assessment of the soft tissue structures of the thorax demonstrates volume\n loss in the left hemithorax with shift of the mediastinal structures towards\n the left. There is massive enlargement of the main and central pulmonary\n arteries, in keeping with pulmonary artery hypertension. Multichamber cardiac\n enlargement is noted, particularly the left atrium, right atrium, and right\n ventricle. There is dense opacification throughout the left lower lobe, which\n appears heterogeneous. Areas of enhancing lung are intermixed with areas of\n extensive low attenuation. Although this predominantly involves the left\n lower lobe, there is also involvement of portions of the left upper lobe and\n lingula. Within the mediastinum, there are mildly enlarged nodes in the\n precarinal region. There is also lymph node enlargement in the left hilum\n which is difficult to measure due to contiguity with adjacent areas of\n consolidation within the adjacent lung parenchyma.\n\n As mentioned, there is cardiac enlargement. Coronary calcifications are\n observed.\n\n Within the imaged portion of the upper abdomen, note is made of an elevated\n left hemidiaphragm. The imaged portions of the liver and spleen are\n unremarkable as well as the imaged portions of the left kidney. The right\n kidney is not included on this imaging study. The adrenal glands are not well\n demonstrated.\n\n A trace amount of pleural effusion is seen on the left.\n\n Assessment of the lungs reveals a small nodule at the left lung apex, which\n was present on the previous study. New in the interval are areas of patchy\n ground-glass attenuation and small airways disease involving the left upper\n (Over)\n\n 4:46 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: is there an obstructive neoplasm explaining worsening left l\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lobe and superior segment of the left lower lobe. Rounded ground-glass nodule\n is seen in the superior segment of the left lower lobe and appears larger in\n the interval compared to the previous study. It currently measures 10 mm in\n diameter and previously measured approximately 7 mm in diameter on the earlier\n study. As mentioned, there is heterogeneous consolidation throughout most of\n the left lower lobe and portions of the lingula and left upper lobe. There is\n impaction of the bronchi to the left lung beginning at the left main stem\n bronchus proximal to the bifurcation at the left upper lobe and left lower\n lobe bronchi. These bronchi are extensively impacted with low attenuation\n material.\n\n Assessment of the right lung is remarkable for a small peripheral right lower\n lobe nodule measuring slightly less than 5 mm in diameter and an adjacent\n smaller satellite nodule, both of which were present in and are probably\n unchanged allowing for differences in slice selection. Note is also made of\n heterogeneous pattern of lung attenuation, which likely represents a component\n of air trapping, which has been described on previous studies of this patient.\n Note is also made of increased opacity within the right middle lobe medial\n segment which has been present previously with associated volume loss,\n attributable to a focal area of scarring.\n\n The skeletal structures of the thorax demonstrate evidence of a previous\n sternotomy procedure.\n\n IMPRESSION:\n\n 1) Obstruction of the central airways in the left lung, with a fluid level\n present in the left main stem bronchus and extensive low attenuation material\n throughout the central bronchi to the left upper lobe and left lower lobe, as\n well as extensive impaction of distal airways. No obstructing enhancing mass\n is identified. These findings may be due to extensive mucous plugging.\n However, correlation with bronchoscopy is recommended, in order to exclude a\n distally obstructing lesion.\n\n 2) Extensive heterogeneous opacification of the left upper lobe, and, to a\n lesser degree, within portions of the lingula and left upper lobe. The\n extensive low attenuation areas suggest areas of necrosis, probably due to\n long-standing post obstructive pneumonitis. Follow up studies are recommended\n following bronchoscopic clearing of intraluminal secretions and following\n antibiotic therapy, in order to assess for resolution of the parenchymal\n process. As the patient has demonstrated areas of consolidation in the left\n lower lobe and lingula on older studies, it is important to exclude\n bronchiolalveolar cell carcinoma.\n\n 3) Cardiac enlargement and enlargement of the main pulmonary artery. The\n latter is suggestive of pulmonary artery hypertension.\n (Over)\n\n 4:46 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: is there an obstructive neoplasm explaining worsening left l\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 4) Small, less than 5 mm diameter right lower lobe and biapical lung nodules\n are probably unchanged compared to allowing for differences in slice\n selection, but there has been apparent interval increase in size of a 10 mm\n diamete nodule in the superior segment of the left lower lobe.\n Broncholalveolar cell carcinoma is a possible diagnosis for this slowly\n growing nodule. However, respiratory motion and adjacent inflammatory changes\n limit evaluation of this finding. Attention to this region on follow up scans\n is suggested.\n\n 5) An additional new tiny nodule in the right middle lobe can also be\n reassessed at the time of follow up CT scan.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-06 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 785359,
"text": " 4:06 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o free air\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman s/p colonoscopy . No w increasing abdominal pain and ?\n feee air on CT.\n REASON FOR THIS EXAMINATION:\n r/o free air\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JLLW SUN 9:33 PM\n no free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P colonoscopy with increasing abdominal pain and question free\n air on plain film.\n\n TECHNIQUE: Contiguous axial images are obtained from the lung bases to the\n pubic symphysis without oral or IV contrast.\n\n Comparison is made to prior study 2 days ago.\n\n FINDINGS:\n\n CT OF THE ABDOMEN WITH CONTRAST: The lung bases demonstrate minimal\n atelectasis at the left lung base. There is calcification of the aorta with\n marked calcification of the iliac vessels. Again seen is significant air\n within the colon, essentially unchanged from the study 2 days ago. However,\n there is more fluid within the abdominal and pelvic bowel. There may be mild\n hepatomegaly. On noncontrast views, the spleen, left kidney, adrenals, and\n stomach are unremarkable. There is a cyst within the right kidney. The\n uterus is unremarkable. No intra-abdominal free air. Multiple phleboliths are\n present.\n\n Multiple soft tissue calcifications are present within the buttocks\n consistent with injection granulomas. Additionally, there is extensive\n degenerative change of the spine.\n\n IMPRESSION:\n 1) No evidence of free air.\n 2) Extensive dilation of the bowel is unchanged from the prior study. There\n has been interval increase in the amount of enteric fluid, which may be\n related to enteritis or possibly the colonoscopy preparation.\n 3) Left-sided atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-06 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 785349,
"text": " 2:58 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: abd distention\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with abd distention\n REASON FOR THIS EXAMINATION:\n abd distention\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal distention status post failed colonoscopy and virtual\n colonoscopy.\n\n SUPINE ABDOMINAL RADIOGRAPH: Air is present within mildly dilated loops of\n large bowel. A small amount of air is present throughout the small\n bowel. There is an ovoid opacity noted overlying the right iliac bone which\n may represent a injection granuloma. The patient is rotated. The bilateral\n hips are unremarkable. There is diffuse osteopenia.\n\n IMPRESSION: Intra-abdominal free air cannot be excluded on this single view of\n the abdomen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-06 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 785350,
"text": " 2:59 PM\n CHEST (PA & LAT) Clip # \n Reason: abd distention\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with abd distention\n REASON FOR THIS EXAMINATION:\n abd distention\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal distention.\n\n AP AND LATERAL CHEST RADIOGRAPHS: There has been no change in the appearance\n of the chest compared with the prior examination dated . No\n definite free air under the diaphragm is identified. There is severe kyphosis\n and increased retrosternal air space consistent with emphysematous change.\n\n IMPRESSION:\n 1. There is persistent left retrocardiac infiltrate. This may represent a\n chronic infection. An underlying neoplasm cannot be excluded.\n 2. No free air seen on the current radiographs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-08 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 785509,
"text": " 8:36 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ABD. DISTENTION S/P AIR INSUFFLATION;RECTAL TUBE PLACED, PLEASE COPMPARE WITH PRIOR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with abd distention s/p air insufflation now w/ rectal tube\n placed\n REASON FOR THIS EXAMINATION:\n please compare with kub from \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of abdominal distention and rectal tube placement.\n\n Multiple gas filled loops of minimally dilated and nondilated small bowel with\n gas present in the colon and scattered small air fluid levels in the small\n bowel and colon. No evidence for intestinal obstruction. No free\n intraperitoneal gas. The cecum is not unduly dilated.\n\n IMPRESSION: No significant change since the prior study. No evidence for\n intestinal obstruction. Status post median sternotomy. Epicardial pacing\n wires overlie the left upper abdomen and left lower hemithorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-07 00:00:00.000",
"description": "ABDOMEN (SUPINE ONLY)",
"row_id": 785461,
"text": " 5:35 PM\n ABDOMEN (SUPINE ONLY) Clip # \n Reason: check progression of intestinal distention\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with abd distention s/p air insufflation now w/ rectal tube\n placed\n REASON FOR THIS EXAMINATION:\n check progression of intestinal distention\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM:\n\n HISTORY: Abdominal distention with rectal tube placement.\n\n There are multiple gas filled loops of non-dilated small bowel with gas\n present throughout the colon and in the rectum. Rectal tube in situ. No\n evidence for intestinal obstruction. The cecum is not unduely dilated. There\n are vascular calcifications and calcified injection granulomas in both\n buttocks.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-05-09 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 785629,
"text": " 10:56 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: is there any perforation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with abd distention s/p air insufflation now w/ rectal\n tube placed, advanced today with increaed pain.\n REASON FOR THIS EXAMINATION:\n is there any perforation\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN 2 VIEWS:\n\n HISTORY: Abdominal distention and for tube placement.\n\n There are gas filled loops of non-dilated small bowel with gas present\n throughout the colon. No evidence for intestinal obstruction. There is no\n undue distention of the cecum. No free intraperitoneal gas. No rectal tube\n is identified on the available films.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-06-04 00:00:00.000",
"description": "L UNILAT LOWER EXT VEINS LEFT",
"row_id": 787799,
"text": " 1:05 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: LEG SWELLING PT ON BED REST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with aspiration pneumonia and immobility\n REASON FOR THIS EXAMINATION:\n is there a dvt\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 73-year-old woman with aspiration pneumonia and immobility.\n Is there a DVT in the left lower extremity?\n\n FINDINGS: There is normal flow, compression, respiratory variation and\n augmentation in all the deep venous structures from the left inguen to the\n popliteal region. The right common femoral vein was also assessed and is\n normal.\n\n Pulsatile flow is seen in all the venous structures suggestive of congestive\n failure.\n\n a 1.2 x 0.5 x 3.3 cm fluid collection is seen in the medial aspect of the left\n knee which may represent a ruptured cyst.\n\n IMPRESSION:\n 1. No evidence of DVT in the left lower extremity.\n 2. Pulsatile flow in all veins suggestive of congestive heart failure.\n 3. Ruptured cyst in the left medial knee.\n\n"
},
{
"category": "Echo",
"chartdate": "2142-05-15 00:00:00.000",
"description": "Report",
"row_id": 60567,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Past history of ASD repair.\nHeight: (in) 64\nWeight (lb): 92\nBSA (m2): 1.41 m2\nBP (mm Hg): 110/58\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 09:54\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is moderately dilated. No\natrial septal defect is seen by 2D or color Doppler. The inferior vena cava is\ndilated (>2.5 cm). The inferior vena cava is dilated (>2.5 cm), with minimal\nrespiratory variation consistent with a right atrial pressure >20 mmHg.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity is unusually small. Left ventricular systolic function is\nhyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract\nobstruction.\n\nRIGHT VENTRICLE: The right ventricular free wall is hypertrophied. The right\nventricular cavity is dilated. Right ventricular systolic function appears\ndepressed.\n\nAORTA: The aortic root is normal in diameter. There are focal calcifications\nin the aortic root. The ascending aorta is normal in diameter. There are focal\ncalcifications in the ascending aorta.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is mild mitral annular calcification. There is\nmild thickening of the mitral valve chordae. The tips of the papillary muscles\nare calcified. There is no significant mitral stenosis. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. The tricuspid valve\nsupporting structures are normal. Moderate [2+] tricuspid regurgitation is\nseen. There is moderate pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal. There is no pulmonic valve stenosis. Significant pulmonic\nregurgitation is seen. The main pulmonary artery is dilated. The branch\npulmonary arteries are dilated. No color Doppler evidence for a patent ductus\narteriosus is visualized.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nNo atrial septal defect is seen by 2D or color Doppler. The inferior vena cava\nis dilated (>2.5 cm). There is mild symmetric left ventricular hypertrophy.\nThe left ventricular cavity is small. Left ventricular systolic function is\nhyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract\nobstruction. The right ventricular free wall is hypertrophied. The right\nventricular cavity is dilated. Right ventricular systolic function appears\ndepressed. The aortic valve leaflets (3) are mildly thickened but not\nstenotic. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. Significant pulmonic\nregurgitation is seen. The main pulmonary artery is dilated. The branch\npulmonary arteries are dilated. There is no pericardial effusion.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-05-18 00:00:00.000",
"description": "Report",
"row_id": 1567292,
"text": "pmicu nursing progress 7a-7p\nreview of systems\nCV-hr has been in the 70's-120's afib with no ectopy noted.BP has been stable for the most part- did dip to 77/ after sedatives for bronch given- tx with 250 ccs NS- has been improved.all po CV meds have been held due to lack of NGT/OGT. team aware.we are recycling CKs- have been 27-26, with troponin2.3-->1.9.no further c/o chest pain\nID-has been afebrile. wbc=11.8. receiving flagyl and levo IV as ordered.no results on bronch washing from yesterday.\nNEURO-was tx with total 100 mcgs fentanyl and 2 mgs versed for bronch-slept in naps for several hours after that. has been alert, writing this afternoon. has been antsy but no further sedatives given due to hopes of extubation early this evening.\nF/E/N-urine output has been only mediocre, amber colored.as above was tx with a 250cc NS bolus for hypotension.no peripheral edema noted.pt c/o thirst, dry mouth.please see labs as listed in carevue.she's receiving only IVF at KVO and PPN at 41/hr.\nGI-abd is soft wwith positive bowel sounds. no stool today. pt npo.no discussion around PEG took place today.\nSKIN-duoderm intact on coccyx. pt repositioned freq side-side.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-05-18 00:00:00.000",
"description": "Report",
"row_id": 1567293,
"text": "pmicu nursing progress continued...\nRESP-pt was bronched first thing this am- no active bleeding-lots of clots removed.pt was left on a/c until she woke up considerably-on 40% her sats were 100% and she was periodically tachypneic. was sx several times for mod-large amts thick bloody clots.lungs initially clear after bronch-became coarser later in day. was briefly trialed on PS and did fine-then placed on T-piece- abg on this with a RR of ~30 was 166/36/7.47/27/3.she was then bronced again for a smaller amt of clot, sats still 100%-pt looks comfortable.\nHEME-hct stable at 30ish. Coags slightly elevated. was tx with 2 units FFP this evening. no active bleeding apparent.\na-busy day for pt\np-will hopefully extubate shortly-continue to provide good pulm toilet-monitor for active bleeding.continue with PPN until PEG issue resolved.watch i's and o's-assess need for maintainence fluid.follow CKs. good skin care as usual.keep husband informed as to all events,plans. will resume po meds when gag returns after extubation.need to reinstate bowel regimine\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-05-17 00:00:00.000",
"description": "Report",
"row_id": 1567289,
"text": "admission/shift note\nPt admitted to to MICU from bronch suite after BAL. At end of procedure BP increased to 200 and sats decreased into 70's. Large clot occluding L airway. Pt intubated and sent to MICU waiting for call to go to OR.\n\nneuro: Pt is alert, communicates by writing, follows commands, MAE. No sedation has been necesssary today. No restraints in place.\n\nresp: PS 10/60%/TV 300 RR 25-30. LS clear. Some oral secretions. None suctioned from ETT.\n\nCV: AF 90-110. No ectopy.\n\nGI/GU: Patent foley in place and belly soft with + BS. No BM this shift. No OGT or NGT in place. No meds given. Dr aware. If pt returns to MICU after procedure will place OGT. Consult into IV for PICC. Pt is cachectic and weighs only 44kg. Chronic issue along with constipation.\n\nSkin; intact\n\nSocial: Elderly husband at bedside all day.\n\nPlan: OR tonight for rigid bronch with Dr ; is an add-on case. Time unknown.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-05-18 00:00:00.000",
"description": "Report",
"row_id": 1567290,
"text": "MICU NPN 1900-0730:\n Pt stable overnight sleeping fitfully in brief naps.\n Neuro: Pt awake, alert and communicating with pen/paper during most of evening. Pt c/o sore throat several times during night--pt medicated with total of 3 mg IV MS04. After morphine, pt would sleep 30-45 minutes, but would wake with coughing. Pt medicated with total of 1.5 mg ativan for sleep/anxiety aid overnight--moderate effect. Team wishes to minimize sedation as pt to be extubated in am after bronch. Pt is not restrained and likes to use yankeur to suction mouth. She has not shown tendency to pull at any line/tubing.\n CV: Pt with low grade temp (tmax = 99.0). Flagyl and levofloxacin changed to IV while pt intubated (for pneumonia). Pt in afib (controlled rate), no ectopy. BP stable-systolic in 90's only when pt sound asleep. Pt diuresed on days for ? CHF (contributing to desat after bronch), and UOP trending down overnight. Pt given 250 cc NS fluid bolus with marginal effect. 40 meq KCl repleted (IV) for am level of 3.8. AM labs to be sent. Pt with 2 PIV initially--L #22 PIV d/c'd for redness/pain at insertion site. New #20 PIV placed on pts R arm for PPN. Pt with stable hcts (to be done q 6 hours) in setting of pulmonary bleeding.\n Pulm: Pt recieved intubated on PSV 10/5 with 60% FI02--spo2 100%. FI02 weaned to 40% with no change in O2 sat. Lungs essentially clear--occasional rhonchi that clear with suction. Pt suctioned q 3-4 hours for small to moderate amts thick bloody sputum. Bronch to be done early this morning.\n GI: Pt cachetic. PPN started this evening. Pt to be eval for PEG in setting of severe nutritional depletion. Abd bengin--pt without c/o abd pain or discomfort. FSBG checked q 6 hours--sugars are well controlled. No stool.\n GU: Foley draining cloudy amber urine. UOP dwindling after lasix admin on days. Pt essentially even since admission to ICU.\n Skin: Pt with large stage I over coccyx--reddened, blanchable, intact skin. Duoderm applied. Other bony prominences appear intact--pt requesting frequent repositioning in bed.\n Family: Pts elderly husband at bedside for most of evening--updated on POC by Dr. . He has MICU B's # and will call to check on wife later today.\n Plan for bronch and hopeful extubation today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-05-21 00:00:00.000",
"description": "Report",
"row_id": 1567300,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT IS ALERT AND ORIENTED X 3. EXTREMELY LUCID HOWEVER, IS DIFFICULT TO UNDERSTAND AT TIMES DUE TO TENDENCY OF MUMBLING. APPROPRIATE. OBEYS COMMANDS AND IS ABLE TO VERBALIZE NEEDS AND WANTS. TMAX OF 99.9 AS PER RECTAL. MAE X 4 WITHOUT DIFFICULTY. OCCASSIONAL BOUTS OF ANXIETY. REASSURED AND GIVEN ATIVAN PRN AS ORDERED WITH THERAPEUTIC RESULT.\n\nCV: NSR WITH NO SIGNS OF ECTOPY. HR 60-80'S. SBP > OR = TO 90 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. PALPABLE PULSES TO BILATERAL DORSALIS PEDIS AND RADIALS. S1 AND S2 AS PER AUSCULTATION. DENIES ANY CHEST PAIN. PT HAS ONE ACCESS # 20 TO LEFT FOREARM- SECURE AND PATENT. NO SIGNS OF JVD NOTED. NO PITTING EDEMA NOTED.\n\nRR: PT IS NOT ON ANY SUPPORTIVE 02. BBS= ESSENTIALLY CLEAR. PRODUCTIVE COUGH FOR CLEAR-TAN SECRETIONS. PT IS ABLE TO SELF YANKAUR. BILATERAL CHEST EXPANSION NOTED.\n\nGI: ABD IS SOFT, NON-DISTENDED AND NON-TENDER. BS X 4 QUADRATNS. NO BM THIS SHIFT. PT INITIALLY REFUSED TO HAVE CT DONE TO RULE OUT RN ABLE TO CONVINCE TO DO SO AFTER REITERATION OF RISKS. TOLERATED PROCEDURE WELL WITH NO UNTOWARD INCIDENCE. NO BM THIS SHIFT. PASSING FLATUS.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. YELLOW, CLEAR URINE IN ADEQUATE AMOUNTS NOTED. NO COMPLAINTS OF DISCOMFORT WHEN VOIDING.\n\nINTEG: INFILTRATION TO RIGHT HAND- SWOLLEN AND SLIGHTLY BRUISED. WARM COMPRESSES AND ELEVATION. COCCYX HAS DUODERM APPLIED. FRAGILE SKIN- THIN.\n\nID: INITIATED ZOSYN THERAPY Q 8 HOURS. WILL CONTINUE.\n\nPLAN: PT IS A POSSIBLE CALL OUT IF DOES NOT CONTINUE TO BE FEBRILE. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-05-19 00:00:00.000",
"description": "Report",
"row_id": 1567296,
"text": "To add: abg today with met/resp alkalosis today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-05-20 00:00:00.000",
"description": "Report",
"row_id": 1567297,
"text": "Neuro: Pt. remains A/A/O and d/o slight constant, chronic back pain. Morphine 2 mg given with relief noted after 30mins. Pt. gets easily agitiated at times, as well she is quite demanding upon all staff members. Pt./nurse communication has improved throughout this shift. Pt. continues to exhibit a low grade temp.\n\nC.V: Pt. has remained afib in a controlled rate. B/P has been stable throughtout this shift. No noted edema noted and all pulses are easily palpable.\n\nResp: Lungs are clear and audible in all lobes with the exception of the LLL which exhibits crackles. Pt's O2 sats have been 93-95% with no cough noted at this time.\n\nG.I: Dobhoff tube remains securely inplace with respalor infusing at 20cc/hr with goal of 35cc/hr. Abd. remains soft and slightly distended with bowel sounds easily audible in all 4 quadrants at this time.\n\nG.U: Foley catheter remains intact while draining ample amt's of amber sediment urine.\n\nI.V: I.V. nurse obtained i.v. access. Pt. is presently refusing PICC line. Team is aware of her access at this time.\n\nSkin: Duoderm to coccyx remains intact. Pt. has been turned side to side without incidence.\n\nPlan: No order as of yet. But pt. is in need of swallowing study due on Monday, this was discussed by team on .\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-05-20 00:00:00.000",
"description": "Report",
"row_id": 1567298,
"text": "NPN-MICU\nMrs has made min progress today.\nID:pt spiked again this am. With cont abd c/o discomfort, fever, increased WBC's(11) and sl evevated LFT's and lactate, pt's TF where stopped and pt went for an abd CT to eval for ?mesenteric ischemia.IVAB cont and ? adding another. She cont to refuse tylenol so a tepid bath given and fever has come down.\nGI:pt cont to be NPO for ? asp. To have swallowing study tomorrow. She is now passing liq stool(from the gastograffin).She cont with mild abd pain but is taking MSO4 for back pain. Her CT was neg for ischemia so her TF where restarted. We have had IV access problems all day,pt had been refusing any central access but she is now aware that she will need a central line of some sort today or tomorrow. THe IV nurse is now unable to find any further , we will get TF to goal and use IV for IVAB. She will be eval for a PICC/central tomorrow (unless this Last IV goes, than she will get a central line by the house staff.).\nResp:pt cont on RA with sats of 94-97%. lungs sound okay. She has a junky cough of thick brownish sputum. CT shows min improvement in her LLLconsolidation. She has been OOB, using IS and C&DB when asked.\nGU:pt able to take her usual meds, so her VS are much improved and she has even diuresed some. Foley changed d/t +UTI.\nHeme:hct up to 37 post transfusionINR still up, plan heme consult.\nCV:VSS, no c/p CP troponin and CK down.Cont to refuse lopressor so it was d/c'd\nSkin: duoderm intact\nNeuro:she has been very tired today but still up to chair and commode.\nCont to c/o back pain and occas sore throat, got MSO4 x1 at 3pm with relief\nA/P:Min improvement\n Will cont to encourage use of IS, C&DB and sx as needed to clr pnx\n Cont IVAB, if loss of line, call HO for central line placement\n Note TF tol and check asp if able, note stool amts.\n Swallow study in am.\n Local care to rt hand infiltrate\n Cont to follow VS for changes\n Asses for pain and medicate as needed\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-05-20 00:00:00.000",
"description": "Report",
"row_id": 1567299,
"text": "NURSING NOTE 2200\n, MD CT TO RULE OUT BOWEL PERFORATION. WITNESSED AS , MD EXPLAINED ALL RISKS INCLUSIVE OF INFECTION AND DEATH. PT WAS ABLE TO VERBALIZE BACK TO RN AND MD RISKS AS DISCUSSED. ADAMANTLY REFUSING TO HAVE THIS TEST DONE ALTHOUGH REPEATED ATTEMPTS TO REITERATE IMPORTANCE AND POSSIBLE RISK OF DEATH. PT. IS ALERT AND ORIENTED X 3- LUCID AND APPROPRIATE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-05-19 00:00:00.000",
"description": "Report",
"row_id": 1567294,
"text": "MICU NPN 7P-7A\nEvents of shift: Overall, a quiet night for this pt. She remains extubated and has O2 sats 95-97% on RA.\n\nReview of systems:\n\nNeuro: Pt. is AAO x 3, MAE, assists with care.\n\nResp: Lungs are coarse T/O. O2 sats in mid-90's on RA with RR 26-32. She denies SOB. Pt. has been coughing up small amts. bloody phlegm all night and appropriately suctioning them with a Yankauer.\n\nCV: BP 110-120/60's, HR remains A-fib without ectope in the 70-90's. Troponin up to 2.3 @ 2200 last night; team aware, no orders given. Pt. refused Lopressor @ , stating that her cardiologist told her never to take it. + good peripheral pulses.\n\nGI: + BS x 4, abd. soft, not distended or tender. Pt. asking for fluids, so attempted small amts. of ice chips, italian ice and H20 with mixed results; pt. noted to be coughing after given some sips of H20, so no further POs given. She remains on PPN for nourishment. No decision yet on ? PEG placement. Pt. attempted BM x 2 with no success; she remains on her regular bowel regimen.\n\nGU: Foley patent, draining 20-35 cc/hr clear amber urine. No maintenance fluids running at present.\n\nSkin: Small stage I pressure ulcer on coccyx with duoderm; dressing remains intact. Pt. turns herself in bed.\n\nID: Awaiting AM labs, pt. remains afebrile, no changes made in abx regimen.\n\nSocial: Pt.'s husband called early in the shift and was updated by this RN.\n\nDispo: Pt. may be ready to transfer to floor today or tomorrow, provided that her respiratory status does not change and that her Hcts do not drop acutely.\n\nSee CareVue for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-05-19 00:00:00.000",
"description": "Report",
"row_id": 1567295,
"text": "NPN 7a-7P\n Nuero: pt lethargic this am.. abg showed mild resp alkalosis, and pt found to have temp 102.6.. pt perked up as day progressed and temp went down. pt has muffled voice.. needs her dentures to speak more clearly. PT follows commands oob to chair with 1 assist. Pt reporting diffuse ab pain/tenderness this afternoon, as well as lower back pain (pt has h/o lbp). will try mso4 prn bolus.\n ID: tmax 102.4 as noted. blood cx x1, ua, C+S sent and stool sent. needs sputum if able. CXR done and kub done. on levo/flagyl.\n RESP: rr 20's-32.. LS course L base, LLL peumonia.. cpt x 1. oob as noted. sats mid 90's on RA. PT with cough productive of thin bloody secrtions in small amts.\n GI: pt agreed to ogt today.. HO placed and confirmed by xray.. will start tf's, but pt to cont on PPN for now until tf's at goal.. will restart po meds. pt with elevated LFT's and INR.. RUQ US done, no cholecyctitis evident. pt given dulcolax and fleets with about 500 cc's liquid stool out, brown, ob+, sent for spec. Huge hemorrhoids present. PT will ultimately need ent eval/formal swallow study to diagnose cause of persistent aspirations.\n ACCESS: very difficult access. iv therapy able to place 2nd piv.. team aware pt is out of peripheral access.. No plans at this time for PICC or central access.\n Heme: hct 26.8 today.. ordered to receive 2uprbc's today.. 2nd unit infusing over 4 hours.\n GU: foley intact, urine amber with sediment.\n integ: stage 1 decube to coccyx. duoderm intact.\n A/P: pt with new temp spike.. to cont to remain in unit o/n to follow resp status.. follow cx, temps.. unable to med with tylenol as is listed as an allergy (her pcp told her not to take tylenol as her lft's are elevated. will need to follow fluid balance, as may need lasix this eve s/p tx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-05-18 00:00:00.000",
"description": "Report",
"row_id": 1567291,
"text": "MICU NPN Addendum:\n At 0600 (during turn), pt coughed and acutely dropped TV on PSV ventillation. Pt bagged/suctioned/lavaged for LARGE amts old blood and clots. Breath sounds course. BP transiently elevated to 206/100 for less than five minutes. HR also mildly elevated during this episode to 110-120. Sp02 100% at all times (pt placed on 100% suction). About 30 minutes later, pt c/o CP. EKG with no acute changes per Dr. . Stat CXR done. Pt given 1mg MS04 with decrease of pain to . If pt still has pain at 0710, morphine to be repeated. Pt is allergic to NTP. Enzymes/troponin added on to 0530 labs. CPK's to be cycled X 3. EKG also to be repeated when pt pain free.\n"
},
{
"category": "ECG",
"chartdate": "2142-05-18 00:00:00.000",
"description": "Report",
"row_id": 109415,
"text": "Probable atrial flutter with unusual 3:1 A-V block. Ventricular rate 85-90,\natrial rate 255-270. Left axis deviation. Possible old lateral myocardial\ninfarction. Possible right ventricular hypertrophy. Non-specific repolarization\nchanges. Compared to the previous tracing of probably no significant\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2142-05-25 00:00:00.000",
"description": "Report",
"row_id": 109378,
"text": "Sinus rhythm, rate 63. Prolonged Q-T interval. Indeterminate frontal plane\naxis. Possible biventricular hypertrophy. Compared to the previous tracing\nof the Q-T interval is longer.\n\n"
},
{
"category": "ECG",
"chartdate": "2142-05-25 00:00:00.000",
"description": "Report",
"row_id": 109379,
"text": "Atrial fibrillation with a controlled ventricular response rate. Q-T interval\nprolongation and inferior and anterolateral T wave inversions. Left ventricular\nhypertrophy by voltage. Possible right ventricular hypertrophy. Compared to the\nprevious tracing of the rhythm appears to have changed from atrial\nflutter to coarse atrial fibrillation. The ventricular rate is slower. Votlage\ncriteria for left ventricular hypertrophy have appeared. In addition, there is\nprobably variation in precordial lead placement.\n\n"
},
{
"category": "ECG",
"chartdate": "2142-05-13 00:00:00.000",
"description": "Report",
"row_id": 109416,
"text": "Supraventricular rhythm, probably sinus rhythm with prolonged P-R interval.\nBaseline artifact. Compared to the previous tracing of the rhytnm now\nappears to be a sinus mechanism.\n\n"
},
{
"category": "ECG",
"chartdate": "2142-05-09 00:00:00.000",
"description": "Report",
"row_id": 109417,
"text": "Indeterminate regular supraventricular rhythm with baseline artifact. Possibly\nsinus mechanism, although cannot exclude an accelerated junctional rhythm with\ndigoxin toxicity if patient is on this medication. Compared to the previous\ntracing of cardiac rhythm is now regularized.\n\n"
},
{
"category": "ECG",
"chartdate": "2142-05-06 00:00:00.000",
"description": "Report",
"row_id": 109418,
"text": "Atrial fibrillation, mean ventricular rate 70. Indeterminate QRS axis. Probable\nleft ventricular hypertrophy. Compared to the previous tracing of \nmultiple abnormalities persist without diagnostic change.\n\n\n\n\n\n\n\n"
}
] |
10,653 | 117,279 | A/P: This is an 86 y/o F w/ h/o HTN, CAD, , p/w syncope, found to have complete heart block. She had a pacemaker placed, complicated by a post-placement hematoma which was evacuated. . # Cardiac: a) Rhythm: Ms presented with complete heart block, likely worsening of long-documented conduction disease (RBBB and L post-hemiblock). She had reverted to sinus rhythm with prolonged AV conduction by presentation; a temporary pacing wire was placed and she was eventually taken to the EP lab for permanent pacemaker. This procedure was complicated by a large hematoma (requiring 9 U pRBCs) which was also associated with hypotension requiring dopamine. She was sent to the CCU for monitoring; her anticoagulation was not reversed secondary to her mechanical AV valve. She was intubated and taken to the EP lab on for hematoma evacuation. She improved and was taken to the floor on for further cares. . b) Ischemia: Ms. is s/p old IMI. She is currently on statin therapy. Her aspirin was held throughout her hospital stay given her persistent risk of bleeding. It may need to be restarted as an outpatient, after documentation of stable hct. | Mitral valve disease.Height: (in) 59Weight (lb): 152BSA (m2): 1.64 m2BP (mm Hg): 119/50HR (bpm): 67Status: InpatientDate/Time: at 13:47Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate [2+] tricuspid regurgitation is seen. The patient is status post median sternotomy and dense calcification is again seen in the mitral annulus. Pt had R EJ and L femoral aline placed. RESP: pt intubated, vented 450 x 12/.40/peep5.. abg: 7.37/43/80/26. Moderate tricuspid regurgitation. Right femoral venous TLC placed in semi emergency on 3. Moderate mitral stenosis, likely secondary toextensive mitral annular calcification. HR-AVPaced RSBI done on 0 peep/5 ips 72.3. Mild (1+) aorticregurgitation is seen. Normal LV inflow patternfor age.TRICUSPID VALVE: Tricuspid valve not well visualized. FINDINGS: There is a hypoechoic, likely fluid collection, measuring 4.1 x 2.6 cm just medial to the pacemaker along the anterior aspect of the left chest. Groin with breakdown/excoriaton with DSD intact. Bileaflet aortic valve prosthesis with high transvalvular gradientsand mild aortic regurgitation. There is moderate mitralstenosis (area 1.0-1.5cm2). There is moderatepulmonary artery systolic hypertension. Pull Femoral line once pt stable. Percocetts have made her confused this admit and requiring a sitter.CV-Remains on low dose dopamine 2mcg/kg/min maintaining MAPs >65, weaned down from 3.1mcg/kg/min. Otherwise, remains with large extended hematoma/ecchymosis over chest L >R, down L arm and extending to R arm. s/p OR for evacuation of hematoma. overbreathing 0-2x/min. LS clear, but after fluid and blood did have some scattered crackles t/o bases and exp wheezes. Increased AVR gradient.Mild (1+) AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. L groin (old aline site) with small serosang ooze. Abdominal pannus crease line is open and bleeding- for now placed /duoderm gel/aquafor dressing then DSD, area still has a right femoral venous line in place.Access-Right brachial double lumen PICC placed by IR on . will need cxr in am to evaluate volume status. Secondary ST-T waveabnormalities. right IJ temp. temp. takes respiridal at HS. Left atrialabnormality. s/p 2 UPRBC . First degree A-V delay. Pt has h/o hypothyroid. guiac neg. neg. "O: pt. Compared to the previous tracing of nosignificant change.TRACING #1 Compared to the previous tracing of A-V pacing isnew.TRACING #1 monitor u/o. I&O neg 1 iter.ID: Low grade temp 99.4. bld cultures pending. Lasix prn. transfused 2UPRBC. takes O2 off. HCT up after 1U.? LS cta, diminished @ bases. Baseline artifact. NPN 7p-7a continuedEKG obtained x2. HCT drop- unclear . Right axis deviation. Check lytes and INR. Ectopic atrial rhythm reverting to sinus rhythmFirst degree A-V delayProbable left atrial abnormalityRight bundle branch blockPossible inferior (and ? transfused 2UPRBC (12a-0400), 0430 to present. F/U with pnd labs/cultures. Sinus rhythm. Sinus rhythm. Sinus rhythm. Intraventricular conductiondefect of the right bundle-branch block variety. O x1-2. MA 2/ . O2 sats > 93 on 4l. Cont with POC. am INR pnd.GI/GU: foley patent. Sinus rhythmFirst degree A-V delayProbable left atrial abnormalityRight bundle branch blockPossible inferior (and ? Sinus rhythmFirst degree A-V delayProbable left atrial abnormalityRight bundle branch blockPossible inferior (and ? U/O marginal, 5.0-100cc/hr. NPO since midnite. Hct 25 after 1 unit of bld. BP 117/71-133/47. Rightbundle-branch block. Repeat pending. 1L NS @ 100cc/hr started for low Na.ENDO: stim pending. Perm pacer to be placed once bld cultures are negative and INR wnl.Resp: Lungs with rales in bases slightly diminshed. Right bundle-branch block. Right bundle-branch block. Normal sinus rhythm with A-V conduction delay. tylenol x1. Non-diagnostic Q waves in the inferior leadsconsistent with possible prior infarction. BP stable. TPA inserted, awaiting result. Denies shortness of breath. Possible prior inferior and lateralmyocardial infarction. monitor lytes. Consider right ventricular overloador possible left posterior fascicular block. Possible evacuation of pacer. Abd is soft distended nontnder. down to 97Ax in AM. RR 20s.GI/GU: ABD is soft, +BS. HCT down 2pts since transfusions.prn restraints. Post transfusion hct 30. SBP 120-150s. cultures pnd from admit.CV: 99/45-135/40. INTUBATED/SEDATED OVERNOC. Moderate stenosis of the SMA at its origin. A right thalamic lacune is again noted. The right upper extremity was prepped and draped in sterile fashion. HYPOTENSIVE TO 70'S->DOPA. TECHNIQUE: Non-contrast head CT. At C3/4, there is mild anterior spondylolisthesis with degenerative changes of the facet joints bilaterally consistent with degenerative spondylolisthesis. ->OR FOR EVACUA-TION HEMATOMA L CHEST. REASON FOR THIS EXAMINATION: eval for acute cardiopulmonary process. FINAL REPORT EXAMINATION: PA and lateral chest. IMPRESSION: Findings consistent with bibasilar atelectasis without frank consolidation. concern for dissection. IMPRESSION: AP chest reviewed: The patient has had median sternotomy. TECHNIQUE: Routine non-contrast head CT. 11:51 AM CHEST (PORTABLE AP) Clip # Reason: eval for acute cardiopulmonary process. Right PICC line has been placed, terminating within the upper superior vena cava. CT ABDOMEN WITHOUT ORAL, WITH INTRAVENOUS CONTRAST: Imaging of the abdomen is limited by the early phase of injection. Mild degenerative anterolisthesis at C3/4 and C5/6 as well as mild posterior degenerative spondylolisthesis at C6/7. Question pneumothorax. Hypodensity within the right thalamus is consistent with lacunar infarction. At C6/7, there is mild retrolisthesis of C6 on C7 with mild degenerative changes of the facet joints. Loss of height of L1 and T9 - age indeterminate. Coronal and sagittal reformatted images were obtained. Bilateral scattered ethmoid air cells. AMT BLEEDING.GI: ABD. 2.5 mm axial, coronal, and sagittal reconstructions were obtained. There is a small hiatal hernia. A right transjugular right ventricular temporary pacer lead follows the expected course to the floor of the right ventricle. Post-surgical changes are seen together with a left-sided transvenous bipolar pacemaker. IMPRESSION: Unchanged mild pulmonary edema. COURSE C/B LG. FINAL REPORT PORTABLE CHEST, . | 44 | [
{
"category": "Radiology",
"chartdate": "2116-02-03 00:00:00.000",
"description": "L US EXTREMITY NONVASCULAR LEFT",
"row_id": 944162,
"text": " 12:51 PM\n US EXTREMITY NONVASCULAR LEFT Clip # \n Reason: Evaluate L upper chest pacemaker site for hematoma v. absces\n Admitting Diagnosis: 3RD DEGREE HEART BLOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman s/p Pacemaker placement now with fever and swelling around\n pacer site.\n REASON FOR THIS EXAMINATION:\n Evaluate L upper chest pacemaker site for hematoma v. abscess\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Upper extremity, left chest, superficial ultrasound examination.\n\n INDICATION: 86-year-old female status post pacemaker placement with fever and\n swelling around pacemaker site. Assess for hematoma versus abscess.\n\n COMPARISONS: None.\n\n FINDINGS: There is a hypoechoic, likely fluid collection, measuring 4.1 x 2.6\n cm just medial to the pacemaker along the anterior aspect of the left chest.\n There is no abnormal blood flow in this area. The left subclavian vein is\n visualized and appears to be patent.\n\n IMPRESSION: 4.1 x 2.6 cm subcutaneous fluid collection just medial to the\n pacemaker insertion site. Differential includes abscess versus hematoma.\n Clinical correlation is advised.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 944859,
"text": " 7:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess change\n Admitting Diagnosis: 3RD DEGREE HEART BLOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with temp pacer wire placed, now hypothermic with\n leukocytosis.\n REASON FOR THIS EXAMINATION:\n assess change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: Leukocytosis.\n\n One view. Comparison with . Interstitial markings are more prominent\n and the pulmonary vasculature is now indistinct. There is increased hazy\n density in the lower right chest. The retrocardiac area appears dense. The\n patient is status post median sternotomy and dense calcification is again seen\n in the mitral annulus. A bipolar transvenous pacemaker remains in place. A\n PICC line is unchanged in position. An endotracheal tube has been inserted\n and terminates at the thoracic inlet.\n\n IMPRESSION: Evidence for development of pulmonary vascular congestion and\n right pleural effusion. Persistent increased density in the retrocardiac area\n consistent with volume loss or consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-08 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 944903,
"text": " 2:45 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for chf\n Admitting Diagnosis: 3RD DEGREE HEART BLOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with temp pacer wire placed, now hypothermic with\n leukocytosis.\n REASON FOR THIS EXAMINATION:\n eval for chf\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: Leukocytosis, hypothermia.\n\n One view. Comparison with the previous study done earlier the same day.\n There is continued evidence of pulmonary vascular congestion and pleural fluid\n on the right has increased and there is now development of increased density\n in the left costophrenic sulcus. This is difficult to assess, however, due to\n change in the patient's position. The retrocardiac area appears dense as\n before consistent with atelectasis or consolidation. Mediastinal structures\n are unchanged. The patient has been extubated. A PICC line and transvenous\n pacemaker remain in place.\n\n IMPRESSION: Persistent pulmonary vascular congestion. Interval increase in\n pleural fluid. Persistent retrocardiac density consistent with volume loss or\n consolidation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2116-01-28 00:00:00.000",
"description": "Report",
"row_id": 84534,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congestive heart failure. Left ventricular function. Mitral valve disease.\nHeight: (in) 59\nWeight (lb): 152\nBSA (m2): 1.64 m2\nBP (mm Hg): 119/50\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 13:47\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Hyperdynamic LVEF >75%.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). Increased AVR gradient.\nMild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Severe mitral\nannular calcification. Moderate MS (MVA 1.0-1.5cm2) Mild to moderate (+)\nMR. Prolonged (>250ms) transmitral E-wave decel time. Normal LV inflow pattern\nfor age.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Moderate [2+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). A\nbileaflet aortic valve prosthesis is present. The transaortic gradient is\nhigher than expected for this type of prosthesis. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are moderately thickened.\nThere is severe mitral annular calcification. There is moderate mitral\nstenosis (area 1.0-1.5cm2). Mild to moderate (+) mitral regurgitation is\nseen. Moderate [2+] tricuspid regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION:\nMild symmetric left ventricular hypertrophy with hyperdynamic systolic\nfunction. Bileaflet aortic valve prosthesis with high transvalvular gradients\nand mild aortic regurgitation. Moderate mitral stenosis, likely secondary to\nextensive mitral annular calcification. Mild-to-moderate mitral regurgitation.\nModerate pulmonary hypertension. Moderate tricuspid regurgitation.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-09 00:00:00.000",
"description": "Report",
"row_id": 1403019,
"text": "Nursing Progress Note\n\nS: Why am I here?\"\n\nO: Please see flow sheet for objective data. Tele remains AV paced rate 50's-60's. Restarted on Lopressor 25mg TID and Norvasc 5mg daily. L fem a line dc'd by house staff as well as triple lumen. Dsg over pacer site changed by EP fellow. Area covered with adaptic, DSD and pressure dsg. Lg ecchymotic area noted unchanged from am. Hct 28 then 30 this pm. Bilateral Radial pulses present. Both arms are elevated with pillow. SBP 120-150 via NIBP via L leg. Given lasix 20mg IV this pm. IV Heparin restarted after lines were pulled at 800units/hr without bolus as per EP.\n\nResp: Lungs diminshed in bases otherwise clear. O2 sats > 95% on 2l. Nonproductive cough.\n\nNeuro: Early in am pt was alert and oriented x's3. Able to follow commands. During the pm pt more disoriented to surroundings and what has happened. Conts to be cooperative with care. C/o generalized discomfort esp when turning. Conts with Tylenol ATC and given MSO4 2mg IV with some effect.\n\nGI/GU: Appetite is fair. abd is soft with bowel sounds present. No BM today. Foley draining CYU. Creat 1.4.\n\nSkin: Excoriated areas in both folds cleansed with wound cleanser and covered with adaptic and dsd.\n\nAccess: R PICC line remain in place. Red port used to infuse Heparin. Atleplase instilled in Blue port x's 1hr. Able to draw back and flush with saline afterward. REJ remains in place.\n\nID: Afebrile. To remain on Vancomycin until Friday. Zosyn dc'd.\n\nSocial: Daughter called and son-in-law in to visit.\n\nA&P: Hct remains stable today. Cont to monitor hct closely while on low dose Heparin. Check PTT at 9pm. Titrate dose without any bolus. To start coumadin this pm. Cont with POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-10 00:00:00.000",
"description": "Report",
"row_id": 1403020,
"text": "CCU NRSG NOTE\n86yo s/p fall due to CHB > perm pacer c/b large bleed into L arm/chest area.\nID: Afebrile on vanco.\nCV: Hr 50's AV paced/first degree AVB. Bp 100-140's via l leg dinemap. Tolerating lopressor 25mg tid. L groin (old aline site) with small serosang ooze. R groin (old TLC site) D/I. Distal pulses 2+/dop bilat. Heparin decreased to 650units/hr after ptt 80, given coumadin 2.5mg.\nResp: Lungs with crackles in bases, but difficult to assess due to poor effort on pt's part. O2 at 2lnp with sats in the high 90's. No cough/sputum production. Rec'd lasix 20mg with fair diuresis. Was neg approx 1 liter for yesterday and approx 500cc neg for today.\nGI/GU: Abd softly distended with (+) bowel sounds, no bm. Foley drng yellow urine with sediment. Taking in small sips of fluid for me. Rec'd her glargine as ordered.\nMS: She is a little off tonight. She is oriented at times to person, place and time but then asking odd questions, ie) are we in . Moving all extrems.\nSkin: Arms cont to be reddened and bruised L>R and chest also very eccymotic. Skin very fragile/edematous. Groin with breakdown/excoriaton with DSD intact. Coccyx is intact.\nAccess: Currently with R arm PICC line, both ports flushable. Also, has a R EJ line that is patent.\nA: hemodynamically stable.\n Hct stable\n slightly off tonight with her mental status, but cooperative\n adjusted hep\nP: maintain ptt on low side\n follow l arm/chest with starting hep/coumadin again\n follow lungs assessment/ fluid status ? further lasix\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-06 00:00:00.000",
"description": "Report",
"row_id": 1403011,
"text": "CCU Nursing Progress Note/MICU 7 boarder\nS-\"Could I have some juice?\"\nO-Neuro-Occasional periods of deep sleep, then wakes up and is ready to talk and take her pills etc. Pleasantly confused talking about taking a cruise and being in the Navy(daughter says she has never taken a cruise or been in the Navy.) Cooperative however she is legally blind and HOH, and you have to make sure she is awake enough and has your attention before she will take her pills. For pacemaker/left chest hematoma receiving tylenol 500mg-1000mg QID RTC. Has not required morphine. Percocetts have made her confused this admit and requiring a sitter.\nCV-Remains on low dose dopamine 2mcg/kg/min maintaining MAPs >65, weaned down from 3.1mcg/kg/min. Goal to d/c dopamine. HR 80-90's with AV delay PR .24 and rare PVC's. Has not required permanent pacemaker.\nINR 2.8 at 0600 and repeat at 1700 3.6/PT 33.1/PTT 36.3-last dose of coumadin 4mg . HO aware of increase in INR. To receive 1 unit of FFP with goal to attempt to get INR to 2.4 Serial HCTs q6-8hrs @ 6am 31.9, at 1300 HCT 29.4 received one unit PRBC's over 2 hours. Repeat HCT check at .\nResp-LS clear with decreased BS at left base. No cough or c/o SOB. O2 sats remain good at 97-99% 2lNP.\nID afebrile with elevated WBC 21.2 started on Vanco/Zosyn for hematoma and pacer pocket protection.\nGU-BUN/Cr 20/1.2 Foley draining 0-10cc/hr amber urine. Received 1 liter NS at 100cc/hr without change in hourly urine output.\nGI-Appetite poor, taking sips of water and juice with pills without difficulty. +BS x4, no BM on bowels meds.\nSkin-Left breast/chest hematoma stable without further expansion, eccymosis tracking downward and across chest to right side. Pressure dressing that surrounds entire chest remains intact and will be removed 1/19 per EP consult. Abdominal pannus crease line is open and bleeding- for now placed /duoderm gel/aquafor dressing then DSD, area still has a right femoral venous line in place.\nAccess-Right brachial double lumen PICC placed by IR on . Right femoral venous TLC placed in semi emergency on 3. Plan to remove femoral line after dopamine d/c'd.\nSocial-Her daughter and son in law into visit. Very supportive and concerned about patient\nA/P-s/p permanent pacemaker c/b hematoma at site while still on heparin infusion/coumadin and expanding hematoma with hypotension and HCT drop requiring 6 units PRBC and transfer into ICU.\nContinue to closely monitor serial HCT's and INR. Next draw at to include HCT, INR, chemistry. Tylenol 1000mg QID for pain. Monitor increase in hematoma size. Continue to keep pt and family aware of POC as discussed in multi disciplanary rounds.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-07 00:00:00.000",
"description": "Report",
"row_id": 1403012,
"text": "NPN 7p-7a\nPt is 86y/o with h/o CAD s/p CABG and in , CHF, HTN, blindness and dementia. Pt s/p permanent pacer after complete heart block on admission. Pt then developed large hematoma over pacer pocket, and while heparinized for began to bleed further into arm and left side of chest. Pt has had 8u PRBCs over last 24H and will go to EP lab tomorrow for evacuation of permanent pacer.\n\nEVENTS over night: Pt received 2.5L fluid boluses for low u/o with really no effect. Hct 28.0 down to 25.5, pt received 1u PRBCs hct 27.0 and is now getting 2nd unit of PRBCs. Goal hct >30. Pt has unit of FFP on hold for procedure, not to be given until ordered by EP resident.\n\nNEURO: Pt is pleasantly confused, with very descriptive fascinating fables to tell. Pt did c/o increased pain and medicated with total of 2mg Morphine with good effect. Pt also on standing Tylenol. Pt slept on/off most of shift, follows commands.\n\nCV: HR 60s-80s in 1st degree AV block. Rare PVCs. Dopamine weaned off at 2200. BP 90s-120s/30s-50s, MAPs >60. Palpable pulses bilaterally. Pacer has not been activated.\n\nRESP: Pt on 2.0L NC with sats>98%. LS clear, but after fluid and blood did have some scattered crackles t/o bases and exp wheezes. Pt given albuterol and atrovent nebs with good effect. RR 10-20s.\n\nGI/GU: ABD is soft, obese. + BS, no BM this shift. Pt is NPO for procedure today, but did take ice cream and pills well last night. Pt c/o hunger. U/O very poor, 10-30cc/hr HO aware. Foley flushed and patent.\n\nSKIN: Large hematoma over left chest extending slightly over right side and down left arm. Outlined with marker. Pt with bruising over body. R femoral line site is weaping with excoriation. Catheter tip is in skin fold and difficult to keep dsg intact. Line was also placed in emergent situation on floor and team wants it out as soon as possible.\n\nPLAN: Continue to monitor hematoma for necrosis or further bleeding. F/U with am labs including post transfusion hct. Monitor u/o. Pt to have pacer extraction in EP lab today. Pull Femoral line once pt stable.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-07 00:00:00.000",
"description": "Report",
"row_id": 1403013,
"text": "Nursing Progress Note:\nReport received from day shift; all alarms in place and functioning normally; environment secured for safety\n\nPt is an 86 year old female with history of CAD, s/p CABG; St. for AS; type II dm, CHF, HTN, blindness and dementia; pt was admitted after a fall at home; at home pt became nauseated and walked into BR with walker, felt lightheaded and fell; family reports pt had 4 episodes of syncope in the past 6 months\n\nShe then presented to ED with right knee and hip pain and HA, denied CP, SOB, BS 294 initial vitals in ED 142/37-hr 35-45, 97%2LNC, 97.4; after this became less rsponsive and HR in 30's with QRS 150's and SBP 80's; EKG showed complete heart block; vomited x2 in ED, received atropine x1 with increase in HR to 70's for less than 1 minute and back down to 30's; OSH labs showed WBC 19, HCT 28.8, trancutaneous pads placed and pt transferred to \n\nPermanent pacer placed on and on heparin drip for ; pt transferred to 3 where she began to bleed from pacer site and developed large hematoma originating at left breast and spreading down left arm, pt became hypotensive and HCT dropped from 29 to 19; pt was transfused with 5 unit prbc's and right femoral line placed emergently; dopamine started; pt transferred to MICU\n\nSince admission, pt has had foley placed, BCx2 sent, stim test done, zosyn started, total of 8U PRBCs transfused, intermittent need for dopamine; pt currently in OR for evacuation of hematoma.\n\nNeuro: pt lethargic but easily arousable to verbal stim; pleasantly confused; oriented to person and place; is frequently forgetful; has baseline dementia; pupils 4mm/sluggish bilaterally, PERL; no seizure activity\n\nCV: SBP 120-100's, HR 1st degree AV block 70-60's, no ectopy; pacer in place; MAP 62-73; +radial/pedal pulses bilaterally; moves all extremities; hematoma throughout left arm and across chest, also ecchymosis at right antecub at PICC site, and left neck; HCT stable; began transfusion 1 unit FFP prior to going down to OR without incident while in MICU; replaced with 40meq kcl and 2 grams magnesium, please see flowsheet for lab values; denies CP, denies SOB; dopamine continues off\n\nResp: LS clear at apices, diminished with occassional exp. wheeze at bilateral bases, no crackles auscultated; sats 99-96%2lnc; RR 20-10; bilateral chest expansion noted; no use of accessory muscles for breathing noted; no SOB; afebrile\n\nGI: +BS x4 quadrants, NPO for procedure; no BM, abd soft distended, non-tender; no nausea/vomiting\n\nGU: two-way foley cath in place, patent and draining sufficient quantities clear yellow urine; U/O poor on NOC; post fluid boluses 3.5 L, U/O now 25-70cc/hr, clear yellow urine\n\nSKIN: hematoma assesed frequently- did not extend beyond outlined areas, large area of red-purple, hard to palpation, swollen, and tender skin at left breast, down entire left arm to hand and across right breast; radial pulses remained strong and palpable, ecchymosis at PICC site, ecchymosis at right hand; ecchy\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-07 00:00:00.000",
"description": "Report",
"row_id": 1403014,
"text": "Nursing Progress Note:\n(Continued)\nmosis at left neck; skin at right fem line is excoriated, weeping, draining serous at times serosang, drainage, dressing changed x2, difficult to maintain intact dsg over site due to drainage and skin folds\n\nIV: right PICC double lumen all ports patent; triple lumen fem line all ports patent\n\nPain: pt is extremely tender at sites of hematoma/ecchymosis, receiving tylenol around the clock, except 1800 dose held for procedure; pain subsides with rest/decrease in nursing activities; cont to have some pain at right hip\n\nPOC: pt to return from OR tonight; monitor U/O; monitor vitals and need for dopa; monitor coags/bleeding/change in hematoma; pain management as needed; monitor S+S of infection. Crits q 4 upon arrival from OR- may be eventually transferred to a CCU bed once one is available.\n\nPlease see flow sheet for additional info as needed.\n\nThis RN being precepted by , RN\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-08 00:00:00.000",
"description": "Report",
"row_id": 1403015,
"text": "NPN 7p-7a:\n Pt returned from OR at 21:30 s/p hematoma evacuation from L chest wall. In OR, pt received 500mcg fentanyl, 100 mg succhinocholine, 13mg pancuronium and 12 mg etomidate for sedation/intubation. Pt also was repleated with calcium chloride 500mg. Pt received 1100 cc's crystalloid, 868 cc's ffp, had 270cc's uo, and ebl 50cc's. Pt had R EJ and L femoral aline placed. OR course eneventful per report. Pt returns to MICU intubated, sedated on propofol, hemodynamically stable. A dsd is intact to R upper chest wall. to remain in place o/n per report. Post op Hct 25.7. hct check 2.5 hrs later showed hct drop to 24.5. HO aware, and pt currently receiving 1upbrc's. will recheck hct after current uprbc's.\nReview of Systems:\n Neuro: pt sedated on propofol which was decreased from 40mcg/kg/min to 30 mcg/kg/min o/n, as pt remained unresponsive upon return from OR. on current propofol, pt still with no withdrawal response to pain, however, noted to have bp rise from 140's to 180's with any tactile stimulation. team aware. received 25mcg fentanyl iv x 1 for suspected pain with bath. pupils reactive to light.\n CV: remains 1st degree heart block, rate 50's-70's. pt transiently av paced o/n as well, rate 50. bp 120's-140's by abp, up to 180's-190's with stimulation. of note, nbp measuring 15 points lower than abp, as it was in OR as well. pt with dsd over site of evacution to L chest wall.. dressing with small amt dried blood. Otherwise, remains with large extended hematoma/ecchymosis over chest L >R, down L arm and extending to R arm. appears unchanged o/n per HO, despite drop in hct. infusing 1uprbc' sat this time as noted.\n RESP: pt intubated, vented 450 x 12/.40/peep5.. abg: 7.37/43/80/26. rate increased to 14 by RT. sats 99-100%. overbreathing 0-2x/min. sx for thick blood tinged secretions in small amts. LS course throughout. pt is 5L + yesterday. will need cxr in am to evaluate volume status. receiving mdi's by RT.\n GI: ab soft, bs +. no ogt at this time per team. no stool.\n GU: foley intact, uo 40-50cc's/hr.\n Access: L groin aline oozing small amts brb, R groin tlc draining small amts serosanguinous fluid. R eJ intact. R arm picc line intact.\n Social: pt's daughter in and was updated by this RN, went home for noc.\n FE: repeat K+ 4.5 post op, mg 2.5. fsbs wnl. lantas held d/t pt npo.\n A/p: pt s/p large hematoma to L chest s/p pacer placement. now off heparin gtt despite St 's valve per team. s/p OR for evacuation of hematoma. hct dropped 1 point since returned from OR. to receive prbc's 1 unit and follow q 4 hr hct.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-08 00:00:00.000",
"description": "Report",
"row_id": 1403016,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details.Suctioned for mod amts thick bldy secretions. MDI's given. HR-AVPaced RSBI done on 0 peep/5 ips 72.3. Sedated with propofol. Given bld products for low hct. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-08 00:00:00.000",
"description": "Report",
"row_id": 1403017,
"text": "Nursing Progress Note\nReport received from day shift; all alarms inplace and functioning normally; environment secured for safety\n\nNeuro:Pt initially on propofol and weaned off. She has been alert and now pleasantly confused at baseline, oriented to person and place; PERL, 4mm brisk bilaterally; no seizure activity; MAE, follows commands.\n\nCV: ABP 200's this am while weaning off sedation; has decreased to 160's after extubation and PO lopressor/lopressor IVx1; HR 60's NSR-SB(after the lopressor), pacer set at 50; +radial/pedal pulses bilaterally, +CSMx4, continues edematous upper extremities\n\nRESP: extubated at 1120a without incident; currently on NC 3L sats 95-100%; RR 23-15; LS coarse throughout; CXR results pending; bilateral chest expansion noted; +non-productive cough\n\nGI: +BS 4x, no BM, no N/V/D, abd soft distended, +tender; tolerated sips after extubation, now tolerates diabetic diet\n\nGU: two way foley cath draining pink tinged urine quantities sufficient; received lasix x1 20mg iv with good effect\n\nSKIN: skin greatly improved from yesterday prior to evac of hematoma; cont discolored and swollen throughout left arm and across chest, PICC site echhymotic, right hand also swollen/discolored; cont draining sero-sang fluid and unable to maintain occlusive dressing on right fem line and left fem art line, md aware\n\nIV: left fem art line, right fem central line, right ej, right PICC, all ports patent. Awaiting decision on pulling groin lines from the CCU team.\n\nSoc: daughter and son in law active in pt's care; daughter is HCP\n\nPOC: d/c lines when possible, cont. to monitor abp; monitor coags and serial crit q8hrs, next due at 8 pm; Watch for signs of vol overload,monitor need for blood products; assess change in skin condition.\n\nPlease see flow sheet as needed for additional ifo\n\nThis RN being precepted by , RN\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-09 00:00:00.000",
"description": "Report",
"row_id": 1403018,
"text": "CCU NRSG TRANSFER ACCEPT NOTE\n86YO initially adm on s/p fall and in CHB. On had perm pacer placed. On had drop in hct from 29 to 19.8 with hypotension in setting of large hematoma over pacer site in left shoulder extending down L arm. At that time her INR was 3.4 (on heparin d/t St. aortic valve). She was transferred at that time to MICU for futher managment (no bed in CCU). Now transferred to CCU for further management.\n Afebrile on Pipercillan/vanco empirically awaiting cultures.\nCV: Hr mostly in the 50's first degree A block or AV paced. BP via L groin aline 110-180's depending upon degree of pain. L and R groin (r groin with TLC intact with sm amt of serous fluid drng).have remained intact with distal pulses 3+/dop bilat. L arm very eccymotic, no increase in size noted. R arm also distally very edematous and redened. Distal pulses in upper extrems 3+ bilat. C/o pain in arm and at times in legs, rec'ing tylenol RTC also rec'ing morphine 2mg iv when needed. Morphine with some relief of discomfort but tylenol seems to work the best.\nResp: O2 at 3lnp with sats in teh upper 90\ns. Crackles heard in bases otherwise clear. No sputum production.\nGI/GU: Taking sips of water. Abd softly distended with (+) bowel sounds. No bm. Foley drng yellow urine with sediment, approx 10-40cc/hr. No urine noted for 1 hour, team aware, awaiting am labs to determine whether needs lasix or blood.\nMS: She is alert and oriented x 3. Did not appear to be confused tonight. Slept in naps.\nAccess: R groin with TLC intact, L groin with aline intact. Has R PICC but red port clotted and other port able to flush though it has slight resistance and unable to draw blood from this port. Also has R ext jug line.\nSkin: Arms are extremely edematous, also upper legs appearing edematous. Skin in upper extrems appear very fragile, and reddened/ ecyymotic appearing. Coccyx intact. Folds in groin excoriated, with small amt of breakdown noted, cleansed with soap and water and DSD placed in folds.\nA: s/p perm pacer placement with large hematoma formation in chest area and L arm.\n hct down slightly this am\nP: cont to follow hct and assess chest/arm for increase in size of hematoma\n follow urine output ? lasix/vs ivf\n will need a new PICC line\n D/c groin lines when possible\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-06 00:00:00.000",
"description": "Report",
"row_id": 1403009,
"text": "NPN 7p-7a\nPt is a 86y/o with h/o CAD s/p CABG x4and , DMII, CHF, HTN, blindness and dementia with multiple recent syncopal episodes. Pt was initially admitted to CCU from OSH s/p fall and complete heart block requiring transcutaneous pacing and finally permanent pacer . Pt was also on Heparin gtt for . Pt transfered to 3, and began to ooze blood into new pacer site developing large hematoma which covers entire left chest extending down left arm. Last night pt became hypotensive to 70s with hct drop from 29 to 19, and was transfused with total of 5u PRBCs. Right femoral line was placed and Dopamine started, Pt then transfered to MICU for further treatment.\n\nSince arrival this am, blood cultures x2 and urine cultures have been sent. stim test has been completed and pending. Foley was replaced per Team request. All of above done elevated WBC and setting of hypotension. Pt also given 1st dose of zosyn.\n\nNEURO: Pt is very lethargic, arousable to voice but unable to unable to communicate verbally. Pt yells out in pain with turning. Pt is demented at baseline, but this is large decline in MS.\n\nCV: Pacer is in place, pressure dsg over site. HR 80s in 1st degree heart block. Occas PVCs. BP 90s-100s/30s-40s supported by Dopamine. Pt with diastolic CHF, EF 75%. palpable pulses bilaterally.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-06 00:00:00.000",
"description": "Report",
"row_id": 1403010,
"text": "NPN 7p-7a continued\nEKG obtained x2. Hold heparin gtt for now, last PTT >150. Hct goal 30, cycling Q6H.\n\nRESP: Pt on 2.0L NC with sats>98%. LS cta, diminished @ bases. RR 20s.\n\nGI/GU: ABD is soft, +BS. No bm since arrival. Pt currently NPO for possible evacuatin and until MS clears. Upper dentures in pt's mouth on transfer. U/O marginal, 5.0-100cc/hr. 1L NS @ 100cc/hr started for low Na.\n\nENDO: stim pending. Pt has h/o hypothyroid. Pt covered on insulin ss and fixed dose.\n\nSKIN: Large hematoma over left chest slightly oer sternum to right side. Left extending down arm. All of which was outlined. Multiple echymosis over body. Coccyx is pink, intact.\n\nACCESS: R double lumen PICC, with red port clotted. TPA inserted, awaiting result. Pt also has R triple lumen femoral line which was placed on floor.\n\nSOCIAL: Pt's daughter called and was updated.\n\nPLAN: Pt is followed by CCU service. Continue to monitor hematoma for necrosis, Q6H hcts (Goal >30), keep compression dsg on. Possible evacuation of pacer. F/U with pnd labs/cultures. Monitor MS.\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2116-02-09 00:00:00.000",
"description": "Report",
"row_id": 206363,
"text": "A-V paced rhythm. Compared to the previous tracing of A-V pacing is\nnew.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2116-02-08 00:00:00.000",
"description": "Report",
"row_id": 206364,
"text": "Sinus rhythm. Right bundle-branch block. Possible prior inferior and lateral\nmyocardial infarction. Compared to the previous tracing of no\nsignificant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2116-02-07 00:00:00.000",
"description": "Report",
"row_id": 206365,
"text": "Sinus rhythm. Right bundle-branch block. First degree A-V conduction delay.\nP-R interval 220 milliseconds. Non-diagnostic Q waves in the inferior leads\nconsistent with possible prior infarction. Right axis deviation with\nprobable right ventricular hypertrophy.\n\n"
},
{
"category": "ECG",
"chartdate": "2116-02-06 00:00:00.000",
"description": "Report",
"row_id": 206366,
"text": "Sinus rhythm\nFirst degree A-V delay\nProbable left atrial abnormality\nRight bundle branch block\nPossible inferior (and ? lateral) myocardial infarction, age indeterminate\nConsider right ventricular overload or possible left posterior fascicular block\nST-T wave abnormalities with probable Q-T interval prolonged although is\ndifficult to measure - clinical correlation is suggested\nSince previous tracing of the same date, ectopic atrial rhythm absent\\\n\n"
},
{
"category": "ECG",
"chartdate": "2116-02-06 00:00:00.000",
"description": "Report",
"row_id": 206367,
"text": "Ectopic atrial rhythm reverting to sinus rhythm\nFirst degree A-V delay\nProbable left atrial abnormality\nRight bundle branch block\nPossible inferior (and ? lateral) myocardial infarction, age indeterminate\nconsider right ventricular overload or possible left posterior fascicular block\nST-T wave abnormalities with probable QT interval prlonged although is\ndifficult to measure - clinical correlation is suggested\nSince previous tracing of , ectopic atrial rhythm seen\n\n"
},
{
"category": "ECG",
"chartdate": "2116-02-05 00:00:00.000",
"description": "Report",
"row_id": 206368,
"text": "Sinus rhythm\nFirst degree A-V delay\nProbable left atrial abnormality\nRight bundle branch block\nPossible inferior (and ? lateral) myocardial infarction, age indeterminate\nConsider right ventricular overload or possible left posterior fascicular block\nST-T wave abnormalities with p\\robable QT interval prolonged although is\ndifficult to measure - clinical correlation is suggested\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2116-02-01 00:00:00.000",
"description": "Report",
"row_id": 206369,
"text": "Normal sinus rhythm with A-V conduction delay. Intraventricular conduction\ndefect of the right bundle-branch block variety. Secondary ST-T wave\nabnormalities. Compared to the previous tracing of no diagnostic\ninterval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2116-01-30 00:00:00.000",
"description": "Report",
"row_id": 206370,
"text": "Sinus rhythm\nProlonged P-R interval\nConsider left atrial abnormality\nMarked right axis deviation\nIntraventricular conduction defect\nConsider inferior infarct - age undetermined\nConsider right ventricular hypertrophy\nQT interval prolonged for rate\nST-T wave abnormalities\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2116-01-28 00:00:00.000",
"description": "Report",
"row_id": 206371,
"text": "Baseline artifact. Sinus rhythm. First degree A-V delay. Left atrial\nabnormality. Probable inferior myocardial infarction, age indeterminate. Right\nbundle-branch block. Right axis deviation. Consider right ventricular overload\nor possible left posterior fascicular block. Diffuse ST-T wave changes with\nprominent U waves. Cannot exclude in part, drug, electrolyte or metabolic\neffect and/or possible ischemia. Clinical correlation is suggested. No previous\ntracing available for comparison.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-01-30 00:00:00.000",
"description": "Report",
"row_id": 1403006,
"text": "CCU NPN 1900-0700\nO:\nTM 100.5po. tylenol x1. WC down to 8.1(9.4)\nHR 60-70's 1st deg. AV block. BP 117/71-133/47. temp. wire on rate 50, MA 10. checked on rounds.\n\nHCT 28(30 ). s/p 2 UPRBC . had small stool x1. guiac neg. brown.\nINR down to 2.3(dose of po Vit. K+ ).\nsats 95-98% on 4lnc. dropping to 87% when pt. takes O2 off. LS crackles bases. no diuresis tonight. neg. 1.2L for .\n\nu/o 40-50cc/hr.\n\npt. cooperative. mildly confused but sweet. hands restrained prn. O x1-2. takes respiridal at HS. slept through night. wakes easily and is lucid. no agitation.\n\nA/P: plan for permanent pacer but waiting for INR to come down. NPO overnight for possible pacer today.\nintermittant fever. no antibiotics. prn tylenol.\nstool guiac neg. HCT down 2pts since transfusions.\nprn restraints. monitor u/o. orient as needed. safety precautions.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-01-30 00:00:00.000",
"description": "Report",
"row_id": 1403007,
"text": "CCU Progress Note:\n\nS- \"Can I eat today?\"\n\nO- see flowsheet for all objective data.\n\ncv- NPO this am for pacer insertion, however INR 2.3- procedure cancelled until tomorrow- Vanco ordered on call to EP- heparin gtt restarted @ 1200u/hr- PTT 84.8- heparin gtt decreased to 1000u/hr- repeat PTT due @ 2230- Hct 28- Plts 176- K 3.7- Kcl 40meq given- Mg 2.1- Tele: 1st degree AVB- HR 59-74- temp pacer set @ 50 MA 10- checked by cardiac fellow- NIBP 121-152/49-54 MAPs 68-76.\n\nresp- In O2 4L via NC- lung sounds with bibasilar crackles- resp even, non-labored- SpO2 93- 96%- lasix 20mg IV given this am.\n\nneuro- A&O X2- moving all extremities- pleasant & cooperative- follows command- Pt legally blind- family brought in Pt's eyeglass this afternoon.\n\ngi- abd soft (+) bowel sounds- taking Po well- no BM- glucose range 86-117 today- ? upper & lower endoscopy tomorrow prior to pacemaker insertion- NPO after 12am.\n\ngu- foley draining large amt light yellow colored urine- diuresed well from am lasix- (-) 1L since 12am- BUN 15- Crea .6\n\nA- Pre-op for pacemaker insertion tomorrow.\n\nP- NPO after 12am- PTT @ 2230- check lytes & replete as needed- D/C heparin gtt @ 3am- offer emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-01-31 00:00:00.000",
"description": "Report",
"row_id": 1403008,
"text": "CCU progress note 7p-7a\n\nNEURO: Alert and seemed oriented x last evening - but since 2am confused O x . bilat wrist retraints needed to keep pt from pulling off O2 + worried about pt accidently pulling out temporary pacer wire.\n\nID/SKIN: Tmax 99.5. abx: cefazolin q8h. small abrasion on coccyx. freq turns + barrier cream to coccyx.\n\nRESP: desaturating overnite while sleeping on 4L n/c. some sleep apnea noted. also having a bloody nose - placed on cool mist shovel mask w/ improvement in sats.\n\nCARDIAC: SR 70-80s 1'avb. SBP 120-150s. Heparin gtt off at 3am in preparation for pacemaker in am. am INR pnd.\n\nGI/GU: foley patent. good u/o. abd soft - stooled x 2 - soft dk brown. NPO since midnite for pacer in am.\n\n\nPLAN: for Permanent pacemaker in am ?2nd case. Vancomycin ordered on call to EP lab. NPO since midnite.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-01-29 00:00:00.000",
"description": "Report",
"row_id": 1403004,
"text": "CCU NPN 1900-0700\nS: \" Help me! \"\nO: pt. yelling out early on - confused to time/thought it was AM. easily oriented . knew her name and \"hospital\". later through night would be only Ox1-to person. slept well with resperidol po in eve.\nwakes easily to name.\nID: TM 100.5po. tylenol x2 po. down to 97Ax in AM. no antibiotics ordered. cultures pnd from admit.\nCV: 99/45-135/40. HR 57-64 SB. no VEA. right IJ temp. wire intact. MA 2/ . low rate 50. checked on days.\nREsp: RR 12-20. 4lnc sats 92-94%. down to 87% when off. NC increased to 5-6L. sats 96-97% no cough. no sputum production.\nGU: u/o . to 10cc/hr. lasix 20mg given (between units of blood)at 0300 with poor reponce. given 40mg at 0430 with better reponce.\nu/o ~ 200cc/hr.\nheme: HCT 22.2 in eve. transfused 2UPRBC (12a-0400), 0430 to present. given lasix between units.\nGI: no stool. no obvious source of low HCT. taking juice with meds.\n\nA/P: stable night - hemodynamically stable. no pacing required. HCT drop- unclear . transfused 2UPRBC. HCT up after 1U.\n? d/c pacing wire today. monitor lytes. orient as needed. safety precautions.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-01-29 00:00:00.000",
"description": "Report",
"row_id": 1403005,
"text": "Nursing Progress Note\n\nS:\" I would like to get up.\"\n\nO: Please see flow sheet for objective data. Tele sinus rhythm with occ paced beats. Pacer tested during rounds by card fellow and Dr . MA left at 10 with backup rate of 50. BP stable. INR remains elevated at 3.3. Repeat pending. Perm pacer to be placed once bld cultures are negative and INR wnl.\n\nResp: Lungs with rales in bases slightly diminshed. O2 sats > 93 on 4l. Denies shortness of breath. Given lasix 40mg IV x's 1.\n\nNeuro: Pt sleeping in naps throughout the day. Pleasantly confused. Oriented to self sometimes to time and place. Cooperative with care. Needs reminders about environment and lines. Both wrists remain in soft restraints while family not present. Bed alarm on.\n\nGI/GI: Pt tolerating diet well. Soft foods d/t not having her dentures with her. Abd is soft distended nontnder. No BM. Hct 25 after 1 unit of bld. Post transfusion hct 30. Foley draining CYU. I&O neg 1 iter.\n\nID: Low grade temp 99.4. bld cultures pending. WBC wnl.\n\nSocial: Daughter into visit this pm. Updated by RN regarding POC.\n\nA&P: Cont to monitor hemodynamics. Check lytes and INR. Lasix prn. Cont with POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-10 00:00:00.000",
"description": "Report",
"row_id": 1403021,
"text": "86 YR OLD SP FALL DUE TO CHB C MULTIPLE BRIUSES ,PACER PLACED C/O BY LARGE BLEED INTO L ARM AND SHOULDER .\n\nPT C/O ACHING ALL OVER BODY .TYLENOL ATC C SOME RELIEF,ABLE TO SLEEP IN NAPS .SKIN FRAGIL,OPEN AREAS IN BOTH GROINS FROM EXCORIATIONS,FORMER LINE SITES .ANTIFUNGAL POWDER AND CREAM C GAUZE TO BOTH GROIN AREAS .SKIN TEARS IN PACER AREA.SKIN CARE CONSULT ORDERED.ADAPTIC C GAUZE AND PAPER TAPE.COCCYX INTACT.HAS ANASARCA.\n\nAV PACED TO SR C FIRST DEGREE AV BLOCK .BP 140 TO 160 SYSTOLIC, TOL LOPRESSER,NORVASC .PALP DP.ON HEPARIN 400U,PTT NOW 48 WHICH IS GOAL .HCT STABLE .31.HAS PICC AND EJ PERIPH .\n\nSAT 95 2LNP,COUGHING,SOMETIMES PRODUCTIVE ,ROBITUSSIN PER PTS REQUEST .BS CL.\n\nEATING WELL C ASSIST.TAKING SUPPLEMENTS. LGE GUIAC NEG BM .REQUIRES SSHUMULOG.\n\nPO LASIX,HUO 20 TO 130 ,NEG 780 TODAY ,BUT POS OVER ALL.\n\nPT CAN STATE TIME AND PLACE,CONVERSE APPROPRIATELY,THEN HAS PERIODS OF CONFUSION ABOUT LEAVING THE GAS ON,SEEING PEOPLE HIDING IN THE CORNER AND WANTING TO GO HOME .STATES SHE IS LONELY ,DAUGHTER CALLED ,SAID SHE IS COMING LATER .\n\nSP BLEED ,HCT STABLE,ON HEPARIN FOR MVR.\n\nMONITOR FOR BLEEDING\nPAIN CONTROL C TYLENOL ATC,MSO4 ALSO ORDERED .\nSKIN CARE PER CONSULT\nENCOURAGE PO\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-11 00:00:00.000",
"description": "Report",
"row_id": 1403022,
"text": "86 YR. OLD WOMAN S/P PERMANENT PACEMAKER D/T CHB. HOSP. COURSE C/B LG. BLEED INTO L. CHEST/ARM D/T HEPARIN GTT. HCT 29->19 REQUIRING\n8U PRBC OVER 24 HRS. HYPOTENSIVE TO 70'S->DOPA. ->OR FOR EVACUA-\nTION HEMATOMA L CHEST. TOL. PROCEDURE WELL. INTUBATED/SEDATED OVERNOC.\n EXTUBATED WITHOUT DIFFICULTY. HEPARIN GTT RE-STARTED & CURRENTLY THERAPEUTIC.\n\nNEURO: LAST EVENING A&O X3, VERY CLEAR & COHERENT. AS NOC PROGRESSED, BECAME MORE CONFUSED. SEEING PEOPLE IN ROOM, UNAWARE THAT SHE IS IN HOSPITAL, WANTING TO TALK TO FAMILY AT THE BANK. PULLED OFF CHEST DSG.\nC/O INABILITY TO SLEEP & OF BEING VERY TIRED. SPOKE WITH DR. ABOUT SLEEPER->DIDN'T FEEL COMFORTABLE ORDERING ONE BECAUSE OF PT'S MENTAL STATUS/DEMENTIA.\n\nRESP: O2->2L NP. RR 15-24. O2 SAT 93-96%. BS CLEAR.\n\nCARDIAC: HR 55-66 AVP(HR<60)/FIRST DEGREE AVB, NO ECTOPY. BP 118-157/41-72. HEPARIN GTT INFUSING AT 400U/HR. PTT 41.2. DENIES CP/SOB. L. CHEST DSG RE-DRESSED WITH ADAPTIC/DSD/PAPER TAPE. AREAS WHERE SKIN HAS TEARS & SM. AMT BLEEDING.\n\nGI: ABD. SOFT. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING YELLOW URINE WITH SEDIMENT. U/O 30-100\nCC/HR.\n\nID: T(MAX)98.8(PO). CONT. ON IV VANCO.\n\nENDO: BS 237->TX PER SLIDING SCALE.\n\nAM LABS PENDING.\n\nPLAN: PT ACTIVITY AS TOL.\n ENCOURAGE DIET\n MONITOR PT/PTT D/T ANTICOAGULATION THERAPY\n ?? CALL OUT TO FLOOR.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 944184,
"text": " 3:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ICH\n Admitting Diagnosis: 3RD DEGREE HEART BLOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with changed mental status, supratherapeutic PTT\n REASON FOR THIS EXAMINATION:\n ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old woman with changed mental status and supratherapeutic\n PTT.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, mass effect,\n hydrocephalus, shift of normally midline structures, or major vascular\n territorial infarction. Hypodensity in the periventricular and deep cerebral\n white matter is consistent with chronic microvascular infarction. A right\n thalamic lacune is again noted. Surrounding osseous and soft tissue\n structures are unchanged.\n\n IMPRESSION: No acute intracranial hemorrhage or mass effect.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 944145,
"text": " 10:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval infiltrate\n Admitting Diagnosis: 3RD DEGREE HEART BLOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with temp pacer wire placed, now with new fever.\n REASON FOR THIS EXAMINATION:\n eval infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST\n\n INDICATION: Fever.\n\n A single AP view of the chest is obtained on at 10:30 hours and is\n compared with the prior radiograph of . Patchy increase in lung\n markings at both bases may indicate some subsegmental atelectasis. No frank\n consolidation is identified. Post-surgical changes are seen together with a\n left-sided transvenous bipolar pacemaker.\n\n IMPRESSION:\n\n Findings consistent with bibasilar atelectasis without frank consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 945543,
"text": " 11:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute cardiopulmonary process.\n Admitting Diagnosis: 3RD DEGREE HEART BLOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 F s/p ICD placement, now w/\"feeling of suffocation\", rales on exam. Hx CHF.\n\n REASON FOR THIS EXAMINATION:\n eval for acute cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old female status post ICD placement, now with feeling of\n suffocation and rales on exam. History of CHF. Question acute process.\n\n COMPARISON: .\n\n FINDINGS: Cardiomediastinal contours have not significantly changed, and\n pulmonary vascular congestion, perihilar haziness and bilateral pleural fluid\n is not significantly changed. There has been prior median sternotomy and\n cardiac surgery. A right PICC line is unchanged. Left-sided permanent\n pacemaker and leads overlying the right atrium and right ventricle\n respectively are unchanged. There is no pneumothorax. There are no new areas\n of consolidation.\n\n IMPRESSION: Unchanged mild pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 944480,
"text": " 4:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate.\n Admitting Diagnosis: 3RD DEGREE HEART BLOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with temp pacer wire placed, now hypothermic with\n leukocytosis.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n COMPARISON: .\n\n INDICATION: Evaluate for infiltrate.\n\n Right PICC line has been placed, terminating within the upper superior vena\n cava. Permanent pacemaker leads are unchanged in position allowing for\n patient rotation. Cardiac and mediastinal contours are stable. A left\n retrocardiac opacity has slightly worsened, but a right basilar opacity has\n resolved in the interval. There is a questionable small left pleural effusion\n present, difficult to assess due to rotation and overlying soft tissues of the\n breast.\n\n IMPRESSION: Worsening left retrocardiac opacity, likely due to atelectasis,\n but infection is also possible in the appropriate clinical setting.\n Resolution of right basilar opacity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-01 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 943929,
"text": " 8:26 AM\n CHEST (PA & LAT) Clip # \n Reason: Lead Position?Pneumothorax?\n Admitting Diagnosis: 3RD DEGREE HEART BLOCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with a new dual chamber PM via left cephalic vein\n REASON FOR THIS EXAMINATION:\n Lead Position?Pneumothorax?\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: PA and lateral chest.\n\n INDICATION: Pacemaker placement.\n\n PA and lateral views of the chest are obtained , and compared with the\n recent radiograph of . The patient has had placement of a dual-lumen\n catheter from the left side with tips in the right atrium and right ventricle.\n There is no evidence of pneumothorax on the current examination. There is no\n evidence of acute infiltrate. The lateral views are degraded due to\n respiratory movement but there is some costophrenic angle blunting posteriorly\n which may indicate a small effusion or fibrosis.\n\n IMPRESSION\n\n No pneumothorax. Left costophrenic angle blunting consistent with fibrosis or\n small left pleural effusion\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-01-28 00:00:00.000",
"description": "Report",
"row_id": 1403003,
"text": "Nursing Progress Note\n\nO: Please see FHP and flow sheet for objective data. Pt admitted from ED s/p fall at home found to be in CHB, transvenous pacer placed via R IJ. Pt in sinus rhythm on arrival 60's. Occ paced beats. Back up rate set at 50 MA 2. SBP 100-140's. Meds held today. Echo done. Pt known to have AVR with CABG. On coumadin at home INR 3.0 here.\n\nResp: Pt arrived on 100% NRB. O2 weaned down to 4 l NP. Lungs dminshed in bases. O2 sats > 92%.\n\nNeuro: Upon arrival to CCU pt very confused. Disoriented x's 3. Head CT negative for bleed. Daughter with pt stating that at baseline she has some confusion but much worse now. Pt received ativan and mso4 in ED for agitation. Pt sleeping in long naps. More oriented this pm. Oriented to person and place intermittently. Less agitated both arms remain restrained to protect temp pacer.\n\nGI/GU: Pt tolerating sips of liquids well. Abd is soft slightly distended. No BM. foley draining dark amber urine.\n\nID: WBC on admission 20,700 down to 14,800 this pm. bld cultures drawn x's 2 here and urine sent in ED. No antibiotic coverage so far.\n\nSocial: Pt lives alone. Pt is legally blind. Daughter lives nearby and assist with meds and ADL. She would like her not to go home after this admission.\n\nA&P: 86yo s/p fall at home with CHB and placement of temp wire. Presently in sinus rhythm. Cont to r/o source of infection. check cultures ? TEE in am. Cont to monitor hemodynamics. Maintain restraints for pt safety.\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-04 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 944230,
"text": " 7:38 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: 86 year old woman adm. with syncope complete heart block\n Admitting Diagnosis: 3RD DEGREE HEART BLOCK\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman adm. with syncope complete heart block now with pacer,\n needs antibiotics via PICC\n REASON FOR THIS EXAMINATION:\n 86 year old woman adm. with syncope complete heart block now with pacer,\n needs antibiotics via PICC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with need for long-term IV antibiotics and IV heparin.\n Please place PICC. Bedside attempt unsuccessful.\n\n RADIOLOGIST: Dr. and Dr. performed the procedure. Dr.\n , the attending radiologist, was present and supervising throughout.\n\n PROCEDURE AND FINDINGS: As no suitable superficial veins were visible,\n ultrasound was used to localize a suitable vein. The right basilic vein was\n patent and compressible. The right upper extremity was prepped and draped in\n sterile fashion. 1% lidocaine was used for local anesthesia. Under direct\n ultrasonographic guidance, a 21 gauge needle was advanced into the right\n basilic vein, and a 0.018 inch guidewire was advanced under fluoroscopic\n guidance into the SVC. Hard copy ultrasound images were obtained before and\n after venous access documenting vessel patency. The needle was exchanged for a\n 5 French micropuncture sheath. By the markings on the wire, it was determined\n that a length of 32 cm was suitable. The dual lumen PICC catheter was trimmed\n to length and advanced over the wire under fluoroscopic guidance into the SVC.\n The wire and peel- away sheath were removed. A final fluoroscopic spot image\n of the chest demonstrates the tip of the PICC catheter in the SVC. The line\n was flushed, statlocked, and heplocked. The patient tolerated the procedure\n well and there were no complications.\n\n IMPRESSION: Successful placement of a 5 French dual lumen PICC catheter\n within the right basilic vein, with the tip in the distal SVC. The line is\n ready for use.\n\n\n\n\n\n\n\n\n\n (Over)\n\n 7:38 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: 86 year old woman adm. with syncope complete heart block\n Admitting Diagnosis: 3RD DEGREE HEART BLOCK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-01-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 943279,
"text": " 4:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: EVALUATE FOR ICH; HEART BLOCK; FOUND DOWN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with complete heart block after fall, on coumadin\n REASON FOR THIS EXAMINATION:\n eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old female with complete heart block status post fall, on\n Coumadin.\n\n COMPARISON: None.\n\n TECHNIQUE: Routine non-contrast head CT.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage, mass effect, or shift\n of normally midline structures. Prominence of the ventricles and sulci are\n age appropriate. Hypodensity within the right thalamus is consistent with\n lacunar infarction. Diffuse low attenuation of the periventricular and\n subcortical white matter is consistent with microvascular infarction. The\n -white matter differentiation appears preserved. No fracture is\n identified. There is a small amount of mucosal thickening within the right\n maxillary sinus. Bilateral scattered ethmoid air cells.\n\n IMPRESSION: No intracranial hemorrhage or mass effect.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-01-28 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 943280,
"text": " 4:40 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: COMPLETE HEART BLOCK; S/P FALL; EVAL FOR FX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with complete heart block after fall, on coumadin\n REASON FOR THIS EXAMINATION:\n eval for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD 6:01 AM\n No fracture or malalignment. Degenerative changes esp. at C6/7.\n\n Overread:\n Agree\n\n MD\n WET READ VERSION #1 MMBn 5:37 AM\n No fracture or malalignment. Degenerative changes esp. at C6/7.\n ______________________________________________________________________________\n FINAL REPORT\n CT CERVICAL SPINE\n\n HISTORY: 86-year-old woman with complete heart block, after fall, on\n Coumadin.\n\n TECHNIQUE: MDCT of the cervical spine from the skull base to the T3/4 levels\n was obtained. 2.5 mm axial, coronal, and sagittal reconstructions were\n obtained.\n\n FINDINGS: No comparisons are available.\n\n There are no cervical spinal fractures. The atlantoaxial and atlanto-\n occipital relationships are normal. There is no prevertebral soft tissue\n swelling.\n\n At C2/3, there are mild degenerative changes of the facet joints bilaterally\n without foraminal narrowing.\n\n At C3/4, there is mild anterior spondylolisthesis with degenerative changes of\n the facet joints bilaterally consistent with degenerative spondylolisthesis.\n There are also degenerative changes of the uncovertebral joints bilaterally\n causing moderate bilateral foraminal narrowing.\n\n At C4/5, there are mild degenerative changes of the facet joints without\n foraminal narrowing.\n\n At C5/6, there is mild anterolisthesis of C5 on C6 with degenerative changes\n of the facet joints bilaterally.\n\n At C6/7, there is mild retrolisthesis of C6 on C7 with mild degenerative\n changes of the facet joints.\n\n (Over)\n\n 4:40 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: COMPLETE HEART BLOCK; S/P FALL; EVAL FOR FX\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The visualized lung apices show thickening of the intra- and inter-lobular\n septa as well as enlargement of the pulmonary vessels consistent with\n pulmonary edema. There are mild atelectatic changes of the dependent portions\n of the lungs.\n\n Dense calcification of the aortic arch seen as well as the internal carotid\n artery bulbs and the V4 segments of the vertebral arteries bilaterally.\n\n Sternotomy wires are in place.\n\n IMPRESSION: No cervical spinal fractures. Mild degenerative anterolisthesis\n at C3/4 and C5/6 as well as mild posterior degenerative spondylolisthesis at\n C6/7.\n\n Prominence of the pulmonary vessels and thickening of the inter- and intra-\n lobular septa consistent with pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-01-28 00:00:00.000",
"description": "CHEST FLUORO WITHOUT RADIOLOGIST",
"row_id": 943288,
"text": " 6:00 AM\n CHEST FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: FLOATING A WIRE\n ______________________________________________________________________________\n FINAL REPORT\n CHEST FLUOROSCOPY WITHOUT RADIOLOGIST.\n\n A chest fluoroscopy was performed without radiologist to assist with the\n floating of a wire. 4 minutes and 39 seconds of fluoro time was used. No\n images were saved.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-01-28 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 943289,
"text": " 6:30 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx? line placement?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with temp pacer wire placed\n REASON FOR THIS EXAMINATION:\n ptx? line placement?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:44 A.M., \n\n HISTORY: Temporary pacer placed. Question pneumothorax.\n\n IMPRESSION: AP chest reviewed:\n\n The patient has had median sternotomy. Cardiac silhouette is moderately\n enlarged with particular left atrial and pulmonary artery enlargement. Mild\n interstitial edema is present. There is no pleural effusion or pneumothorax.\n A right transjugular right ventricular temporary pacer lead follows the\n expected course to the floor of the right ventricle. There is no mediastinal\n widening.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-01-28 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 943285,
"text": " 5:08 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: S/P FALL WITH HEART BLOCK; ASYMMETRIC PULSES; EVAL FOR DISSECTION\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with fall and now with heart block. Asymmetric pulses.\n concern for dissection.\n REASON FOR THIS EXAMINATION:\n dissection?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MMBn 6:04 AM\n No aortic dissection.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old female status post fall, now with heart block.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT imaging of the chest, abdomen, and pelvis was performed after\n the administration of 90 cc of intravenous Optiray. Nonionic contrast was\n administered per protocol. Coronal and sagittal reformatted images were\n obtained.\n\n CT ANGIOGRAM CHEST: The patient is status post median sternotomy with intact\n sternal wires. Dense calcifications line the proximal coronary arteries and\n mitral valve. The aorta is normal in caliber and contour without evidence of\n dissection flap or intramural hematoma. No definite penetrating ulcer is\n identified. There is no pleural or pericardial effusion. There is no\n mediastinal, hilar, or axillary lymphadenopathy.\n\n On lung windows, there are low lung volumes bilaterally, with dependent, right\n middle lobe, and lingular atelectasis. There is a 5 mm soft tissue density\n nodule in the left upper lobe ().\n\n CT ABDOMEN WITHOUT ORAL, WITH INTRAVENOUS CONTRAST: Imaging of the abdomen is\n limited by the early phase of injection. There is a small hiatal hernia. The\n liver is normal in attenuation. The gallbladder, pancreas, spleen, bilateral\n adrenals glands, and both kidneys are grossly unremarkable. The abdominal\n loops of large and small bowel are normal in caliber and contour. There is no\n mesenteric or retroperitoneal lymphadenopathy. There is no free air and no\n free fluid.\n\n Dense calcifications line the abdominal aorta and proximal mesenteric vessels.\n There is severe narrowing of the takeoff of the celiac artery and moderate\n narrowing of the SMA take off. All mesenteric vessels enhance appropriately.\n\n CT PELVIS WITHOUT ORAL, WITH INTRAVENOUS CONTRAST: A Foley catheter is seen\n within a collapsed bladder. A large amount of stool is seen within the rectal\n vault. There is no inguinal or pelvic lymphadenopathy. There is no free air\n and no free fluid.\n\n (Over)\n\n 5:08 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: S/P FALL WITH HEART BLOCK; ASYMMETRIC PULSES; EVAL FOR DISSECTION\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: The bones are osteopenic. There are no suspicious lytic or\n sclerotic osseous abnormalities. Loss of height of the L1 and T9 vertebral\n bodies is age indeterminate. There is grade I anterolisthesis of L4 on 5 with\n severe L4-L5 intervertebral disc space narrowing.\n\n IMPRESSION:\n 1. No evidence of aortic dissection.\n 2. Dense atherosclerosis involving the coronary arteries, mitral valve,\n thoracic and abdominal aorta, and proximal mesenteric branches. Severe\n stenosis of the celiac artery at its origin. Moderate stenosis of the SMA at\n its origin.\n 3. Loss of height of L1 and T9 - age indeterminate.\n 4. 5-mm nodule in the left upper lobe. Followup in six months' time is\n recommended to document stability.\n\n\n"
}
] |
50,268 | 142,718 | 79 y/o F with hx of recent nephrectomy for RCC presents with altered mental status and new onset seizures. Likely secondary to PRES syndrome. While an inpatient, has worsening ARF, found to have NSTEMI and significant Hct drop with melanotic stools. S/p endoscopy and colonoscopy showing severe gastritis. Doing well with stable Hct. Gout is bothering her. . # GI bleed - secondary to gastritis. Pt had both a colonoscopy and endoscopy while here in the workup of the bleed. She is to cont protonix PO, hct stabalized with no melanotic or bloody stools by the time of discharge. Discussion with both cardiologists and gastroeneterologist thought it was fine to start asa for treatment of NSTEMI discussed below. . # NSTEMI - patient with troponin leak, TWI V1-V3, and new hypokinesis. On baby aspirin and high dose statin. Titrated up beta blocker yesterday, HR in 70s and SBPs in 130s-140s, could likely increase again this evening after monitoring her on new dose of 400 mg tid of labetolol. Cards following. Plavix not needed at this time. She should follow up with cards regarding when stress testing and/or cath or other workup is needed. . # Pump - patient with decreased EF in setting of NSTEMI. EF 40%. Pt without signs of fluid overload. Follow up echo with cards to see permanent pump dysfunction after NSTEMI. . # HTN - HTN was initial problem causing the seizure with PRES syndrome. She was titrated up on BB over the course of the , be discharged on labetolol. Renal was following and there was a question of whether renal artery stenosis was possible, epecially after her recent nephrectomy. It was thought that no stenosis was present and an ACEI could be added. Her BP was well controlled by the time of discharge with goal SBPs under 140s. . # Gout - had flare in big toes. rheum and podiatry do not inject big toe joints; given low dose dilaudid (was receiving post nephrectomy) and see if pain improves at all. No NSAIDs or colchicine due to decreased renal function. No steroids due to gastritis. . # Seizure - initial presenting symptoms. Neuro following along, was on neuro service initially. The seizure was secondary to PRES syndrome, on dilantin and titrated according to level; patient only needs to be antisiezure for 10-14 days post seizure. Will continue tight BP control. Repeat MRI done and show resolution of PRES changes. . # ARF - had ARF. Treated with fluids due to likely prerenal state. Renal followinged. Expected her to find new baseline, although likely has some more recovery. Electrolytes stable. . # RCC - staples removed, scar well healed. Tumor was clear cell renal cell carcinoma, s/p left radical nephrectomy and adrenalectomy, left para aortic lymph node dissection on for 6.1 x 5.9 x 5.0 cm mass in the lower pole of the left kidney and bilateral small adrenal nodules found on MRI abdomen . . # DM - on sliding scale. . # Respiratory - stable, no problems. . # Communication - husband , daughter . . # Code - full | Chief complaint: PRES PMHx: CRI Current medications: 1. Chief complaint: PRES PMHx: CRI Current medications: 1. Metoprolol Tartrate 17. Pt had 2 seizures in EW - first about 1min, and self-limited, second about 90seconds, 2mg ativan given IVP and seizure stopped. Pt had 2 seizures in EW - first about 1min, and self-limited, second about 90seconds, 2mg ativan given IVP and seizure stopped. Pt had 2 seizures in EW - first about 1min, and self-limited, second about 90seconds, 2mg ativan given IVP and seizure stopped. Current medications: 1. Action: Neuro checks continue, dilantin . Seizure, without status epilepticus Assessment: Pt s/p seizure upon admission, Action: Monitor for seizure activity, Dilantin re-bolused this shift. Seizure, without status epilepticus Assessment: Pt s/p seizure upon admission, Action: Monitor for seizure activity, Dilantin re-bolused this shift. Given LZP (dose?) Given LZP (dose?) Dilantin continues Q8hrs. Dilantin continues Q12/hr. Dilantin continues Q12/hr. Phenytoin 19. Phenytoin 19. Dorzolamide 2%/Timolol 0.5% Ophth. Dorzolamide 2%/Timolol 0.5% Ophth. Dorzolamide 2%/Timolol 0.5% Ophth. Hydrochlorothiazide 13. Hydrochlorothiazide 13. Hydrochlorothiazide 13. Famotidine 11. Famotidine 11. Famotidine 11. Seizure, without status epilepticus Assessment: Pt remains lethargic, yet more alert this AM. MEDS Colace 100'', Atorvastatin 20', Timolol drops as directed, dorzolamide-timolol drops''', bimatoprost drops', atenolol 50', Tylenol, Dilauded 2 mg q4, HCTZ 25', Lopid 600''. MEDS Colace 100'', Atorvastatin 20', Timolol drops as directed, dorzolamide-timolol drops''', bimatoprost drops', atenolol 50', Tylenol, Dilauded 2 mg q4, HCTZ 25', Lopid 600''. Phenytoin 18. Phenytoin 18. Phenytoin 18. Seizure, without status epilepticus Assessment: Seizures x 2 in EW, received ativan 2mg in EW for second seizure. Seizure, without status epilepticus Assessment: Seizures x 2 in EW, received ativan 2mg in EW for second seizure. Altered mental status (not Delirium) Assessment: Pt. Purposeful movement covering self with during turn yawning, no speech, occ snoring Action: On dilantin, had MRI and EEG today Response: No seizures since admission to , pt still somnolent post seizure and ativan. Purposeful movement covering self with during turn yawning, no speech, occ snoring Action: On dilantin, had MRI and EEG today Response: No seizures since admission to , pt still somnolent post seizure and ativan. Docusate Sodium 9. Docusate Sodium 9. Docusate Sodium 9. Lorazepam 15. Pt brought to OSH and transferred to where she had 2 seizures in the ED (1^st was 1 min, self limited; 2^nd was 90 seconds, 2mg Ativan IVP given, seizure stopped). No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Left pleural effusion.Conclusions:The left atrium and right atrium are normal in cavity size. Current medications: 1. In the interval, the relatively symmetric foci of and FLAIR-hyperintensity in right more than left frontovertex, bilateral paramedian parietal, and left posterior temporal and occipital subcortical white matter have resolved entirely, without sequelae. Clinical correlation issuggested. There is a trivial/physiologic pericardial effusion.IMPRESSION: Regional left ventricular systolic dysfunction most c/w CAD(mid-LAD distribution). Mild-moderateregional LV systolic dysfunction. Exam non-focal, but seizure suggests L sided lesion. Interval complete resolution of the patchy FLAIR-hyperintense foci in bilateral frontal and parietal and left posterior temporal and occipital subcortical white matter, consistent with clinical impression of PRES, with no evident sequelae. Interval complete resolution of the patchy FLAIR-hyperintense foci in bilateral frontal and parietal and left posterior temporal and occipital subcortical white matter, consistent with clinical impression of PRES, with no evident sequelae. Mild mitral annularcalcification. Moderate brain atrophy. Trivialmitral regurgitation is seen. Fluid/opacification of right mastoid air cells, as before. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -hypo; septal apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Unchanged small bilateral pleural effusions. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The right atrialpressure is indeterminate. T1 axial and MP-RAGE sagittal images were obtained following gadolinium. Mild-to-moderate brain atrophy is seen. Moderate atrophy and chronic microvascular infarction, largely in bifrontal subcortical white matter, unchanged. Moderate atrophy and chronic microvascular infarction, largely in bifrontal subcortical white matter, unchanged. Source of embolism.Height: (in) 60Weight (lb): 142BSA (m2): 1.62 m2BP (mm Hg): 134/53HR (bpm): 62Status: InpatientDate/Time: at 11:55Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. There is mild to moderate regional left ventricular systolicdysfunction with severer hypokinesis of the basal 2/3rds of the anteriorseptum and anterior walls. Fluid/opacification of right mastoid air cells. Fluid/opacification of right mastoid air cells. Given LZP (dose?) Modest non-specific ST-T wave changes. FINDINGS: Study is compared with the very recent enhanced MRI and unenhanced MRV, dated . Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Hydrochlorothiazide 13. Famotidine 11. Dorzolamide 2%/Timolol 0.5% Ophth. New left retrocardiac density is noted. Metoprolol Tartrate 17. There is fluid/opacification of scattered air cells at the right mastoid apex, as before. Given recent MRI study current frontrunning diagnosis is posterior reversible encephalopathy syndrome Neurologic: Neuro checks Q: 2 hr, SBP < 150, dilantin with dilantin level in the AM;ativan prn seizures; will continue to monitor on seizure precautions, q2h neuro checks, -currently has right sided weaknness Cardiovascular: hemodynamically stable without need for exogenous blood pressure control; troponin resolving likely demand ischemia Pulmonary: IS, stable with supplemental oxygen - will continue to wean as tolerated - currently able to protect airway without need for intubation Gastrointestinal / Abdomen: will resume oral feeding with improvement in mental status (alertness) which is continuing Nutrition: NPO Renal: Foley, Adequate UO, appropriate urine output in the setting of maintenance fluid hydration and contrast dye administered for MRI study in patient with CKD - will continue serial monitoring of BUN/Cr Hematology: Serial Hct, stable anemia with inflammatory white count thus far - will continue to monitor serially Endocrine: RISS, RISS for bs < 150 Infectious Disease: Check cultures, no acute infectious etiology thus far, but pan cultured for concern of fever- will follow cultures serially Lines / Tubes / Drains: Foley Wounds: Dry dressings Imaging: CT scan head today Fluids: NS, maintenance fluids to continue Consults: Neurology Billing Diagnosis: Seizure ICU Care Nutrition: Glycemic Control: Regular insulin sliding scale Lines: 18 Gauge - 09:16 PM Prophylaxis: DVT: Boots Stress ulcer: H2 blocker VAP bundle: Comments: Communication: Patient discussed on interdisciplinary rounds Comments: Code status: Full code Disposition: ICU Total time spent: 32 minutes Patient is critically ill | 24 | [
{
"category": "Nursing",
"chartdate": "2115-10-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422266,
"text": "Seizure, without status epilepticus\n Assessment:\n Seizures x 2 in EW, received ativan 2mg in EW for second seizure. Does\n not open eyes, does not follow commands, PERRL, + gag, + corneals,\n withdraws all limbs to nailbed pressure. Purposeful movement\n covering self with during turn\n yawning, no speech, occ snoring\n Action:\n On dilantin, had MRI and EEG today\n Response:\n No seizures since admission to , pt still somnolent post seizure\n and ativan.\n Plan:\n Continue supportive care, sys BP < 150, glucose control, monitor u/o,\n orient pt, dilantin as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2115-10-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 422298,
"text": "TSICU\n HPI:\n F79 Underwent radical nephrectomy with adrenalectomy 1 wk ago\n for a coincidentally found 6 cm RCC in the L kidney with no\n invasion of IVC, liver mets or hydronephrosis. Post-op course was\n uncomplicated other than decrease UOP - see D/C summary. She was\n scheduled to see Dr for f/u of fluid status and creat\n check this week.\n At home she was cranky from pain, but walking and resting\n appropriately, normal behavior. On she was more tired, with\n continued poor PO intake, and at night she was trailing off with\n her sentences. They went to bed and at 2.30 AM her husband\n noticed laboured breathing, thought she had a nightmare but found\n her to be stiff and trembling violently while clenching the\n blankets. Duration 3 - 5 minutes, unresp after. EMS came, to\n hospital, exam non-focal but confused and agitated. Given\n LZP (dose?) and Fosphenytoin 1000 mg. CT reportedly revealed L\n frontpar stroke, but not according to our read. Tx to .\n On arrival here, exam as outlined below. Had another 2 seizures,\n GTC with preceding head and eye deviation to R as the only\n localizing feature, lasting 1 - 2 minutes, with 20 minutes in\n between.\n ROS As above\n Chief complaint:\n CC Stroke vs Seizure\n PMHx:\n PMH HTN, DM II, ?hyperchol, s/p cholecystectomy. RCC as above.\n MEDS Colace 100'', Atorvastatin 20', Timolol drops as directed,\n dorzolamide-timolol drops''', bimatoprost drops', atenolol 50',\n Tylenol, Dilauded 2 mg q4, HCTZ 25', Lopid 600''.\n SH Lives with husband, husband and son are both here.\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Aspirin 5. Atorvastatin 6.\n Atenolol 7. Bimatoprost 8. Docusate Sodium\n 9. Dorzolamide 2%/Timolol 0.5% Ophth. 10. Famotidine 11. Gemfibrozil\n 12. Hydrochlorothiazide 13. Insulin\n 14. Lorazepam 15. Magnesium Sulfate 16. Metoprolol Tartrate 17.\n Phenytoin 18. Potassium Chloride\n 19. Sodium Chloride 0.9% Flush 20. Timolol Maleate 0.5%\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 02:36 PM\n left for MRI at 1315 and returned at 1420\n EEG - At 03:00 PM\n EEG prep started about 1500\n EKG - At 06:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dilantin - 08:05 PM\n Metoprolol - 04:15 AM\n Other medications:\n Flowsheet Data as of 05:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 37.7\nC (99.9\n HR: 77 (67 - 86) bpm\n BP: 151/61(84) {132/46(68) - 174/85(106)} mmHg\n RR: 19 (10 - 25) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 665 mL\n 435 mL\n PO:\n Tube feeding:\n IV Fluid:\n 665 mL\n 435 mL\n Blood products:\n Total out:\n 355 mL\n 225 mL\n Urine:\n 355 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 310 mL\n 210 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 396 K/uL\n 9.4 g/dL\n 126 mg/dL\n 2.0 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 44 mg/dL\n 106 mEq/L\n 139 mEq/L\n 27.5 %\n 14.0 K/uL\n [image002.jpg]\n 12:26 PM\n 08:52 PM\n 02:16 AM\n WBC\n 14.0\n Hct\n 27.5\n Plt\n 396\n Creatinine\n 2.0\n Troponin T\n 0.76\n 0.60\n 0.42\n Glucose\n 126\n Other labs: PT / PTT / INR:13.9/22.5/1.2, CK / CK-MB / Troponin\n T:131/6/0.42, Ca:8.2 mg/dL, Mg:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 79 F s/p RCC surgery 1 week ago, on Dilaudid and\n with impaired\n renal function and poor intake, has slow decline in MS (trailing\n of sentences), followed by 3 GTCs, as outlined above. Not\n returned to baseline yet. Exam non-focal, but seizure suggests L\n sided lesion.\n Given recent MRI study current frontrunning diagnosis is posterior\n reversible encephalopathy syndrome\n Neurologic: Neuro checks Q: 2 hr, SBP < 150, dilantin with dilantin\n level in the AM;ativan prn seizures; will continue to monitor on\n seizure precautions, q1h neuro checks\n Cardiovascular: hemodynamically stable without need for exogenous blood\n pressure control\n Pulmonary: IS, stable with supplemental oxygen - will continue to wean\n as tolerated - currently able to protect airway without need for\n intubation\n Gastrointestinal / Abdomen: will resume oral feeding with improvement\n in mental status (alertness) which is continuing\n Nutrition: NPO\n Renal: Foley, Adequate UO, appropriate urine output in the setting of\n maintenance fluid hydration and contrast dye administered for MRI study\n in patient with CKD - will continue serial monitoring of BUN/Cr\n Hematology: Serial Hct, stable anemia with inflammatory white count\n thus far - will continue to monitor serially\n Endocrine: RISS, RISS for bs < 150\n Infectious Disease: Check cultures, no acute infectious etiology thus\n far, but pan cultured for concern of fever- will follow cultures\n serially\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: CT scan head today\n Fluids: NS, maintenance fluids to continue\n Consults: Neurology\n Billing Diagnosis: Seizure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:16 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2115-10-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422299,
"text": "79 YO F s/p L nephrectomy two weeks ago due to renal CA. On , Pt\n had been home about 1 week and developed nausea and some confusion.\n Early morning on , pt seized in bed at home, tx to Good \n Hospital, then to .\n Pt had 2 seizures in EW - first about 1min, and self-limited, second\n about 90seconds, 2mg ativan given IVP and seizure stopped. Tx to TSICU\n for further monitoring.\n Seizure, without status epilepticus\n Assessment:\n Pt remains lethargic, yet more alert this AM. Pt now responsive,\n garbled speech, A&OX1-2. Confused at times, MAE. Pupils equal and\n reactive. No seizure activity this shift.\n Action:\n Neuro checks continue, dilantin . Maintain SBP <150. Seizure pads\n applied to bed.\n Response:\n No seizures noted.\n Plan:\n Continue to monitor neuro status. Maintain SBP <150. Follow up on MRI\n results.\n"
},
{
"category": "Physician ",
"chartdate": "2115-10-21 00:00:00.000",
"description": "Intensivist Note",
"row_id": 422457,
"text": "TSICU\n HPI:\n 79 F s/p RCC surgery 1 week ago, on Dilaudid and with impaired\n renal function and poor intake, has slow decline in MS (trailing\n of sentences), followed by 3 GTCs, as outlined above. Not\n returned to baseline yet. Exam non-focal, but seizure suggests L\n sided lesion.\n Chief complaint:\n PRES\n PMHx:\n CRI\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Aspirin 5. Atorvastatin 6.\n Atenolol 7. Bimatoprost 8. Docusate Sodium\n 9. Dorzolamide 2%/Timolol 0.5% Ophth. 10. Famotidine 11. Gemfibrozil\n 12. Hydrochlorothiazide 13. HydrALAzine\n 14. Insulin 15. Lorazepam 16. Magnesium Sulfate 17. Phenytoin 18.\n Phenytoin 19. Phenytoin 20. Sodium Chloride 0.9% Flush\n 21. Timolol Maleate 0.5%\n 24 Hour Events:\n Called out to floor\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 10:15 AM\n Hydralazine - 01:30 PM\n Famotidine (Pepcid) - 02:42 AM\n Other medications:\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.3\nC (99.2\n HR: 72 (65 - 76) bpm\n BP: 128/45(67) {107/42(61) - 174/90(103)} mmHg\n RR: 23 (15 - 26) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,217 mL\n 217 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,217 mL\n 217 mL\n Blood products:\n Total out:\n 1,150 mL\n 275 mL\n Urine:\n 1,150 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,067 mL\n -58 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 426 K/uL\n 8.2 g/dL\n 125 mg/dL\n 2.2 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 54 mg/dL\n 111 mEq/L\n 140 mEq/L\n 23.5 %\n 10.3 K/uL\n [image002.jpg]\n 12:26 PM\n 08:52 PM\n 02:16 AM\n 02:28 AM\n WBC\n 14.0\n 10.3\n Hct\n 27.5\n 23.5\n Plt\n 396\n 426\n Creatinine\n 2.0\n 2.2\n Troponin T\n 0.76\n 0.60\n 0.42\n Glucose\n 126\n 125\n Other labs: PT / PTT / INR:14.9/25.2/1.3, CK / CK-MB / Troponin\n T:131/6/0.42, Ca:8.3 mg/dL, Mg:2.5 mg/dL, PO4:3.1 mg/dL\n Imaging: No new imaging\n Microbiology: no active issues\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), SEIZURE, WITHOUT STATUS\n EPILEPTICUS\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, No pain or agitation issues\n On phenytoin per neuro\n Cardiovascular: No active issues.\n BP controlled\n Pulmonary: encourage IS\n Gastrointestinal / Abdomen: No active issue\n Nutrition: NPO\n Renal: Foley\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: no active issues\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: no imaging today\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: Other: PRES\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:59 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status:\n Disposition: Transfer to floor\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2115-10-21 00:00:00.000",
"description": "Intensivist Note",
"row_id": 422463,
"text": "TSICU\n HPI:\n 79 F s/p RCC surgery 1 week ago, on Dilaudid and with impaired\n renal function and poor intake, has slow decline in MS (trailing\n of sentences), followed by 3 GTCs, as outlined above. Not\n returned to baseline yet. Exam non-focal, but seizure suggests L\n sided lesion.\n Chief complaint:\n PRES\n PMHx:\n CRI\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Aspirin 5. Atorvastatin 6.\n Atenolol 7. Bimatoprost 8. Docusate Sodium 9. Dorzolamide 2%/Timolol\n 0.5% Ophth. 10. Famotidine 11. Gemfibrozil 12. Hydrochlorothiazide 13.\n HydrALAzine\n 14. Insulin 15. Lorazepam 16. Magnesium Sulfate 17. Phenytoin 18.\n Phenytoin 19. Phenytoin 20. Sodium Chloride 0.9% Flush\n 21. Timolol Maleate 0.5%\n 24 Hour Events:\n Called out to floor\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 10:15 AM\n Hydralazine - 01:30 PM\n Famotidine (Pepcid) - 02:42 AM\n Other medications:\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.3\nC (99.2\n HR: 72 (65 - 76) bpm\n BP: 128/45(67) {107/42(61) - 174/90(103)} mmHg\n RR: 23 (15 - 26) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,217 mL\n 217 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,217 mL\n 217 mL\n Blood products:\n Total out:\n 1,150 mL\n 275 mL\n Urine:\n 1,150 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,067 mL\n -58 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 426 K/uL\n 8.2 g/dL\n 125 mg/dL\n 2.2 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 54 mg/dL\n 111 mEq/L\n 140 mEq/L\n 23.5 %\n 10.3 K/uL\n [image002.jpg]\n 12:26 PM\n 08:52 PM\n 02:16 AM\n 02:28 AM\n WBC\n 14.0\n 10.3\n Hct\n 27.5\n 23.5\n Plt\n 396\n 426\n Creatinine\n 2.0\n 2.2\n Troponin T\n 0.76\n 0.60\n 0.42\n Glucose\n 126\n 125\n Other labs: PT / PTT / INR:14.9/25.2/1.3, CK / CK-MB / Troponin\n T:131/6/0.42, Ca:8.3 mg/dL, Mg:2.5 mg/dL, PO4:3.1 mg/dL\n Imaging: No new imaging\n Microbiology: no active issues\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), SEIZURE, WITHOUT STATUS\n EPILEPTICUS\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, No pain or agitation issues\n On phenytoin per neuro\n Cardiovascular: No active issues.\n BP controlled\n Pulmonary: encourage IS\n Gastrointestinal / Abdomen: No active issue\n Nutrition: NPO\n Renal: Foley\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: no active issues\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: no imaging today\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: Other: PRES\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:59 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status:\n Disposition: Transfer to floor\n Total time spent: 45 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2115-10-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422433,
"text": "79 YO F s/p L nephrectomy two weeks ago due to renal CA. On , Pt\n had been home about 1 week and developed nausea and some confusion.\n Early morning on , pt seized in bed at home, tx to Good \n Hospital, then to .\n Pt had 2 seizures in EW - first about 1min, and self-limited, second\n about 90seconds, 2mg ativan given IVP and seizure stopped. Tx to TSICU\n for further monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&O X , making more sense this shift, able to carry on\n conversations. Yet at times, continues with expressive aphasia.\n Action:\n Continue with neuron exams Q4/hr\n Response:\n Pt more appropriate this shift.\n Plan:\n Continue to monitor neuro assessment, transfer to floor when bed\n available.\n Seizure, without status epilepticus\n Assessment:\n Pt s/p seizure upon admission, \n Action:\n Monitor for seizure activity, Dilantin re-bolused this shift. Dilantin\n continues Q12/hr.\n Response:\n No seizure activity.\n Plan:\n Continue to monitor for seizure activity.\n"
},
{
"category": "Nursing",
"chartdate": "2115-10-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422406,
"text": "Altered mental status (not Delirium)\n Assessment:\n Pt. lethargic but easily arousable. Oriented to person and place.\n Unable to say hospital, using inconherent word, but when given choices\n picked and stated hospital. Appropriate comments once in awhile, but\n also spontaneous inappropriate comments.\n Action:\n Neuro checks q 2-4 hours.\n Response:\n Inappropriate comments and word aphasia. Answered appropriately when\n given options.\n Plan:\n Continue with neuro checks q 2-4 hours.\n Seizure, without status epilepticus\n Assessment:\n No seizures this shift.\n Action:\n Monitored mental status and other s/s of seizures.\n Response:\n No seizures this shift.\n Plan:\n Continue to monitor for seizure activity.\n"
},
{
"category": "Physician ",
"chartdate": "2115-10-20 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 422279,
"text": "Chief Complaint: CC Stroke vs Seizure\n HPI:\n F79 Underwent radical nephrectomy with adrenalectomy 1 wk ago\n for a coincidentally found 6 cm RCC in the L kidney with no\n invasion of IVC, liver mets or hydronephrosis. Post-op course was\n uncomplicated other than decrease UOP - see D/C summary. She was\n scheduled to see Dr for f/u of fluid status and creat\n check this week.\n At home she was cranky from pain, but walking and resting\n appropriately, normal behavior. On she was more tired, with\n continued poor PO intake, and at night she was trailing off with\n her sentences. They went to bed and at 2.30 AM her husband\n noticed laboured breathing, thought she had a nightmare but found\n her to be stiff and trembling violently while clenching the\n blankets. Duration 3 - 5 minutes, unresp after. EMS came, to\n hospital, exam non-focal but confused and agitated. Given\n LZP (dose?) and Fosphenytoin 1000 mg. CT reportedly revealed L\n frontpar stroke, but not according to our read. Tx to .\n On arrival here, exam as outlined below. Had another 2 seizures,\n GTC with preceding head and eye deviation to R as the only\n localizing feature, lasting 1 - 2 minutes, with 20 minutes in\n between.\n ROS As above\n Post operative day:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dilantin - 08:05 PM\n Metoprolol - 12:33 AM\n Other medications:\n Past medical history:\n Family / Social history:\n PMH HTN, DM II, ?hyperchol, s/p cholecystectomy. RCC as above.\n MEDS Colace 100'', Atorvastatin 20', Timolol drops as directed,\n dorzolamide-timolol drops''', bimatoprost drops', atenolol 50',\n Tylenol, Dilauded 2 mg q4, HCTZ 25', Lopid 600''.\n SH Lives with husband, husband and son are both here.\n SH Lives with husband, husband and son are both here.\n Flowsheet Data as of 01:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.2\nC (98.9\n HR: 78 (68 - 86) bpm\n BP: 132/63(79) {132/52(76) - 174/85(106)} mmHg\n RR: 18 (10 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 665 mL\n 98 mL\n PO:\n TF:\n IVF:\n 665 mL\n 98 mL\n Blood products:\n Total out:\n 355 mL\n 60 mL\n Urine:\n 355 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 310 mL\n 38 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n bilaterally)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): , Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n 12:26 PM\n 08:52 PM\n TropT\n 0.76\n 0.60\n Other labs: CK / CKMB / Troponin-T:163/8/0.60\n Fluid analysis / Other labs: \n 8:52p\n -----------------------------------------------------------------------\n ---------\n CK: 163 MB: 8 Trop-T: 0.60\n Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n \n 12:26p\n -----------------------------------------------------------------------\n ---------\n CK: 236 MB: 14 MBI: 5.9 Trop-T: 0.76\n Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n \n 07:38a\n -----------------------------------------------------------------------\n ---------\n LIGHT GREEN\n Trop-T: 0.19\n Comments: cTropnT: Notified -Ed 915 Am \n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n 135 101 29 155 AGap=12\n 4.3 26 1.7\n CK: 106 MB: 6\n Ca: 8.5 Mg: 1.9 P: 4.5\n Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative\n Comments: Positive Tricyclic Results Represent Potentially Toxic\n Levels;Therapeutic Tricyclic Levels Will Typically Have Negative\n Results\n Phenytoin: 10.5\n Urine Opiates Pos\n Urine Benzos, Barbs, Cocaine, Amphet, Mthdne Negative\n 89\n 15.8 D 11.0 444\n 32.7\n N:93.4 L:4.7 M:1.5 E:0.2 Bas:0.2\n PT: 13.3 PTT: 22.9 INR: 1.1\n Color\n Yellow Appear\n Clear SpecGr\n 1.013 pH\n 7.0 Urobil\n Neg Bili\n Neg\n Leuk\n Neg Bld\n Tr Nitr\n Neg Prot\n 500 Glu\n Neg Ket\n Neg\n RBC\n 0 WBC\n 0-2 Bact\n 0 Yeast\n None Epi\n 0-2\n Imaging: CT reveals single lesion (edema) L parietal, high up close to\n vertex, suspect for venous cortical stroke versus metastasis.\n Assessment and Plan\n A/P\n 79 F s/p RCC surgery 1 week ago, on Dilaudid and with impaired\n renal function and poor intake, has slow decline in MS (trailing\n of sentences), followed by 3 GTCs, as outlined above. Not\n returned to baseline yet. Exam non-focal, but seizure suggests L\n sided lesion.\n Given recent MRI study current frontrunning diagnosis is posterior\n reversible encephalopathy syndrome\n Assessment And Plan:\n Neurologic: SBP < 150, dilantin with dilantin level in the AM;ativan\n prn seizures; will continue to monitor on seizure precautions, q1h\n neuro checks\n Cardiovascular: hemodynamically stable without need for exogenous blood\n pressure control\n Pulmonary: stable with supplemental oxygen - will continue to wean as\n tolerated - currently able to protect airway without need for\n intubation\n Gastrointestinal: will resume oral feeding with improvement in mental\n status (alertness) which is continuing\n Renal: appropriate urine output in the setting of maintenance fluid\n hydration and contrast dye administered for MRI study in patient with\n CKD - will continue serial monitoring of BUN/Cr\n Hematology: stable anemia with inflammatory white count thus far - will\n continue to monitor serially\n Infectious Disease: no acute infectious etiology thus far, but pan\n cultured for concern of fever- will follow cultures serially\n Endocrine: RISS for bs < 150\n Fluids: NS @70 for maintenance hydration after contrast dye\n Electrolytes: will replete electrolytes aggressively\n Nutrition: as noted above\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:16 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2115-10-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422425,
"text": "79 YO F s/p L nephrectomy two weeks ago due to renal CA. On , Pt\n had been home about 1 week and developed nausea and some confusion.\n Early morning on , pt seized in bed at home, tx to Good \n Hospital, then to .\n Pt had 2 seizures in EW - first about 1min, and self-limited, second\n about 90seconds, 2mg ativan given IVP and seizure stopped. Tx to TSICU\n for further monitoring.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&O X , pt making more sense, yet confused to date at times.\n Action:\n Continue with neuron exams Q4/hr\n Response:\n Plan:\n Continue to monitor neuro assessment, transfer to floor when bed\n available.\n Seizure, without status epilepticus\n Assessment:\n Pt s/p seizure upon admission, \n Action:\n Monitor for seizure activity, Dilantin re-bolused this shift. Dilantin\n continues Q12/hr.\n Response:\n No seizure activity.\n Plan:\n Continue to monitor for seizure activity.\n"
},
{
"category": "Nursing",
"chartdate": "2115-10-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422410,
"text": "Pt followed until approx 1400, monitored neurological function q 2 hrs\n with no acute changes, seizure pads removed, phenytoin bolus given,\n family updated by NMED, call out to be transferred to the floor. BMAC\n"
},
{
"category": "Nursing",
"chartdate": "2115-10-21 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 422512,
"text": "79 yo female s/p 3 seizures. Pt also recently had a left nephrectomy\n and adrenalectomy 1-2 weeks ago: pt was recovering at home when first\n seizure occurred with nausea and confusion. Pt brought to OSH and\n transferred to where she had 2 seizures in the ED (1^st was 1\n min, self limited; 2^nd was 90 seconds, 2mg Ativan IVP given, seizure\n stopped). Transferred to the TSICU for further care under the neuro\n med service. No seizures occurred during stay in the TSICU.\n Altered mental status (not Delirium)\n Assessment:\n This AM, pt initially alert and oriented x2-3 (knew name, month,\n birthday, not year), pt followed commands, equal strength in all\n extremities, pupils equally brisk 3mm, occasionally perseverating on\n words, rarely unable to answer questions. Pt had change in mental\n status at 12:30: was very lethargic, slurring words, weak strength,\n difficulty holding attention to complete tasks/answer questions, pt\n very sleepy and expressed feeling\nfunny\n. Pt was also unable to\n answer questions that normally come easy to her.\n Action:\n Extensive neuro check done with pt and family to assess change as\n accurately as possible at time of change. TSICU HO made aware, neuro\n med team informed. MD from neuro med came to\n visualize/assess pt.\n Response:\n Pt promptly perked up at 13:30, alert, oriented, awake, interactive,\n neuro exam intact with rare bouts of perseverating and difficulty with\n word finding. Pt able to get OOB to commode and to chair with ease.\n Pt taking adequate PO\ns (full house diet ordered but mostly taking\n clears- would likely tolerate without issue).\n Plan:\n Continue to assess pt\ns neuro status q2-4hrs. Continue to support pt\n and family.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n SEIZURES\n Code status:\n Full code\n Height:\n Admission weight:\n 61 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Diabetes - Oral \n CV-PMH: Hypertension\n Additional history: renal CA - L nephrectomy & adrenalectomy about 2 wk\n ago at \n Surgery / Procedure and date: nephrectomy & adrenalectomy about 2 weeks\n PTA\n MRI \n EEG \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:145\n D:82\n Temperature:\n 96.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 28 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 691 mL\n 24h total out:\n 680 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:28 AM\n Potassium:\n 4.2 mEq/L\n 02:28 AM\n Chloride:\n 111 mEq/L\n 02:28 AM\n CO2:\n 22 mEq/L\n 02:28 AM\n BUN:\n 54 mg/dL\n 02:28 AM\n Creatinine:\n 2.2 mg/dL\n 02:28 AM\n Glucose:\n 125 mg/dL\n 02:28 AM\n Hematocrit:\n 23.5 %\n 02:28 AM\n Finger Stick Glucose:\n 174\n 02:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: TSICU 570\n Transferred to: 1115\n Date & time of Transfer: 04:00 PM\n Seizure, without status epilepticus\n Assessment:\n Pt s/p seizure upon admission, \n Action:\n Monitor for seizure activity, Dilantin re-bolused overnight. Dilantin\n continues Q8hrs. Dilantin level last sent at 15:30 -pending at time\n of note.\n Response:\n No seizure activity during stay in TSICU.\n Plan:\n Continue to monitor for seizure activity. Telemetry ordered for when\n transferred to floor.\n"
},
{
"category": "Nursing",
"chartdate": "2115-10-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422267,
"text": "Nursing Admit note\n pt recovering at home after L nephrectomy for renal CA about 2 wks ago,\n home about 1 week.\n some nausea, some confusion - unable to finish sentences, then\n about 02 am on , pt seized in bed at home, to Good \n Hospital, then to \n had 2 seizures in EW - first about 1min, and self-limited, second about\n 90seconds, 2mg ativan given IVP and seizure stopped\n had MRI and EEG today.\n Current thinking is that this is a reversible process and pt can\n recover with supportive care.\n Seizure, without status epilepticus\n Assessment:\n Seizures x 2 in EW, received ativan 2mg in EW for second seizure. Does\n not open eyes, does not follow commands, PERRL, + gag, + corneals,\n withdraws all limbs to nailbed pressure. Purposeful movement\n covering self with during turn\n yawning, no speech, occ snoring\n Action:\n On dilantin, had MRI and EEG today\n Response:\n No seizures since admission to , pt still somnolent post seizure\n and ativan.\n Plan:\n Continue supportive care, sys BP < 150, glucose control, monitor u/o,\n orient pt, dilantin as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2115-10-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 422333,
"text": "TSICU\n HPI:\n F79 Underwent radical nephrectomy with adrenalectomy 1 wk ago\n for a coincidentally found 6 cm RCC in the L kidney with no\n invasion of IVC, liver mets or hydronephrosis. Post-op course was\n uncomplicated other than decrease UOP - see D/C summary. She was\n scheduled to see Dr for f/u of fluid status and creat\n check this week.\n At home she was cranky from pain, but walking and resting\n appropriately, normal behavior. On she was more tired, with\n continued poor PO intake, and at night she was trailing off with\n her sentences. They went to bed and at 2.30 AM her husband\n noticed laboured breathing, thought she had a nightmare but found\n her to be stiff and trembling violently while clenching the\n blankets. Duration 3 - 5 minutes, unresp after. EMS came, to\n hospital, exam non-focal but confused and agitated. Given\n LZP (dose?) and Fosphenytoin 1000 mg. CT reportedly revealed L\n frontpar stroke, but not according to our read. Tx to .\n On arrival here, exam as outlined below. Had another 2 seizures,\n GTC with preceding head and eye deviation to R as the only\n localizing feature, lasting 1 - 2 minutes, with 20 minutes in\n between.\n ROS As above\n Chief complaint:\n CC Stroke vs Seizure\n PMHx:\n PMH HTN, DM II, ?hyperchol, s/p cholecystectomy. RCC as above.\n MEDS Colace 100'', Atorvastatin 20', Timolol drops as directed,\n dorzolamide-timolol drops''', bimatoprost drops', atenolol 50',\n Tylenol, Dilauded 2 mg q4, HCTZ 25', Lopid 600''.\n SH Lives with husband, husband and son are both here.\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Aspirin 5. Atorvastatin 6.\n Atenolol 7. Bimatoprost 8. Docusate Sodium\n 9. Dorzolamide 2%/Timolol 0.5% Ophth. 10. Famotidine 11. Gemfibrozil\n 12. Hydrochlorothiazide 13. Insulin\n 14. Lorazepam 15. Magnesium Sulfate 16. Metoprolol Tartrate 17.\n Phenytoin 18. Potassium Chloride\n 19. Sodium Chloride 0.9% Flush 20. Timolol Maleate 0.5%\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 02:36 PM\n left for MRI at 1315 and returned at 1420\n EEG - At 03:00 PM\n EEG prep started about 1500\n EKG - At 06:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Dilantin - 08:05 PM\n Metoprolol - 04:15 AM\n Other medications:\n Flowsheet Data as of 05:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 37.7\nC (99.9\n HR: 77 (67 - 86) bpm\n BP: 151/61(84) {132/46(68) - 174/85(106)} mmHg\n RR: 19 (10 - 25) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 665 mL\n 435 mL\n PO:\n Tube feeding:\n IV Fluid:\n 665 mL\n 435 mL\n Blood products:\n Total out:\n 355 mL\n 225 mL\n Urine:\n 355 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 310 mL\n 210 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 396 K/uL\n 9.4 g/dL\n 126 mg/dL\n 2.0 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 44 mg/dL\n 106 mEq/L\n 139 mEq/L\n 27.5 %\n 14.0 K/uL\n [image002.jpg]\n 12:26 PM\n 08:52 PM\n 02:16 AM\n WBC\n 14.0\n Hct\n 27.5\n Plt\n 396\n Creatinine\n 2.0\n Troponin T\n 0.76\n 0.60\n 0.42\n Glucose\n 126\n Other labs: PT / PTT / INR:13.9/22.5/1.2, CK / CK-MB / Troponin\n T:131/6/0.42, Ca:8.2 mg/dL, Mg:1.9 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 79 F s/p RCC surgery 1 week ago, on Dilaudid and\n with impaired\n renal function and poor intake, has slow decline in MS (trailing\n of sentences), followed by 3 GTCs, as outlined above. Not\n returned to baseline yet. Exam non-focal, but seizure suggests L\n sided lesion.\n Given recent MRI study current frontrunning diagnosis is posterior\n reversible encephalopathy syndrome\n Neurologic: Neuro checks Q: 2 hr, SBP < 150, dilantin with dilantin\n level in the AM;ativan prn seizures; will continue to monitor on\n seizure precautions, q2h neuro checks, -currently has right sided\n weaknness\n Cardiovascular: hemodynamically stable without need for exogenous blood\n pressure control; troponin resolving\n likely demand ischemia\n Pulmonary: IS, stable with supplemental oxygen - will continue to wean\n as tolerated - currently able to protect airway without need for\n intubation\n Gastrointestinal / Abdomen: will resume oral feeding with improvement\n in mental status (alertness) which is continuing\n Nutrition: NPO\n Renal: Foley, Adequate UO, appropriate urine output in the setting of\n maintenance fluid hydration and contrast dye administered for MRI study\n in patient with CKD - will continue serial monitoring of BUN/Cr\n Hematology: Serial Hct, stable anemia with inflammatory white count\n thus far - will continue to monitor serially\n Endocrine: RISS, RISS for bs < 150\n Infectious Disease: Check cultures, no acute infectious etiology thus\n far, but pan cultured for concern of fever- will follow cultures\n serially\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: CT scan head today\n Fluids: NS, maintenance fluids to continue\n Consults: Neurology\n Billing Diagnosis: Seizure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 09:16 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Echo",
"chartdate": "2115-10-21 00:00:00.000",
"description": "Report",
"row_id": 64327,
"text": "PATIENT/TEST INFORMATION:\nIndication: Possible stroke. ? Source of embolism.\nHeight: (in) 60\nWeight (lb): 142\nBSA (m2): 1.62 m2\nBP (mm Hg): 134/53\nHR (bpm): 62\nStatus: Inpatient\nDate/Time: at 11:55\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous hypertrophy of the\ninteratrial septum. Normal IVC diameter (<2.1cm) with <35% decrease during\nrespiration (estimated RA pressure indeterminate).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild-moderate\nregional LV systolic dysfunction. Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; septal apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. The right atrial\npressure is indeterminate. Left ventricular wall thicknesses and cavity size\nare normal. There is mild to moderate regional left ventricular systolic\ndysfunction with severer hypokinesis of the basal 2/3rds of the anterior\nseptum and anterior walls. The remaining segments contract normally (LVEF =\n40%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial\nmitral regurgitation is seen. The estimated pulmonary artery systolic pressure\nis normal. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Regional left ventricular systolic dysfunction most c/w CAD\n(mid-LAD distribution). Aortic valve sclerosis. No definited structural\ncardiac source of embolism identified.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-10-23 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 1044103,
"text": " 1:16 PM\n DUPLEX DOP ABD/PEL LIMITED; RENAL U.S. Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: evaluate for renal artery stenosis.\n Admitting Diagnosis: SEIZURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with ARF s/p L nephrectomy for RCC. Want to evalute R kidney\n for hydronephrosis and renal artery for stenosis.\n REASON FOR THIS EXAMINATION:\n evaluate for renal artery stenosis.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): WED 2:36 PM\n Abnormal Doppler, please see full report.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old female with acute renal failure status post left\n nephrectomy. Evaluate for hydronephrosis and renal artery stenosis.\n\n COMPARISON: Abdomen MRI .\n\n FINDINGS: The right kidney measures 10.1 cm. No hydronephrosis is identified\n and there are no stones or solid masses seen in the right kidney.\n\n DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were\n obtained. The waveform of the main renal artery in the right kidney\n demonstrates a tardus parvus appearance. This appearance may be suggestive of\n renal artery stenosis but ultrasound is unable to further characterize. The\n RIs of the intraparenchymal right renal arteries are moderately elevated\n measuring 0.78-0.82. Since the patient is unable to hold her breath. It is\n difficult to determine whether these elevated RIs accurately demonstrate any\n real pathology.\n\n IMPRESSION:\n 1. No hydronephrosis, stones or solid masses seen in the right kidney.\n 2. Tardus parvus waveform of the main right renal artery could suggest a\n renal artery stenosis but in the absence of the left kidney ultrasound is\n unable to further characterize.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-10-23 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 1044104,
"text": ", C. MED FA2 1:16 PM\n DUPLEX DOP ABD/PEL LIMITED; RENAL U.S. Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: evaluate for renal artery stenosis.\n Admitting Diagnosis: SEIZURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with ARF s/p L nephrectomy for RCC. Want to evalute R kidney\n for hydronephrosis and renal artery for stenosis.\n REASON FOR THIS EXAMINATION:\n evaluate for renal artery stenosis.\n ______________________________________________________________________________\n PFI REPORT\n Abnormal Doppler, please see full report.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-10-26 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1044763,
"text": " 7:24 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: pls eval for interval change\n Admitting Diagnosis: SEIZURES\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman p/with seizures, HTN, likely from PRESS\n REASON FOR THIS EXAMINATION:\n pls eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DRT MON 9:22 AM\n 1. Interval complete resolution of the patchy FLAIR-hyperintense foci in\n bilateral frontal and parietal and left posterior temporal and occipital\n subcortical white matter, consistent with clinical impression of PRES, with no\n evident sequelae.\n 2. Moderate atrophy and chronic microvascular infarction, largely in\n bifrontal subcortical white matter, unchanged.\n 3. No pathologic enhancement.\n 4. Fluid/opacification of right mastoid air cells.\n ______________________________________________________________________________\n FINAL REPORT\n MR EXAMINATION OF BRAIN WITH CONTRAST \n\n HISTORY: 79-year-old woman with seizures in the setting of hypertension,\n \"likely from PRES\"; evaluate for interval change.\n\n TECHNIQUE: Routine -enhanced MR examination of brain, including T1-\n weighted axial SE and sagittal MP-RAGE sequences, post-contrast\n administration, the latter with axial and coronal reformations.\n\n FINDINGS: Study is compared with the very recent enhanced MRI and unenhanced\n MRV, dated . In the interval, the relatively symmetric foci of and\n FLAIR-hyperintensity in right more than left frontovertex, bilateral\n paramedian parietal, and left posterior temporal and occipital subcortical\n white matter have resolved entirely, without sequelae. This distribution and\n evolution strongly supports the clinical impression of posterior reversible\n encephalopathy syndrome (PRES). There is no evidence of intra- or extra-axial\n hemorrhage, the midline structures are in midline and the ventricles and\n cisterns are unchanged in size and in contour. There are persistent scattered\n largely round and ovoid FLAIR-hyperintense foci, predominantly in bifrontal\n subcortical white matter; these remain nonspecific, but likely represent\n chronic microvascular infarction. There is no evidence of restricted\n diffusion to indicate an acute ischemic event, and the major intracranial\n vascular flow-voids, including those of the dural venous sinuses, are\n preserved, and these structures enhance normally. Again, there is no\n pathologic focus of parenchymal, leptomeningeal or dural enhancement to\n specifically suggest intracranial metastasis. There is fluid/opacification of\n scattered air cells at the right mastoid apex, as before.\n\n IMPRESSION:\n 1. Complete resolution of the patchy FLAIR-hyperintensities in bilateral\n (Over)\n\n 7:24 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: pls eval for interval change\n Admitting Diagnosis: SEIZURES\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n frontal and parietal and left posterior temporal and occipital subcortical\n white matter, over the preceding week; the findings and their evolution are\n completely consistent with the clinical impression of PRES, without evident\n sequelae.\n 2. Underlying chronic microvascular infarction, predominantly in bifrontal\n subcortical white matter, unchanged, with no evidence of an acute ischemic\n event.\n 3. Moderate global atrophy, particularly central.\n 4. No pathologic focus of enhancement to indicate intracranial metastasis.\n 5. Fluid/opacification of right mastoid air cells, as before.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-10-26 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1044764,
"text": ", C. MED FA2 7:24 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: pls eval for interval change\n Admitting Diagnosis: SEIZURES\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman p/with seizures, HTN, likely from PRESS\n REASON FOR THIS EXAMINATION:\n pls eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Interval complete resolution of the patchy FLAIR-hyperintense foci in\n bilateral frontal and parietal and left posterior temporal and occipital\n subcortical white matter, consistent with clinical impression of PRES, with no\n evident sequelae.\n 2. Moderate atrophy and chronic microvascular infarction, largely in\n bifrontal subcortical white matter, unchanged.\n 3. No pathologic enhancement.\n 4. Fluid/opacification of right mastoid air cells.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1043447,
"text": " 8:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with delta MS \n REASON FOR THIS EXAMINATION:\n ?acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old woman with altered mental status and seizure.\n\n Comparison is made to the prior study of .\n\n PORTABLE SUPINE RADIOGRAPH OF THE CHEST: The cardiomediastinal silhouette and\n hilar contours are unchanged. There are low lung volumes bilaterally.\n Increased prominence of the interstitial markings is noted bilaterally which\n is suggestive of mild pulmonary edema. Small bilateral pleural effusions are\n present. New left retrocardiac density is noted.\n\n IMPRESSION:\n 1. New left retrocardiac density might represent pneumonia/atelectasis.\n Repeat radiography following appropriate diuresis recommended.\n 2. Pulmonary edema, likely cardiogenic.\n 3. Unchanged small bilateral pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-10-19 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1043460,
"text": " 12:13 PM\n MR HEAD W & W/O CONTRAST; MRV HEAD W/O CONTRAST Clip # \n Reason: ?acute infarct versus metastatic disease\n Admitting Diagnosis: SEIZURES\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with acute change in mental status, multiple seizures, hx\n renal cell ca, on head CT has an area of hypodensity\n REASON FOR THIS EXAMINATION:\n ?acute infarct versus metastatic disease\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 4:53 PM\n PFI: Patchy hyperintensities in the subcortical and subcortical white matter\n of both frontal and parietal lobes are suspicious for changes of posterior\n reversible encephalopathy. No enhancing lesions seen or acute infarcts noted.\n Normal MRV. Findings discussed with Dr. .\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain.\n\n CLINICAL INFORMATION: Patient with mental status changes for further\n evaluation. The patient has hypodensities in the cortical region on outside\n CT. The patient has history of recent resection of renal cell cancer.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images of the brain were acquired. T1 axial and MP-RAGE sagittal images\n were obtained following gadolinium. 2D time-of-flight MRV of the head was\n obtained. There are no prior similar examinations for comparison.\n\n FINDINGS:\n\n BRAIN MRI:\n\n Diffusion images demonstrate no evidence of acute infarct. There is no\n evidence of mass effect, midline shift or hydrocephalus. Mild-to-moderate\n brain atrophy is seen.\n\n There are several hyperintensities seen in the periventricular white matter\n including some patchy hyperintensities in the subcortical white matter of both\n frontal and parietal lobes as well as in the left posterior temporal and\n occipital lobe. Following gadolinium, no abnormal enhancement is seen. In\n addition, subtle signal abnormalities are seen in the region of facial\n colliculi bilaterally in the pons as well as subtle increased signal is seen\n in the pons.\n\n IMPRESSION:\n 1. The patchy FLAIR hyperintensities seen in the subcortical white matter of\n both frontal and parietal lobes as well as in the left posterior temporal lobe\n are not typical for small vessel ischemic changes. This finding could\n represent reversible encephalopathy syndrome.\n 2. The other periventricular hyperintensities visualized as well as\n (Over)\n\n 12:13 PM\n MR HEAD W & W/O CONTRAST; MRV HEAD W/O CONTRAST Clip # \n Reason: ?acute infarct versus metastatic disease\n Admitting Diagnosis: SEIZURES\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hyperintensities seen in the brainstem could be due to small vessel disease.\n 3. Moderate brain atrophy.\n 4. No enhancing brain lesions or acute infarcts.\n\n MRA OF THE HEAD:\n\n The head MRA demonstrates normal flow signal in the superior sagittal sinus\n and transverse sinuses. No evidence of sinus thrombosis is seen.\n\n COMMENT: Findings were discussed with Dr. at the time of interpretation\n of the study on at 2:00 p.m.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-10-19 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1043461,
"text": ", NMED TSICU 12:13 PM\n MR HEAD W & W/O CONTRAST; MRV HEAD W/O CONTRAST Clip # \n Reason: ?acute infarct versus metastatic disease\n Admitting Diagnosis: SEIZURES\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with acute change in mental status, multiple seizures, hx\n renal cell ca, on head CT has an area of hypodensity\n REASON FOR THIS EXAMINATION:\n ?acute infarct versus metastatic disease\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Patchy hyperintensities in the subcortical and subcortical white matter\n of both frontal and parietal lobes are suspicious for changes of posterior\n reversible encephalopathy. No enhancing lesions seen or acute infarcts noted.\n Normal MRV. Findings discussed with Dr. .\n\n"
},
{
"category": "ECG",
"chartdate": "2115-10-22 00:00:00.000",
"description": "Report",
"row_id": 132361,
"text": "Sinus rhythm. Anteroseptal T wave inversions. Since the previous tracing\nof probably no significant change. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2115-10-19 00:00:00.000",
"description": "Report",
"row_id": 132362,
"text": "Normal sinus rhythm. T wave inversion in lead V2 which is unchanged from\nprevious tracing earlier same date but was not present on the previous tracing\nof . This is a non-specific effect and may be related to lead\nplacement. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2115-10-19 00:00:00.000",
"description": "Report",
"row_id": 132363,
"text": "Sinus rhythm. Modest non-specific ST-T wave changes. Compared to the previous\ntracing of lateral ST-T wave changes are new. Clinical correlation is\nsuggested.\n\n\n"
}
] |
65,837 | 184,409 | Primary Reason for Hospitalization: ==================================== Mr. is a 67 yo gentleman with history of HIV on HAART, last CD4 ct >500 and VL undetectable, s/p recent colectomy on for perforated diverticulum who presented on with fever and was found to have multifocal PNA on CT requiring intubation and an ICU course that was complicated by delirium and malnutrition. . ACTIVE ISSUES: =============== # Acute Respiratory failure: Due to bilateral, multifocal necrotizing pneumonia, worst in the RLL. He was intially given Vanc/Levaquin. However, after CT scan results, he was broadened to vanc/cipro/meropenem given his recent hospitalization. Shortly after transfer to the MICU, the patient had worsening respiratory distress requiring intubation . He was maintained on ARDS net ventilation settings. Antibiotic regimen was adjusted to Linezolid/Cipro/meropenem. he had worsening oxygenation, with bronchoscopy showing a lot of thick yellowish secretions. Sputum and BAL cultures were all negative. Viral DFA negative, legionella urine antigen negative. Acid-fast smears were negative x3. On patient found on repeat CT scan to have worsening bilateral R>L pleural effusions. 700cc of light-coloured fluid drained from the left side, with elevated LDH to suggest exudative effusion, but was considered to be transudative given bland cell count and gross appearance. On He was successfully extubated. He completed his antibiotic course on . On pt had respiratory decompensation and increased O2 requirement. He went from 99% on 1L the evening of to 85% on 3L the AM of . He received nebs and lasix but continued to require 6L O2 on floor and had labored breathing with audible breath sounds at bedside. CXR showed diffuse hazy opacities bilaterally. EKG without ischemia or right axis dev but ?Q wave in lead III. He was transferred to MICU for continued work of breathing and nursing concern. Restarted vanc//cipro for suspicion of recurrent pneumonia. He was reintubated for increased work of breathing. He was extubated on and had PEG placed for nutritional support on . Since that time he has had a consistent 1.5 to 2 liter oxygen requirement. He continues to breath 20-30 times per minute with rapid shallow breathing, however this has been stable for over a week. The source of his continued breathing difficulties appears to be a combination of severe necrotizing pneumonia which is slow to heal as well as a possible component of respiratory muscle weakness due to cachexia. The neccessary duration of treatment for necrotizing pneumonia is not well established and depends on response to therapy. In consultation with thoracic surgery, a 6 week course of antibiotics was planned to be completed . If the patient continues to have respiratory difficulties at that point a repeat CT scan of the chest should be considered. Because a causative organism was never identified he will require continued broad spectrum coverage with Vancomycin, Meropenem, Ciprofloxacin, and Micafungin. Interventional Pulmonology considered a tap of pleural fluid but felt that it was too risky given the small amount of fluid. . #. HCAP/Fevers/chills: Thought to be due to necrotizing pneumonia. All blood and urine cultures were negative. Recent CD4 ct >500 therefore unlikely opportunistic infection. Given recent surgery were initially concerned for intra-abdominal infection, however no evidence of focal collection; moderate free-fluid in abdomen likely represents normal post-surgical changes. The surgery team followed along, but did not feel this was a post-surgical infection. TTE did not show endocarditis. The ID team was consulted. Because of persistent fevers, fluconazole was added . Urine crypto antigen negative and galactomannan negative. Beta-glucan and HHV8 were positive however this was not considered clincially relevant by the infectious disease service given improving clinical status. , given continued fevers, vanco stopped and linezolid started. The cytology from his pleural effusion fluid showed "vesicular chromatin, irregular nuclear membranes and some plasmacytoid cell", raising the possibility of malignancy causing his continued fevers. The oncology team was consulted, who recommended multiple viral markers, but felt that his lung mass would be very atypical for a malignancy. CMV was positive in the BAL. Ultimately because of response to therapy, it was concluded that the fevers had been due to the pneumonia. The patient was afebrile for over 10 days prior to discharge with stable white count. . #. Malnutrition, severe: patient has recent history of chronic diarrhea and weight loss from possible Crohn's vs microscopic colitis. On admission had albumin 1.8, trended down to 1.2 despite initiating tube feeds. He was fed via dobhoff but he was displaced several times. There was difficulty replacing it even with endoscopy and he had a PEG placed on . With tube feeds, albumin had trended up to 2.4 prior to discharge. Urine protein to creatinine ratios were checked to look for an alternative explanation for hypoalbuminemia. These were elevated but not in nephrotic range and results can be falsely elevated in the setting of cachexia. No other evidence of synthetic dysfunction was found to suggest hepatic origin. -- If persistently hypoalbuminemic despite treatment of infection and appropriate nutritional support then should consider further GI workup to investigate protein losing enteropathy. . # Acute metabolic encephalopathy: Most likely related to prolonged severe illness. No evidence of CNS infection. VBG ruled out CO2 narcosis. Patient has many obligate tethers. TSH and RPR are normal. - - Small dose of trazodone QHS to help sleep wake cycle. . # Possible Zenker's seen on EGD: - video speech and swallow when patient improved from respiratory standpoint . # s/p Colectomy: Patient had wound dehiscence, however the wound remained clean and dry with granulation tissue and evidence of adequate wound healing. - Pouch change 2 x a week: Monday/Thursday - Cleanse skin with warm water - Pat dry - Cut wafer to fit template pattern with supplies - Apply seal to back of wafer - Center pouch over stoma and apply to abdomen and hold in place x 2 minutes . # Sacral decubitis: Seen by wound care, has sacral coccygeal ulcer measuring 4 x 3 cm that is covered with a black eschar. Treated with special bed and dressing changes. . #. Anemia: lower than recent baseline, however pt does have anemia at baseline. be in part due to blood loss during surgery. Studies were checked which showed anemia of chronic disease. He had brown guaic postive stools. Endoscopy showed Schatzki ring and non-bleeding duodenal ulcer. He was started on pantoprazole. His HCT then trended up and has remained stable for several days. . CHRONIC ISSUES: =============== # HIV: continued home antiretrovirals, RiTONAvir 100 mg PO BID and Darunavir 600 mg PO BID . # HLD: continued rosuvastatin . # CAD s/p NSTEMI in : rate well controlled. metoprolol held in setting of hypotension, but later restarted. Continued aspirin and rosuvastatin. . # Glaucoma: continued eye drops . TRANSITIONAL ISSUES: ==================== -- 6 week total course of antibiotics planned, which is to be completed . If the patient continues to have respiratory difficulties at that point a repeat CT scan of the chest should be considered. -- Video swallow when medically appropriate before starting anything PO and also to investigate possible Zenker's Diveriticulum. -- GI follow-up outpatient to investigate protein losing enteropathy -- Questions about ostomy should be referred to Acute Care Surgery (Dr. did the sigmoid Colectomy) | IMPRESSION: AP chest compared to through : Tip of the right internal jugular line is unchanged in the low SVC. Further minimal increase in extent and severity of the massive bilateral alveolar opacities with slightly central predominance and multiple air bronchograms. Moderate b/l nonhemorrhagic layering pleural effusions. There are stable subcentimeter sized lymph nodes within the upper paraesophageal region (series #2, image #7). There is mild aortic valve and coronary artery calcifications. The pancreas appears within normal limits. The splenic and superior mesenteric veins appear within normal limits. FINDINGS: In comparison with the earlier study of this date, diffuse bilateral pulmonary opacifications persist. Also noted are non-hemorrhagic effusions, left greater than right, moderate quantity in both lungs, unchanged. Moderate abdominal ascites, mensenteric edema and anasarca. At least a small right pleural effusion is present, probably unchanged. IMPRESSION: AP chest compared to through 28: ET tube is in standard placement. Mild degenerative changes are seen in the thoracic and lumbar spine. Admitting Diagnosis: PNEUMONIA Contrast: OPTIRAY Amt: FINAL REPORT (Cont) gallbladder is distended but appears to have a thin wall. New moderate bilateral pleural effusions. CT OF THE ABDOMEN WITH IV CONTRAST: The liver shows a focal area of hypodensity along the falciform ligament (2:21), which is unchanged compared to multiple previous examinations and likely represents an area of focal fat. Persistent widespread bilateral alveolar opacities accompanied by small left and small-to-moderate right pleural effusions. TECHNIQUE AND FINDINGS: Normal respirophasic waveform in the bilateral common femoral veins with normal response to Valsalva. Trace perihepatic and abdominal and left paracolic gutter ascitic fluid is noted. ET tube and right internal jugular line are in standard placements. Diffuse bilateral pulmonary opacifications persist. FINDINGS: The endotracheal tube terminates approximately 4.8 cm above the carina and is appropriate. Moderate amount of free fluid in the abdomen with indeterminate attenuation values, likely representing post-surgical fluid. On the right, the pre-existing parenchymal abnormality is unchanged in extent. Bilateral, moderate, posteriorly layering, non-hemorrhagic pleural effusions with adjacent passive lung atelectasis have improved on the left but unchanged on the right side. Moderate aortic valve calcification, unknown hemodynamic significance. Contrast material fills the appendix which is normal in appearance. Normal post-surgical appearance of the Hartmann's pouch and colon. ET tube is in standard placement and nasogastric tube passes below the diaphragm and out of view. Severe atelectasis at the base is unchanged. There are small bilateral pleural effusions, left greater than right, with simple attenuation value of the fluid. Likely given the ventilatory pressure, the extensive bilateral parenchymal opacities have minimally decreased in severity. *please use PO contrast* No contraindications for IV contrast WET READ: GMSj FRI 12:41 AM -Multifocal opacities throughout both lungs - ground glass attenuation superiorly and more confluent consolidation with air-bronchograms in the bases - concerning for multifocal pneumonia -Small bilateral pleural effusions, Left > right -Mild free fluid in the abdomen - indeterminate attenuation ( ) likely post-operative -No intra-abdominal abscess or contained collection -Stable post-surgical changes of pouch and end colostomy. Bilateral moderate pleural effusions, improved on the left and unchanged on the right side since . Small right pleural effusion persists. Right jugular line ends approximately 1 cm above the level of the superior cavoatrial junction. The aorta demonstrates dense atherosclerotic calcifications, however, is non-aneurysmal and grossly patent. Mild component of pulmonary edema coexists. Bilateral small pleural effusions are unchanged. The thoracic aorta is non-aneurysmal throughout its course. *please use PO contras Field of view: 36 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) CT ABDOMEN WITH INTRAVENOUS CONTRAST: The liver demonstrates homogeneous parenchymal enhancement without suspicious focal lesion. Novegetation/mass on pulmonic valve.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Informed consent was obtained. Suboptimal image quality - patient unable to cooperate.Conclusions:The left atrium is normal in size. No restingLVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- akinetic; mid inferior - hypo; basal inferolateral - akinetic; midinferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo;lateral apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Regional left ventricular systolic function is depressed.Right ventricular chamber size and free wall motion are normal. There is no pericardial effusion.IMPRESSION: Mild to moderate mitral regurgitation without discrete vegetation.Regional left ventricular systolic dysfunction. Unchanged small bilateral pleural effusions. No ASD by2D or color Doppler.LEFT VENTRICLE: Depressed LVEF.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild tomoderate (+) mitral regurgitation is seen. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Moderate regional LV systolic dysfunction. FINDINGS/IMPRESSION: The heart size and mediastinal contours are within normal limits. Mild [1+] TR.Borderline PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Normal aortic arch diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+) mitralregurgitation is seen. Moderate focal left ventricularsystolic dysfunction consistent with inferior/inferolateral infarction. Left pleural effusion.Conclusions:The left atrium is normal in size. Small bilateral pleural effusions are unchanged. There is moderateregional left ventricular systolic dysfunction with akinesis of the basal tomid inferior and inferolateral segments. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality as the patient was difficult toposition. On the decubitus view, there is a small layering right pleural effusion. The appearance of the lung parenchyma is unchanged. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. The lateral wall is hypokinetic.Right ventricular chamber size and free wall motion are normal. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 68Weight (lb): 135BSA (m2): 1.73 m2BP (mm Hg): 123/73HR (bpm): 72Status: InpatientDate/Time: at 12:45Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. | 47 | [
{
"category": "Radiology",
"chartdate": "2104-11-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1216970,
"text": " 12:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia, ?overload\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with pneumonia, worsening hypoxia\n REASON FOR THIS EXAMINATION:\n pneumonia, ?overload\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-UPRIGHT CHEST, \n\n COMPARISON: chest x-ray.\n\n FINDINGS: Indwelling support and monitoring devices are unchanged in\n position. Heart size remains normal. Persistent widespread bilateral\n alveolar opacities accompanied by small left and small-to-moderate right\n pleural effusions. Etiology of the pulmonary consolidation is uncertain, but\n probably reflects diffuse pneumonia complicated by ARDS.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1217198,
"text": " 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? line placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with multifocal PNA\n REASON FOR THIS EXAMINATION:\n ? line placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:12 A.M., \n\n HISTORY: Check line placement.\n\n IMPRESSION: AP chest compared to through :\n\n Tip of the right internal jugular line is unchanged in the low SVC. ET tube\n and nasogastric tube in standard placements respectively. Opacification in\n the left lung has worsened over 24 hours, probably pulmonary edema, since\n there was previously an improvement over the course of 20 hours on . Concurrent pneumonia or noncardiogenic edema may well be present.\n Moderate right and small left pleural effusion is stable. Heart size normal.\n There is no mediastinal vascular engorgement. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1216837,
"text": " 1:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with PNA, intubated\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2 A.M., \n\n HISTORY: Pneumonia.\n\n IMPRESSION: AP chest compared to through 22:\n\n Severe symmetric pulmonary consolidation has worsened in the lower lungs since\n yesterday. At least a small right pleural effusion is present, probably\n unchanged. ET tube and right internal jugular line are in standard\n placements. The nasogastric tube ends in the stomach. There is no\n pneumothorax. Heart size is normal and there is no mediastinal venous\n engorgement. I suspect the severe pulmonary abnormality is due to a\n combination of widespread multifocal pneumonia and concurrent non-cardiogenic\n pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1217549,
"text": " 1:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with continued respiratory failure from PNA\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 1:25 A.M., \n\n HISTORY: Continued respiratory failure after pneumonia.\n\n IMPRESSION: AP chest compared to through 28:\n\n ET tube is in standard placement. Nasogastric tube ends in the stomach and a\n left PICC line ends just below the estimated location of the superior\n cavoatrial junction.\n\n There is some increase in consolidation in the right mid lung, but otherwise\n very little change in severe widespread infiltrative pulmonary abnormality\n involving both lungs relative to . Small right pleural effusion\n may be little larger. The heart is normal size. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1217059,
"text": " 3:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for progression of opacities, support structur\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with necrotizing pneumonia complicated by ARDS\n REASON FOR THIS EXAMINATION:\n evaluate for progression of opacities, support structure position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Necrotizing pneumonia and ARDS.\n\n FINDINGS: In comparison with the study of , there is little change.\n Monitoring and support devices remain in place. Diffuse bilateral pulmonary\n opacifications persist.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1216436,
"text": " 1:52 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with new line\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n WET READ: MLHh SUN 2:37 AM\n R IJ line at cavoat jctn. Multifocal PNA, effusions, inc ctrl vascular\n congestion/perihilar opacity reflecting superimp edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multifocal pneumonia, evaluation for line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n right internal jugular vein catheter. The tip of the catheter projects over\n the upper parts of the right atrium, the catheter could be pulled back by 2 to\n 3 cm.\n\n No evidence of complications, notably no pneumothorax.\n\n Further minimal increase in extent and severity of the massive bilateral\n alveolar opacities with slightly central predominance and multiple air\n bronchograms.\n\n The presence of a small right pleural effusion cannot be excluded.\n\n Unchanged size of the cardiac silhouette.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-13 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1217016,
"text": " 12:26 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: evaluate for fluid collection in abdomen or pathology in \n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old male with history HIV on HAART, colitis who presented to ED on\n with severe abdominal pain for 3 days, was admitted to the surgical\n service for perforated diverticulum and is now s/p sigmoid colectomy,\n represented for fever yesterday and was found to have multifocal PNA, continues\n to spike fevers\n REASON FOR THIS EXAMINATION:\n evaluate for fluid collection in abdomen or pathology in chest\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the torso with IV and oral contrast.\n\n COMPARISON: CT of the torso dated and CT of the abdomen and pelvis\n dated .\n\n INDICATION: A 67-year-old male with history of HIV on HAART, with colitis and\n status post sigmoid colectomy, admitted with fever.\n\n TECHNIQUE: Multidetector CT images of the chest, abdomen, and pelvis were\n performed after the administration of intravenous and oral contrast.\n Multiplanar reconstructions were performed and reviewed.\n\n FINDINGS:\n\n CHEST: The patient is intubated with the ET tube approximately 4.2 cm above\n the level of the carina. There is a right intravenous catheter with tip\n terminating in the SVC and right atrial junction. An NG tube is seen\n terminating within the stomach.\n\n The visualized thyroid gland appears within normal limits. There is\n atherosclerotic calcification of the thoracic aorta and its branches.\n Coronary artery and aortic valvular calcifications are present. The cardiac\n appear within normal limits. There is no pericardial effusion.\n\n No central filling defects are seen within the pulmonary arterial system.\n\n There are stable subcentimeter sized lymph nodes within the upper\n paraesophageal region (series #2, image #7). There is no axillary,\n mediastinal, or hilar lymphadenopathy.\n\n There are moderate-to-large sized bilateral pleural effusions. Since previous\n studies, there is worsening interstitial thickening with alveolar edema\n corresponding to crazy-paving pattern within the lungs bilaterally.\n Additional more dense alveolar opacities are seen within the dependent\n portions of the upper lobes bilaterally with evidence of air bronchograms.\n Similar opacities are also seen within the medial left upper lobe. There are\n (Over)\n\n 12:26 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: evaluate for fluid collection in abdomen or pathology in \n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n additional patchy alveolar opacities in the periphery of the lungs\n bilaterally. The more confluent opacities with only necrotizing changes in\n the right lower lobe are again seen (series 2, image 39) with evidence of more\n necrosis and refraction. It measures approximately 6.3 x 4.8 cm in size.\n\n ABDOMEN AND PELVIS: No focal hepatic lesions are seen. There is no intra- or\n extra-hepatic biliary ductal dilatation. The portal vein and hepatic veins\n are patent. A small non-specific hypodense lesion in the spleen is unchanged.\n The gallbladder, adrenal glands, and kidneys are normal.\n\n The pancreas appears within normal limits. The splenic and superior\n mesenteric veins appear within normal limits.\n\n Note is again made of left-sided colostomy. The patient is status post\n sigmoid colon resection. The Hartmann's pouch appears within normal limits,\n without evidence of extraluminal collection. There is no distention of the\n small bowel loops. Contrast is seen in the right colon. Trace perihepatic and\n abdominal and left paracolic gutter ascitic fluid is noted.\n\n There is no retroperitoneal or mesenteric lymphadenopathy.\n\n Atherosclerotic vascular calcification of the abdominal aorta and its branches\n are seen. The abdominal aorta is normal in caliber.\n\n There is no pelvic lymphadenopathy. Foley catheter is seen within the urinary\n bladder with air in the urinary bladder.\n\n There is anasarca in the subcutaneous soft tissues.\n\n Within the osseous structures, note is made of remote healed fracture\n involving the left clavicle. No suspicious osteoblastic or osteolytic lesions\n are seen. Mild degenerative changes are seen in the thoracic and lumbar\n spine.\n\n IMPRESSION:\n\n 1. Interval worsening alveolar pulmonary opacities with crazy-paving pattern,\n which could be related to worsening pneumonitis versus pulmonary edema and\n developing adult respiratory distress syndrome. More organized and\n necrotic-appearing right lower lobe necrotizing pneumonia. Worsening pleural\n effusions.\n\n 2. New moderate bilateral pleural effusions.\n\n 3. Slight interval increase in abdominal and pelvic ascites.\n (Over)\n\n 12:26 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: evaluate for fluid collection in abdomen or pathology in \n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 4. Worsening anasarca.\n\n 5. Status post sigmoid colectomy and diverting colostomy.\n\n Findings were discussed with Dr. of Medicine Service on\n at 1:30 p.m.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-18 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1217628,
"text": " 12:15 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval OG tube placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man intubated, replaced OG tube today\n REASON FOR THIS EXAMINATION:\n eval OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 12:16 P.M., \n\n HISTORY: A 67-year-old man intubated. Evaluate orogastric tube.\n\n IMPRESSION: Orogastric tube ends in the distal stomach. ET tube in standard\n placement. Left PIC line ends in the right atrium, now approximately 3 cm\n beyond the estimated location of the superior cavoatrial junction.\n Generalized pulmonary abnormality has improved on the left, indicating either\n increase in positive pressure ventilation, or improvement in the component of\n pulmonary edema. The heterogeneous almost nodular quality of abnormality in\n the right lung is more suggestive of widespread infection. The heart size is\n normal. Small right pleural effusion is stable. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-12-04 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1219991,
"text": " 5:43 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Abscess or other source of persistent infection?\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67yo man with HIV, on HAART, last CD4 ct 419, s/precent colectomy for\n perforated diverticulum. Persistent leukocytosis despite broad spectrum\n antibiotics and antifungals.\n REASON FOR THIS EXAMINATION:\n Abscess or other source of persistent infection?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:02 PM\n Decreased size of necrotic appearing collection at the right lung base\n measuring 3.5 x 3.0 cm compared to 6.7 x 4.3 cm previously. Increased\n consolidative opacity surrounding the collection at the right base and\n increased airspace disease at the left base could represent\n concurrent/worsening infection. Moderate b/l nonhemorrhagic layering pleural\n effusions. Coronary artery atherosclerotic calcifications. Moderate abdominal\n ascites, mensenteric edema and anasarca. Small amount of intraperitoneal free\n air presumed recent PEG placement. No acute intra-abdominal abnl. d/w\n by phone at 6:30 pm on .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old man with HIV, on HAART, status post recent colectomy\n for perforated diverticulum. Persistent leukocytosis, question abscess or\n other source of persistent infection.\n\n COMPARISON: CT of the torso from . CT of the abdomen and\n pelvis from .\n\n TECHNIQUE: MDCT images were acquired through the abdomen and pelvis with IV\n and oral contrast. Multiplanar reformations were obtained and reviewed.\n\n FINDINGS:\n\n The partially imaged lungs show unchanged consolidation in the right lower\n lobe with decrease in the size of a necrotic area compared to the previous\n examination measuring 3 x 3.4 cm today (2:7, previously measuring 4.3 x 6.7\n cm). There is unchanged airspace opacities in the left lower lobe. Also\n noted are non-hemorrhagic effusions, left greater than right, moderate\n quantity in both lungs, unchanged. There is mild aortic valve and coronary\n artery calcifications. A stent is noted within the distal right coronary\n artery.\n\n CT OF THE ABDOMEN WITH IV CONTRAST:\n\n The liver shows a focal area of hypodensity along the falciform ligament\n (2:21), which is unchanged compared to multiple previous examinations and\n likely represents an area of focal fat. The portal vein is patent. The\n spleen, both adrenals, both kidneys, pancreas are unremarkable. The\n (Over)\n\n 5:43 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Abscess or other source of persistent infection?\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n gallbladder is distended but appears to have a thin wall. There is diffuse\n simple fluid ascites with small locules of air, likely related to recent PEG\n insertion. A PEG tube is noted in appropriate position. The small and large\n bowel loops are unremarkable. The appendix is not definitely visualized.\n\n CT OF THE PELVIS WITH IV CONTRAST:\n\n The rectal stump is unremarkable. No pelvic or inguinal lymphadenopathy or\n pelvic free fluid is present. Air within the bladder is noted likely\n secondary to Foley insertion.\n\n OSSEOUS STRUCTURES:\n\n The visible osseous structures show mild anterior osteophyte formation in the\n lower thoracic and lumbar spine, but no acute lytic or blastic lesions or\n fractures are present. There is joint space narrowing with osteophyte\n formation of both hip joints, unchanged.\n\n IMPRESSION:\n\n 1. Interval decrease in the size of a necrotic pneumonia in the right lung\n base measuring 3.5 x 3 cm today.\n\n 2. Consolidation in the left lower lobe consistent with aspiration or\n pneumonia.\n\n 3. Left greater than right moderate nonhemorrhagic effusions.\n\n 4. Nonhemorrhagic ascitic fluid with foci of free air, likely related to\n recent PEG insertion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1216680,
"text": " 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: lines, opacities\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with multifocal PNA, intubated\n REASON FOR THIS EXAMINATION:\n lines, opacities\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia.\n\n FINDINGS: In comparison with the study of , there is little change in\n the diffuse bilateral pulmonary opacifications and the monitoring and support\n devices.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1216548,
"text": " 3:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with HIV, multifocal PNA, intubated\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: HIV with multifocal pneumonia.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. The tip of the right IJ catheter is within the lower\n portion of the SVC. There is still diffuse bilateral pulmonary\n opacifications, though the degree has somewhat improved.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-09 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1216506,
"text": " 3:56 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: PT IMMOBILE, DVTS\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with multifocal PNA, hypoxia, intubated\n REASON FOR THIS EXAMINATION:\n DVTs\n ______________________________________________________________________________\n WET READ: NATg SUN 6:24 PM\n neg for dvt b/l\n fluid in groin adjacent to CFV bilaterally\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 67-year-old male with multifocal pneumonia and hypoxia,\n question DVT.\n\n TECHNIQUE AND FINDINGS: Normal respirophasic waveform in the bilateral common\n femoral veins with normal response to Valsalva. There is normal\n compressibility, color flow, and response to augmentation within the bilateral\n common femoral, superficial femoral, and popliteal veins. Incidental note is\n made of fluid in the bilateral groins. There is normal compressibility of the\n posterior tibial and peroneal veins of the calves.\n\n IMPRESSION: No DVT of the bilateral lower extremities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-29 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1219246,
"text": " 3:14 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Pt with right arm D.L.41cm PICC. ? PICC tip\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with new right arm D.L.41cm PICC. ? PICC tip location\n REASON FOR THIS EXAMINATION:\n Pt with right arm D.L.41cm PICC. ? PICC tip\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:11 P.M. ON \n\n HISTORY: PIC.\n\n IMPRESSION: AP chest compared to , 7:22 a.m.:\n\n New right PIC line curves in the mediastinum quite likely in the azygos vein.\n Subsequent radiograph concurrently shows re-positioning close to the superior\n cavoatrial junction. ET tube is in standard placement. The pulmonary\n abnormalities are slightly improved since the earlier study, probably a\n function of level of greater inspiration. No pneumothorax or appreciable\n pleural effusion. Heart size normal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1216358,
"text": " 3:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 67 yo gentleman with PNA, please eval for worsening PNA, vol\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with recent colectomy, now presenting with new PNA\n REASON FOR THIS EXAMINATION:\n 67 yo gentleman with PNA, please eval for worsening PNA, volume overload\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Recent colectomy, pneumonia, evaluation for worsening.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the left-sided parenchymal\n opacities have minimally increased in extent. The right-sided parenchymal\n opacities are constant. No evidence of pleural effusions. No change in\n normal size of the cardiac silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1217038,
"text": " 7:52 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: for post-procedure complications such as pneumothorax\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with pneumonia s/ \n REASON FOR THIS EXAMINATION:\n for post-procedure complications such as pneumothorax\n ______________________________________________________________________________\n WET READ: 8:45 PM\n Aeration of left lung base is improved after thoracentesis (yielded 850 cc of\n serous fluid - per hx). No post-procedure pneumothorax is evident. Diffuse\n alveolar opacities, right > left and cavitary consolidation in the right lung\n base are better characterized on CT chest from the same day at 12:26pm. The\n endotracheal tube terminates 3.8 cm from the carina. Right IJ in low SVC. NG\n tube wihtin the stomach. Acute findings d/w Dr. at 8:40 pm on\n by telephone. GSenapati \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia, thoracentesis.\n\n FINDINGS: In comparison with the earlier study of this date, diffuse\n bilateral pulmonary opacifications persist. No evidence of pneumothorax\n following thoracentesis. The overall radiographic appearance most likely\n reflects diffuse pneumonia with possible ARDS.\n\n Monitoring and support devices remain in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1219117,
"text": " 1:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for ET tube placement, interval changes\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man now intubated\n REASON FOR THIS EXAMINATION:\n eval for ET tube placement, interval changes\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: Single AP upright portable chest view was read in comparison with\n multiple prior radiographs with the most recent from acquired\n few hours apart.\n\n FINDINGS:\n\n The endotracheal tube terminates approximately 4.8 cm above the carina and is\n appropriate. Tip of the orogastric tube ends at the cervical esophagus just\n above the level of the clavicle. Consider advancing the orogastric tube\n further for optimal seating. Bilateral multifocal lung consolidations have\n very minimally progressed in the left lower lung whereas elsewhere remain\n unchanged. Mild-to-moderate pleural effusions are similar. Cardiomediastinal\n silhouette is unchanged.\n\n Dr. discussed findings with Dr. on at 2:15 p.m.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1219287,
"text": " 4:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval changes\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with pneumonia, intubated\n REASON FOR THIS EXAMINATION:\n eval for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:34 A.M., \n\n HISTORY: 67-year-old man with pneumonia.\n\n IMPRESSION: AP chest compared to through 10:\n\n Multifocal pneumonia, some cavitary, probably unchanged, but there has been an\n improvement in generalized lung density since , probably improved\n and a component of concurrent edema. Heart is not enlarged. Pleural\n effusions are small if any. ET tube is in standard placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-08 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1216398,
"text": " 12:28 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ett placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with s/p intubation\n REASON FOR THIS EXAMINATION:\n ett placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Intubation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n intubated. The tip of the endotracheal tube projects 3.4 cm above the carina.\n Likely given the ventilatory pressure, the extensive bilateral parenchymal\n opacities have minimally decreased in severity.\n\n No pleural effusions. No complications, notably no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-06 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1216202,
"text": " 9:31 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: fluid collection in chest/abd/pelvis? *please use PO contras\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with recent colectomy now with fever\n REASON FOR THIS EXAMINATION:\n fluid collection in chest/abd/pelvis? *please use PO contrast*\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GMSj FRI 12:41 AM\n -Multifocal opacities throughout both lungs - ground glass attenuation\n superiorly and more confluent consolidation with air-bronchograms in the bases\n - concerning for multifocal pneumonia\n\n -Small bilateral pleural effusions, Left > right\n\n -Mild free fluid in the abdomen - indeterminate attenuation ( ) likely\n post-operative\n\n -No intra-abdominal abscess or contained collection\n\n -Stable post-surgical changes of pouch and end colostomy. Oral\n contrast passes freely through colon into ostomy bag. No obstruction,\n inflammation or extraluminal leak\n\n -Normal appendix\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with HIV, Crohn's colitis status post recent\n colectomy, now presenting with fever.\n\n COMPARISON: Preoperative CT abdomen and pelvis from .\n\n TECHNIQUE: 64 MDCT-acquired axial images from the thoracic inlet to the pubic\n symphysis were displayed with 5-mm slice thickness. Oral and intravenous\n contrast was administered. Coronal and sagittal reformations were prepared.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: The thyroid gland is homogeneous without\n suspicious focal lesion. No supraclavicular, axillary, or mediastinal\n lymphadenopathy is identified. The heart size is normal, and there is no\n pericardial effusion. The thoracic aorta is non-aneurysmal throughout its\n course. No central pulmonary embolism is identified on this venous phase\n study. The tracheobronchial tree is patent to subsegmental levels. There are\n multiple opacities within the right and upper lungs as well as in the\n bilateral lower lobes with air bronchograms seen in the lower lobes, findings\n concerning for multifocal pneumonia. Additionally, in the right lower lobe at\n the site of prior consolidation, there are irregular foci of gas in a\n non-enhancing consolidation, findings concerning for the new development of\n necrotizing pneumonia. There are small bilateral pleural effusions, left\n greater than right, with simple attenuation value of the fluid.\n (Over)\n\n 9:31 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: fluid collection in chest/abd/pelvis? *please use PO contras\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: The liver demonstrates homogeneous\n parenchymal enhancement without suspicious focal lesion. The hepatic veins\n and portal venous system are grossly patent. No intra- or extra-hepatic\n biliary ductal dilatation is identified. The gallbladder, spleen, and\n pancreas are normal. The adrenal glands are normal without focal nodule.\n There is symmetric enhancement and excretion of the kidneys without suspicious\n focal lesion or hydronephrosis. There is a small amount of free fluid within\n the abdomen in the perihepatic region and left paracolic gutter. The\n attenuation values range from 10 to 30 Hounsfield units. The stomach and\n small bowel loops are normal in caliber and configuration without evidence of\n obstruction or inflammation. Contrast material fills the appendix which is\n normal in appearance. There is no intra-abdominal free air. The aorta\n demonstrates dense atherosclerotic calcifications, however, is non-aneurysmal\n and grossly patent. Incidentally noted is a small fat containing ventral\n hernia.\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: The patient is status post sigmoid\n colectomy with Hartmann's pouch and end colostomy. The remainder of the colon\n appears normal in caliber and configuration without evidence of obstruction.\n Contrast passes freely through the colon and into the ostomy bag. The\n Hartmann's pouch appears intact without extraluminal collection. The\n prostate, seminal vesicles, and bladder are within normal limits. There is no\n pelvic free fluid.\n\n OSSEOUS STRUCTURES: No bone destructive lesion or acute fracture is\n identified.\n\n IMPRESSION:\n\n 1. Multifocal opacities in the upper and lower lungs, consistent with diffuse\n pneumonia. New irregular gas containing cavities concerning for necrotizing\n pneumonia in the previously seen area of right lower lobe consolidation.\n\n 2. Small bilateral pleural effusions, left greater than right.\n\n 3. Moderate amount of free fluid in the abdomen with indeterminate\n attenuation values, likely representing post-surgical fluid. No confined\n collection within the abdomen or pelvis to suggest abscess.\n\n 4. Normal post-surgical appearance of the Hartmann's pouch and colon. No\n evidence of obstruction, perforation, or leak.\n\n Dr. communicated the above updated findings to Dr. \n at 10:40 am on by telephone.\n (Over)\n\n 9:31 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: fluid collection in chest/abd/pelvis? *please use PO contras\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-20 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1217980,
"text": " 3:39 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for NG tube placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with new dobhoff tube placement\n REASON FOR THIS EXAMINATION:\n eval for NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 67-year-old male patient with new Dobbhoff tube placement,\n evaluate position.\n\n FINDINGS: AP single view of the chest was obtained with patient in sitting\n semi-upright position. Image field is directed to lower chest and upper\n abdomen identifies the newly inserted Dobbhoff line. The line reaches well\n below the diaphragm and is slightly curled up within the area of the fundus of\n the stomach. On the next preceding similar chest examination obtained 12\n hours earlier during the same day, a conventional NG tube was present pointing\n towards the pylorus of the stomach. Apparently, these lines have been\n exchanged.\n\n Previously described extensive bilateral pulmonary parenchymal densities\n persist.\n\n IMPRESSION: Dobbhoff line reaches fundus of stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1217242,
"text": " 2:29 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 54 cm Picc in left brachial vein, text Picc placement to 953\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 54 cm Picc in left brachial vein, text Picc placement to \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:36 P.M., \n\n HISTORY: New left PICC line.\n\n IMPRESSION: AP chest compared to , 3:12 a.m.:\n\n Severe widespread and confluent pulmonary consolidation probably combination\n of edema and pneumonia are unchanged since earlier in the day. Tip of the new\n left PIC line extends between 7 and 8 cm beyond the estimated location of the\n superior cavoatrial junction and should be withdrawn at least 7.5 cm, as\n discussed with the IV nurse by telephone at the time of this dictation. Right\n jugular line ends approximately 1 cm above the level of the superior\n cavoatrial junction. The ET tube is in standard placement. Nasogastric tube\n ends in the stomach. The heart is normal size. Small bilateral pleural\n effusions are presumed, right greater than left. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1217870,
"text": " 2:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: for interval changes\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval changes.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are unchanged, with exception of the left PICC line that has been\n pulled back. The tip of the line now projects over the lower SVC.\n\n On the left, the diffuse parenchymal opacities have mildly increased in\n extent. In addition, a small left pleural effusion might have newly occurred.\n\n On the right, the pre-existing parenchymal abnormality is unchanged in extent.\n Better visible than on the previous radiographs are cavitary lesions at the\n right lateral lung base. These lesions were already documented on a CT\n examination from . The number and extent of the cavitary\n structures and the distribution of small air-fluid levels suggest that these\n changes have slowly increased in number and size over time. A repeat CT might\n be advisable.\n\n Unchanged size of the cardiac silhouette. Unchanged appearance of the hilar\n and mediastinal structures.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-20 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1217929,
"text": " 10:47 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: rule out PE\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with colectomy, large wound, currently intubated, with evidence\n of increased lung dead space.\n REASON FOR THIS EXAMINATION:\n rule out PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT\n\n INDICATION: A 79-year-old man with colectomy, currently intubated with\n evidence of increased lung dead space. Rule out pulmonary embolism.\n\n TECHNIQUE: Contrast-enhanced CT of the thorax were performed using standard\n department protocol. Contiguous axial images at 5-mm and 1.25-mm slice\n thickness were reviewed concurrently with coronal and sagittal reformats.\n Comparison was made with prior studies through to .\n\n FINDINGS:\n\n MEDIASTINUM: The pulmonary artery before bifurcation measures 26 mm and is\n normal in caliber. The heart is of normal size without pericardial effusion.\n No filling defect within main lobar segmental or subsegmental branches of\n pulmonary artery to suggest pulmonary embolism. The left PICC ends at lower\n SVC. The endotracheal tube terminates approximately 4.5 cm above the carina\n and is appropriate in position. There is no pathological enlargement of\n mediastinal, supraclavicular, or axillary lymph nodes. Moderate aortic valve\n calcification is of unknown hemodynamic significance. Atherosclerotic\n calcification involving coronary arteries is moderately severe. Low density\n cardiac contents suggest anemia. The thyroid gland is normal.\n\n AIRWAYS AND LUNGS: The airways are patent to subsegmental bronchi. Bilateral,\n moderate, posteriorly layering, non-hemorrhagic pleural effusions with\n adjacent passive lung atelectasis have improved on the left but unchanged on\n the right side. Confluent opacity in the right lower lung concerning for\n necrotizing consolidation (4:55) measuring approximately 6.1 x 3.1 cm was\n previously 7.0 x 4.2 cm, improved since . Bilateral, diffuse,\n interstitial opacities with crazy-paving pattern and multifocal lung\n consolidations reflecting infection have improved since . Mild\n component of pulmonary edema coexists.\n\n ABDOMEN: This study is not designed for assessment of subdiaphragmatic\n pathology; however, limited views are unremarkable. The adrenal glands are\n normal. An orogastric tube is seen to course below the diaphragm into the\n stomach and is appropriate.\n\n BONES: There is no bone lesion suspicious for malignancy/infection.\n (Over)\n\n 10:47 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: rule out PE\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism.\n\n 2. Multifocal interstitial opacities and consolidations reflecting infection\n and necrotizing consolidation in right lower lung have improved since\n . Mild pulmonary edema may coexists.\n\n 3. Bilateral moderate pleural effusions, improved on the left and unchanged\n on the right side since .\n\n 4. Moderate aortic valve calcification, unknown hemodynamic significance.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1219035,
"text": " 2:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cavitating PNA, with worsening respiratory status\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:34 A.M., \n\n HISTORY: Cavitary pneumonia. Worsening respiratory status.\n\n IMPRESSION: Widespread heterogeneous pulmonary opacification has improved\n slightly in the left lung, worsened slightly on the right. Severe atelectasis\n at the base is unchanged. Heart size is normal and the mediastinal veins are\n not dilated. Relative contribution of widespread pneumonia, asymmetric\n pulmonary edema and organizing stage of ARDS is radiographically\n indeterminate. The heart is not enlarged and there is no pneumothorax.\n Pleural effusions are small.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1217372,
"text": " 3:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? line placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with continued respiratory failure from PNA\n REASON FOR THIS EXAMINATION:\n ? line placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:23 A.M., \n\n HISTORY: Respiratory failure from pneumonia. Check line placement.\n\n IMPRESSION: AP chest compared to through :\n\n Left PIC line ends roughly at the level of the estimated location of the\n superior cavoatrial junction. ET tube is in standard placement and\n nasogastric tube passes below the diaphragm and out of view.\n\n Widespread pulmonary consolidation has improved dramatically since \n indicating remission of a component of pulmonary edema, but many areas of more\n focal pulmonary opacification could be infection, and there is at least a\n handful of small nodules most easily seen in the right lung at the level of\n the first, fourth, and fifth interspaces suggesting either metastasis or\n septic emboli. Heart size is normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1218732,
"text": " 8:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for consolidation\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with SOB, increased oxygen needs\n REASON FOR THIS EXAMINATION:\n evaluate for consolidation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: Portable semi-erect chest view was reviewed in comparison with\n prior chest radiographs through with most recent from\n . Concurrently, a chest CT from was\n reviewed.\n\n FINDINGS:\n\n Bilateral, heterogeneous opacities, predominantly in the lower lobes, continue\n to persist. Given low lung volumes and long standing opacities, it likely\n represents an organizing fibrosing stage or ARDS. Bilateral small pleural\n effusions are unchanged. Mediastinal and hilar contours are normal.\n\n IMPRESSION: Persisting, multifocal, heterogeneous lung consolidations with\n low lung volumes likely represent an organizing fibrosing stage or ARDS.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-06 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1216194,
"text": " 8:10 PM\n CHEST (PA & LAT) Clip # \n Reason: pna?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with fever\n REASON FOR THIS EXAMINATION:\n pna?\n ______________________________________________________________________________\n WET READ: 10:54 PM\n Left retrocardiac and basilar opacities might represent pneumonia. CT is\n already ordered.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old with fever.\n\n TECHNIQUE: Frontal radiographs of the chest were obtained.\n\n COMPARISON: KUB from and CT of the abdomen from .\n\n FINDINGS:\n There is a left retrocardiac opacity, possibly representing pneumonia based on\n clinical presentation, less likely atelectasis. There is a small left pleural\n effusion. Cardiomediastinal silhouette and hila are normal. There is no\n pneumothorax.\n\n IMPRESSION: Left retrocardiac opacity might represent pneumonia given\n context. Atelectasis considered given volume loss.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1217251,
"text": " 3:59 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Eval PICC\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with PICC line, PICC pulled back 7.5cm\n REASON FOR THIS EXAMINATION:\n Eval PICC\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:52 P.M., \n\n HISTORY: PICC line withdrawn 7.5 cm.\n\n IMPRESSION: AP chest compared to 2:36 p.m.:\n\n Left PIC line has been withdrawn to the level of the superior cavoatrial\n junction or slightly above, alongside the tip of the right internal jugular\n line. ET tube is in standard placement, as is a nasogastric tube. A severe\n widespread pneumonia and pulmonary edema may have improved slightly. Small\n right pleural effusion persists. Heart size is normal. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1216258,
"text": " 8:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: PNEMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with HIV new bilateral pulmonary process seen on CT chest, with\n new temp this am\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old male with HIV and new fevers.\n\n COMPARISON: CT of the chest and chest radiograph performed .\n\n PORTABLE UPRIGHT CHEST:\n\n The right costophrenic angle is excluded from the field of view. There are\n increased diffuse parenchymal opacities, which given the rapid progression\n from one day prior, likely reflect an element of pulmonary edema superimposed\n upon known multifocal pneumonia, which was better evaluated by recent CT.\n Effusions and area of cavitation necrosis medially at the right lung base are\n not apparent radiographically. There is no pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1217296,
"text": " 3:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval lungs, lines\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with necrotizing pneumonia, intubated\n REASON FOR THIS EXAMINATION:\n Eval lungs, lines\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Necrotizing pneumonia.\n\n FINDINGS: In comparison with the study of , the right IJ catheter has\n been removed. Diffuse bilateral pulmonary opacifications are slightly\n improved. These presumably represent widespread pneumonia and pulmonary\n edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-29 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1219252,
"text": " 3:50 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: repositioned Picc\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with repo Picc\n REASON FOR THIS EXAMINATION:\n repositioned Picc\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:41 P.M. ON \n\n HISTORY: PICC line reposition.\n\n IMPRESSION: AP chest compared to , 3:11 p.m.:\n\n Right PIC line has been repositioned from the azygos vein to the region of the\n superior cavoatrial junction. Widespread infiltrative pulmonary abnormality,\n probably combination of multifocal infection and organizing stage of ARDS, has\n not changed in several days. There is no pneumothorax or pleural effusion.\n Heart size is normal. ET tube is in standard placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1218629,
"text": " 2:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for dobhoff placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p treatment for PNA with dobhoff placement\n REASON FOR THIS EXAMINATION:\n eval for dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dobbhoff placement.\n\n FINDINGS: In comparison with study of , there has been placement of a\n Dobbhoff tube that coils in the upper stomach. Diffuse bilateral pulmonary\n opacifications appear to have worsened since the prior study, worrisome for\n increasing pneumonia and possible increase in pulmonary vascular congestion.\n\n The left subclavian catheter is no longer seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1218783,
"text": " 1:37 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for opacity\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with SOB, tacypnea\n REASON FOR THIS EXAMINATION:\n assess for opacity\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Shortness of breath and tachypnea.\n\n Comparison is made with prior study performed the same day earlier in the\n morning.\n\n There are lower lung volumes. Otherwise, there has been no change in\n extensive bilateral diffuse lung consolidation, likely representing an\n organizing fibrosis, or progressing stage for ARDS. Cardiomediastinal\n contours are unchanged. NG tube tip is coiled in the stomach. There is no\n pneumothorax. Small bilateral pleural effusions are stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1218844,
"text": " 8:13 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with dobhoff replaced\n REASON FOR THIS EXAMINATION:\n eval for placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Dobbhoff placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the Dobbhoff of the patient\n has been replaced. However, there is still extensive coiling of the tube in\n the region of the pharynx. The appearance of the lung parenchyma is\n unchanged.\n\n No evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1218435,
"text": " 10:38 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for interval change in PNA\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with HIV h/o necrotizing PNA, elevated WBC count, and positive\n b-glucan. concern for fungal colonization of necrotic lesions\n REASON FOR THIS EXAMINATION:\n eval for interval change in PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: HIV, history of necrotizing pneumonia, elevated white blood cell\n count and positive D-glucan, concern for fungal colonization or necrotic\n lesions, evaluate for interval change.\n\n COMPARISON: Chest radiographs on and .\n\n FINDINGS: PA AND LATERAL VIEWS OF THE CHEST. Compared to most recent study,\n there is a decrease in bilateral diffuse opacities. There are still several\n patchy heterogeneous opacities predominantly in the lower lobes likely\n representing multifocal pneumonia. Unchanged small bilateral pleural\n effusions. Left PICC line ends in the right atrium. An NG tube has been\n removed. No pneumothorax.\n\n IMPRESSION:\n\n 1. Decrease in bilateral diffuse opacities likely from a combination of\n decreasing pulmonary edema and extent of pneumonia. Small bilateral pleural\n effusions are unchanged.\n\n 2. The PICC line ends in the right atrium. Suggest pulling back 4-5 cm.\n\n These findings were discussed with Dr. at 4:00pm on by\n telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1218253,
"text": " 1:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? new PNA\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with recent necrotizing PNA and ARDS now extubated, new\n elevation in WBC\n REASON FOR THIS EXAMINATION:\n ? new PNA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST\n\n CLINICAL INDICATION: A 56-year-old with recent necrotizing pneumonia and\n ARDS, now extubated with new elevated white count, question new pneumonia.\n\n Comparison is made to the patient's prior study of at 1531 hours\n and at 2:00 a.m.\n\n A portable semi-erect chest film of at 1342 hours is submitted.\n\n IMPRESSION:\n\n 1. Interval extubation. Left subclavian PICC line has its tip near the\n cavoatrial junction. Feeding tube remains in place with the tip within the\n stomach.\n\n 2. Stable bilateral diffuse airspace process which makes it challenging to\n detect any subtle interval changes. Relatively lower lung volumes when\n compared to several multiple previous prior studies. Diffuse airspace process\n is probably not significantly changed given the interval reduction in lung\n volumes. No pleural effusions or pneumothoraces.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1219199,
"text": " 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for interval change.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with HIV, resp failure\n REASON FOR THIS EXAMINATION:\n Eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:22 A.M.\n\n HISTORY: HIV. Respiratory failure.\n\n IMPRESSION: AP chest compared to through 9:\n\n Still intubated, lung volumes have increased. Heterogeneous opacification\n throughout both lungs suggests widespread pneumonia, possibly cavitary. No\n doubt chronic changes of organzing ARDS are contributory. The heart is normal\n size, and there is no mediastinal distention to suggest either volume overload\n or cardiac decompensation. Small bilateral pleural effusions are presumed.\n ET tube is in standard placement. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-12-11 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1220949,
"text": " 3:38 PM\n CHEST (PA & LAT); CHEST (LAT DECUB ONLY) Clip # \n Reason: Please evaluate for progression of pneumonia and whether eff\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with necrotizing right lower lung pneumonia and pleural\n effusions\n REASON FOR THIS EXAMINATION:\n Please evaluate for progression of pneumonia and whether effusion is free\n flowing\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with right lower lung pneumonia and pleural\n effusions.\n\n STUDY: PA, lateral, and right lateral decubitus chest radiographs.\n\n COMPARISON: .\n\n FINDINGS/IMPRESSION: The heart size and mediastinal contours are within\n normal limits. Bibasilar opacities persist. On the decubitus view, there is\n a small layering right pleural effusion. There is no pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1218838,
"text": " 7:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: dobhoff placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man, replaced dobhoff\n REASON FOR THIS EXAMINATION:\n dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for Dobbhoff placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the Dobbhoff has been\n replaced. The tube shows coiling in the hypopharynx, the tip projects over\n the mid esophagus. A phone contact was made at the time of the wet read.\n\n The appearance of the lung parenchyma, with multiple bilateral parenchymal\n opacities, is constant.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2104-11-17 00:00:00.000",
"description": "Report",
"row_id": 100337,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Mitral valve disease.\nHeight: (in) 67\nWeight (lb): 135\nBSA (m2): 1.71 m2\nBP (mm Hg): 114/74\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 13:55\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nDrs. and notified in person.\nLEFT ATRIUM: Normal LA size. All four pulmonary veins identified and enter the\nleft atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No mass or thrombus in the RA or RAA. A\ncatheter or pacing wire is seen in the RA and extending into the RV. No ASD by\n2D or color Doppler.\n\nLEFT VENTRICLE: Depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. Results were personally reviewed with the MD caring for the\npatient. Left pleural effusion.\n\nConclusions:\nThe left atrium is normal in size. No mass or thrombus is seen in the right\natrium or right atrial appendage. Catheters/wires are identified in the RA\nwithout associated vegetations/thrombi. No atrial septal defect is seen by 2D\nor color Doppler. Regional left ventricular systolic function is depressed.\nRight ventricular chamber size and free wall motion are normal. There are\nsimple atheroma in the descending thoracic aorta. The aortic valve leaflets\n(3) are mildly thickened. No masses or vegetations are seen on the aortic\nvalve. Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. No mass or vegetation is seen on the mitral valve. Mild to\nmoderate (+) mitral regurgitation is seen. No vegetation/mass is seen on\nthe pulmonic valve. There is no pericardial effusion.\n\nIMPRESSION: Mild to moderate mitral regurgitation without discrete vegetation.\nRegional left ventricular systolic dysfunction.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2104-11-08 00:00:00.000",
"description": "Report",
"row_id": 100338,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 68\nWeight (lb): 135\nBSA (m2): 1.73 m2\nBP (mm Hg): 123/73\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 12:45\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Moderate regional LV systolic dysfunction. No resting\nLVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - hypo; basal inferolateral - akinetic; mid\ninferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo;\nlateral apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No masses or vegetations\non aortic valve, but cannot be fully excluded due to suboptimal image quality.\nTrace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No masses or vegetations\non mitral valve, but cannot be fully excluded due to suboptimal image quality.\nMild mitral annular calcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nBorderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - patient unable to cooperate.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and global systolic function are normal (LVEF>55%). There is moderate\nregional left ventricular systolic dysfunction with akinesis of the basal to\nmid inferior and inferolateral segments. The lateral wall is hypokinetic.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets are mildly thickened (?#). No masses or vegetations are seen on\nthe aortic valve, but cannot be fully excluded due to suboptimal image\nquality. Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. No masses or vegetations are seen on the mitral valve, but\ncannot be fully excluded due to suboptimal image quality. Mild (1+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is borderline pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: No echocardiographic evidence of endocarditis, however cannot\nexclude due to subooptimal image quality. Moderate focal left ventricular\nsystolic dysfunction consistent with inferior/inferolateral infarction. Mild\nmitral regurgitation.\n\nIf clinically indicated, a transesophageal echocardiogram may better assess\nfor valvular vegetations.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2104-11-28 00:00:00.000",
"description": "Report",
"row_id": 274049,
"text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\ntracing no clear change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2104-11-27 00:00:00.000",
"description": "Report",
"row_id": 274050,
"text": "Sinus tachycardia. Top normal Q-T interval. Compared to the previous tracing\nof no clear change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2104-11-26 00:00:00.000",
"description": "Report",
"row_id": 274051,
"text": "Sinus tachycardia. Possible prior inferior myocardial infarction. Diffuse\nnon-specific ST-T wave changes. Compared to the previous tracing of \nthe rate is increased. Non-specific ST-T wave changes are seen.\n\n"
},
{
"category": "ECG",
"chartdate": "2104-11-18 00:00:00.000",
"description": "Report",
"row_id": 274052,
"text": "Sinus rhythm. Compared to the previous tracing of no diagnostic\ninterim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2104-11-13 00:00:00.000",
"description": "Report",
"row_id": 274053,
"text": "Sinus tachycardia at a rate of 101 beats per minute. Tendency toward low\nvoltage in the limb leads and lateral precordial leads. Non-specific\nST-T waves changes. Compared to the previous tracing of no diagnostic\ninterval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2104-11-11 00:00:00.000",
"description": "Report",
"row_id": 274054,
"text": "Sinus tachycardia. Ventricular ectopy. Non-specific ST-T wave changes.\nNo previous tracing available for comparison.\n\n"
}
] |
96,686 | 189,846 | Patient is a 41yo female with PMHx of poorly controlled DMI (last HbA1c 7.9 ) complicated by PVD (s/p bilateral ) with non-healing stump wound infection, neurogenic bladder with recurrent UTIs who initially presented to ED with left ear pain, transferred to the MICU because of presumptive diagnosis of malignant otitis externa, course complicated by ATN/ARF, hypotension and rapid drop in hct with unstable blood volume. . #. Sepsis: On presentation patient admitted to MICU for sepsis. Several potential sources of infection, but did not appear to have signs of shock. UA dirty though urine culture with fecal contamination, history of pan-resistant Klebsiella urine infections (sensitive only to Tetracyclie). She denied any urinary or respiratory complaints though she has neurogenic bladder and straight caths herself. Her CXR appeared normal without evidence of consolidation. History of C. Diff in the past, but without diarrhea and had a negative C.Diff toxin. Based on physical examination findings of cellulitis and ear involvement ED was concerned with Malignant external otitis. often reported in patients infected with human immunodeficiency virus (HIV), as well as elderly diabetics. Last HIV was negative year ago, but A1c's uncontrolled. ENT was consulted and did not think her clinical picture was consistent with malignant otitis externa. She was treated with bacitracin ointment to her left ear, warm compresses, and follow up in outpatient clinic. She was started on Vancomycin/Zosyn/Cipro initially for broad coverage. ID was consulted given her history of multiple resistant bacteria in the past. After being on broad coverage overnight, she was narrowed to Vancomycin (for cellulitis on face) and cipro (for possible UTI). Patient with terrible access and so Vancomycin changed to Linezolid for health care associated MRSA and PO Vancomycin started given history of severe C.Diff infections. Patient will complete Linezolid and Ciprofloxacin as an outpatient and will take PO Vanco until 1 week following completion of course. . #. AOCKD: On admission to MICU patient with Acute renal failure to Creatinine of 9.4 from baseline CRF of Cr=2. FeNa in MICU 6.77%, consistent with ATN likely related to sepsis and hypotension. Renal ultrasound was unremarkable. Home lisinopril was held and she was instructed to hold until instructed by nephrologist. Creatinine downtrended to mid 6 on discharge, will likely improve with time. Patient set up with Neprhologist as an outpatient. . #. Type 1 DM: Followed by and A1c 8.9%. was consulted and home insulin regimen was asjusted. Discharged on Lantus 3am 4pm and liberal HISS . #. Anion Gap Acidosis: Likely secondary to new onset kidney injury (uremia) as well as mild lactic acidosis. Resolved . #. Systolic CHF (Chronic, LVEF 40% in ), no acute exacerbation. Regional hypokinesis raises suspicion for ischemic etiology. Started Carvedlilol and Atorvastatin . Atorvastatin 20mg started given hyperlipidemia and high risk of cardiovascular disease. Simva not chosen because her need for tight control requiring higher doses of simva than would be possible in this patient. Lipids drawn prior to discharge and her LDL was 89, good as it is LDL<100 but goal is <70 given already reduced LVEF which likely ischemic in nature. Did not repeat TTE. Avoided Spironolactone while in ARF and presented with hyperkalemia on admission, should readdress as an outpatient . #. Anemia: Has known renal disease, with HCT initially at baseline of 25 but trended down to 21.7. No signs of bleed during admission. Iron studies c/w anemia of chronic disease. . #. Hypertension: CRF. Held ACE-I given and stated Carvedilol as above. . #. CAD: Continued ASPIRIN 81 mg Daily. Started Atorvastatin and Carvedilol as above . #. Pain control: Treated initially with Dilaudid PO, but had nausea so switched to oxycodone 5-10mg PO q6 hours PRN pain. Her home regimen consists of MORPHINE 10 mg/5 mL - 1 tsp Q3H PRN*, MORPHINE 15 mg Extended Release TID*, OXYCODONE 10 mg Q6H PRN severe pain*, OXYCODONE-ACETAMINOPHEN 5 mg-325 mg 1 tablet Q6H PRN*. During admission discontinued morphine opiates because of renal failure and switched to Oxycontin 10mg PO BID which is equivalent MS Contin dose. Patient discharged with Oxycontin and instructed not to take Morphine. . #. Dyslipidemia: Simvastatin 20 mg Daily inactivated by ID (per note was taken off by another provider for unclear reasons). Started on Atorvastatin 20mg Daily, LDL <100 but would push for ideally <70. . #. Left ischial bed sore: Obtained wound care consult. . TRANSITIONAL ISSUES: #. Code: Full Code #. Patient to complete Linezolid/Cipro course as outpatient, to finish , she will complete PO Vanco on #. Patient should start Statin as an outpatient. Encourage PCP to restart statin as patient requiring prior-authorization for Atorvastatin #. Carvedilol started while inpatient #. Patient should have -weekly labs drawn to monitor ARF improvement #. Patient discharged on Oxycontin and should not take MS Contin #. Consider Spironolactone when ARF/Hyper-K resolve | An isolated opacified anterior left ethmoidal air cell is seen. Non-specific ST-T wave changes. evidence of malignant otitis FINAL REPORT (Cont) aside from evidence of minimal cerumen. No acute intracranial process. No acute intracranial process. No acute intracranial process. There is no evident pneumothorax. No osseous erosions. No osseous erosions. no change in hearing. IMPRESSION: Normal renal ultrasound. There is opacification of scattered left mastoid air cells. Compared to the previoustracing of there is no significant change. Pt with IDDM who presents with pain and swelling around the ear but not inside. There is partial opacification of the left middle ear. Sinus tachycardia. COMPARISON: CT head from . Mild prominence of the ventricles and sulci is stable compared to CT from . There is no pleural effusion. Evaluate pneumothorax. There are low lung volumes. There is minimal mucosal thickening within the maxillary sinuses as well as within the posterior aspect of the left sphenoid sinus. mastoiditis? mastoiditis? mastoiditis? There is no hydronephrosis. There is no pneumothorax or pleural effusion. No drainage from ear. The visualized portions of the orbits are unremarkable. Cardiac size is top normal. Cardiac size is top normal. Right upper lobe atelectasis is new. IMPRESSION: 1. TECHNIQUE: Sequential axial images were acquired through the head without the administration of intravenous contrast material. evidence of malignant otitis No contraindications for IV contrast WET READ: 9:55 PM 1. Calcifications of the bilateral cavernous carotid and vertebral arteries are noted. Otherwise the lungs are clear. The right mastoid air cells are well aerated. FINDINGS: There is no evidence of intracranial hemorrhage, edema, shift of normally midline structures, hydrocephalus, or acute large vascular territorial infarction. No fevers or chills. Draining a little bit now. There is no evidence of osseous erosion. Marked calcifications of the cavernous carotid and vertebral arteries. Marked calcifications of the cavernous carotid and vertebral arteries. Soft tissue induration at the base of the left auricle extending superiorly along the scalp, raising concern for early malignant otitis externa. Soft tissue induration at the base of the left auricle extending superiorly along the scalp, raising concern for early malignant otitis externa. The lungs are clear. COMPARISON: Renal ultrasound . Evaluate for mastoiditis or malignant otitis externa. 3. 3. 2. 2. Blood sugars have been "excellent." REASON FOR THIS EXAMINATION: ? There is extensive soft tissue induration and stranding in the subcutaneous fat, extending from the root of the left auricle superiorly along the left frontoparietal region (2:). The external auditory canal is patent (Over) 4:04 PM CT HEAD W/O CONTRAST Clip # Reason: ? No stone or cyst or concerning solid mass is seen in either kidney. Also with a bed sore on the left ischium that is still painful and not healed. FINDINGS: The right kidney measures 10.3 cm and the left kidney measures 10.2 cm. WET READ VERSION #1 7:21 PM Findings concerning for cellulitis along the left auricle root, extending superiorly, although early malignancy otitis externa is certainly of high concern. She thinks she may have an ear infection. 4:04 PM CT HEAD W/O CONTRAST Clip # Reason: ? The pre-void bladder is collapsed on a Foley catheter. FINAL REPORT INDICATION: History of diabetes, presenting with complaints of left ear swelling. Multiplanar reformations were performed. 10:20 AM RENAL U.S. evidence of malignant otitis MEDICAL CONDITION: This patient is a 41 year old female who complains of ear swelling. 9:11 PM CHEST (PORTABLE AP) Clip # Reason: Please asssess for volume overload, PNA Admitting Diagnosis: ACUTE RENAL FAILURE MEDICAL CONDITION: 41 year old woman with new onset luekocytosis REASON FOR THIS EXAMINATION: Please asssess for volume overload, PNA FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Leukocytosis. Clip # Reason: Please assess for any renal pathology to explain new Admitting Diagnosis: ACUTE RENAL FAILURE MEDICAL CONDITION: 41 year old woman with new REASON FOR THIS EXAMINATION: Please assess for any renal pathology to explain new FINAL REPORT INDICATION: 41-year-old female with new . | 5 | [
{
"category": "Radiology",
"chartdate": "2115-04-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1231116,
"text": " 4:04 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? mastoiditis? evidence of malignant otitis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n This patient is a 41 year old female who complains of ear swelling. Pt with\n IDDM who presents with pain and swelling around the ear but not inside. She\n thinks she may have an ear infection. No drainage from ear. no change in\n hearing. No fevers or chills. Also with a bed sore on the left ischium that is\n still painful and not healed. Draining a little bit now. Blood sugars have been\n \"excellent.\"\n REASON FOR THIS EXAMINATION:\n ? mastoiditis? evidence of malignant otitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 9:55 PM\n 1. Soft tissue induration at the base of the left auricle extending\n superiorly along the scalp, raising concern for early malignant otitis\n externa. No osseous erosions.\n\n 2. No acute intracranial process.\n\n 3. Marked calcifications of the cavernous carotid and vertebral arteries.\n WET READ VERSION #1 7:21 PM\n Findings concerning for cellulitis along the left auricle root, extending\n superiorly, although early malignancy otitis externa is certainly of high\n concern. No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of diabetes, presenting with complaints of left ear\n swelling. Evaluate for mastoiditis or malignant otitis externa.\n\n TECHNIQUE: Sequential axial images were acquired through the head without the\n administration of intravenous contrast material. Multiplanar reformations\n were performed.\n\n COMPARISON: CT head from .\n\n FINDINGS: There is no evidence of intracranial hemorrhage, edema, shift of\n normally midline structures, hydrocephalus, or acute large vascular\n territorial infarction. Mild prominence of the ventricles and sulci is stable\n compared to CT from . Calcifications of the bilateral cavernous\n carotid and vertebral arteries are noted. The visualized portions of the\n orbits are unremarkable. There is minimal mucosal thickening within the\n maxillary sinuses as well as within the posterior aspect of the left sphenoid\n sinus. An isolated opacified anterior left ethmoidal air cell is seen. The\n right mastoid air cells are well aerated.\n\n There is extensive soft tissue induration and stranding in the subcutaneous\n fat, extending from the root of the left auricle superiorly along the left\n frontoparietal region (2:). There is opacification of scattered left\n mastoid air cells. There is no evidence of osseous erosion. There is partial\n opacification of the left middle ear. The external auditory canal is patent\n (Over)\n\n 4:04 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? mastoiditis? evidence of malignant otitis\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n aside from evidence of minimal cerumen.\n\n IMPRESSION:\n\n 1. Soft tissue induration at the base of the left auricle extending\n superiorly along the scalp, raising concern for early malignant otitis\n externa. No osseous erosions.\n\n 2. No acute intracranial process.\n\n 3. Marked calcifications of the cavernous carotid and vertebral arteries.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-04-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1231145,
"text": " 12:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for PTX\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with s/p attempted central line\n REASON FOR THIS EXAMINATION:\n Please assess for PTX\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Attempted central line. Evaluate pneumothorax.\n\n There is no evident pneumothorax. There are low lung volumes. Right upper\n lobe atelectasis is new. Otherwise the lungs are clear. Cardiac size is top\n normal. There is no pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-04-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1231140,
"text": " 9:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please asssess for volume overload, PNA\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with new onset luekocytosis\n REASON FOR THIS EXAMINATION:\n Please asssess for volume overload, PNA\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Leukocytosis.\n\n Cardiac size is top normal. The lungs are clear. There is no pneumothorax or\n pleural effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2115-04-11 00:00:00.000",
"description": "Report",
"row_id": 165760,
"text": "Sinus tachycardia. Non-specific ST-T wave changes. Compared to the previous\ntracing of there is no significant change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2115-04-12 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1231179,
"text": " 10:20 AM\n RENAL U.S. Clip # \n Reason: Please assess for any renal pathology to explain new \n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old woman with new \n REASON FOR THIS EXAMINATION:\n Please assess for any renal pathology to explain new \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 41-year-old female with new .\n\n COMPARISON: Renal ultrasound .\n\n FINDINGS: The right kidney measures 10.3 cm and the left kidney measures 10.2\n cm. There is no hydronephrosis. No stone or cyst or concerning solid mass is\n seen in either kidney. The pre-void bladder is collapsed on a Foley catheter.\n\n IMPRESSION: Normal renal ultrasound.\n\n\n"
}
] |
92,947 | 190,453 | Patient had ICP placed, opening pressure 37. She was admitted to TICU on neurosurgery service and closely monitored. She was started on mannitol for ICP management which was transitioned to hypertonic saline. Her Serum Osm and serum Na were checked every six hours and saline was held for OSM>320 and Na>155. Upon initial discussion and given her initial prognosis she was made DNR. Her ICP's remained slightly elevated in the mid twenties but her Serum Osm and Na were elevated making treatment contraindicated. Her ICP's did resolve to normal values and a head ct was obtained on . Head CT was consistent with large bifrontal hypodensity that was consistent with stroke or edema. This was repeated on and showed little change from previous exam. Her ICP monitor was removed on without complication. In family discussion it was decided to move towards Trach/PEG which was performed on . During tracheostomy procedure pneumothorax occured and chest tube was placed. She spiked fever to 104 and sputum cultures grew gram negative rods and she was begun on broad spectrum antibiotics. There was concern for possible infection and head CT with contrast was performed but did not reveal infection. However due to fever and drainage from wound it was decided to bring her to the OR for craniectomy and debridement on . She tolerated this procedure very well with no complications and returned to the ICU post operatively. Her chest tube was removed on with no complication. A chest x ray on showed decrease size in her pneumothorax, she had no difficulty with O2 saturations. She was transferred to the floor and the step down unit on . Upon arrival to the floor she was seen by the physical therapy team and it was decided she would benefit from long term rehab placement. She remained afebrile while on the floor and her antibiotics were discontinued after an 8 day course for hospital aquired pneumonia and her whire blood cell count remained in normal range and she was afebrile. Her staples were removed and wound was well healed. She remained stable over the weekend of and and was discharged to Rehab on . | Hyperdense foci consistent with areas of subarachnoid and probable subdural hemorrhage are unchanged. A chest tube in the right hemithorax appears unchanged. Parenchymal edema and degree of sulcal effacement appear similar to the prior examination. Slight decrease in small right apical pneumothorax. Slight decrease in right pneumothorax. Slight decrease in right pneumothorax. New large right pneumothorax and pneumomediastinum without tension. IMPRESSION: Increase in small right apical pneumothorax without evidence of tension. There is again a small amount of hemorrhage identified, unchanged. 12:03 AM CT HEAD W/ & W/O CONTRAST Clip # Reason: Eval left temporal wound with bulging contents - ? A large right pneumothorax and small pneumomediastinum are new. INDICATION: Confirmation of line placement, rule out of pneumothorax. Though there (Over) 12:03 AM CT HEAD W/ & W/O CONTRAST Clip # Reason: Eval left temporal wound with bulging contents - ? There is still a moderate-to-large quantity of pneumoperitoneum. , W. NSURG TSICU 12:03 AM CT HEAD W/ & W/O CONTRAST Clip # Reason: Eval left temporal wound with bulging contents - ? However, newly appeared are bilateral apical, obviously pleural opacities, left more than right. FINAL REPORT INDICATIONS: Right pneumothorax, status post chest tube placement. FINDINGS: A small right apical pneumothorax is slightly decreased compared to . NONCONTRAST HEAD CT: There is little change from . Herniated brain tissue, similar in extent to the prior examination. Herniated brain tissue, similar in extent to the prior examination. Bibasilar opacities are unchanged and may represent aspiration. Unchanged course and position of the nasogastric tube. Mild amount of intra-axial/subarachnoid hemorrhage injury. Pneumoperitoneum is unchanged from but is increased from . A right PICC projects over the mid SVC. There is interval decrease in the right apical pneumothorax. Observed that there is a kink in the chest tube in the right apical area, similar as it existed before. IMPRESSION: Interval decrease in right pneumothorax. CT VENOGRAM: Some of the radiodense foci are noted in close proximity to the superior sagittal sinus, with a few tiny foci, noted in particular, in very close proximity to the sinus and location within the venous sinus cannot be differentiated/excluded. Evidence of significant postoperative pneumoperitoneum remains as before. Right pneumothorax is appreciably smaller following insertion of the apical pleural tube. A right apical pneumothorax appears stable. Unchanged position of tracheotomy, right-sided subclavian central venous line and right-sided chest tube. Small areas of subarachnoid hemorrhage in the vertex, along with possible small subdural hemorrhage along the falx and minimal amount in the right lateral ventricle. IMPRESSION: Slight interval worsening in degree of alveolar edema. The same holds for previously described right subclavian approach central venous line. The previously dye identified bibasilar hazy pulmonary densities have regressed slightly. A tracheostomy tube and right subclavian line are unchanged in position. A new right-sided chest tube is identified advanced in the axillary area and terminating in the right-sided upper mediastinal region after a semi-circular curvature in the apical area. TECHNIQUE: Non-contrast CT head, followed by CT venogram. 2:37 AM CTA HEAD W&W/O C & RECONS Clip # Reason: Trauma eval Contrast: OPTIRAY Amt: 110 FINAL ADDENDUM @@@@@@@@@@@@@@ This is a revision of a previously signed report @@@@@@@@@@@@@@ A few tiny non-enhancing foci in the superior sagittal sinus at vertex can relate to thrombosis/ slow flow. FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. Small areas of pneumocephalus and soft tissue laceration as described above. Remaining paranasal sinuses and mastoid air cells are relatively well aerated, with opacification of scattered mastoid air cells inferiorly. pneumomediastinum and large pneumoperitoneaum persists. Tracheostomy tube in standard placement. Pneumoperitoneum as before. Some degree of cerebral edema, as mentioned in the report. Small amount of air is noted in the left parietal scalp soft tissues. TECHNIQUE: Non-contrast MDCT images were acquired from the skull base to the cervicothoracic junction. A few displaced fragments on the right side as described above. FINDINGS: A right subclavian central line projects over the mid SVC, terminating at the level of the left central venous line tip. Mild mucosal thickening in fullness in the fossa of Rosenmuller are noted. Admitting Diagnosis: GUN SHOT WOUND FINAL REPORT (Cont) debridement, with hypodense material between the patch and the calvarium likely reflecting a small extra-axial collection. | 24 | [
{
"category": "Radiology",
"chartdate": "2139-01-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1168419,
"text": " 12:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval interval change.\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman s/p R PTX and CT on water seal\n REASON FOR THIS EXAMINATION:\n Eval interval change.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MDAg FRI 5:27 PM\n 1. Slight decrease in right pneumothorax.\n 2. Pneumoperitoneum stable from , but increased from .\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Right pneumothorax with chest tube on water seal, evaluate\n for interval change.\n\n COMPARISON: CXR at 4:20 p.m.\n\n FINDINGS: A small right apical pneumothorax is slightly decreased compared to\n . There is no left pneumothorax and no pleural effusions. The\n cardiac and mediastinal silhouettes are stable without evidence of tension.\n Bibasilar opacities are unchanged and may represent aspiration.\n Pneumoperitoneum is unchanged from but is increased from\n . The remainder of the support monitoring devices are in unchanged\n position.\n\n IMPRESSION:\n 1. Slight decrease in small right apical pneumothorax.\n 2. Pneumoperitoneum stable from , but increased from .\n\n Discussed with Dr. by phone at 4:12 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1168450,
"text": " 2:48 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval s/p chest tube removal on R\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman s/p R chest tube removal.\n REASON FOR THIS EXAMINATION:\n Eval s/p chest tube removal on R\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post right chest tube removal.\n\n COMPARISON: CXR at 1:18 p.m. and at 5:55 a.m.\n\n FINDINGS: Since 1:18 p.m., the right apical pneumothorax has\n increased after the removal of the right chest tube. The remainder of the\n monitoring and support devices are unchanged. Basilar opacities are stable.\n The cardiac and mediastinal silhouettes are stable without evidence of\n tension. Pneumoperitoneum is unchanged from 1:18 p.m., but is increased from\n .\n\n IMPRESSION: Increase in small right apical pneumothorax without evidence of\n tension.\n\n Discussed with Dr. by phone at 4:12 p.m., .\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-24 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1168596,
"text": " 4:07 PM\n PORTABLE ABDOMEN Clip # \n Reason: Eval for ileus\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with PEG and pneumoperitoneum high residuals on TFs\n REASON FOR THIS EXAMINATION:\n Eval for ileus\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN\n\n HISTORY: Pneumoperitoneum, evaluate for ileus.\n\n One portable supine view. The diaphragm is not included. Comparison is made\n with the previous study done . A gastrostomy tube remains in place.\n Contrast material has advanced from the stomach to the colon. The bowel gas\n pattern is unremarkable. There is continued evidence of free air in the\n peritoneal cavity. Soft tissues and bony structures are unremarkable.\n\n IMPRESSION: Pneumoperitoneum. Transit of contrast material to the colon.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1167980,
"text": " 5:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval interval change.\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with R PTX s/p CT placement.\n REASON FOR THIS EXAMINATION:\n Eval interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Right pneumothorax, status post chest tube placement.\n\n COMPARISONS: Prior evening.\n\n CHEST, PORTABLE AP SEMI-UPRIGHT: The heart is normal in size. The\n mediastinal and hilar contours are unremarkable. A right subclavian central\n venous catheter again terminates in the lower superior vena cava. A chest\n tube in the right hemithorax appears unchanged. The patient has a\n tracheostomy tube. The lung has fully re-expanded with a suspected trace\n residual pneumothorax. There is still a moderate-to-large quantity of\n pneumoperitoneum. Pneumomediastinum is less conspicuous. Streaky opacities\n in the right lower lung suggest resolving atelectasis. Patchy opacification\n of the left lower lung, probably involving the lower lobe for the most part,\n appears similar.\n\n IMPRESSION: Essentially complete reinflation of the right lung with suspected\n trace residual pneumothorax only. Moderate-to-large quantity of\n pneumoperitoneum, but probably not increased.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1167594,
"text": " 2:58 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Pls eval for interval change, eval shift\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with GSW to head\n REASON FOR THIS EXAMINATION:\n Pls eval for interval change, eval shift\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy SUN 5:10 PM\n PFI: Little change from . Large area of hypodensity\n involving the bilateral frontal lobes with associated metallic and osseous\n fragments, are compatible with history of gunshot wound. There is no new\n parenchymal edema. Small amount of intracranial hemorrhage is also stable,\n without new hemorrhagic focus identified. Ventricles are stable in size, and\n there is again no shift of midline structures. Basal cisterns are patent.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old female status post gunshot wound to the head.\n Evaluate for interval change.\n\n COMPARISON: .\n\n NONCONTRAST HEAD CT:\n\n There is little change from . Again seen involving both\n frontal lobes near the vertex are large areas of hypodensity, with innumerable\n hyperdense osseous and metallic fragments seen in a similar distribution,\n compatible with history of gunshot wound. The degree of parenchymal edema is\n similar to two days prior. A small amount of intra and extraparenchymal\n hyperdensity at the left vertex is compatible with hemorrhage, stable. There\n is hyperdense thickening in the falx and tentorium, likely reflecting subdural\n blood. This is also stable from prior study. There is no new intracranial\n hemorrhage identified. There is no new parenchymal edema, including no\n evidence of evolving infarction. Ventricles and sulci remain normal in size\n and configuration, without midline shift or other evidence of herniation. The\n basal cisterns are patent.\n\n An intracranial pressure monitoring bolt is seen in the right frontal region.\n\n\n There is mucosal thickening in the right maxillary sinus and ethmoid air\n cells, and partial opacification of the left mastoids.\n\n IMPRESSION:\n\n Little change from . Large areas of hypodensity involving\n the frontal lobes at the vertex with associated hyperdense metallic and\n osseous fragments are compatible with sequelae of gunshot wound. There is\n again a small amount of hemorrhage identified, unchanged. No increased mass\n effect or evidence of herniation.\n (Over)\n\n 2:58 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Pls eval for interval change, eval shift\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1167595,
"text": ", W. NSURG TSICU 2:58 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Pls eval for interval change, eval shift\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with GSW to head\n REASON FOR THIS EXAMINATION:\n Pls eval for interval change, eval shift\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Little change from . Large area of hypodensity\n involving the bilateral frontal lobes with associated metallic and osseous\n fragments, are compatible with history of gunshot wound. There is no new\n parenchymal edema. Small amount of intracranial hemorrhage is also stable,\n without new hemorrhagic focus identified. Ventricles are stable in size, and\n there is again no shift of midline structures. Basal cisterns are patent.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-21 00:00:00.000",
"description": "CT HEAD W/ & W/O CONTRAST",
"row_id": 1167955,
"text": " 12:03 AM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: Eval left temporal wound with bulging contents - ? infection\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with GSW and left temporal wound with bulging contents.\n REASON FOR THIS EXAMINATION:\n Eval left temporal wound with bulging contents - ? infection vs brain matter.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): OXZa WED 1:11 AM\n Overall stable examination as compared to . Herniated brain\n tissue, similar in extent to the prior examination. No evidence of abscess or\n fluid collection. The presence of cerebritis, however, would be difficult to\n exclude on this examination.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post gunshot wound to the head. Now with bulging\n contents. Evaluation for brain herniation or infection.\n\n TECHNIQUE: Multidetector CT scan of the head was obtained before and after\n the administration of IV Optiray contrast. Axial, coronal, and sagittal\n reformations were prepared.\n\n COMPARISON: Multiple prior examinations, most recent CT of the head dated\n .\n\n FINDINGS: Overall, there is little interval change from .\n Large areas of hypodensity in the frontal lobes near the vertex are similar in\n extent with innumerable osseous fragments and metallic shrapnel in a similar\n distribution. Parenchymal edema and degree of sulcal effacement appear\n similar to the prior examination. Hyperdense foci consistent with areas of\n subarachnoid and probable subdural hemorrhage are unchanged. No new\n intracranial hemorrhage is identified.\n\n The ventricles and sulci are normal in caliber and configuration, with no\n shift of the normally-midline structures. In the region of the defect in the\n left parietal bone, there is a soft tissue density with similar attenuation to\n brain tissue. On post-contrast images, enhancement of the soft tissue follows\n brain tissue compatible herniated brain parenchyma (4:21-22). No\n discrete abscess or fluid collection is seen.\n\n An intracranial pressure monitoring bolt has been removed, leaving a \"ghost\n tract\" in the right paramedian frontal bone.\n\n Mucosal thickening of the ethmoid air cells, sphenoid sinuses, maxillary\n sinuses, and opacification of the mastoid air cells are not significantly\n changed.\n\n IMPRESSION: Overall stable examination as compared to .\n Extracranial herniation of brain tissue, is similar in extent to the prior\n examination. No evidence of abscess or fluid collection. N.B. Though there\n (Over)\n\n 12:03 AM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: Eval left temporal wound with bulging contents - ? infection\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n is no discrete fluid collection or abscess, the presence of cerebritis would\n be difficult to exclude on this examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-21 00:00:00.000",
"description": "CT HEAD W/ & W/O CONTRAST",
"row_id": 1167956,
"text": ", W. NSURG TSICU 12:03 AM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: Eval left temporal wound with bulging contents - ? infection\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with GSW and left temporal wound with bulging contents.\n REASON FOR THIS EXAMINATION:\n Eval left temporal wound with bulging contents - ? infection vs brain matter.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Overall stable examination as compared to . Herniated brain\n tissue, similar in extent to the prior examination. No evidence of abscess or\n fluid collection. The presence of cerebritis, however, would be difficult to\n exclude on this examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1166712,
"text": " 5:34 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: confirm line placement, r/o PTX\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with new L SC CVL\n REASON FOR THIS EXAMINATION:\n confirm line placement, r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n INDICATION: Confirmation of line placement, rule out of pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n new left central venous access line over the subclavian vein. The course of\n the line is unremarkable. There is no evidence of pneumothorax. The tip of\n the line projects over the mid SVC.\n\n The tip of the endotracheal tube has been pulled back. The tip of the tube\n now projects 4.3 cm above the carina. The tube could be advanced by\n approximately 1 cm. Unchanged course and position of the nasogastric tube.\n No pneumothorax. No focal parenchymal opacity suggesting pneumonia. No\n pleural effusions.\n\n However, newly appeared are bilateral apical, obviously pleural opacities,\n left more than right. Although the left apex appears unremarkable on the\n spine CT examination performed , at 2:45, the area should\n receive close attention on followup radiographs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1167248,
"text": " 4:09 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please assess for interval change\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with GSW to head\n REASON FOR THIS EXAMINATION:\n Please assess for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa FRI 6:53 AM\n Interval large area of hypodensity in the superior frontal lobes in the\n vertex, with relatively unchanged scattered hyperdense fragments. No\n significant amount of SAH. No intraventricular hemorrhagic extension. No\n hydrocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: CTA head on .\n\n HISTORY: 26-year-old woman with gunshot wound to head. Assess for interval\n change.\n\n TECHNIQUE: Noncontrast MDCT images were acquired through the head.\n Multiplanar reformatted images were obtained for evaluation.\n\n FINDINGS: Compared to the study approximately three days ago, there is\n interval development of large area of hypodensity in the bifrontal regions\n near the vertex. The innumerable scattered hyperdense fragments are in\n approximately similar distribution. There is small amount of intraparenchymal\n hemorrhage and subarachnoid hemorrhage in the left greater than right frontal\n regions. Small subtle hyperdense segments along the falx likely representing\n subdural hematomas. The ventricles symmetric in configuration and normal in\n size without evidence of intraventricular hemorrhagic extension. The\n shattering fractures of the left temporal and right superior frontal calvarium\n are similar in configuration with an interval placement of a bolt in the right\n frontal region. The visualized paranasal sinuses and mastoid air cells are\n noted with scattered opacifications.\n\n IMPRESSION:\n 1. Interval development of large area of hypodensity along the superior\n frontal lobes near the vertex, concerning for interval development of\n parenchymal edema versus infarction.\n\n 2. Mild amount of intra-axial/subarachnoid hemorrhage injury. No\n intraventricular hemorrhagic extension or hydrocephalus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1167918,
"text": " 4:46 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval trach position and cause of hypoxemia\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with trach today and O2 Sat low 90's\n REASON FOR THIS EXAMINATION:\n Eval trach position and cause of hypoxemia\n ______________________________________________________________________________\n WET READ: AJy TUE 10:28 PM\n large right PTX is new. there is also pneumomediastinum and a large amount of\n free intraperitoneal air. the latter may reflect interval PEG placement,\n though the amount of air is large and correlation is advised with cilnical\n exam. there is increased left mid and lower lung opacity, which could\n reflect asymmetric edema vs aspiration. correlate clinically. trach tube\n terminates 3 cm above the carina. right central line unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n The study just came to our attention leading to a delay in reporting.\n\n CLINICAL HISTORY: Low oxygen saturation, hypoxemia.\n\n COMPARISON: CXR at 10:28 a.m.\n\n FINDINGS: The lung apices are not included on the radiograph. A tracheostomy\n tube ends 3.3 cm above the carina. A right PICC projects over the mid SVC. A\n large right pneumothorax and small pneumomediastinum are new. A\n moderate-to-large amount of pneumoperitoneum is likely related to PEG\n placement. An opacity at the left lung base is likely aspiration. The cardiac\n and mediastinal silhouettes are normal without evidence of tension.\n\n IMPRESSION:\n 1. New large right pneumothorax and pneumomediastinum without tension.\n 2. Moderate-to-large pneumoperitoneum, likely related to PEG placement.\n 3. New left aspiration.\n\n Dr. discussed the findings with Dr. at the time of\n preliminary report.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1168420,
"text": ", W. NSURG TSICU 12:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval interval change.\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman s/p R PTX and CT on water seal\n REASON FOR THIS EXAMINATION:\n Eval interval change.\n ______________________________________________________________________________\n PFI REPORT\n 1. Slight decrease in right pneumothorax.\n 2. Pneumoperitoneum stable from , but increased from .\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1166686,
"text": " 2:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Trauma eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22F s/p GSW to L temporal region\n REASON FOR THIS EXAMINATION:\n Trauma eval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 22-year-old female, with gunshot wound to the left temple. Assess\n for trauma in rest of the body.\n\n COMPARISON: None.\n\n TRAUMA X-RAY OF THE CHEST AND PELVIS: The study is slightly obscured by the\n underlying trauma board. Allowing for the limitation, there is no\n radiographic evidence of traumatic injury in the chest, abdomen or pelvis.\n The patient is status post placement of endotracheal tube, which terminates\n just above the carina. The NG tube is seen traversing to the stomach with the\n tip lying outside of the radiograph. The lungs are clear. The\n cardiomediastinal silhouettes, hilar contour, and pulmonary vasculature are\n unremarkable. There is no free air in the abdomen. The bony pelvis is\n intact.\n\n IMPRESSION:\n 1. No radiographic evidence of acute trauma in the chest, abdomen, and\n pelvis.\n 2. Tip of endotracheal tube ending at the carina, recommend pulling back\n approximately 3 cm for better positioning.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1168436,
"text": " 1:40 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval interval change.\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with GSW s/p debridement and pericardial bovine patch POD#2.\n REASON FOR THIS EXAMINATION:\n Eval interval change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc FRI 2:41 PM\n Interval improvement in herniation of intracranial contents following\n debridement and patch. Minimal rightward bowing of upprt falx (3 mm) without\n herniation. Slight increase in white matter edema extending further\n inferiorly in the left cerebral hemisphere. No new intracranial hemorrhage.\n\n PFI VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 26-year-old woman status post gunshot wound with recent debridement\n and placement of pericardial bovine patch, postoperative day 2.\n\n COMPARISON: Multiple prior head CTs, most recently .\n\n TECHNIQUE: Non-contrast axial images were obtained through the brain.\n\n FINDINGS: Since the prior study, the patient has undergone debridement and\n placement of a pericardial bovine patch over the large bony defect in the left\n parietal bone. There has been an associated decrease in herniation of\n intracranial contents through the defect, with mild bulging of the patch\n material towards the vertex, containing low-density material. This collection\n measures 10 x 29 mm (2:23).\n\n Frontal lobes again demonstrate large regions of white matter hypodensity.\n The falx demonstrates minimal rightward bowing at the level of the cranial\n defect, measuring 4 mm. Again extending towards the vertex are innumerable\n high-density fragments within the cranial vault.\n\n The extent of edema has increased, particularly on the left, now extending\n further caudally, to the level of the lateral ventricles. There is no new\n intracranial hemorrhage, or evidence of herniation. Ventricles and sulci are\n unchanged in size and configuration. Swelling and inflammatory change of the\n scalp overlying the left parietal defect have increased, compatible with\n recent procedure.\n\n Sphenoid air cells demonstrate mucosal thickening and contain aerosolized\n material. Remaining paranasal sinuses and mastoid air cells are relatively\n well aerated, with opacification of scattered mastoid air cells inferiorly.\n\n IMPRESSIONS:\n\n 1. Interval improvement in herniation of intracranial contents after\n (Over)\n\n 1:40 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval interval change.\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n debridement, with hypodense material between the patch and the calvarium\n likely reflecting a small extra-axial collection.\n\n 2. No new intracranial hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1168437,
"text": ", W. NSURG TSICU 1:40 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval interval change.\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with GSW s/p debridement and pericardial bovine patch POD#2.\n REASON FOR THIS EXAMINATION:\n Eval interval change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Interval improvement in herniation of intracranial contents following\n debridement and patch. Minimal rightward bowing of upprt falx (3 mm) without\n herniation. Slight increase in white matter edema extending further\n inferiorly in the left cerebral hemisphere. No new intracranial hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-13 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1166684,
"text": " 2:37 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Trauma eval\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL ADDENDUM\n @@@@@@@@@@@@@@ This is a revision of a previously signed report @@@@@@@@@@@@@@\n\n\n A few tiny non-enhancing foci in the superior sagittal sinus at vertex can\n relate to thrombosis/ slow flow. Assessment is limited due to artifacts.\n\n\n\n\n 2:37 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Trauma eval\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22F s/p GSW to L temporal region\n REASON FOR THIS EXAMINATION:\n Trauma eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa TUE 4:43 AM\n Non-contract CT head: shattering L temporal calvarial fracture at the GSB\n entry site. Exit site in the right parietal lobe at the vertex. Marked soft\n tissue swelling. Retained bullet fragment in the right frontoparietal lobe,\n with bony fragments in surrounding parenchyma. Small amount of SAH.\n CTV: pending 3-D rendering. Shattering debris seen in the superior sagittal\n sinus near the vertex, but the sinus remains patent. No large active\n extravasation noted.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Gunshot injury, to evaluate for abnormalities.\n\n COMPARISON: CT head done on .\n\n TECHNIQUE: Non-contrast CT head, followed by CT venogram. 2D and 3D\n reformations were obtained.\n\n FINDINGS:\n\n NON-CONTRAST CT HEAD: There are multiple radiodense foci noted in the soft\n tissues of the head as well as in the calvarial bones and in the brain\n parenchyma at the vertex related to the gunshot wounds. There are several\n retained fragments in the right frontal/parietal lobe at the vertex, along\n with small amount of gas in the tract.\n A few dense foci are noted in close proximity to the superior sagittal sinus\n at the vertex and location within the sinus cannot be completley excluded.\n There are comminuted fractures noted involving the left parietal bone with\n scattered/shattered fragments, along with displacement and likely represents\n the exit site ( contrary to the prelim read which mentions this as entry\n site). There are also fractures involving the right parietal bone, to a\n lesser degree with few inwardly displaced fragments and this likely represents\n the entry site (contrary to the prelim. read). Small amount of air is noted\n in the left parietal scalp soft tissues. There is also a small amount of air\n in the extra-axial spaces in the head and in close proximity to the falx/dural\n reflection or in the superior sagittal sinus and straight sinus and if in the\n venous sinuses, there is concern for venous air embolism.\n There are a few scattered areas of subarachnoid hemorrhage in the frontal and\n the parietal sulci on both sides along with a small amount of intraventricular\n hemorrhage in the posterior part of the body of the right lateral ventricle\n and possibly along the falx. A few foci of paranchymal contusions are noted\n at the vertex. There is also some degree of cerebral edema, in parituclar in\n the frontal and parietal lobes.\n (Over)\n\n 2:37 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Trauma eval\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Given the extent of fractures and possibility of dural tear, CSF leak is a\n possible sequela and attention to be paid clinically and at follow up.\n A small CSF density focus in the right side of the posterior fossa may\n represent a small arachnoid cyst. This measures 1.8 x 1.5 cm.\n Mild mucosal thickening in fullness in the fossa of Rosenmuller are noted.\n The visualized mastoid air cells are clear.\n\n CT VENOGRAM: Some of the radiodense foci are noted in close proximity to the\n superior sagittal sinus, with a few tiny foci, noted in particular, in very\n close proximity to the sinus and location within the venous sinus cannot be\n differentiated/excluded. However, there is no contrast extravasation noted to\n suggest injury to the sinus within the limitations of artifacts from the\n gunshots.\n\n The confluence of the venous sinuses, the inferior sagittal sinus, the\n straight sinus, transverse and sigmoid sinuses are patent.\n\n Evaluation of the intracranial arteries is limited due to the delayed\n acquisition, as not targeted. Within these limitations, the major\n intracranial arteries are patent, without focal flow-limiting stenosis or\n occlusion.\n\n IMPRESSION:\n\n 1. Status post gunshot injury with multiple radiodense foci related to the\n gunshots noted in the soft tissues of the scalp at the vertex, in the brain\n parenchyma in the frontal and the parietal lobes at the vertex, and in very\n close proximity to the superior sagittal sinus. A few tiny foci are noted in\n extremely close proximity to the superior sagittal sinus at the vertex and an\n intrasinus location cannot be completely excluded. However, there is no\n obvious contrast extravasation to suggest obvious injury within the\n limitations of artifacts. Some degree of cerebral edema, as mentioned in the\n report.\n\n 2. Multiple fractures involving the left and the right parietal bones as\n described above, with displaced and shattered fragments on the left side,\n likely exit site. A few displaced fragments on the right side as described\n above.\n\n 3. Small areas of subarachnoid hemorrhage in the vertex, along with possible\n small subdural hemorrhage along the falx and minimal amount in the right\n lateral ventricle. Few possible foci of parenchymal contusion are also noted\n in the vicinity of the gunshot wounds, in the brain parenchyma at the vertex.\n Small areas of pneumocephalus and soft tissue laceration as described above.\n Followup as clinically indicated.\n\n (Over)\n\n 2:37 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Trauma eval\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Possibility of venous air embolism and dural tear that can lead onto CSf\n leak and intracrnail hypotension later cannot be completely excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-13 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1166685,
"text": " 2:38 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Trauma eval\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22F s/p GSW to L temporal region\n REASON FOR THIS EXAMINATION:\n Trauma eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa TUE 3:04 AM\n No acute cervical fx or malalignment.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 22-year-old female, status post gunshot wound to the left temporal\n region. Assess for cervical injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT images were acquired from the skull base to the\n cervicothoracic junction. Multiplanar reformatted images were obtained for\n evaluation.\n\n FINDINGS: The study is slightly limited by motion artifacts. There is no\n evidence of an acute cervical fracture or malalignment. The vertebral body\n heights and disc space heights are preserved. The prevertebral soft tissues\n are unremarkable. The patient is status post placement of endotracheal tube\n and NG tube. The visualized lung apices are unremarkable.\n\n IMPRESSION: Slightly motion-limited study. No evidence of an acute cervical\n fracture or malalignment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1167848,
"text": " 10:12 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval placement of new CVL RSC\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with new R SC CVL\n REASON FOR THIS EXAMINATION:\n Eval placement of new CVL RSC\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: New right subclavian central venous line.\n\n COMPARISON: CXR at 05:39 a.m.\n\n FINDINGS: A right subclavian central line projects over the mid SVC,\n terminating at the level of the left central venous line tip. The\n endotracheal tube is 5.5 cm above the carina. A nasogastric tube is in place.\n The lungs are clear without focal consolidation or pulmonary venous\n congestion. The cardiac mediastinal silhouettes and hilar contours are\n stable. There is no pleural effusion or pneumothorax.\n\n IMPRESSION: Right CVL projects over mid SVC. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1167928,
"text": " 6:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval new R chest tube, eval for ptx\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with new R chest tube s/p PTX\n REASON FOR THIS EXAMINATION:\n eval new R chest tube, eval for ptx\n ______________________________________________________________________________\n WET READ: AJy TUE 10:32 PM\n\n interval placement of right chest tube, with markedly decreased PTX. RLL is\n reexpanded. pneumomediastinum and large pneumoperitoneaum persists. central\n line and trach tube unchanged. decreased left basilar and increased right\n basilar opacities favor redistribution of edema.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:30 P.M. ON \n\n HISTORY: New right chest tube for pneumothorax.\n\n IMPRESSION: AP chest compared to , 5:14 p.m.\n\n Right pneumothorax is appreciably smaller following insertion of the apical\n pleural tube. New consolidation at the base of the right lung is either mild\n reexpansion edema or given the extent of severe consolidation on the left the\n manifestation of a recent large aspiration. Pneumoperitoneum is substantial,\n presumably related to the gastrostomy tube, projecting over the mid stomach.\n Tracheostomy tube in standard placement. Pleural effusion is minimal if any.\n Heart size is normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-23 00:00:00.000",
"description": "G/GJ/GI TUBE CHECK",
"row_id": 1168490,
"text": " 7:48 PM\n G/GJ/GI TUBE CHECK Clip # \n Reason: Eval PEG for causes of pneumoperitoneum.\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with recent PEG and increasing pneumoperitoneum.\n REASON FOR THIS EXAMINATION:\n Eval PEG for causes of pneumoperitoneum.\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN X-RAY\n\n HISTORY: PEG. Increasing pneumoperitoneum.\n\n One supine view. Contrast material has been injected via the patient's\n gastrojejunostomy tube. This outlines the stomach and pools in the gastric\n fundus. No extravasation of contrast is apparent. There is evidence of free\n air in the peritoneal cavity. The bowel gas pattern is unremarkable.\n\n IMPRESSION: Injected contrast enters and accumulates in the stomach without\n apparent extravasation. Pneumoperitoneum is demonstrated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1168535,
"text": " 5:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with recurrent PTX s/p CT pull\n REASON FOR THIS EXAMINATION:\n Please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: Recurrent pneumothorax, evaluate for change.\n\n One view. Comparison with the previous study done . There is\n interval decrease in the right apical pneumothorax. Bibasilar pulmonary\n infiltrates are unchanged. Mediastinal structures are unchanged as well. A\n tracheostomy tube and right subclavian line are unchanged in position. There\n is a large pneumoperitoneum as before.\n\n IMPRESSION: Interval decrease in right pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1168261,
"text": " 4:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval interval change.\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with R chest tube s/p PTX. Water seal today at 10AM.\n REASON FOR THIS EXAMINATION:\n Eval interval change.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 26-year-old female patient with right-sided chest tube, status\n post pneumothorax. Waterseal today placed at 10:00 a.m. Evaluate interval\n change.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position. Comparison is made with a preceding similar\n study dated . Tracheostomy cannula remains in unchanged\n position. The same holds for previously described right subclavian approach\n central venous line. A new right-sided chest tube is identified advanced in\n the axillary area and terminating in the right-sided upper mediastinal region\n after a semi-circular curvature in the apical area. Observed that there is a\n kink in the chest tube in the right apical area, similar as it existed before.\n It may compromise the chest tube lumen moderately, but no interval change is\n identified. Evidence of significant postoperative pneumoperitoneum remains as\n before. The previously dye identified bibasilar hazy pulmonary densities have\n regressed slightly. Consider regression of aspiration pneumonitis in this\n patient with history of gunshot wound to head. The lateral pleural sinuses\n remain free, so pleural effusion is unlikely.\n\n IMPRESSION: Slight regression of basal densities. No reoccurrence of\n pneumothorax. Unchanged position of tracheotomy, right-sided subclavian\n central venous line and right-sided chest tube. Pneumoperitoneum as before.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1167803,
"text": " 5:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval r/o interval change\n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with fever\n REASON FOR THIS EXAMINATION:\n please eval r/o interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, exclude interval change.\n\n COMPARISON: Radiograph dated .\n\n FINDINGS: Subtle alveolar opacities in both lower lobes have slightly\n worsened since and suggest alveolar edema. The position of the\n endotracheal tube, which has been further advanced since , is\n satisfactory. The left subclavian central venous catheter and nasogastric\n tube are in satisfactory position.\n\n IMPRESSION:\n Slight interval worsening in degree of alveolar edema.\n Satisfactory position of endotracheal tube.\n\n This report was made available for approval on the evening of .\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-01-23 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1168489,
"text": " 7:39 PM\n CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval interval change. Please do XRAY at \n Admitting Diagnosis: GUN SHOT WOUND\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with recurrent PTX s/p CT pull\n REASON FOR THIS EXAMINATION:\n Eval interval change. Please do XRAY at \n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: Recurrent pneumothorax, chest tube removed.\n\n One view. Comparison with .\n\n The apices are not entirely included. A right apical pneumothorax appears\n stable. Bibasilar pulmonary opacities are stable as well. The heart and\n mediastinal structures are unchanged. A tracheostomy tube and right\n subclavian catheter remain in place. A large pneumoperitoneum is\n redemonstrated.\n\n IMPRESSION: No definite change.\n\n\n"
}
] |
44,876 | 128,912 | 83 yo F with recent dx of metastatic colon cancer s/p C1D1 FOLFOX chemotherapy who presents with diarrhea, SOB, sinus tachycardia and found to have R superior segmental PE. . # Pulmonary embolism: Subsegmental on CTA. Pt denies h/o DVT or clotting hx, likely hypercoag. state secondary to malignancy. No evidence of R heart strain on EKG. Sinus tach may be related to PE or dehydration. Unclear from hx if this was an acute event or incidental finding on presentation. No O2 requirement while in ICU. Started heparin gtt, was transitioned to lovenox after transfer out of the ICU. She was started on coumadin 2mg daily. On discharge the INR was 1.1 and she was given a Rx for coumadin 2mg daily and lovenox for 5 days. She is to have your blood drawn at home on for an INR check to be faxed to her PCP and Dr . Further adjustments to the coumadin may be necessary at that time. . # Dehydration: Pt with diarrhea and poor po intake for several days. Sinus tachycardia and borderline low uop. Patient was given IVF and lytes were replete. She became euvolemic with hydration and resolution of the diarrhea. . # Diarrhea: Nonbloody, guiac positive after several hours of diarrhea (likely due to irritation). HCT stable. Most likely trigger is chemotherapy with FOLFOX. No fevers. C diff negative x 3. Stool culture negative. Patient given loperamide and lomotil, required rectal tube. Diarrhea gradually stopped and her electrolytes stabilized. Further chemotherapy should be carefully chosen in the setting of severe diarrhea caused by FOLFOX. Patient should continue a lactose free diet. She should also continue to avoid fresh fruits. Discharged on loperamide prn. . # Colon cancer: Metastatic to liver, adrenal. Defer treatment to primary oncology team. No chemotherapy while in the hospital given her acute illness. . # Hypertension: SBP 140s-160s, stabilized on metoprolol and nifedipine. Transtitioned back to atenolol and nifedipine on discharge . # GERD: continued home PPI, increased dose to for worsening symptoms. . #Hypercholesterolemia: Stain held as liver enzymes (AST, alk phos) showed a slight increase during the ICU stay. The statin was restarted upon discharge. . # Code: DNR/DNI - confirmed with pt. . # Comm: husband - | DIARRHEA: First C. Diff negative. # Dispo: ICU care . She is s/p one treatment of folfox on . She is s/p one treatment of folfox on . She is s/p one treatment of folfox on . She is s/p one treatment of folfox on . She is s/p one treatment of folfox on . She is s/p one treatment of folfox on . She is s/p one treatment of folfox on . She is s/p one treatment of folfox on . She is s/p one treatment of folfox on . Will guaic stools (negative as outpatient recently). HYPERTENSION, BENIGN: Restart atenolol. Metastatic colon CA s/p chemoRx . # PPx: heparin drip, pneumoboots, PPI (GERD), hold bowel regimen . Action: Continues on fluids NS 150cc/hr Response: Pt still complains of feeling dehydrated and can take POs as tolerated. Action: Continues on fluids NS 150cc/hr Response: Pt still complains of feeling dehydrated and can take POs as tolerated. Action: Continues on fluids NS 150cc/hr Response: Pt still complains of feeling dehydrated and can take POs as tolerated. Action: Continues on fluids NS 150cc/hr Response: Pt still complains of feeling dehydrated and can take POs as tolerated. Response: AM labs K+ 3.7, Mag 1.9, pt continues to have diarrhea guiac negative. Will replete K and Mg. Repeat electrolytes thsi pm. Plan: Lomotil prn for diarrhea, follow up with c-diff reports. Plan: Lomotil prn for diarrhea, follow up with c-diff reports. Plan: Lomotil prn for diarrhea, follow up with c-diff reports. Plan: Lomotil prn for diarrhea, follow up with c-diff reports. ALT 29, AST 44, AP 185, TBili 0.5, Lip 24 . # Code: DNR/DNI - confirmed with pt. ------ Protected Section Addendum Entered By: , RN on: 20:50 ------ Pts stool guiac positive before transfer to floor. Hypertension, benign Assessment: Pt with BP 140-150. Hypertension, benign Assessment: Pt with BP 140-150. Hypertension, benign Assessment: Pt with BP 140-150. Hypertension, benign Assessment: Pt with BP 140-150. Hypertension, benign Assessment: Pt with BP 140-150. Hypertension, benign Assessment: Pt with BP 140-150. Started on IV heparin in ED. In the ED, her vital signs were T: 97.2, HR 137, BP 1148/73, RR 16, O2 98% on RA. - replete lytes - monitor uop . - replete lytes prn - monitor uop . She is s/p one treatment of folfox on . She is s/p one treatment of folfox on . She is s/p one treatment of folfox on . She is s/p one treatment of folfox on . She is s/p one treatment of folfox on . Hypertension, benign Assessment: Pt with BP 140-150. Hypertension, benign Assessment: Pt with BP 140-150. Hypertension, benign Assessment: Pt with BP 140-150. Hypertension, benign Assessment: Pt with BP 140-150. Patient is status post hysterectomy. pleuritic CP which showed right subsegmental PE. pleuritic CP which showed right subsegmental PE. pleuritic CP which showed right subsegmental PE. pleuritic CP which showed right subsegmental PE. pleuritic CP which showed right subsegmental PE. However, a note of the pancreas divisum was noted on prior study. Plan: # Pulmonary embolism: Subsegmental on CTA. - replete lytes prn - monitor uop . There is a 3.4 x 3.3 cm low attenuation (Over) 10:49 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: eval PE, acute process FINAL REPORT (Cont) mass in the left kidney consistent with a simple cyst and is unchanged in appearance compared to prior study. There has been interval resolution of pneumobilia. Action: Continues on fluids NS with 40meq Kcl at 150cc/hr Response: Pt still complains of feeling dehydrated and can take POs as tolerated. Action: Continues on fluids NS with 40meq Kcl at 150cc/hr Response: Pt still complains of feeling dehydrated and can take POs as tolerated. Action: Continues on fluids NS with 40meq Kcl at 150cc/hr Response: Pt still complains of feeling dehydrated and can take POs as tolerated. Action: Continues on fluids NS with 40meq Kcl at 150cc/hr Response: Pt still complains of feeling dehydrated and can take POs as tolerated. In ED was sent for CTA given ? In ED was sent for CTA given ? In ED was sent for CTA given ? | 23 | [
{
"category": "Nursing",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 541633,
"text": "83 y.o. woman with HTN who was recently diagnosed with metastatic colon\n CA (cecal mass, right adrenal, liver). She is s/p one treatment of\n folfox on . Referred to ED today by Oncologist secondary to black\n watery stools. Since the chemoRx she notes increasing diarrhea up to 4\n x day which is watery and black/dark green. Feeling nauseous but no\n emesis. Has had left sided 'rib' pain for several months, unchanged.\n Noticed shortness of bed getting off the toilet on the day of\n admssion. Had three stools sent by outside doctor which were guaiac\n negative x 3. Hct in ED was 36 which is above baseline. In ED was\n sent for CTA given ? pleuritic CP which showed right subsegmental PE.\n Head CT, noncontrast read as negative. Received 3L NS for dehyration,\n started on IV heparin.\n Hypertension, benign\n Assessment:\n Pt with BP 140-150. HR initially 140\ns and has come down to 80\ns after\n restarting PO Lopressor and getting fluids.\n Action:\n Continues on fluids NS with 40meq Kcl at 150cc/hr\n Response:\n Pt still complains of feeling dehydrated and can take PO\ns as\n tolerated.\n Plan:\n Follow vital signs closely. Continue to increase antihypertensives as\n ordered.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt still complains of diaphragmatic pain in abdominal area which is\n worse with deep breath. CTA has shown PE.\n Action:\n Pt remains on heparin drip at 850u/hr with stable PTT at 9AM. Goal PTT\n 60-100.\n Response:\n Stable on 850u/hr heparin. Please draw next PTT in 6hrs.\n Plan:\n Next PTT to be drawn with labs ordered for 1500.\n Electrolyte & fluid disorder, other\n Assessment:\n Due to frequent diarrhea pt has had fluid and electrolyte disturbance\n requiring K+, Magnesium and Phos repletion.\n Action:\n Lytes repleted as ordered and repeat labs ordered for 1500.\n Response:\n Will follow labs/diarrhea closely\n Plan:\n Replete electrolytes as needed. Follow pt closely. Encourage PO\ns as\n tolerated.\n Diarrhea\n Assessment:\n Pt passing liquid green stool frequently. OB-\n Action:\n Watching pt closely for further dehydration symptoms. Second specimen\n for c-diff sent today.\n Response:\n Repleting electrolytes and fluids as needed.\n Plan:\n Needs third c-diff specimen sent tomorrow. Pt ordered for immodium one\n time dose to give as soon as it is available from the pharmacy.\n Cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with newly diagnosed metastatic colon cancer and has started chemo\n prior to this PE diagnosis. Pt states the cancer has to liver and\n is inoperable. She has a poor appetite and has lost 10lb recently.\n Family is asking for her to start on an appetite stimulant.\n Action:\n Allowing pt to verbalize and have involved social service due to the\n new diagnosis. Pt is DNR/DNI after discussion with our team. Team\n writing for her to start on magace for appetite stimulant.\n Response:\n To be determined.\n Plan:\n Social service to assist with coping.\n IVF order finished and team will readdress fluids once her labs return.\n Labs sent at 1430. Please give pt anti-diarrheal when available\n from pharmacy. Pt called out to the floor and awaiting bed assignment\n on 7 .\n ------ Protected Section ------\n Pt continues to have diarrhea, green/brown liquid stools in\n small-moderate amounts. LS clear on RA sats 95-100%. No c/o SOB. C/O\n pain under rib cage. Refused medication, given heat pack with\n good relief. Given 25mg Lopressor, 325 Ferrous Sulfate and 20meq PO\n Potassium for K of 3.8. Pt continues on 850 units/hr Heparin gtt. PTT\n to be drawn at 2100 followed by pt transfer to floor. Plan to adjust\n heparin gtt on floor when PTT results obtained. Report given to 7\n at and pt to be transferred to floor after PTT drawn.\n ------ Protected Section Addendum Entered By: , RN\n on: 20:50 ------\n Pt\ns stool guiac positive before transfer to floor. Multiple episodes\n of diarrhea. Mushroom catheter placed. PTT 56 at 2050. 1100 units\n heparin bolus given x 1 and heparin gtt raised to 950units/hr. Crit\n 25.7, team aware and pt ordered to be transferred to 7 . VSS.\n ------ Protected Section Addendum Entered By: , RN\n on: 23:11 ------\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 541619,
"text": "83 y.o. woman with HTN who was recently diagnosed with metastatic colon\n CA (cecal mass, right adrenal, liver). She is s/p one treatment of\n folfox on . Referred to ED today by Oncologist secondary to black\n watery stools. Since the chemoRx she notes increasing diarrhea up to 4\n x day which is watery and black/dark green. Feeling nauseous but no\n emesis. Has had left sided 'rib' pain for several months, unchanged.\n Noticed shortness of bed getting off the toilet on the day of\n admssion. Had three stools sent by outside doctor which were guaiac\n negative x 3. Hct in ED was 36 which is above baseline. In ED was\n sent for CTA given ? pleuritic CP which showed right subsegmental PE.\n Head CT, noncontrast read as negative. Received 3L NS for dehyration,\n started on IV heparin.\n Hypertension, benign\n Assessment:\n Pt with BP 140-150. HR initially 140\ns and has come down to 80\ns after\n restarting PO Lopressor and getting fluids.\n Action:\n Continues on fluids NS 150cc/hr\n Response:\n Pt still complains of feeling dehydrated and can take PO\ns as\n tolerated. Nifedepine scheduled dose started this p.m.\n Plan:\n Follow vital signs closely\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt still complains of diaphragmatic pain in abdominal area which is\n worse with deep breath. CTA has shown PE.\n Action:\n Pt remains on heparin drip at 850u/hr with stable PTT at 9AM. Goal PTT\n 60-100. PTT repeated at 1500\n Response:\n PTT at 1500 remains within the goal, Continues on 850u/hr heparin .\n Please draw next PTT in 6hrs.\n Plan:\n Next PTT to be drawn at 2100..\n Electrolyte & fluid disorder, other\n Assessment:\n Due to frequent diarrhea pt has had fluid and electrolyte disturbance\n requiring K+, Magnesium and Phos repletion.\n Action:\n Lytes repleted as ordered , IVF NS started at 150cc/hr\n Response:\n Will follow labs/diarrhea closely\n Plan:\n Replete electrolytes as needed. Follow pt closely. Encourage PO\ns as\n tolerated.\n Diarrhea\n Assessment:\n Pt passing liquid green stool frequently. OB-\n Action:\n Watching pt closely for further dehydration symptoms. Second specimen\n for c-diff sent today. Immodium 4 mg po given at 1530 hrs.\n Response:\n Pt had 2 l episodes of diarrhea after the immodium. Team aware.\n Lomotil 2 tabs po given at 1745 as per order of team. No further\n episodes of diarrhea since then. Repleting electrolytes and fluids as\n needed.\n Plan:\n Lomotil prn for diarrhea, follow up with c-diff reports. Skin care.\n Cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with newly diagnosed metastatic colon cancer and has started chemo\n prior to this PE diagnosis. Pt states the cancer has to liver and\n is inoperable. She has a poor appetite and has lost 10lb recently.\n Family is asking for her to start on an appetite stimulant.\n Action:\n Allowing pt to verbalize and have involved social service due to the\n new diagnosis. Pt is DNR/DNI after discussion with our team. Team\n writing for her to start on magace for appetite stimulant.\n Response:\n To be determined.\n Plan:\n Social service to assist with coping.\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 541620,
"text": "83 y.o. woman with HTN who was recently diagnosed with metastatic colon\n CA (cecal mass, right adrenal, liver). She is s/p one treatment of\n folfox on . Referred to ED today by Oncologist secondary to black\n watery stools. Since the chemoRx she notes increasing diarrhea up to 4\n x day which is watery and black/dark green. Feeling nauseous but no\n emesis. Has had left sided 'rib' pain for several months, unchanged.\n Noticed shortness of bed getting off the toilet on the day of\n admssion. Had three stools sent by outside doctor which were guaiac\n negative x 3. Hct in ED was 36 which is above baseline. In ED was\n sent for CTA given ? pleuritic CP which showed right subsegmental PE.\n Head CT, noncontrast read as negative. Received 3L NS for dehyration,\n started on IV heparin.\n Hypertension, benign\n Assessment:\n Pt with BP 140-150. HR initially 140\ns and has come down to 80\ns after\n restarting PO Lopressor and getting fluids.\n Action:\n Continues on fluids NS 150cc/hr\n Response:\n Pt still complains of feeling dehydrated and can take PO\ns as\n tolerated. Nifedepine scheduled dose started this p.m.\n Plan:\n Follow vital signs closely\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt still complains of diaphragmatic pain in abdominal area which is\n worse with deep breath. CTA has shown PE.\n Action:\n Pt remains on heparin drip at 850u/hr with stable PTT at 9AM. Goal PTT\n 60-100. PTT repeated at 1500\n Response:\n PTT at 1500 remains within the goal, Continues on 850u/hr heparin .\n Please draw next PTT in 6hrs.\n Plan:\n Next PTT to be drawn at 2100..\n Electrolyte & fluid disorder, other\n Assessment:\n Due to frequent diarrhea pt has had fluid and electrolyte disturbance\n requiring K+, Magnesium and Phos repletion.\n Action:\n Lytes repleted as ordered , IVF NS started at 150cc/hr\n Response:\n Will follow labs/diarrhea closely\n Plan:\n Replete electrolytes as needed. Follow pt closely. Encourage PO\ns as\n tolerated.\n Diarrhea\n Assessment:\n Pt passing liquid green stool frequently. OB-\n Action:\n Watching pt closely for further dehydration symptoms. Second specimen\n for c-diff sent today. Immodium 4 mg po given at 1530 hrs.\n Response:\n Pt had 2 l episodes of diarrhea after the immodium. Team aware.\n Lomotil 2 tabs po given at 1745 as per order of team. No further\n episodes of diarrhea since then. Repleting electrolytes and fluids as\n needed.\n Plan:\n Lomotil prn for diarrhea, follow up with c-diff reports. Skin care.\n Cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with newly diagnosed metastatic colon cancer and has started chemo\n prior to this PE diagnosis. Pt states the cancer has to liver and\n is inoperable. She has a poor appetite and has lost 10lb recently.\n Family is asking for her to start on an appetite stimulant.\n Action:\n Allowing pt to verbalize and have involved social service due to the\n new diagnosis. Pt is DNR/DNI after discussion with our team. Team\n writing for her to start on magace for appetite stimulant.\n Response:\n To be determined.\n Plan:\n Social service to assist with coping.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 61 Inch\n Admission weight:\n 61.1 kg\n Daily weight:\n Allergies/Reactions:\n Codeine\n Lightheadedness\n Sulfa (Sulfonamides)\n Unknown;\n Aspirin\n upset stomach;\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: Newly dx CA colon via virtual colonoscopy. Started\n Chemo last monday. Now CT w/spots on liver and kidneys.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:153\n D:60\n Temperature:\n 97.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 99 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 2,841 mL\n 24h total out:\n 956 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:21 PM\n Potassium:\n 3.8 mEq/L\n 02:21 PM\n Chloride:\n 112 mEq/L\n 02:21 PM\n CO2:\n 19 mEq/L\n 02:21 PM\n BUN:\n 12 mg/dL\n 02:21 PM\n Creatinine:\n 0.5 mg/dL\n 02:21 PM\n Glucose:\n 127 mg/dL\n 02:21 PM\n Hematocrit:\n 27.5 %\n 02:21 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4 icu\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 541621,
"text": "83 y.o. woman with HTN who was recently diagnosed with metastatic colon\n CA (cecal mass, right adrenal, liver). She is s/p one treatment of\n folfox on . Referred to ED today by Oncologist secondary to black\n watery stools. Since the chemoRx she notes increasing diarrhea up to 4\n x day which is watery and black/dark green. Feeling nauseous but no\n emesis. Has had left sided 'rib' pain for several months, unchanged.\n Noticed shortness of bed getting off the toilet on the day of\n admssion. Had three stools sent by outside doctor which were guaiac\n negative x 3. Hct in ED was 36 which is above baseline. In ED was\n sent for CTA given ? pleuritic CP which showed right subsegmental PE.\n Head CT, noncontrast read as negative. Received 3L NS for dehyration,\n started on IV heparin.\n Hypertension, benign\n Assessment:\n Pt with BP 140-150. HR initially 140\ns and has come down to 80\ns after\n restarting PO Lopressor and getting fluids.\n Action:\n Continues on fluids NS 150cc/hr\n Response:\n Pt still complains of feeling dehydrated and can take PO\ns as\n tolerated. Nifedepine scheduled dose started this p.m.\n Plan:\n Follow vital signs closely\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt still complains of diaphragmatic pain in abdominal area which is\n worse with deep breath. CTA has shown PE.\n Action:\n Pt remains on heparin drip at 850u/hr with stable PTT at 9AM. Goal PTT\n 60-100. PTT repeated at 1500\n Response:\n PTT at 1500 remains within the goal, Continues on 850u/hr heparin .\n Please draw next PTT in 6hrs.\n Plan:\n Next PTT to be drawn at 2100..\n Electrolyte & fluid disorder, other\n Assessment:\n Due to frequent diarrhea pt has had fluid and electrolyte disturbance\n requiring K+, Magnesium and Phos repletion.\n Action:\n Lytes repleted as ordered , IVF NS started at 150cc/hr\n Response:\n Will follow labs/diarrhea closely\n Plan:\n Replete electrolytes as needed. Follow pt closely. Encourage PO\ns as\n tolerated.\n Diarrhea\n Assessment:\n Pt passing liquid green stool frequently. OB-\n Action:\n Watching pt closely for further dehydration symptoms. Second specimen\n for c-diff sent today. Immodium 4 mg po given at 1530 hrs.\n Response:\n Pt had 2 l episodes of diarrhea after the immodium. Team aware.\n Lomotil 2 tabs po given at 1745 as per order of team. No further\n episodes of diarrhea since then. Repleting electrolytes and fluids as\n needed.\n Plan:\n Lomotil prn for diarrhea, follow up with c-diff reports. Skin care.\n Cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with newly diagnosed metastatic colon cancer and has started chemo\n prior to this PE diagnosis. Pt states the cancer has to liver and\n is inoperable. She has a poor appetite and has lost 10lb recently.\n Family is asking for her to start on an appetite stimulant.\n Action:\n Allowing pt to verbalize and have involved social service due to the\n new diagnosis. Pt is DNR/DNI after discussion with our team. Team\n writing for her to start on magace for appetite stimulant.\n Response:\n To be determined.\n Plan:\n Social service to assist with coping.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 61 Inch\n Admission weight:\n 61.1 kg\n Daily weight:\n Allergies/Reactions:\n Codeine\n Lightheadedness\n Sulfa (Sulfonamides)\n Unknown;\n Aspirin\n upset stomach;\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: Newly dx CA colon via virtual colonoscopy. Started\n Chemo last monday. Now CT w/spots on liver and kidneys.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:153\n D:60\n Temperature:\n 97.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 99 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 2,841 mL\n 24h total out:\n 956 mL\n Access: Portacath in L subclavian and 2 18 gauge PIV\ns one on each arm\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:21 PM\n Potassium:\n 3.8 mEq/L\n 02:21 PM\n Chloride:\n 112 mEq/L\n 02:21 PM\n CO2:\n 19 mEq/L\n 02:21 PM\n BUN:\n 12 mg/dL\n 02:21 PM\n Creatinine:\n 0.5 mg/dL\n 02:21 PM\n Glucose:\n 127 mg/dL\n 02:21 PM\n Hematocrit:\n 27.5 %\n 02:21 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4 icu\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 541629,
"text": "83 y.o. woman with HTN who was recently diagnosed with metastatic colon\n CA (cecal mass, right adrenal, liver). She is s/p one treatment of\n folfox on . Referred to ED today by Oncologist secondary to black\n watery stools. Since the chemoRx she notes increasing diarrhea up to 4\n x day which is watery and black/dark green. Feeling nauseous but no\n emesis. Has had left sided 'rib' pain for several months, unchanged.\n Noticed shortness of bed getting off the toilet on the day of\n admssion. Had three stools sent by outside doctor which were guaiac\n negative x 3. Hct in ED was 36 which is above baseline. In ED was\n sent for CTA given ? pleuritic CP which showed right subsegmental PE.\n Head CT, noncontrast read as negative. Received 3L NS for dehyration,\n started on IV heparin.\n Hypertension, benign\n Assessment:\n Pt with BP 140-150. HR initially 140\ns and has come down to 80\ns after\n restarting PO Lopressor and getting fluids.\n Action:\n Continues on fluids NS with 40meq Kcl at 150cc/hr\n Response:\n Pt still complains of feeling dehydrated and can take PO\ns as\n tolerated.\n Plan:\n Follow vital signs closely. Continue to increase antihypertensives as\n ordered.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt still complains of diaphragmatic pain in abdominal area which is\n worse with deep breath. CTA has shown PE.\n Action:\n Pt remains on heparin drip at 850u/hr with stable PTT at 9AM. Goal PTT\n 60-100.\n Response:\n Stable on 850u/hr heparin. Please draw next PTT in 6hrs.\n Plan:\n Next PTT to be drawn with labs ordered for 1500.\n Electrolyte & fluid disorder, other\n Assessment:\n Due to frequent diarrhea pt has had fluid and electrolyte disturbance\n requiring K+, Magnesium and Phos repletion.\n Action:\n Lytes repleted as ordered and repeat labs ordered for 1500.\n Response:\n Will follow labs/diarrhea closely\n Plan:\n Replete electrolytes as needed. Follow pt closely. Encourage PO\ns as\n tolerated.\n Diarrhea\n Assessment:\n Pt passing liquid green stool frequently. OB-\n Action:\n Watching pt closely for further dehydration symptoms. Second specimen\n for c-diff sent today.\n Response:\n Repleting electrolytes and fluids as needed.\n Plan:\n Needs third c-diff specimen sent tomorrow. Pt ordered for immodium one\n time dose to give as soon as it is available from the pharmacy.\n Cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with newly diagnosed metastatic colon cancer and has started chemo\n prior to this PE diagnosis. Pt states the cancer has to liver and\n is inoperable. She has a poor appetite and has lost 10lb recently.\n Family is asking for her to start on an appetite stimulant.\n Action:\n Allowing pt to verbalize and have involved social service due to the\n new diagnosis. Pt is DNR/DNI after discussion with our team. Team\n writing for her to start on magace for appetite stimulant.\n Response:\n To be determined.\n Plan:\n Social service to assist with coping.\n IVF order finished and team will readdress fluids once her labs return.\n Labs sent at 1430. Please give pt anti-diarrheal when available\n from pharmacy. Pt called out to the floor and awaiting bed assignment\n on 7 .\n ------ Protected Section ------\n Pt continues to have diarrhea, green/brown liquid stools in\n small-moderate amounts. LS clear on RA sats 95-100%. No c/o SOB. C/O\n pain under rib cage. Refused medication, given heat pack with\n good relief. Given 25mg Lopressor, 325 Ferrous Sulfate and 20meq PO\n Potassium for K of 3.8. Pt continues on 850 units/hr Heparin gtt. PTT\n to be drawn at 2100 followed by pt transfer to floor. Plan to adjust\n heparin gtt on floor when PTT results obtained. Report given to 7\n at and pt to be transferred to floor after PTT drawn.\n ------ Protected Section Addendum Entered By: , RN\n on: 20:50 ------\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 541630,
"text": "83 y.o. woman with HTN who was recently diagnosed with metastatic colon\n CA (cecal mass, right adrenal, liver). She is s/p one treatment of\n folfox on . Referred to ED today by Oncologist secondary to black\n watery stools. Since the chemoRx she notes increasing diarrhea up to 4\n x day which is watery and black/dark green. Feeling nauseous but no\n emesis. Has had left sided 'rib' pain for several months, unchanged.\n Noticed shortness of bed getting off the toilet on the day of\n admssion. Had three stools sent by outside doctor which were guaiac\n negative x 3. Hct in ED was 36 which is above baseline. In ED was\n sent for CTA given ? pleuritic CP which showed right subsegmental PE.\n Head CT, noncontrast read as negative. Received 3L NS for dehyration,\n started on IV heparin.\n Hypertension, benign\n Assessment:\n Pt with BP 140-150. HR initially 140\ns and has come down to 80\ns after\n restarting PO Lopressor and getting fluids.\n Action:\n Continues on fluids NS 150cc/hr\n Response:\n Pt still complains of feeling dehydrated and can take PO\ns as\n tolerated. Nifedepine scheduled dose started this p.m.\n Plan:\n Follow vital signs closely\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt still complains of diaphragmatic pain in abdominal area which is\n worse with deep breath. CTA has shown PE.\n Action:\n Pt remains on heparin drip at 850u/hr with stable PTT at 9AM. Goal PTT\n 60-100. PTT repeated at 1500\n Response:\n PTT at 1500 remains within the goal, Continues on 850u/hr heparin .\n Please draw next PTT in 6hrs.\n Plan:\n Next PTT to be drawn at 2100..\n Electrolyte & fluid disorder, other\n Assessment:\n Due to frequent diarrhea pt has had fluid and electrolyte disturbance\n requiring K+, Magnesium and Phos repletion.\n Action:\n Lytes repleted as ordered , IVF NS started at 150cc/hr\n Response:\n Will follow labs/diarrhea closely\n Plan:\n Replete electrolytes as needed. Follow pt closely. Encourage PO\ns as\n tolerated.\n Diarrhea\n Assessment:\n Pt passing liquid green stool frequently. OB-\n Action:\n Watching pt closely for further dehydration symptoms. Second specimen\n for c-diff sent today. Immodium 4 mg po given at 1530 hrs.\n Response:\n Pt had 2 l episodes of diarrhea after the immodium. Team aware.\n Lomotil 2 tabs po given at 1745 as per order of team. No further\n episodes of diarrhea since then. Repleting electrolytes and fluids as\n needed.\n Plan:\n Lomotil prn for diarrhea, follow up with c-diff reports. Skin care.\n Cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with newly diagnosed metastatic colon cancer and has started chemo\n prior to this PE diagnosis. Pt states the cancer has to liver and\n is inoperable. She has a poor appetite and has lost 10lb recently.\n Family is asking for her to start on an appetite stimulant.\n Action:\n Allowing pt to verbalize and have involved social service due to the\n new diagnosis. Pt is DNR/DNI after discussion with our team. Team\n writing for her to start on magace for appetite stimulant.\n Response:\n To be determined.\n Plan:\n Social service to assist with coping.\n Pt continues to have diarrhea, green/brown liquid stools in\n small-moderate amounts. LS clear on RA sats 95-100%. No c/o SOB. C/O\n pain under rib cage. Refused medication, given heat pack with\n good relief. Given 25mg Lopressor, 325 Ferrous Sulfate and 20meq PO\n Potassium for K of 3.8. Pt continues on 850 units/hr Heparin gtt. PTT\n to be drawn at 2100 followed by pt transfer to floor. Plan to adjust\n heparin gtt on floor when PTT results obtained. Report given to 7\n at and pt to be transferred to floor after PTT drawn.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PULMONARY EMBOLIS\n Code status:\n Full code\n Height:\n 61 Inch\n Admission weight:\n 61.1 kg\n Daily weight:\n Allergies/Reactions:\n Codeine\n Lightheadedness\n Sulfa (Sulfonamides)\n Unknown;\n Aspirin\n upset stomach;\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: Newly dx CA colon via virtual colonoscopy. Started\n Chemo last monday. Now CT w/spots on liver and kidneys.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:153\n D:60\n Temperature:\n 97.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 99 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 2,841 mL\n 24h total out:\n 956 mL\n Access: Portacath in L subclavian and 2 18 gauge PIV\ns one on each arm\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:21 PM\n Potassium:\n 3.8 mEq/L\n 02:21 PM\n Chloride:\n 112 mEq/L\n 02:21 PM\n CO2:\n 19 mEq/L\n 02:21 PM\n BUN:\n 12 mg/dL\n 02:21 PM\n Creatinine:\n 0.5 mg/dL\n 02:21 PM\n Glucose:\n 127 mg/dL\n 02:21 PM\n Hematocrit:\n 27.5 %\n 02:21 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4 icu\n Transferred to: 7 \n Date & time of Transfer: 2100 \n"
},
{
"category": "Physician ",
"chartdate": "2153-11-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 541513,
"text": "Chief Complaint: Black watery stools\n Reason for ICU admission: Pulmonary embolism\n HPI:\n Mrs. is an 83 yo woman with HTN and recent diagnosis of\n metastatic colon cancer, s/p C1D1 FOLFOX who was referred to the\n ED today because of loose black stools. Since starting chemotherapy,\n she reports having diarrhea approx 4-5x daily, +nausea and anorexia,\n with poor po intake. Denies diarrhea prior to starting chemotherapy.\n She reports LUQ abdominal pain that radiates to the right, though\n points to L ribcage area, which she has had for > 1 month. Denies\n vomiting. She denies any acute onset of respiratory sx but states that\n she notices some SOB when getting off the toilet, but otherwise denies\n dyspnea on exertion, cough, or pleuritic chest pain. Of note, she has\n continued her bowel regimen and iron supplements.\n .\n In the ED, her vital signs were T: 97.2, HR 137, BP 1148/73, RR 16, O2\n 98% on RA. She was found to have greenish stool that was guiac negative\n in the ED. Also had 3 stool cards recently done at her PCP's office\n that were guiac negative. HCT was 36 (above baseline). Given the\n complaint of pleuritic chest pain and SOB, CXR was done and\n unremarkable, and subsequent CTA showed a R superior subsegmental PE.\n She was felt to be dehydrated with initial HR sinus rhythm in the 140s,\n and received IVFs, potassium repletion with improvement in rate to low\n 100s. She received levo/flagyl for diarrhea. CT Head was performed\n prior to starting a heparin drip and showed no obvious brain mets.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Codeine\n Lightheadedness\n Sulfa (Sulfonamides)\n Unknown;\n Aspirin\n upset stomach;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:15 PM\n Other medications:\n Home medications:\n ATENOLOL 25mg po daily\n NIFEDIPINE SR 30mg po daily\n OMEPRAZOLE 20mg po daily\n OXYCODONE - 5 mg Tablet 1-2 tabs q4hr prn\n PROCHLORPERAZINE 10 mg Tablet q6hr prn\n SIMVASTATIN 40mg po qhs\n ACETAMINOPHEN 1gm q6hr prn\n DOCUSATE SODIUM 100mg po bid\n FERROUS SULFATE - 325 mg po daily\n MULTIVITAMIN daily\n PYRIDOXINE 100 mg po daily\n SENNA 8.6 mg po daily\n Past medical history:\n Family history:\n Social History:\n ONC history:\n - Colon cancer: diagnosed with metastatic colon cancer during\n work-up for chronic left-sided abdominal pain and weight loss of 10lbs\n /3 months. CT showed numerous hypo-enhancing hepatic masses and a right\n adrenal mass as well as a cecal soft tissue mass. Liver biopsy on\n was consistent with colon cancer and CEA = 8331.\n Unable to complete colonoscopy b/c of fixed sigmoid\n loops of bowel. CT colonoscopy showed known ileocecal valve mass.\n - Received one dose of chemotherapy :\n Oxaliplatin 85 mg/m2 D1,D15\n Leucovorin Calcium 400 mg/m2 IV D1,D15\n Fluorouracil 400 mg/m2 IV D1,D15\n Fluorouracil 2400 mg/m2 IV D1,D15.\n .\n Past Medical History:\n 1. Hypercholesterolemia.\n 2. Hypertension.\n 3. History of hysterectomy.\n 4. History of cholecystectomy.\n 5. Arthritis.\n 6. Basal cell cancer, removed.\n 7. GERD.\n Her mother died of diabetes. Her father died at 74 of old age. She\n had a brother who died at 42 of heart disease and a sister died of\n diabetes.\n Occupation: homemaker\n Drugs: none\n Tobacco: past\n Alcohol: none\n Other: She lives with her husband. In addition, she has two sons and a\n daughter who all live in the area. She was a housewife in the past.\n She has six grandchildren. She smoked three packs per day for the age\n of 21 to age of 48. She does not drink alcohol.\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, Weight loss\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Chest pain, Tachycardia\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: Abdominal pain, Nausea, No(t) Emesis, Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Pain: Moderate\n Pain location: L side/abdomen\n Flowsheet Data as of 08:16 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 114 (114 - 135) bpm\n BP: 152/50(75) {146/38(66) - 182/56(86)} mmHg\n RR: 23 (19 - 24) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 61 Inch\n Total In:\n 982 mL\n PO:\n 100 mL\n TF:\n IVF:\n 882 mL\n Blood products:\n Total out:\n 0 mL\n 630 mL\n Urine:\n 330 mL\n NG:\n 100 mL\n Stool:\n 200 mL\n Drains:\n Balance:\n 0 mL\n 352 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n Physical Examination\n General Appearance: Well nourished, Anxious\n Eyes / Conjunctiva: No(t) PERRL, surgical pupils, EOMI\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic), 2/6 SEM > LUBS\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : , No(t)\n Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender:\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 311 K/uL\n 9.2 g/dL\n 0.7\n 17\n 17\n 93\n 2.9\n 133\n 29.2 %\n 4.4 K/uL\n [image002.jpg]\n \n 2:33 A10/29/ 07:24 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 4.4\n Hct\n 29.2\n Plt\n 311\n Other labs: Lactic Acid:1.6 mmol/L\n Fluid analysis / Other labs: Ca+ 9.4, Mg 1.5, P 3.7\n .\n Lactate 2.9\n .\n ALT 29, AST 44, AP 185, TBili 0.5, Lip 24\n .\n WBC 5.8 (N 65%, Band 5, L 15, M 12), HCT 36.4, Plt 435\n .\n CK 52, Trop-T < 0.01\n PT 13.8, INR 1.2\n .\n U/A: clear\n Imaging: CXR: There is a left-sided central line with the tip at the\n cavoatrial junction. There is stable appearance to the bibasal\n atelectasis as well as elevation of the right hemidiaphragm. There is\n no focal pulmonary consolidation. Cardiomediastinal silhouette appears\n unremarkable. Incidentally noted are clips in the right upper abdomen\n likely representing cholecystectomy clips.\n .\n CT Chest/Abd/Pelvis with contrast:\n 1. Thrombus in the right subsegmental branch of the superior branch of\n the right pulmonary artery. No other areas of pulmonary emboli noted.\n 2. Multiple hepatic metastases, unchanged from prior examination.\n 3. Bilateral renal cystic structures are unchanged.\n 4. Metastatic collision tumor adjacent to the right adrenal gland,\n unchanged.\n 5. Sigmoid diverticulosis without diverticulitis. Mucosal thickening in\n the cecum adjacent to the ileocecal valve consistent with patient's\n known diagnosis of colonic mass.\n .\n CT Head:\n There is generalized cerebral atrophy with mild periventricular\n ischemic change. There is no mass effect, edema or midline shift. The\n midline structures are central. There is no intracranial hemorrhage.\n There is no skull fracture. The visualized paranasal sinuses are clear.\n CONCLUSION: Generalized atrophy with no evidence of mass effect or\n midline shift. Please note MRI is more sensitive for assessment of\n subtle early metastases.\n ECG: Sinus rhythm at 118 bpm, nl axis, nl PR, QRS, and QT intervals,\n poor R-wave progress, no ST segment abnormalities, non-specific T-wave\n changes from baseline.\n Assessment and Plan\n Assesment: This is an 83 yo F with recent dx of metastatic colon cancer\n s/p C1D1 FOLFOX chemotherapy who presents with diarrhea, SOB,\n sinus tachycardia and found to have R superior segmental PE with now\n evidence of GI bleed.\n .\n Plan:\n # Pulmonary embolism: Subsegmental on CTA. Pt denies h/o DVT or\n clotting hx, likely hypercoag. state secondary to malignancy. No\n evidence of R heart strain on EKG. Sinus tach may be related to PE or\n dehydration. Unclear from hx if this was an acute event or incidental\n finding on presentation. No new O2 requirement.\n - Heparin gtt, will discuss transition to Lovenox or Coumadin w/ onc\n team\n - Monitor on telemetry\n .\n # Dehydration: Pt with diarrhea and poor po intake for several days.\n Sinus tachycardia and borderline low uop. Potassium and mag low.\n - Cont. IVF hydration, add KCl.\n - replete lytes\n - monitor uop\n .\n # Diarrhea: Nonbloody, guiac negative. HCT stable. Most likely trigger\n is chemotherapy with FOLFOX. No fevers. No recent abx. Need to r/o\n infectious etiology. Lactate elevated.\n - stool cx, C.dif\n - IVFs\n - blood cultures\n - replete lytes\n - hold bowel regimen\n .\n # Colon cancer: Metastatic to liver, adrenal. Defer treatment to\n primary oncology team. Likely no chemotherapy while in the hospital.\n .\n # Hypertension: SBP 140s-160s, will add metoprolol (on atenolol at\n home), restart nifedipine if needed.\n .\n # GERD: cont. home PPI\n .\n # FEN: IVFs, regular diet, replete lytes\n .\n # Access: POC, PIV\n .\n # PPx: heparin drip, pneumoboots, PPI (GERD), hold bowel regimen\n .\n # Code: DNR/DNI - confirmed with pt. ICU consent signed\n .\n # Dispo: ICU care\n .\n # Comm: husband - \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:44 PM\n Indwelling Port (PortaCath) - 04:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 541508,
"text": "83 y.o. woman with HTN who was recently diagnosed with metastatic colon\n CA (cecal mass, right adrenal, liver). She is s/p one treatment of\n folfox on . Referred to ED today by Oncologist secondary to black\n watery stools. Since the chemoRx she notes increasing diarrhea up to 4\n x day which is watery and black/dark green. Feeling nauseous but no\n emesis. Has had left sided 'rib' pain for several months, unchanged.\n Noticed shortness of bed getting off the toilet on the day of\n admssion. Had three stools sent by outside doctor which were guaiac\n negative x 3. Hct in ED was 36 which is above baseline. In ED was\n sent for CTA given ? pleuritic CP which showed right subsegmental PE.\n Head CT, noncontrast read as negative. Received 3L NS for dehyration,\n started on IV heparin.\n Pulmonary Embolism (PE), Acute\n Assessment:\n subsegmental PE\n Action:\n Heparin gtt at 1000 Units/hr\n Response:\n TBD\n Plan:\n Check coags at 1900. Develop plan w/Onc Med regarding lovenox or\n warfarin tx at time of discharge.\n Electrolyte & fluid disorder, dehydration fluid loss\n Assessment:\n 3 days of diarrhea, poor po intake, tachycardic, K and Mag low. Liq\n stool and emesis at 1700\n Action:\n Mag repleted, KCL 40 MEQ in one liter x\ns 1. Stool spec sent to lab.\n Response:\n Remains tachycardic. TBD\n Plan:\n 1900 labs\n"
},
{
"category": "Physician ",
"chartdate": "2153-11-21 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 541495,
"text": "Chief Complaint: black stools\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 83 y.o. woman with HTN who was recently diagnosed with metastatic colon\n CA (cecal mass, right adrenal, liver). She is s/p one treatment of\n folfox on . Referred to ED today by Oncologist secondary to black\n watery stools. Since the chemoRx she notes increasing diarrhea up to 4\n x day which is watery and black/dark green. Feeling nauseous but no\n emesis. Has had left sided 'rib' pain for several months, unchanged.\n Noticed shortness of bed getting off the toilet on the day of\n admssion. Denies chest pain, cough, hemoptysis. Had three stools sent\n by outside doctor which were guaiac negative x 3. Hct in ED was 36\n which is above baseline. In ED was sent for CTA given ? pleuritic CP\n which showed right subsegmental PE. Head CT, noncontrast read as\n negative. Received 3L NS for dehyration, started on IV heparin. Notes\n 20 lb weight loss.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Codeine\n Lightheadedness\n Sulfa (Sulfonamides)\n Unknown;\n Aspirin\n upset stomach;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Other ICU medications:\n Other medications:\n Fe supplements\n atenolol\n nifedipine\n omeprazole\n oxycodone\n compazine\n zocor\n tylenol\n colace\n senna\n MVI\n Past medical history:\n Family history:\n Social History:\n Metastatic colon CA \n HTN\n Hypercholesterolemia\n Hysterectomy\n CCY\n Arthritis\n Basal cell carcinoma\n DM in mother and sister\n CAD, brother died at age 42\n Occupation: Homemaker\n Drugs: None\n Tobacco: 3 ppd x 20 yrs; quit at age 48\n Alcohol: None\n Other: Livess with husband\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: Tachycardia\n Gastrointestinal: Nausea\n Genitourinary: Foley\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 05:42 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 114 (114 - 115) bpm\n BP: 153/38(66) {146/38(66) - 153/54(76)} mmHg\n RR: 22 (19 - 22) insp/min\n SpO2: 100%\n Height: 61 Inch\n Total In:\n 185 mL\n PO:\n TF:\n IVF:\n 185 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -15 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 435\n 36.4\n 203\n 0.7\n 17\n 22\n 93\n 2.9\n 133\n 5.8\n [image002.jpg]\n Other labs: PT / PTT / INR://1.8, CK / CKMB / Troponin-T:52//<0.01, ALT\n / AST:29/44, Alk Phos / T Bili:185/0.5, Amylase / Lipase:/24,\n Differential-Neuts:65, Band:5, Lymph:15, Mono:12, Lactic Acid:2.9,\n Ca++:9.4, Mg++:1.5, PO4:3.7\n Imaging: CT torso: multiple hepatic metastases unchanged from prior;\n right adrenal mass unchanged; colonic mass unchanged\n CXR: No inflitrates or effusions. Elevated right hemidiaphragm.\n Assessment and Plan\n 1. Metastatic colon CA s/p chemoRx . Head CT today shows no\n masses prior to starting heparin. Will guaic stools (negative as\n outpatient recently).\n 2. Pulmonary embolism: Unclear if this is acute or subactue, pain is on\n the left. At higher risk given underlying malignancy. Started on IV\n heparin in ED. Known colon mass. At risk for bleeding on\n anticoagulation. Will follow serial Hcts as well as coags to avoid\n over anticoagulating her.\n 3. Watery, black stools: Guaiac negative. Unclear if this is related to\n known cecal tumor, related to recent chemoRX or infectious. Send\n stools for O + P, cultures. IVFs. Stop antibiotics and await culture\n results.\n 4. Mild dehydration: Likely related to losses with diarrhrea and poor\n po intake. IVFs.\n 5. Hypokalemia: Secondary to GI losses. Mg low as well. Will replete\n K and Mg. Repeat electrolytes thsi pm.\n 6. Hypertension: Will give lopressor, with tachycardia may have beta\n blocker withdrawal.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 18 Gauge - 03:44 PM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 55 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 541546,
"text": "83 y.o. woman with HTN who was recently diagnosed with metastatic colon\n CA (cecal mass, right adrenal, liver). She is s/p one treatment of\n folfox on . Referred to ED today by Oncologist secondary to black\n watery stools. Since the chemoRx she notes increasing diarrhea up to 4\n x day which is watery and black/dark green. Feeling nauseous but no\n emesis. Has had left sided 'rib' pain for several months, unchanged.\n Noticed shortness of bed getting off the toilet on the day of\n admssion. Had three stools sent by outside doctor which were guaiac\n negative x 3. Hct in ED was 36 which is above baseline. In ED was\n sent for CTA given ? pleuritic CP which showed right subsegmental PE.\n Head CT, noncontrast read as negative. Received 3L NS for dehyration,\n started on IV heparin.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt ruled in for subsegmental PE. Experiences pain under left\n rib.\n Action:\n PTT checked at 0300 = 44.6, Heparin gtt currently at 850 units/hr.\n Given 5mg Oxycodone PO and 2mg Morphine IV for pain.\n Response:\n Pain relieved with Morphine.\n Plan:\n Recheck PTT at 0900. Monitor for pain.\n Electrolyte & fluid disorder, other\n Assessment:\n K+ 3.0 at , mag 2.7 and phos 2.2\n Action:\n pt given 1000ml NS with 40 meq KCL x 2 and 30mmol Kphos.\n Response:\n AM labs K+ 3.7, Mag 1.9, pt continues to have diarrhea guiac negative.\n Plan:\n Continue to monitor electrolytes and treat as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 541549,
"text": "Chief Complaint: Diarrhea\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 04:00 PM\n EKG - At 06:00 PM\n Pt continued to get IVF with aggressive repletion of lytes o/n\n History obtained from Patient\n Allergies:\n History obtained from PatientCodeine\n Lightheadedness\n Sulfa (Sulfonamides)\n Unknown;\n Aspirin\n upset stomach;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:15 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n Diarrhea\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Delirious\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 107 (103 - 135) bpm\n BP: 138/74(89) {138/38(66) - 182/74(91)} mmHg\n RR: 18 (17 - 24) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 61 Inch\n Total In:\n 1,834 mL\n 867 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,734 mL\n 867 mL\n Blood products:\n Total out:\n 721 mL\n 206 mL\n Urine:\n 421 mL\n 206 mL\n NG:\n 100 mL\n Stool:\n 200 mL\n Drains:\n Balance:\n 1,113 mL\n 661 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///17/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub, (Murmur: No(t)\n Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Wheezes : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 286 K/uL\n 8.8 g/dL\n 144 mg/dL\n 0.4 mg/dL\n 17 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 111 mEq/L\n 139 mEq/L\n 27.4 %\n 4.6 K/uL\n [image002.jpg]\n 07:24 PM\n 05:07 AM\n WBC\n 4.4\n 4.6\n Hct\n 29.2\n 27.4\n Plt\n 311\n 286\n Cr\n 0.5\n 0.4\n Glucose\n 156\n 144\n Other labs: PT / PTT / INR:16.9/64.1/1.5, Lactic Acid:1.6 mmol/L,\n Ca++:7.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n CANCER (MALIGNANT NEOPLASM), COLORECTAL (COLON CANCER)\n DIARRHEA\n HYPERTENSION, BENIGN\n GASTROESOPHAGEAL REFLUX DISEASE (GERD)\n ELECTROLYTE & FLUID DISORDER, OTHER\n dehydration\n PULMONARY EMBOLISM (PE), ACUTE\n Assesment: This is an 83 yo F with recent dx of metastatic colon cancer\n s/p C1D1 FOLFOX chemotherapy who presents with diarrhea, SOB,\n sinus tachycardia and found to have R superior segmental PE with now\n evidence of GI bleed.\n .\n Plan:\n # Pulmonary embolism: Subsegmental on CTA. Pt denies h/o DVT or\n clotting hx, likely hypercoag. state secondary to malignancy. No\n evidence of R heart strain on EKG. Sinus tach may be related to PE or\n dehydration. Unclear from hx if this was an acute event or incidental\n finding on presentation. No new O2 requirement.\n - Heparin gtt for now will discuss transition to Lovenox or Coumadin w/\n onc team\n - Monitor on telemetry\n .\n # Dehydration: Pt with diarrhea and poor po intake for several days.\n Sinus tachycardia and borderline low uop. Potassium and mag low.\n - Cont. IVF hydration- 3L given so far, add KCl.\n - replete lytes prn\n - monitor uop\n .\n # Diarrhea: Nonbloody, guaiac negative. HCT stable. Most likely trigger\n is chemotherapy with FOLFOX. No fevers. No recent abx. Need to r/o\n infectious etiology. Lactate elevated.\n - stool cx, C.dif pending\n - IVFs\n - blood cultures pending\n - replete lytes prn\n - hold bowel regimen\n .\n # Colon cancer: Metastatic to liver, adrenal. Defer treatment to\n primary oncology team. Likely no chemotherapy while in the hospital.\n .\n # Hypertension: SBP 140s-160s, will add metoprolol (on atenolol at\n home), restart nifedipine if needed.\n .\n # GERD: cont. home PPI\n # FEN: IVFs, regular diet as tolerated, replete lytes\n # Access: POC, PIV\n # PPx: heparin drip, pneumoboots, PPI (GERD), hold bowel regimen\n # Code: DNR/DNI - confirmed with pt. ICU consent signed\n # Dispo: ICU care\n # Comm: husband - \n ICU Care\n Nutrition: regular diet as tolerated\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 03:44 PM\n Indwelling Port (PortaCath) - 04:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 541567,
"text": "Chief Complaint: pulmonary embolism\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 04:00 PM\n EKG - At 06:00 PM\n Continued tachycardic\n Hypertensive\n Fluid balance positive 1 L\n SaO2 on room air > 93%\n Poor appetite\n History obtained from Patient\n Allergies:\n Codeine\n Lightheadedness\n Sulfa (Sulfonamides)\n Unknown;\n Aspirin\n upset stomach;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 850 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:15 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth, Hard of hearing\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.5\n HR: 98 (97 - 135) bpm\n BP: 158/56(76) {138/38(66) - 182/74(91)} mmHg\n RR: 23 (17 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 61 Inch\n Total In:\n 1,834 mL\n 1,437 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,734 mL\n 1,437 mL\n Blood products:\n Total out:\n 721 mL\n 436 mL\n Urine:\n 421 mL\n 286 mL\n NG:\n 100 mL\n Stool:\n 200 mL\n 150 mL\n Drains:\n Balance:\n 1,113 mL\n 1,001 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///17/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases, clear partially with deep breathing)\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): fullly oriented, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.8 g/dL\n 286 K/uL\n 144 mg/dL\n 0.4 mg/dL\n 17 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 111 mEq/L\n 139 mEq/L\n 27.4 %\n 4.6 K/uL\n [image002.jpg]\n 07:24 PM\n 05:07 AM\n WBC\n 4.4\n 4.6\n Hct\n 29.2\n 27.4\n Plt\n 311\n 286\n Cr\n 0.5\n 0.4\n Glucose\n 156\n 144\n Other labs: PT / PTT / INR:16.9/64.1/1.5, Lactic Acid:1.6 mmol/L,\n Ca++:7.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL\n Microbiology: C. diff negative x 1\n Assessment and Plan\n CANCER (MALIGNANT NEOPLASM), COLORECTAL (COLON CANCER): Oncology\n following.\n PULMONARY EMBOLISM (PE), ACUTE: Denies shortness of breath,\n pleuritic chest pain. No cough/hemoptysis. Therapeutic on IV\n heparin.\n DIARRHEA: First C. Diff negative. Sent repeat today.\n HYPERTENSION, BENIGN: Restart atenolol.\n ELECTROLYTE & FLUID DISORDER, OTHER\n Dehydration in setting of poor po intake and diarrhea. Clinically\n still mildly dehydrated.\n Will encourage po intake, continue IVF for another liter.\n POOR APPETITE: Start megace\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:44 PM\n Indwelling Port (PortaCath) - 04:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 541569,
"text": "Chief Complaint: Diarrhea\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 04:00 PM\n EKG - At 06:00 PM\n Pt continued to get IVF with aggressive repletion of lytes o/n\n History obtained from Patient\n Allergies:\n History obtained from PatientCodeine\n Lightheadedness\n Sulfa (Sulfonamides)\n Unknown;\n Aspirin\n upset stomach;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Morphine Sulfate - 07:15 PM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n Diarrhea\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, No(t) Delirious\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 107 (103 - 135) bpm\n BP: 138/74(89) {138/38(66) - 182/74(91)} mmHg\n RR: 18 (17 - 24) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 61 Inch\n Total In:\n 1,834 mL\n 867 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,734 mL\n 867 mL\n Blood products:\n Total out:\n 721 mL\n 206 mL\n Urine:\n 421 mL\n 206 mL\n NG:\n 100 mL\n Stool:\n 200 mL\n Drains:\n Balance:\n 1,113 mL\n 661 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///17/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub, (Murmur: No(t)\n Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n No(t) Crackles : , No(t) Wheezes : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 286 K/uL\n 8.8 g/dL\n 144 mg/dL\n 0.4 mg/dL\n 17 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 111 mEq/L\n 139 mEq/L\n 27.4 %\n 4.6 K/uL\n [image002.jpg]\n 07:24 PM\n 05:07 AM\n WBC\n 4.4\n 4.6\n Hct\n 29.2\n 27.4\n Plt\n 311\n 286\n Cr\n 0.5\n 0.4\n Glucose\n 156\n 144\n Other labs: PT / PTT / INR:16.9/64.1/1.5, Lactic Acid:1.6 mmol/L,\n Ca++:7.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n CANCER (MALIGNANT NEOPLASM), COLORECTAL (COLON CANCER)\n DIARRHEA\n HYPERTENSION, BENIGN\n GASTROESOPHAGEAL REFLUX DISEASE (GERD)\n ELECTROLYTE & FLUID DISORDER, OTHER\n dehydration\n PULMONARY EMBOLISM (PE), ACUTE\n Assesment: This is an 83 yo F with recent dx of metastatic colon cancer\n s/p C1D1 FOLFOX chemotherapy who presents with diarrhea, SOB,\n sinus tachycardia and found to have R superior segmental PE with now\n evidence of GI bleed.\n .\n Plan:\n # Pulmonary embolism: Subsegmental on CTA. Pt denies h/o DVT or\n clotting hx, likely hypercoag. state secondary to malignancy. No\n evidence of R heart strain on EKG. Sinus tach may be related to PE or\n dehydration. Unclear from hx if this was an acute event or incidental\n finding on presentation. No new O2 requirement.\n - Heparin gtt for now will discuss transition to Lovenox or Coumadin w/\n onc team\n - Monitor on telemetry\n .\n # Dehydration: Pt with diarrhea and poor po intake for several days.\n Sinus tachycardia and borderline low uop. Potassium and mag low.\n - Cont. IVF hydration- 3L given so far, add KCl.\n - replete lytes prn\n - monitor uop\n .\n # Diarrhea: Nonbloody, guaiac negative. HCT stable. Most likely trigger\n is chemotherapy with FOLFOX. No fevers. No recent abx. Need to r/o\n infectious etiology. Lactate elevated.\n - stool cx, C.dif pending\n - IVFs\n - blood cultures pending\n - replete lytes prn\n - hold bowel regimen\n .\n # Colon cancer: Metastatic to liver, adrenal. Defer treatment to\n primary oncology team. Likely no chemotherapy while in the hospital.\n .\n # Hypertension: SBP 140s-160s, will add metoprolol (on atenolol at\n home), restart nifedipine if needed.\n .\n # GERD: cont. home PPI\n # FEN: IVFs, regular diet as tolerated, replete lytes\n # Access: POC, PIV\n # PPx: heparin drip, pneumoboots, PPI (GERD), hold bowel regimen\n # Code: DNR/DNI - confirmed with pt. ICU consent signed\n # Dispo: ICU care\n # Comm: husband - \n ICU Care\n Nutrition: regular diet as tolerated\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 03:44 PM\n Indwelling Port (PortaCath) - 04:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n ------ Protected Section ------\n After rounds today, the following changes were made:\n A second stool culture is being sent. If this is negative, will\n consider Imodium for symptomatic tx of diarrhea\n Will consider restarting nifedipine for better BP control today.\n Will consult SW for pt\ns likely situational depression at this time.\n Will add megace TID for appetite stimulation.\n Plan to call out to the floor today\n Also, of note, the pt\ns code status above is listed as full. It was\n confirmed on admission with the pt that she is DNR/DNI.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:00 ------\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 541570,
"text": "83 y.o. woman with HTN who was recently diagnosed with metastatic colon\n CA (cecal mass, right adrenal, liver). She is s/p one treatment of\n folfox on . Referred to ED today by Oncologist secondary to black\n watery stools. Since the chemoRx she notes increasing diarrhea up to 4\n x day which is watery and black/dark green. Feeling nauseous but no\n emesis. Has had left sided 'rib' pain for several months, unchanged.\n Noticed shortness of bed getting off the toilet on the day of\n admssion. Had three stools sent by outside doctor which were guaiac\n negative x 3. Hct in ED was 36 which is above baseline. In ED was\n sent for CTA given ? pleuritic CP which showed right subsegmental PE.\n Head CT, noncontrast read as negative. Received 3L NS for dehyration,\n started on IV heparin.\n Hypertension, benign\n Assessment:\n Pt with BP 140-150. HR initially 140\ns and has come down to 80\ns after\n restarting PO Lopressor and getting fluids.\n Action:\n Continues on fluids NS with 40meq Kcl at 150cc/hr\n Response:\n Pt still complains of feeling dehydrated and can take PO\ns as\n tolerated.\n Plan:\n Follow vital signs closely\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt still complains of diaphragmatic pain in abdominal area which is\n worse with deep breath. CTA has shown PE.\n Action:\n Pt remains on heparin drip at 850u/hr with stable PTT at 9AM.\n Response:\n Plan:\n Next PTT to be drawn with labs ordered for 1500.\n Electrolyte & fluid disorder, other\n Assessment:\n Due to frequent diarrhea pt has had fluid and electrolyte disturbance\n requiring K+, Magnesium and Phos repletion.\n Action:\n Lytes repleted as ordered and repeat labs ordered for 1500.\n Response:\n Will follow labs/diarrhea closely\n Plan:\n Replete electrolytes as needed. Follow pt closely.\n Diarrhea\n Assessment:\n Pt passing liquid green stool frequently. OB-\n Action:\n Watching pt closely for further dehydration symptoms. Second specimen\n for c-diff sent today.\n Response:\n Repleting electrolytes and fluids as needed.\n Plan:\n If c-diff remains negative may benefit from some Imodium.\n Cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with newly diagnosed colon cancer and has started chemo prior to\n this PE diagnosis. Pt states the cancer has to liver and is\n inoperable.\n Action:\n Allowing pt to verbalize and have involved social service due to the\n new diagnosis. Pt is DNR/DNI after discussion with our team.\n Response:\n Plan:\n Social service to assist with coping.\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 541583,
"text": "83 y.o. woman with HTN who was recently diagnosed with metastatic colon\n CA (cecal mass, right adrenal, liver). She is s/p one treatment of\n folfox on . Referred to ED today by Oncologist secondary to black\n watery stools. Since the chemoRx she notes increasing diarrhea up to 4\n x day which is watery and black/dark green. Feeling nauseous but no\n emesis. Has had left sided 'rib' pain for several months, unchanged.\n Noticed shortness of bed getting off the toilet on the day of\n admssion. Had three stools sent by outside doctor which were guaiac\n negative x 3. Hct in ED was 36 which is above baseline. In ED was\n sent for CTA given ? pleuritic CP which showed right subsegmental PE.\n Head CT, noncontrast read as negative. Received 3L NS for dehyration,\n started on IV heparin.\n Hypertension, benign\n Assessment:\n Pt with BP 140-150. HR initially 140\ns and has come down to 80\ns after\n restarting PO Lopressor and getting fluids.\n Action:\n Continues on fluids NS with 40meq Kcl at 150cc/hr\n Response:\n Pt still complains of feeling dehydrated and can take PO\ns as\n tolerated.\n Plan:\n Follow vital signs closely\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt still complains of diaphragmatic pain in abdominal area which is\n worse with deep breath. CTA has shown PE.\n Action:\n Pt remains on heparin drip at 850u/hr with stable PTT at 9AM. Goal PTT\n 60-100.\n Response:\n Stable on 850u/hr heparin. Please draw next PTT in 6hrs.\n Plan:\n Next PTT to be drawn with labs ordered for 1500.\n Electrolyte & fluid disorder, other\n Assessment:\n Due to frequent diarrhea pt has had fluid and electrolyte disturbance\n requiring K+, Magnesium and Phos repletion.\n Action:\n Lytes repleted as ordered and repeat labs ordered for 1500.\n Response:\n Will follow labs/diarrhea closely\n Plan:\n Replete electrolytes as needed. Follow pt closely. Encourage PO\ns as\n tolerated.\n Diarrhea\n Assessment:\n Pt passing liquid green stool frequently. OB-\n Action:\n Watching pt closely for further dehydration symptoms. Second specimen\n for c-diff sent today.\n Response:\n Repleting electrolytes and fluids as needed.\n Plan:\n If c-diff remains negative may benefit from some Imodium.\n Cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with newly diagnosed metastatic colon cancer and has started chemo\n prior to this PE diagnosis. Pt states the cancer has to liver and\n is inoperable. She has a poor appetite and has lost 10lb recently.\n Family is asking for her to start on an appetite stimulant.\n Action:\n Allowing pt to verbalize and have involved social service due to the\n new diagnosis. Pt is DNR/DNI after discussion with our team. Team\n writing for her to start on magace for appetite stimulant.\n Response:\n To be determined.\n Plan:\n Social service to assist with coping.\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 541586,
"text": "83 y.o. woman with HTN who was recently diagnosed with metastatic colon\n CA (cecal mass, right adrenal, liver). She is s/p one treatment of\n folfox on . Referred to ED today by Oncologist secondary to black\n watery stools. Since the chemoRx she notes increasing diarrhea up to 4\n x day which is watery and black/dark green. Feeling nauseous but no\n emesis. Has had left sided 'rib' pain for several months, unchanged.\n Noticed shortness of bed getting off the toilet on the day of\n admssion. Had three stools sent by outside doctor which were guaiac\n negative x 3. Hct in ED was 36 which is above baseline. In ED was\n sent for CTA given ? pleuritic CP which showed right subsegmental PE.\n Head CT, noncontrast read as negative. Received 3L NS for dehyration,\n started on IV heparin.\n Hypertension, benign\n Assessment:\n Pt with BP 140-150. HR initially 140\ns and has come down to 80\ns after\n restarting PO Lopressor and getting fluids.\n Action:\n Continues on fluids NS with 40meq Kcl at 150cc/hr\n Response:\n Pt still complains of feeling dehydrated and can take PO\ns as\n tolerated.\n Plan:\n Follow vital signs closely\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt still complains of diaphragmatic pain in abdominal area which is\n worse with deep breath. CTA has shown PE.\n Action:\n Pt remains on heparin drip at 850u/hr with stable PTT at 9AM. Goal PTT\n 60-100.\n Response:\n Stable on 850u/hr heparin. Please draw next PTT in 6hrs.\n Plan:\n Next PTT to be drawn with labs ordered for 1500.\n Electrolyte & fluid disorder, other\n Assessment:\n Due to frequent diarrhea pt has had fluid and electrolyte disturbance\n requiring K+, Magnesium and Phos repletion.\n Action:\n Lytes repleted as ordered and repeat labs ordered for 1500.\n Response:\n Will follow labs/diarrhea closely\n Plan:\n Replete electrolytes as needed. Follow pt closely. Encourage PO\ns as\n tolerated.\n Diarrhea\n Assessment:\n Pt passing liquid green stool frequently. OB-\n Action:\n Watching pt closely for further dehydration symptoms. Second specimen\n for c-diff sent today.\n Response:\n Repleting electrolytes and fluids as needed.\n Plan:\n If c-diff remains negative may benefit from some Imodium.\n Cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with newly diagnosed metastatic colon cancer and has started chemo\n prior to this PE diagnosis. Pt states the cancer has to liver and\n is inoperable. She has a poor appetite and has lost 10lb recently.\n Family is asking for her to start on an appetite stimulant.\n Action:\n Allowing pt to verbalize and have involved social service due to the\n new diagnosis. Pt is DNR/DNI after discussion with our team. Team\n writing for her to start on magace for appetite stimulant.\n Response:\n To be determined.\n Plan:\n Social service to assist with coping.\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 541589,
"text": "83 y.o. woman with HTN who was recently diagnosed with metastatic colon\n CA (cecal mass, right adrenal, liver). She is s/p one treatment of\n folfox on . Referred to ED today by Oncologist secondary to black\n watery stools. Since the chemoRx she notes increasing diarrhea up to 4\n x day which is watery and black/dark green. Feeling nauseous but no\n emesis. Has had left sided 'rib' pain for several months, unchanged.\n Noticed shortness of bed getting off the toilet on the day of\n admssion. Had three stools sent by outside doctor which were guaiac\n negative x 3. Hct in ED was 36 which is above baseline. In ED was\n sent for CTA given ? pleuritic CP which showed right subsegmental PE.\n Head CT, noncontrast read as negative. Received 3L NS for dehyration,\n started on IV heparin.\n Hypertension, benign\n Assessment:\n Pt with BP 140-150. HR initially 140\ns and has come down to 80\ns after\n restarting PO Lopressor and getting fluids.\n Action:\n Continues on fluids NS with 40meq Kcl at 150cc/hr\n Response:\n Pt still complains of feeling dehydrated and can take PO\ns as\n tolerated.\n Plan:\n Follow vital signs closely. Continue to increase antihypertensives as\n ordered.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt still complains of diaphragmatic pain in abdominal area which is\n worse with deep breath. CTA has shown PE.\n Action:\n Pt remains on heparin drip at 850u/hr with stable PTT at 9AM. Goal PTT\n 60-100.\n Response:\n Stable on 850u/hr heparin. Please draw next PTT in 6hrs.\n Plan:\n Next PTT to be drawn with labs ordered for 1500.\n Electrolyte & fluid disorder, other\n Assessment:\n Due to frequent diarrhea pt has had fluid and electrolyte disturbance\n requiring K+, Magnesium and Phos repletion.\n Action:\n Lytes repleted as ordered and repeat labs ordered for 1500.\n Response:\n Will follow labs/diarrhea closely\n Plan:\n Replete electrolytes as needed. Follow pt closely. Encourage PO\ns as\n tolerated.\n Diarrhea\n Assessment:\n Pt passing liquid green stool frequently. OB-\n Action:\n Watching pt closely for further dehydration symptoms. Second specimen\n for c-diff sent today.\n Response:\n Repleting electrolytes and fluids as needed.\n Plan:\n Needs third c-diff specimen sent tomorrow. Pt ordered for immodium one\n time dose to give as soon as it is available from the pharmacy.\n Cancer (Malignant Neoplasm), Colorectal (Colon Cancer)\n Assessment:\n Pt with newly diagnosed metastatic colon cancer and has started chemo\n prior to this PE diagnosis. Pt states the cancer has to liver and\n is inoperable. She has a poor appetite and has lost 10lb recently.\n Family is asking for her to start on an appetite stimulant.\n Action:\n Allowing pt to verbalize and have involved social service due to the\n new diagnosis. Pt is DNR/DNI after discussion with our team. Team\n writing for her to start on magace for appetite stimulant.\n Response:\n To be determined.\n Plan:\n Social service to assist with coping.\n IVF order finished and team will readdress fluids once her labs return.\n Labs sent at 1430. Please give pt anti-diarrheal when available\n from pharmacy. Pt called out to the floor and awaiting bed assignment\n on 7 .\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 541536,
"text": "83 y.o. woman with HTN who was recently diagnosed with metastatic colon\n CA (cecal mass, right adrenal, liver). She is s/p one treatment of\n folfox on . Referred to ED today by Oncologist secondary to black\n watery stools. Since the chemoRx she notes increasing diarrhea up to 4\n x day which is watery and black/dark green. Feeling nauseous but no\n emesis. Has had left sided 'rib' pain for several months, unchanged.\n Noticed shortness of bed getting off the toilet on the day of\n admssion. Had three stools sent by outside doctor which were guaiac\n negative x 3. Hct in ED was 36 which is above baseline. In ED was\n sent for CTA given ? pleuritic CP which showed right subsegmental PE.\n Head CT, noncontrast read as negative. Received 3L NS for dehyration,\n started on IV heparin.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt ruled in for subsegmental PE. Experiences pain under left\n rib.\n Action:\n PTT checked at 0300 = 44.6, Heparin gtt currently at 850 units/hr.\n Given 5mg Oxycodone PO and 2mg Morphine IV for pain.\n Response:\n Pain relieved with Morphine.\n Plan:\n Recheck PTT at 0900. Monitor for pain.\n Electrolyte & fluid disorder, other\n Assessment:\n K+ 3.0 at , mag 2.7 and phos 2.2\n Action:\n pt given 1000ml NS with 40meq KCL x 2 and 30mmol KPhos\n Response:\n AM labs\n Plan:\n Continue to monitor electrolytes and treat as needed.\n"
},
{
"category": "Radiology",
"chartdate": "2153-11-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1042781,
"text": " 12:30 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for metastases\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with metastatic colon CA, PE\n REASON FOR THIS EXAMINATION:\n eval for metastases\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FXKd WED 1:51 PM\n Atrophy with no mass effect or midline shift. MRI is more sensitive for\n brain mets.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old female with metastatic colon cancer, to assess for\n intracranial metastases.\n\n TECHNIQUE: Non-contrast CT of the brain was performed. There is no relevant\n prior imaging for comparison.\n\n FINDINGS:\n\n There is generalized cerebral atrophy with mild periventricular ischemic\n change. There is no mass effect, edema or midline shift. The midline\n structures are central. There is no intracranial hemorrhage.\n\n There is no skull fracture. The visualized paranasal sinuses are clear.\n\n CONCLUSION: Generalized atrophy with no evidence of mass effect or midline\n shift. Please note MRI is more sensitive for assessment of subtle early\n metastases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-11-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1042754,
"text": " 10:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with colon ca, dark stools, tachy, sob\n REASON FOR THIS EXAMINATION:\n eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old female with colon cancer, now presenting with\n tachycardia and shortness of breath, to rule out a cardiopulmonary process.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed.\n Comparison is made with examination of .\n\n FINDINGS:\n\n There is a left-sided central line with the tip at the cavoatrial junction.\n There is stable appearance to the bibasal atelectasis as well as elevation of\n the right hemidiaphragm. There is no focal pulmonary consolidation.\n Cardiomediastinal silhouette appears unremarkable.\n\n Incidentally noted are clips in the right upper abdomen likely representing\n cholecystectomy clips.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-11-21 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1042759,
"text": " 10:49 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval PE, acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with colon CA, LUQ/Chest wall/pleuritic pain, tachy/sob\n REASON FOR THIS EXAMINATION:\n eval PE, acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JMGw WED 11:45 AM\n segmental pulmonary embolism in right superior branch. no other emboli noted.\n multiple unchanged liver mets, unchanged adrenal met, unchanged renal cysts,\n unchanged cecal mass/wall thickening. no bowel dilation.\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST, ABDOMEN, AND PELVIS WITH CONTRAST\n\n HISTORY: 83-year-old woman with colon cancer, left upper quadrant chest wall\n pleuritic pain. Tachycardia and shortness of breath. Evaluate for pulmonary\n embolism or other acute process.\n\n COMPARISON: CT abdomen and pelvis per colonoscopy from and\n CT torso from .\n\n TECHNIQUE: Contiguous axial imaging was performed from the thoracic inlet\n through the pubic symphysis following administration of intravenous contrast.\n Sagittal and coronal reformats were obtained as well as right and left oblique\n MIPS.\n\n CHEST CT WITH CONTRAST: There is a filling defect within a subsegmental\n branch of the right superior pulmonary artery, best visualized on (302B:46).\n There are no other areas of filling defect to suggest other areas of pulmonary\n emboli. There are calcifications of the aortic arch and aortic valve. There\n are no areas of aortic aneurysm or evidence to suggest aortic dissection. The\n thoracic great vessels are unremarkable. There is minimal right basilar\n atelectasis and dependent area of the lung. Otherwise, the lungs are clear\n without areas, masses or consolidations or nodules. There are no pleural\n effusions. There are no pericardial effusions. There is no significant\n axillary, mediastinal or hilar lymphadenopathy. There is a Port-A-Cath device\n in the left upper chest wall with a catheter terminating in the superior vena\n cava right atrial junction.\n\n CT ABDOMEN WITH CONTRAST: There are multiple heterogeneous masses distributed\n through the liver consistent with patient's known diagnosis of metastatic\n colon cancer, unchanged from prior study. There is mild intrahepatic biliary\n dilatation also unchanged. Patient is status post cholecystectomy, and the\n common bile duct measures approximately 16 mm, also unchanged. There has been\n interval resolution of pneumobilia. There is a 3.5 x 2.9 cm heterogeneously\n enhancing mass adjacent to the right adrenal gland, which is stable in\n appearance and was previously characterized as a collision tumor. The spleen\n and left adrenal are unremarkable. There is a 3.4 x 3.3 cm low attenuation\n (Over)\n\n 10:49 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval PE, acute process\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n mass in the left kidney consistent with a simple cyst and is unchanged in\n appearance compared to prior study. There are multiple other bilateral renal\n hypodensities, too small to characterize but likely represents a simple cyst.\n The pancreas is unremarkable. However, a note of the pancreas divisum was\n noted on prior study. The stomach and abdominal loops of small and large\n bowel are grossly unremarkable. There is no free air. There is no free\n fluid. There is no significant retroperitoneal or mesenteric lymphadenopathy.\n\n CT PELVIS WITH CONTRAST: The rectum is normal in appearance. There are\n scattered diverticulae in the sigmoid colon without evidence for\n diverticulitis. There is mucosal thickening of the cecum consistent with\n patient's prior diagnosis of colon cancer. The remainder of the abdominal\n loops of small and large bowel are unremarkable. There is no bowel\n dilatation. There is no significant retroperitoneal or mesenteric\n lymphadenopathy. There is a Foley present within a decompressed bladder.\n Patient is status post hysterectomy. There is no free air. There is no free\n fluid.\n\n BONE WINDOWS: There are mild degenerative changes noted of the thoracolumbar\n spine. There is a sclerotic focus within the L2 vertebral body, likely\n representing a bone island. There were no suspicious sclerotic or lytic\n lesions identified.\n\n IMPRESSION:\n 1. Thrombus in the right subsegmental branch of the superior branch of the\n right pulmonary artery. No other areas of pulmonary emboli noted.\n 2. Multiple hepatic metastases, unchanged from prior examination.\n 3. Bilateral renal cystic structures are unchanged.\n 4. Metastatic collision tumor adjacent to the right adrenal gland, unchanged.\n 5. Sigmoid diverticulosis without diverticulitis. Mucosal thickening in the\n cecum adjacent to the ileocecal valve consistent with patient's known\n diagnosis of colonic mass.\n\n The findings of the study were posted as a wet read on the emergency\n department dashboard at the time of study interpretation.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2153-11-21 00:00:00.000",
"description": "Report",
"row_id": 254499,
"text": "Artifact is present. Sinus tachycardia. Low voltage in the limb leads.\nNon-specific ST-T wave changes. Compared to the previous tracing there is no\nsignificant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2153-11-21 00:00:00.000",
"description": "Report",
"row_id": 254500,
"text": "Sinus tachycardia. Non-specific ST-T wave changes. Low voltage in the limb\nleads. Compared to the previous tracing the rate is faster and ST-T wave\nchanges are new.\n\n"
}
] |
53,439 | 135,942 | MICU Course: 52 yo man with history of alcohol abuse, bipolar disorder, anxiety/depression, found down by police, unresponsive in the setting of elevated alcohol level. Was intubated for airway protection. Obtundation likely secondary to toxic-metabolic etiology. Tox screen otherwise negative. Was given IV fluids, MVI, thiamine, folate, CIWA scale PRN. Found to have evolving low grade fevers, secretions, and radiographic support for right lower lobe pneumonia. Sputum sample gram stain consistent with haemophilus, started on ceftriaxone and azithromycin. Was extubated and now with clearing mental status. . Floor course: #. Obtundation/TME: His confusion progressively resolved as he cleared his ETOH and PNA. He received a banana bag in the unit and will be discharged with scripts for MVI, Thiamine, and folate. . #. Low grade fever: The patient was discovered to have H.Flu in his sputum, and was treated for H. flu pneumonia. He received broad spectrum abx in the unit, IV ceftriaxone and azithro on the floor and was narrowed to oral levaquin on the day prior to discharge. Social work filled his meds before he left, CT chest showed no hilar lymphadenopathy. . Alcohol abuse/withdrawl: The patient was intubated and sedated in the Patient scored x1 for his stay thus far, but this is his first 24hours off of sedation. Patient states he is interested in quitting though states AA is as much as he will do. Patient refused any other social work interventions. - continue thiamine, folate, MVI. . #. Right perihilar nodular opacities on CXR: represent lymphadenopathy or masses. - f/u CT Chest . | The lungs are essentially clear except for left basal opacities that might represent (Over) 3:09 PM CT CHEST W/CONTRAST Clip # Reason: Please assess perihilar node. Hiatal hernia is present, small. The lungs demonstrate a small retrocardiac opacity. Small hiatal hernia and small left posterior diaphragmatic hernia. There is minimal bilateral pleural effusion and small areas of bibasilar atelectasis, left more than right with the left one potentially representing infectious process. No contraindications for IV contrast FINAL REPORT REASON FOR EXAMINATION: Suspected hilar lymph nodes. Right perihilar nodular opacities may represent lymphadenopathy or masses - a nonemergent chest CT is recommended. There is mild vascular congestion. Patient post unresponsiveness. Normal sinus rhythm. ET tube is in standard position. Admitting Diagnosis: UNRESPONSIVE Contrast: OPTIRAY Amt: 75 FINAL REPORT (Cont) atelectasis versus small area for infection and small right basal atelectasis. Nodular appearance of the right hilum is stable, CT is recommended for further evaluation. 3:11 AM CHEST (PORTABLE AP) Clip # Reason: Any acute cardiopulmonary process? Tracing is within normal limits. Bilateral axillary lymph nodes are slightly prominent, although not pathologically enlarged based on the size criteria, with the largest one on the left, approaching 11 mm in the shortest diameter and on the right 8.5 mm in the shortest diameter. The aorta is unremarkable. The airways are patent to the level of subsegmental bronchi bilaterally. Two nodular opacities are seen in the right perihilar region. Cardiomegaly is stable. REASON FOR THIS EXAMINATION: Any acute cardiopulmonary process? The heart size is normal. The heart size is normal. Retrocardiac opacity may represent atelectasis although pneumonia or aspiration can not be ruled out. FINDINGS: There are no pathologically enlarged mediastinal, hilar or axillary lymph nodes. The imaged portion of the upper abdomen demonstrates posterior left hiatal hernia containing fat and small amount of fluid. STUDY: Portable AP semi-upright/supine radiograph. IMPRESSION: 1. IMPRESSION: 1. Bony structures are grossly intact. The abnormality seen on the chest radiograph is most likely positional or a combination of a portable technique with slightly dilated main pulmonary arteries. No evidence of failure. There is no pericardial effusion. There is no pneumothorax or pleural effusions. COMPARISON: Chest radiograph from . The mediastinal contours are unremarkable. There is no pleural effusion or pneumothorax. Borderline bilateral axillary lymph nodes, please correlate with clinical findings. FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Intubated patient. 3:09 PM CT CHEST W/CONTRAST Clip # Reason: Please assess perihilar node. There are no bone lesions worrisome for infection or neoplasm. The evaluation of the lung parenchyma demonstrates no pulmonary nodules worrisome for infection or neoplasm, but note is made that the breathing artifacts are relatively significant and preclude evaluation of the lung for the presence of small pulmonary nodules. No previous tracingavailable for comparison. COMPARISON: None available. This study is limited due to motion artifact, allowing this limitation left lower lobe opacity has increased, as before, could represent atelectasis or aspiration pneumonia. REASON FOR THIS EXAMINATION: Please assess perihilar node. Spleen is unremarkable as well as the imaged portion of the pancreas, kidneys, and adrenals. An endogastric tube courses inferiorly and out of the field of view, so that side port is presumably below the GE junction. FINDINGS: An endotracheal tube tip is seen 2.5 cm above the carina. No evidence of mediastinal or hilar lymphadenopathy. NG tube tip is in the stomach. 4. Axial images were reviewed in conjunction with coronal and sagittal reformats. 3. The liver is slightly enlarged. 2. 2. TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper abdomen after administration of IV contrast. High resolution. Admitting Diagnosis: UNRESPONSIVE MEDICAL CONDITION: 52 year old man status post unresponsiveness, intubated to protect airway. Admitting Diagnosis: UNRESPONSIVE Contrast: OPTIRAY Amt: 75 MEDICAL CONDITION: 52 year old man with chest node. 12:16 PM CHEST (PORTABLE AP) Clip # Reason: ? pulm path MEDICAL CONDITION: 52 year old man with intubated REASON FOR THIS EXAMINATION: ? | 4 | [
{
"category": "Radiology",
"chartdate": "2149-06-12 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1138920,
"text": " 3:09 PM\n CT CHEST W/CONTRAST Clip # \n Reason: Please assess perihilar node.\n Admitting Diagnosis: UNRESPONSIVE\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with chest node. High resolution.\n REASON FOR THIS EXAMINATION:\n Please assess perihilar node.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Suspected hilar lymph nodes.\n\n COMPARISON: Chest radiograph from .\n\n TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper\n abdomen after administration of IV contrast. Axial images were reviewed in\n conjunction with coronal and sagittal reformats.\n\n FINDINGS:\n\n There are no pathologically enlarged mediastinal, hilar or axillary lymph\n nodes. The abnormality seen on the chest radiograph is most likely positional\n or a combination of a portable technique with slightly dilated main pulmonary\n arteries. The aorta is unremarkable. The heart size is normal. There is no\n pericardial effusion. Hiatal hernia is present, small.\n\n There is minimal bilateral pleural effusion and small areas of bibasilar\n atelectasis, left more than right with the left one potentially representing\n infectious process. The airways are patent to the level of subsegmental\n bronchi bilaterally. The evaluation of the lung parenchyma demonstrates no\n pulmonary nodules worrisome for infection or neoplasm, but note is made that\n the breathing artifacts are relatively significant and preclude evaluation of\n the lung for the presence of small pulmonary nodules.\n\n The imaged portion of the upper abdomen demonstrates posterior left hiatal\n hernia containing fat and small amount of fluid. The liver is slightly\n enlarged. Spleen is unremarkable as well as the imaged portion of the\n pancreas, kidneys, and adrenals.\n\n There are no bone lesions worrisome for infection or neoplasm.\n\n Bilateral axillary lymph nodes are slightly prominent, although not\n pathologically enlarged based on the size criteria, with the largest one on\n the left, approaching 11 mm in the shortest diameter and on the right 8.5 mm\n in the shortest diameter.\n\n IMPRESSION:\n\n 1. No evidence of mediastinal or hilar lymphadenopathy. The lungs are\n essentially clear except for left basal opacities that might represent\n (Over)\n\n 3:09 PM\n CT CHEST W/CONTRAST Clip # \n Reason: Please assess perihilar node.\n Admitting Diagnosis: UNRESPONSIVE\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n atelectasis versus small area for infection and small right basal atelectasis.\n\n 2. No evidence of failure.\n\n 3. Borderline bilateral axillary lymph nodes, please correlate with clinical\n findings.\n\n 4. Small hiatal hernia and small left posterior diaphragmatic hernia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-06-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1138551,
"text": " 12:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulm path\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with intubated\n REASON FOR THIS EXAMINATION:\n ? pulm path\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 52-year-old male status post intubation.\n\n STUDY: Portable AP semi-upright/supine radiograph.\n\n COMPARISON: None available.\n\n FINDINGS: An endotracheal tube tip is seen 2.5 cm above the carina. An\n endogastric tube courses inferiorly and out of the field of view, so that side\n port is presumably below the GE junction. The heart size is normal. The\n mediastinal contours are unremarkable. Two nodular opacities are seen in the\n right perihilar region. The lungs demonstrate a small retrocardiac opacity.\n There is no pleural effusion or pneumothorax. Bony structures are grossly\n intact.\n\n IMPRESSION:\n 1. Retrocardiac opacity may represent atelectasis although pneumonia or\n aspiration can not be ruled out.\n 2. Right perihilar nodular opacities may represent lymphadenopathy or masses -\n a nonemergent chest CT is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-06-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1138651,
"text": " 3:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any acute cardiopulmonary process?\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man status post unresponsiveness, intubated to protect airway.\n REASON FOR THIS EXAMINATION:\n Any acute cardiopulmonary process?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Intubated patient. Patient post unresponsiveness.\n\n Comparison is made with prior study performed a day earlier.\n\n Cardiomegaly is stable. This study is limited due to motion artifact,\n allowing this limitation left lower lobe opacity has increased, as before,\n could represent atelectasis or aspiration pneumonia. Nodular appearance of\n the right hilum is stable, CT is recommended for further evaluation. There is\n no pneumothorax or pleural effusions. There is mild vascular congestion. ET\n tube is in standard position. NG tube tip is in the stomach.\n\n"
},
{
"category": "ECG",
"chartdate": "2149-06-10 00:00:00.000",
"description": "Report",
"row_id": 237468,
"text": "Normal sinus rhythm. Tracing is within normal limits. No previous tracing\navailable for comparison.\n\n"
}
] |
12,284 | 159,550 | Patient went thorough negative work-up which included a negative head CT times two; normal electrocardiogram. He ruled out for myocardial infarction by serial enzymes. His B12, folate and TSH were all within normal limits. His B12 was in the low ranges of normal, so he received B12 injections for one week. His urine serum toxicology was negative. Adrenal function was within normal limits. His LFTs were all normal. There was no infection found except for Staph aureus that grew from sputum. His lumbar puncture showed no remarkable findings including an HSV that was negative. He received an abdominal CT during the hospital course which showed no intraabdominal process. Patient was extubated on hospital day four and the extubation was successful and he was transferred to the floor. At that time, he spiked temperatures up to 102 degrees Fahrenheit and was placed on a course of levofloxacin and vancomycin for suspected pneumonia. Vancomycin was soon stopped, but he continued on a ten day course of levofloxacin. Patient continued to have waxing and mental status despite discontinuing all medications including cogentin that was started in the Medical Intensive Care Unit. On hospital day 14, patient received a physostigmine challenge test to rule out the possibility of anti-cholinergic syndrome and the results of which were equivocal. Patient remained confused although was a bit more alert after administration of 2 mg of physostigmine. During the hospital stay, patient received a PICC line and was began on TPN on hospital day 12. This dictation will be continued at a later date. , M.D. Dictated By: MEDQUIST36 D: 14:16 T: 09:52 JOB#: | Minimal atelectasis right cardiophrenic angle. TECHNIQUE: Non-contrast head CT. RIGHT LATERAL DECUBITUS: No pneumothorax is identified. IMPRESSION: No evidence of acute hemorrhage. IMPRESSION: No active lung disease. No acute hemorrhage identified. The small area of hyperdensity indicated by an arrow on series 3, image 13 of the prior head CT is not redemonstrated and most likely reflects beam-hardening artifact. IMPRESSION: No evidence of acute pulmonary process. There has been interval removal of an endotracheal tube. There is some minimal ill-defined opacity in the left retrocardiac region which partially obscures the descending aortic interface. HEAD CT WITHOUT IV CONTRAST: No intra or extra-axial hemorrhage is identified. IMPRESSION: No definite evidence of pneumonia. HEAD CT WITHOUT IV CONTRAST: As on the previous exam, no intra- or extraaxial hemorrhage is identified. The liver is within normal limits, without focal hepatic lesions, and the gallbladder is unremarkable. No acute hemorrhage or edema identified. Minimal left retrocardiac opacity is noted and is without change compared to prior studies. The non-contrast-filled loops of large and small bowel in the abdomen are unremarkable. The patient's arm obscures much of the right lung. TECHNIQUE: Contiguous axial images were obtained from the foramen magnum through the cranial vertex without the administration of IV contrast. TECHNIQUE: Contiguous axial images were obtained from the foramen magnum through the cranial vertex without the administration of IV contrast. CT OF THE ABDOMEN WITH IV CONTRAST: There are patchy dependent opacities of the lung bases bilaterally, consistent with atelectasis. Patient found unresponsive. No confluent areas of consolidation are seen in either lung. FINDINGS: There is no intra or extraaxial hemorrhage. There has been no significant change since the previous chest x-ray of . The lungs are otherwise clear except for a small calcified granuloma at the left lung base. This appearance could represent pneumothorax, and a right lateral decubitus view is recommended to exclude this. Cardiac and mediastinal contours are within normal limits. Optiray contrast was adminstered secondary to the patient's cardiac history. There is a minimal amount of mucosal thickening within the ethmoid sinuses. Pulmonary vasculature is within normal limits for technique. Now extubated on floor with copious secretions and intermittent fevers, non-communicative, etiology unknown. No obvious fractures are identified. FINDINGS: The patient is status post CABG. no pneumothorax. The visualized osseous structures and soft tissues are unremarkable. Surgical clips and sternotomy wires indicate prior CABG. CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder is collapsed around a Foley balloon, and there is a small amount of intraluminal air. IMPRESSION: Stable radiographic appearance of the chest. The patient has prior CABG and median sternotomy. Deviated septum is seen. The prostate gland, seminal vesicles, rectum, and sigmoid colon are all unremarkable. CHEST, SINGLE AP VIEW. (Over) 1:03 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: FEVER OF UNKNOWN ORIGIN, ? Traceaortic regurgitation is seen. PT IS AN DNR. yankauered for moderate amnts. MAX TEMP 99.0.GI/GU: ABD SOFT, +BS, +BM. PT MAX TEMP 100.6 AX.GI/GU: ABD SOFT, +BS, +BM. PT REMAINS +2L.DISPO: PLAN IS TO THIS AM EXTUBATE PT. Discuss cogentine dose. PT X1 FOR SCANT AMT THIN CLEAR SECRETIONS. is DNR. MAX TEMP 99.GI/GU: ABD SOFT, HYPO BS, NO BM. PT REMAINS A DNR. PT REMAINS A DNR. NEURO TO PT THIS AM. SBP 110-190'S. LS CLEAR.CV: HR 60-70'S NSR W/ NO ECTOPY. GIUAC +. PT FOR LG AMT ORAL SECREATION. PT FOR LG AMT ORAL SECRETIONS, MOUTH CARE Q2HRS. IVF changed to NS w/20meq KCL at 100cc/hr.ID: Low grade temp at 100.2 rectal this AM. ETT Q2 FOR SMALL AMT THICK TAN SECREATIONS. ADDENDUM- MICU-B, NPN, :Pt. Moving q 4 extremities, cont. Needs to go to floor with celar DNR/DNI status. gtt off. An 0.018 guide wire was advanced on fluoroscopy into the superior vena cava. has producted cough/ suxn'd. Plan was to extub. Pt. Pt. Pt. Pt. Pt. Pt. so pt. for moderate amnts. MICU-B, NPN:Neuro: Pt. LS CLEAR/DIMINISHED AT BASES.EET ROTATED.CV: HR 70-80'S NSR, NO ECTOPY NOTED. WHEN POSSIBLE FOR EXTUBATION. PT ON PROPOFOL 12MCG/KG/MIN. No BM today.Derm: D&ISocial/Dispo: Plan is to extub/call out after proxy/DNI status contact and confirmed. IV's. Sx moderate secretions, copious oral secretions. Small amt thick pale yelow secretions noted via the ETT. RR 13-28. @ this time. PT T&P.ACCESS: PT ARRIVED IN MICU W/ 3PIV. CT CHEST NEGATIVE. POST BOLUS U/O 70CC.SKIN: SKIN WARM, PALE. and diminished bilat. MD AWARE. PT GIVEN 10MG IV LASIX. PT WAS RESTARTED ON PROPOFOL GTT AT 10MCG/KG/MIN. PATIENT/TEST INFORMATION:Indication: R/O Endocarditis.BP (mm Hg): 170/94Status: InpatientDate/Time: at 10:59Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: Overall left ventricular systolic function is mildlydepressed.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal anteroseptal - hypokinetic; mid anteroseptal -hypokinetic; basal inferior - hypokinetic; septal apex - hypokinetic;RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is moderately dilated. LS CLEAR. MD NOTIFIED, DECISION MADE TO SEDATE PT W/ PROPOFOL GTT OVERNIGHT. SBP 88-160'S. PT NPO. 3 working periph. SBP 88-120'S. Grimace to sternal rub. NPO. NPO. Prop. Clear lungs to aus. The aortic root is moderately dilated. The ascendingaorta is mildly dilated. #16G X2 AND ONE #18G. PRIOR TO PROPOFOL GTT SBP AS HIGH AS 190. soft wrist restraints.CV: HR 60's-low 90's, SBP 120's-160, no ectopy, 0 edema. U/O ~2L OVERNIGHT. be started on cogentin as recommended by neuro and may have LP done later today. FREQUENT MOUTH CARE GIVEN DUE TO PT NOT CLOSING MOUTH.CV: HR NSR 60-70'S, NO ECTOPY. RISBI DONE THIS AM, 33. PROPOFOL TURNED OFF FOR NEURO CHECKS Q4. Remains intubated for airway protection, will extubate when more awake. | 24 | [
{
"category": "Radiology",
"chartdate": "2162-11-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 770593,
"text": " 3:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: found unresponsive, intubated in ER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with above\n r/o head bleed\n REASON FOR THIS EXAMINATION:\n found unresponsive\n intubated in ER\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JCCJ FRI 4:13 PM\n no bleed; cerebellar calcifications\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient found unresponsive. ? stroke.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intra or extraaxial hemorrhage. There is no mass\n effect, shift of normally midline structures, or hydrocephalus. Incidental\n note is made of calcifications of the dentate nucleus in the cerebellum\n bilaterally, which is a physiologic finding. There is moderate brain atrophy\n and evidence of tissue loss, more prominent on the right side adjacent to the\n posterior of the lateral ventricle. There is a minimal amount of mucosal\n thickening within the ethmoid sinuses. Deviated septum is seen. There is no\n soft tissue swelling or fracture identified.\n\n IMPRESSION: No evidence of acute hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-11-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 770932,
"text": " 3:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pls assess for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with Alzheimer's dimentia who was intubated in MICU for 3\n days. Now extubated on floor with copious secretions.\n REASON FOR THIS EXAMINATION:\n Pls assess for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest of compared to previous study of four days earlier.\n\n CLINICAL INDICATION: Status post extubation. Copious secretions. Clinical\n suspicion for pneumonia.\n\n There has been interval removal of an endotracheal tube. Cardiac and\n mediastinal contours are within normal limits. No confluent areas of\n consolidation are seen in either lung. There is some minimal ill-defined\n opacity in the left retrocardiac region which partially obscures the\n descending aortic interface. The lungs are otherwise clear except for a small\n calcified granuloma at the left lung base.\n\n IMPRESSION: No definite evidence of pneumonia. Minimal left retrocardiac\n opacity is noted and is without change compared to prior studies. This may be\n due to an area of atelectasis. A focal pneumonia in this area is not fully\n excluded and follow-up films may be helpful if clinical suspicion persists.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-11-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 770591,
"text": " 3:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: unresponsive\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with unresponsive arrival\n REASON FOR THIS EXAMINATION:\n unresponsive\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Unresponsive. Intubation.\n\n AP CHEST: The endotracheal tube lies 4.5 cm from the carina. Surgical clips\n and sternotomy wires indicate prior CABG. There is a lentiform lucency which\n extends from the left costophrenic sulcus over the left upper quadrant of the\n abdomen. The lungs are clear and no pleural effusions are seen. No obvious\n fractures are identified.\n\n IMPRESSION: Lucency extending from the left costophrenic sulcus over the left\n upper quadrant of the abdomen. This appearance could represent pneumothorax,\n and a right lateral decubitus view is recommended to exclude this.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-11-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 770624,
"text": " 9:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Rule out Pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man unresponsive, intubated for airway protection\n REASON FOR THIS EXAMINATION:\n Rule out Pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n History of unresponsiveness with intubation. To evaluate ET tube and for\n pneumothorax.\n\n Endotracheal tube is approximately 5cm above carina. no pneumothorax. Status\n post CABG. There is slight elevation of the left hemidiaphragm and linear\n atelectasis at the left lung base with blunting of the left costophrenic\n angle.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-11-10 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 771042,
"text": " 5:28 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: CSF xanthochromia in lethargic elderly male with suspected P\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with cad, htn, found unresponsive this am 3 days ago with\n some return in mental status.\n REASON FOR THIS EXAMINATION:\n CSF xanthochromia in lethargic elderly male with suspected PNA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old man found unresponsive three days ago. Some return\n in mental status. Xanthochromia on CSF.\n\n TECHNIQUE: Contiguous axial images were obtained from the foramen magnum\n through the cranial vertex without the administration of IV contrast.\n\n COMPARISONS: Comparison is made to the next prior study dated .\n\n HEAD CT WITHOUT IV CONTRAST: No intra or extra-axial hemorrhage is\n identified. There is no mass effect or shift of the normally mid-line\n structures. The ventricles are stable in size. Note is again made of\n calcifications within the dentate nuclei within cerebellar hemispheres\n bilaterally, which is a degenerative, dystrophic process.\n\n IMPRESSION: Stable CT appearance of the brain. No acute hemorrhage or edema\n identified.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-11-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 770616,
"text": " 8:19 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: compare to previous ct, ? of finding in cut 13 of prior stud\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with cad, htn, found unresponsive this am.\n REASON FOR THIS EXAMINATION:\n compare to previous ct, ? of finding in cut 13 of prior study\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 86 year old man found unresponsive. ?High-density\n region on prior head CT. Please re-evaluate.\n\n TECHNIQUE: Contiguous axial images were obtained from the foramen magnum\n through the cranial vertex without the administration of IV contrast.\n\n COMPARISONS: Comparison is made to the patient's next-prior study of\n approximately five hours earlier.\n\n HEAD CT WITHOUT IV CONTRAST: As on the previous exam, no intra- or extraaxial\n hemorrhage is identified. The small area of hyperdensity indicated by an\n arrow on series 3, image 13 of the prior head CT is not redemonstrated and\n most likely reflects beam-hardening artifact. There is no mass effect or\n shift of normally midline structures. The ventricles are stable in size.\n Note is again made of calcifications within the cerebellar hemispheres. No\n skull fractures are identified.\n\n IMPRESSION: Stable CT appearance of the brain. No acute hemorrhage\n identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-11-05 00:00:00.000",
"description": "CHEST (LAT DECUB ONLY)",
"row_id": 770598,
"text": " 3:50 PM\n CHEST (LAT DECUB ONLY) Clip # \n Reason: r/p ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with findings on supine \n r/o ptx\n REASON FOR THIS EXAMINATION:\n r/p ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Question of pneumothorax on AP chest film. Patient found\n unresponsive.\n\n RIGHT LATERAL DECUBITUS: No pneumothorax is identified. Multiple surgical\n clips and midline sternotomy wires indicate prior CABG. The patient's arm\n obscures much of the right lung.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-11-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 772579,
"text": " 2:32 PM\n CHEST (PA & LAT) Clip # \n Reason: please assess for interval change, possible pneumonia.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with Alzheimer's dimentia. Intubated in MICU for delta MS.\n Now extubated and on floor -- bringing up much sputum.\n REASON FOR THIS EXAMINATION:\n please assess for interval change, possible pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Alzheimer's. Intubated. Excessive aspirate. Evaluate for\n pneumonia.\n\n CHEST, PA AND LATERAL: The cardiac size is within the upper limits of normal.\n No evidence of failure is seen. No infiltrates are identified either on the\n lateral films. Some old granulomata are again identified.\n\n There has been no significant change since the previous chest x-ray of .\n\n IMPRESSION: No evidence of infiltrate.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-11-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 771965,
"text": " 3:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with Alzheimer's dimentia who was intubated in MICU for 3\n days. Now extubated on floor with copious secretions and intermittent fevers,\n etiology unknown.\n REASON FOR THIS EXAMINATION:\n please assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Alzheimer's disease, fever.\n\n IMPRESSION: No active lung disease.\n\n COMMENT: Portable AP film of the chest is reviewed, and compared to previous\n study of .\n\n The patient has prior CABG and median sternotomy. The tip of the right sided\n PICC line is identified in the inferior vena cava. No pneumothorax is\n seen. The lungs are clear. The heart is normal in size.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-11-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 772122,
"text": " 10:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any change from prior study.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with Alzheimer's dimentia who was intubated in MICU for 3\n days. Now extubated on floor with copious secretions and intermittent fevers,\n non-communicative, etiology unknown.\n REASON FOR THIS EXAMINATION:\n Any change from prior study.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 86-year-old male with Alzheimer's dementia with\n intermittent fevers and copious secretions.\n\n Portable AP chest dated is compared to the prior study dated\n .\n\n FINDINGS: The patient is status post CABG. The cardiac and mediastinal\n contours appear stable. Pulmonary vasculature is within normal limits for\n technique. The appear clear, with no focal infiltrates. There are no pleural\n effusions. The visualized osseous structures and soft tissues are\n unremarkable. The right PICC catheter remains in stable position.\n\n IMPRESSION: Stable radiographic appearance of the chest.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-11-13 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 771261,
"text": " 1:03 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: FEVER OF UNKNOWN ORIGIN, ? INTRAABDOMINAL PROCESS AS SOURCE OF FEVER\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with rapid onselt dementia and fevers of unknown etiology.\n REASON FOR THIS EXAMINATION:\n R/o intrabdominal process as a source of fever. Pt unable to take POs\n (encephalopathic and not cleared by speech and swallow).\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 86-year-old man with fevers of unknown etiology. Evaluate\n for source of fever.\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n lung bases through the pubic symphysis following the administration of 150 cc\n of Optiray contrast IV. Optiray contrast was adminstered secondary to the\n patient's cardiac history.\n\n COMPARISONS: None.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There are patchy dependent opacities of\n the lung bases bilaterally, consistent with atelectasis. There is a 9 mm x 11\n mm densely calcified nodule at the left lung base. The liver is within normal\n limits, without focal hepatic lesions, and the gallbladder is unremarkable.\n The adrenal glands, pancreas, and spleen are also normal. The kidneys are\n symmetric in size and demonstrate prompt excretion of contrast. There is a\n 2.4 cm x 2.6 cm low-attenuation lesion at the mid pole of the left kidney,\n consistent with a simple renal cyst. Two smaller cysts are also present, one\n in the lower pole of the left kidney and the second at the mid pole of the\n right kidney. There is no evidence of hydronephrosis or renal masses. The\n non-contrast-filled loops of large and small bowel in the abdomen are\n unremarkable. No abscess collections are identified, and there is no free air\n in the abdomen.\n\n CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder is collapsed around a\n Foley balloon, and there is a small amount of intraluminal air. The prostate\n gland, seminal vesicles, rectum, and sigmoid colon are all unremarkable. There\n is no free fluid in the pelvis.\n\n There are marked degenerative changes of the osseous structures, particularly\n in the lower lumbar spine secondary to mild scoliosis, concave to the right.\n\n IMPRESSION: No CT evidence of abscess or acute inflammatory process in the\n abdomen or pelvis to explain the patient's fever.\n\n (Over)\n\n 1:03 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: FEVER OF UNKNOWN ORIGIN, ? INTRAABDOMINAL PROCESS AS SOURCE OF FEVER\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-11-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 771333,
"text": " 4:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrative process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with Alzheimer's dimentia who was intubated in MICU for 3\n days. Now extubated on floor with copious secretions and intermittent fevers,\n etiology unknown.\n REASON FOR THIS EXAMINATION:\n eval for infiltrative process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dementia in MICU, copious secretions and intermittent fevers.\n Question pneumonia.\n\n CHEST, SINGLE AP VIEW.\n\n Sternotomy wires and multiple mediastinal clips. The heart is not enlarged.\n There is no CHF, focal infiltrate or effusion. Minimal atelectasis right\n cardiophrenic angle. Calcified granuloma noted left base.\n\n IMPRESSION: No evidence of acute pulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-11-15 00:00:00.000",
"description": "CVL/PICC",
"row_id": 771368,
"text": " 8:19 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place _DOUBLE_ lumen PICC into either arm\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with acute onset demential needs PICC for TPN.\n REASON FOR THIS EXAMINATION:\n Please place _DOUBLE_ lumen PICC into either arm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute onset dementia requiring PICC for TPN.\n\n RADIOLOGISTS: The procedure was performed by Drs. and ,\n with Dr. (attending radiologist) being present and supervising.\n\n TECHNIQUE AND FINDINGS: The right upper arm was prepped and draped in the\n usual sterile fashion. No suitable superficial veins were visible, ultrasound\n was used for localization. The basilic vein was patent and compressible. After\n local anesthesia with 2 cc of 1% lidocaine, the basilic vein was entered under\n ultrasonographic guidance with a 21 gauge needle. An 0.018 guide wire was\n advanced on fluoroscopy into the superior vena cava. Based on the markers on\n the guide wire it was determined a length of 44 cm would be appropriate. The\n PICC line was trimmed to length and advanced through a 4 French introducer\n sheath. The sheath was removed and the catheter was flushed. A final chest X-\n ray was obtained and demonstrating the tip to be in the distal SVC at the\n SVC/right atrial junction. The line is ready for use. A StatLock was applied\n and the line was heplocked.\n\n IMPRESSION: Successful placement of a 44 cm long 5 French double lumen PICC\n line with tip at the SVC right atrial junction, ready for use.\n\n"
},
{
"category": "Echo",
"chartdate": "2162-11-24 00:00:00.000",
"description": "Report",
"row_id": 72504,
"text": "PATIENT/TEST INFORMATION:\nIndication: R/O Endocarditis.\nBP (mm Hg): 170/94\nStatus: Inpatient\nDate/Time: at 10:59\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Overall left ventricular systolic function is mildly\ndepressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anteroseptal - hypokinetic; mid anteroseptal -\nhypokinetic; basal inferior - hypokinetic; septal apex - hypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is moderately dilated. The ascending aorta is mildly\ndilated.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. Trace aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Physiologic\nmitral regurgitation is seen (within normal limits).\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Overall left ventricular systolic function\nis mildly depressed. Resting regional wall motion abnormalities include\nanteroseptal and inferior hypokinesis. Right ventricular chamber size and free\nwall motion are normal. The aortic root is moderately dilated. The ascending\naorta is mildly dilated. The aortic valve leaflets are mildly thickened. Trace\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no pericardial effusion.\n\nNo vegetation identified.\n\nNOTE: Report modified on to correct the name of the ordering\nphysician.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2162-11-05 00:00:00.000",
"description": "Report",
"row_id": 171006,
"text": "Sinus rhythmxns\nNormal ECGxns\nNonspecific lateral ST-T wave abnormalities\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-11-06 00:00:00.000",
"description": "Report",
"row_id": 1423317,
"text": "NURSING MICU NOTE 7P-7A\n\nPT ADMITTED TO MICU 2200 FROM EW. PT WAS FOUND UNRESPONSIVE AT HOUSE. PLEASE SEE FHP FOR PMH AND EVENTS.\n\nNEURO: ON ARIVAL TO UNIT PT POSTURING, RESPONSE TO NAIL BED PRESSURE. NO SPONTANEOUS MVT. PUPILS 3-4MM, BRISK. AS NIGHT PROGRESSED PT MOVING RIGHT LOWER EXTREMITIE, GRIMICING W/ MOUTH CARE/SUCTIONING. BUT CONTINUES TO BE POSTURING. CT NEGATIVE. PT HAD RECEIVED 2MG IV ATIVAN BY EW NURSE WHILE IN CT.\n\nRESP: PT CONTINUES ON VENT SETTINGS OF 550X10 PEEP5 AT 50%. PT X1 FOR SCANT AMT THIN CLEAR SECRETIONS. LS CLEAR. O2 SATS 100%. RR 14-20. CT CHEST NEGATIVE. FREQUENT MOUTH CARE GIVEN DUE TO PT NOT CLOSING MOUTH.\n\nCV: HR NSR 60-70'S, NO ECTOPY. SBP 88-120'S. PT CONT ON IV NSW/20KCL AT 150CC/HR. NO EDEMA NOTED. PT MAX TEMP 100.6 AX.\n\nGI/GU: ABD SOFT, +BS, +BM. PT HAS HAD 4BM. LAST BM WAS BROWN/MAROON MUCOUS. GIUAC +. MD AWARE. PT NPO. FOLEY INTACT DRAINING CLEAR AMBER URINE ~5CC/HR. PT GIVEN 500CC BOLUS X2 FOR LOW U/O. POST BOLUS U/O 70CC.\n\nSKIN: SKIN WARM, PALE. INTACT. SMALL RED PATCHES NOTED ON CHEST AND BACK. PT T&P.\n\nACCESS: PT ARRIVED IN MICU W/ 3PIV. #16G X2 AND ONE #18G. ALL WNL.\n\nDISPO: AT THIS TIME MICU TEAM STILL UNAWARE OF CAUSE FOR CHANGE IN MENTAL STATUS. CONTINUE TO GIVE IVF FOR DEHYDRATION. NEURO TO PT THIS AM. POSSIBLE MRI AND EEG TODAY. MD SPOKE WITH PT'S NIECE OVER THE PHONE IN EW, THE NIECE HAD STATED TO MD THAT PT IS DNR. NO CONNTACT FROM FAMILY WHILE PT IN MICU. PT IS AN DNR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-11-08 00:00:00.000",
"description": "Report",
"row_id": 1423324,
"text": "MICU-B, NPN:\n\nNeuro: Pt. sedated on 10 mcg/hr Propofol @ start of shift. Prop. gtt off @ 10:30. Pt. remained unresponsive except for slight withdrawal from noxiuos stimuli until 14:30-15:00. Pt. became agitated, biting ET tube,does not follow commands well. Moving q 4 extremities, cont. soft wrist restraints.\n\nCV: HR 60's-low 90's, SBP 120's-160, no ectopy, 0 edema. IVF NS with 20mEq Kcl @ 100cc/hr. 3 working periph. IV's. Plan is to keep SBP up to ensure adequate cerebral perfusion/prevent further risk for MS changes.\n\nHeme/lytes: WNL\n\nResp: Lungs are clear upper lobes bilat. and diminished bilat. lower lobes. Pt. vented on 5 CPAP and 5 PS with O2Sats mid to high 90's. Plan was to extub. so pt. placed on 40% T-piece, tolerated well. Team needed to confirm DNI status with proxy but unable to contact by telephone. Pt placed back on vent after 1.5 hr on T-piece (5 CPAP 5 PS) until nephew, who is the proxy, can be contact. Pt. has producted cough/ suxn'd. for moderate amnts. thick, white sputum.\n\nGI: Pt. NPO. No tube feeds/nutitional support. @ this time. BS increased after Prop. gtt off. No BM today.\n\nDerm: D&I\n\nSocial/Dispo: Plan is to extub/call out after proxy/DNI status contact and confirmed. Pt. is DNR. Needs to go to floor with celar DNR/DNI status.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-11-08 00:00:00.000",
"description": "Report",
"row_id": 1423325,
"text": "ADDENDUM- MICU-B, NPN, :\n\nPt. extubated @ 17:45. O2Sat mid 90's-100's on 40% CN. Pt. yankauered for moderate amnts. thick white sputum, able to cough up small amnts. independently. Given 1 mg IV Haldol for increasing agitation. Will monitor MS/maintain safety.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-11-07 00:00:00.000",
"description": "Report",
"row_id": 1423320,
"text": "CCU NSG PROG NOTE: AM'S\nRemains intubated on psv w/ good volumes (30% fio2 5psv w/ spont vt 500-700cc). Sx moderate secretions, copious oral secretions. Clear lungs to aus. Remains intubated for airway protection, will extubate when more awake. +gag +cough.\n\nPropofol off 1000, responsive to any stimuli, mae, combative, appropriate movement. Does not respond to commands, does not interact.EEG done, results pnd. For LP tonight.\n\nV.S.S., afebrile\n\nPlan: extubate when awake. LP. Discuss cogentine dose. For re-write of neutraphos (discussing giving it iv)\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-11-07 00:00:00.000",
"description": "Report",
"row_id": 1423321,
"text": "Patient remains on CPAP 5 without any difficulty.Good RSBI , but too somenolant to pull ETT. No recent ABG seen,patient generating good VT and VE.Sat 99%,BP 122/86,HR 90 will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-11-08 00:00:00.000",
"description": "Report",
"row_id": 1423322,
"text": "NURSING MICU NOTE 7P-7A\n\nNEURO: AT START OF SHIFT PT AGITATED, RESPONDING TO VOICE STIMULI, NOT ABLE TO FOLLOW COMMANDS, MAE. PT BECAME INCREASING AGITATED AS NIGHT WNET ON. PT WAS RESTARTED ON PROPOFOL GTT AT 10MCG/KG/MIN. DRIP TURNED OFF Q4 FOR NEURO CHECKS. AFTER 20 MIN PT BECOMES AGITATED RESPONDING TO PAIN STIMULI, MAE. PT CONTINUES TO MAVE MODERATE AMT RIGIDITY, BUT LESS THEN ON ADMISSION. PT REMAINS ON IM COGENTIN .\n\nRESP: NO VENT CHANGES MADE, PT CONTINUES ON PS 5/5 30%. RR10-20. O2 SATS 97-100%. PT FOR LG AMT ORAL SECREATION. ETT Q2 FOR SMALL AMT THICK TAN SECREATIONS. LS CLEAR/DIMINISHED AT BASES.\nEET ROTATED.\n\nCV: HR 70-80'S NSR, NO ECTOPY NOTED. SBP 110-190'S. PRIOR TO PROPOFOL GTT SBP AS HIGH AS 190. MAX TEMP 99.\n\nGI/GU: ABD SOFT, HYPO BS, NO BM. FOLEY INTACT DRAINING ~30CC/HR AMBER URINE.\n\nACCESS: ALL PIV INFILTRATED OVERNIGHT. PT HAS THREE NEW PIV, 2 #18G AND 1 #20G.\n\nDISPO: PT REMAINS INTUBATED FOR AIRWAY PROTECTION. ? WHEN POSSIBLE FOR EXTUBATION. LP FOR TODAY. CONTINUE TO MONITOR MENTAL STATUS. NO CONTACT FROM FAMILY OVERNIGHT. PT REMAINS A DNR.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-11-08 00:00:00.000",
"description": "Report",
"row_id": 1423323,
"text": "Patient on T-Piece 40% HR 74, RR 20, BP 150/72, Sat 100%. Patient for small amount of white thick sputum; confortable will be closely monitored.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-11-06 00:00:00.000",
"description": "Report",
"row_id": 1423318,
"text": "MICU NPN 7AM-7PM:\nNeuro: Pt somnolent but seems more responsive than previously described. Grimace to sternal rub. Withdraws and stiffens up to noxious stimuli. Kicking legs in air at the neuro team during their exam. Has strong cough but weak and difficult to elicit gag reflex. be started on cogentin as recommended by neuro and may have LP done later today. Also plan for EEG but probably not today. Family was in to visit today and health care proxy spoke to intern on call and got an update. He remains DNR and discussions regarding inserting NGT for meds is ongoing since this was listed in his proxy form to not be done for feedings.\n\nCardiac: BP stable as well as HR. No VEA noted.\n\nResp: Weaned down to 5PSV and 5cm peep with 30% FIO2. Good ABG and sats remain stable. Will most likely leave him intubated tonight and plan for possible extubation tomorrow. Small amt thick pale yelow secretions noted via the ETT. Lungs are clear with deminished sounds at the bases.\n\nGI: Passed small amts mucous stool twice today. NPO. No NGT for now.\n\nGU: Urine remains amber in color. UO 30-40cc/hr today. IVF changed to NS w/20meq KCL at 100cc/hr.\n\nID: Low grade temp at 100.2 rectal this AM. Down to 98 this evening. No antibiotics currently oredered.\n\nIV's: Continues to habe good peripheral IV access with three working IV's.\n\nSocial: Pt never married. His brother's son is his healthcare proxy. was in to visit today and spoke to team regarding his uncles condition.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-11-07 00:00:00.000",
"description": "Report",
"row_id": 1423319,
"text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT AT START OF SHIFT WAS ABLE TO OPEN EYES SPONTANEOUSLY, MAE, NOT ABLE TO FOLLOW COMMANDS. PT BECAME INCREASING AGITATED, APPEARED TO BE ATTEMPTING TO MOUTH WORDS. MD NOTIFIED, DECISION MADE TO SEDATE PT W/ PROPOFOL GTT OVERNIGHT. PT ON PROPOFOL 12MCG/KG/MIN. PROPOFOL TURNED OFF FOR NEURO CHECKS Q4. WHEN GTT OFF PT IS AGITATED, MAE, RIGID, OPENS EYES TO STIMULI. PT STARTED ON IM COGENTIN.\n\nRESP: PT REMAINS ON PS 5/5 AT 30%. RR 13-28. RISBI DONE THIS AM, 33. PT FOR LG AMT ORAL SECRETIONS, MOUTH CARE Q2HRS. ETT SCUTIONED X4 FOR SMALL AMT THICK TAN SECRETIONS. LS CLEAR.\n\nCV: HR 60-70'S NSR W/ NO ECTOPY. SBP 88-160'S. MAX TEMP 99.0.\n\nGI/GU: ABD SOFT, +BS, +BM. FOLEY DRAINING YELLOW URINE. PT GIVEN 10MG IV LASIX. U/O ~2L OVERNIGHT. PT REMAINS +2L.\n\nDISPO: PLAN IS TO THIS AM EXTUBATE PT. CONTINUE TO MONITOR NEURO STATUS. NO CONTACT FROM FAMILY OVERNIGHT. PT REMAINS A DNR.\n"
}
] |
59,612 | 144,737 | PRINCIPLE REASON FOR ADMISSION This is a 47 yo M w/ PMH of HCV, prior GIB in from peptic ulcer, presenting with sudden onset of hematemesis and blood in NG lavage that did not clear; EGD showed 2-3mm ulcer with associated gastritis. ACTIVE PROBLEMS #PUD: Patient with UGIB on presentation, and admitted to MICU as blood did not clear in NG lavage. PPI gtt was started and hematcrit was stable overnight in MICU. The morning after admission, he was found to have 2-3cm bleeding ulcer in fundus of stomach in addition to diffuse gastritis, esophagitis and duodenitis on EGD. Ulcer was clipped, and patient was trasferred to the floor o po PPI. Hematocrit remained stable on the floor and patient was discharged home with GI follow up with H. pylori biopsy pending at time of discharge. #Abdominal pain: Patient with RUQ pain in setting of bleeding GI ulcer. Of note, patient with question of narcotic abuse and drug seeking behavior per PCP . Patient received IV morphine in the MICU, but no additional narcotics were provided on the floor. # : Patient presented with Cr to 1.6 in setting of upper GI bleed. Resolved and decreased to 0.8 after hydration overnight. # Lung nodule - Incidentally noted on CXR on admission. Repeat films with nipple markers did not redemonstrate the nodule. Recommend repeat film in months. CHRONIC PROBLEMS # Chronic hepatitis C. Patient with known hepatitis C, and elevated transmaminases. Unknown genotype and never been treated. CT scan in with no evidence of cirrhosis or splenomegaly. Synthetic function with INR, albumin and CBC appear to be grossly normal. No signs of liver masses on CT in 7/. HCV viral load of 17,400,000 IU/mL in . # Back Pain: Chronic. Extensive workup in past, with large narcotic requirement. Patient currently not on narcotics, and concern for abuse per PCP. treated with gabapentin 800 qid per patient report. Patient was given gabapentin 300 in setting of ARF, and increased to tid on the floor. Patient was discharged without prescription for any add'l pain medication. He was instructed to avoid NSAIDs. # Psych: Patient with hx of depression, anxiety and adhd. Reportedly well controlled, pt denies feeling depressed. Adderall was held during admission. Clonazepam and sertraline continued at home dose. TRANSITIONAL ISSUES -Will need GI follow with repeat EGD per GI recs -FU H.Pylori and treat if necessary -Repeat Chest film in months to monitor nodule seen on admission CXR Medications on Admission: -Prilosec - has not been taking as prescribed -Gabapentin 800mg QID per pt -adderall 30mg TID -Zoloft 50mg QD -Klonopin 2mg TID Discharge Medications: 1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 2. gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times a day. 3. Adderall 30 mg Tablet Sig: One (1) Tablet PO three times a day. 4. Zoloft 50 mg Tablet Sig: One (1) Tablet PO once a day. 5. clonazepam 2 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety: Do not drink or drive while taking this medication. Discharge Disposition: Home Discharge Diagnosis: Peptic Ulcer Disease Upper GI Bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. , You were admitted to the hospital for an episode of bloody vomit. We did an EGD, which showed an ulcer in your stomach had started to bleed. We stopped the bleeding and your blood counts remained stable. You will need to keep taking omeprazole 40 mg by mouth twice daily and avoid NSAID's (like ibuprofen), alcohol, and caffeine. You should not eat within 30 minuts of going to bed. You need to follow up with Dr. in the clinic in weeks. You will also need repeat EGD in weeks. Followup Instructions: You will need to follow up with Dr. in the clinic in weeks by calling (. It is very important to make this appointment to ensure healing of your ulcer. Please follow up with your primary care doctor within the next week. | In the absence of a repeat AP view with nipple markers, it is difficult to completely exclude whether the nodular opacity represented a nipple shadow on the prior film. Linear opacity in the RLL, likely pulmonary vasculature. The NG tube has been removed in the interim. The nodule, which appear to overlie the right anterior fifth rib near its crossing point with the right ninth rib on the film obtained at 16:44 p.m., is not distinctly identified on these views. A repeat PA and lateral radiograph with shallow obliques and nipple markers is recommended to rule out a nodule in the right lower lobe. IMPRESSION: No acute intrathoracic process. No acute pulmonary process is identified. No acute pulmonary process is identified. No evidence of intraperitoneal free air is noted. No evidence of intraperitoneal free air. CHEST, THREE VIEWS (2 shallow obliques, 1 lateral): No frontal PA view to correlate with the prior film was obtained. An NG tube passes with its tip out of view below the diaphragm. Mild deformity of the left scapula incidentally noted. No pleural effusion or pneumothorax is present. COMPARISON: No relevant comparisons available. FINAL REPORT HISTORY: Incidentally noted nodule, nipple markers. The nodular opacity seen on the 16:44 p.m. x-ray examination is not definitively identified on the current examination. REASON FOR THIS EXAMINATION: Reevaluate nodule with nipple markers and shallow obliques FINAL REPORT HISTORY: Incidentally found nodule, evaluate with nipple markers and shallow oblique views. free air REASON FOR THIS EXAMINATION: {See Clinical Indication Field} No contraindications for IV contrast FINAL REPORT INDICATION: 47-year-old male with blood and vomit and left upper quadrant pain. 12:54 PM CHEST (PA & LAT) Clip # Reason: Eval for nodule with nipple markers Admitting Diagnosis: UPPER GI BLEED MEDICAL CONDITION: 47 year old man with incidentally noted nodule REASON FOR THIS EXAMINATION: Eval for nodule with nipple markers WET READ: KKgc SAT 1:43 PM No defnite pulmonary nodule seen. The cardiomediastinal silhouette, hilar contours, and pleural surfaces are normal. AP and lateral views obtained with nipple markers. Recommend additional AP view, similar to that obtained on , with nipple markers in place. Nipple markers are in place. 8:13 PM CXR WITH NIPPLE MARKERS 2 VIEWS; CHEST (SINGLE VIEW) Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: Reevaluate nodule with nipple markers and shallow obliques Admitting Diagnosis: UPPER GI BLEED MEDICAL CONDITION: 47 year old man with incidentally found nodule. Question free air. 4:49 PM CHEST (PORTABLE AP) Clip # Reason: {See Clinical Indication Field} MEDICAL CONDITION: History: 47M with blood in vomit, LUQ pain Clinical Question: ? Alternatively a PA view could be obtained. Recommend followup radiograph in four to six months to confirm stability. ONE VIEW OF THE CHEST: The lungs are well expanded and show a nodule in the right lower lobe. | 3 | [
{
"category": "Radiology",
"chartdate": "2169-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1230250,
"text": " 4:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 47M with blood in vomit, LUQ pain Clinical Question: ? free air\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old male with blood and vomit and left upper quadrant\n pain. Question free air.\n\n COMPARISON: No relevant comparisons available.\n\n ONE VIEW OF THE CHEST:\n\n The lungs are well expanded and show a nodule in the right lower lobe. The\n cardiomediastinal silhouette, hilar contours, and pleural surfaces are normal.\n No pleural effusion or pneumothorax is present. An NG tube passes with its\n tip out of view below the diaphragm. No evidence of intraperitoneal free air\n is noted.\n\n IMPRESSION:\n\n No acute intrathoracic process. No evidence of intraperitoneal free air.\n\n A repeat PA and lateral radiograph with shallow obliques and nipple markers is\n recommended to rule out a nodule in the right lower lobe.\n\n These findings were communicated to via telephone on 5:37 pm on\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-03-03 00:00:00.000",
"description": "CXR WITH NIPPLE MARKERS 2 VIEWS",
"row_id": 1230419,
"text": " 8:13 PM\n CXR WITH NIPPLE MARKERS 2 VIEWS; CHEST (SINGLE VIEW) Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: Reevaluate nodule with nipple markers and shallow obliques\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with incidentally found nodule.\n REASON FOR THIS EXAMINATION:\n Reevaluate nodule with nipple markers and shallow obliques\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Incidentally found nodule, evaluate with nipple markers and shallow\n oblique views.\n\n CHEST, THREE VIEWS (2 shallow obliques, 1 lateral):\n\n No frontal PA view to correlate with the prior film was obtained.\n\n Nipple markers are in place. The nodule, which appear to overlie the right\n anterior fifth rib near its crossing point with the right ninth rib on the\n film obtained at 16:44 p.m., is not distinctly identified on these\n views. In the absence of a repeat AP view with nipple markers, it is difficult\n to completely exclude whether the nodular opacity represented a nipple shadow\n on the prior film.\n\n Recommend additional AP view, similar to that obtained on , with nipple\n markers in place. Alternatively a PA view could be obtained.\n\n The NG tube has been removed in the interim. No acute pulmonary process is\n identified. Mild deformity of the left scapula incidentally noted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-03-04 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1230484,
"text": " 12:54 PM\n CHEST (PA & LAT) Clip # \n Reason: Eval for nodule with nipple markers\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with incidentally noted nodule\n REASON FOR THIS EXAMINATION:\n Eval for nodule with nipple markers\n ______________________________________________________________________________\n WET READ: KKgc SAT 1:43 PM\n No defnite pulmonary nodule seen. Linear opacity in the RLL, likely pulmonary\n vasculature.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Incidentally noted nodule, nipple markers.\n\n AP and lateral views obtained with nipple markers. The nodular opacity seen\n on the 16:44 p.m. x-ray examination is not definitively identified on\n the current examination. No acute pulmonary process is identified. Recommend\n followup radiograph in four to six months to confirm stability.\n\n"
}
] |
14,004 | 132,439 | Neuro: Pt. was found to have a large L MCA infarct on CT perfusion (see results above). She continued to have global aphasia and R hemiparesis throughout admission. TTE was performed and showed no evidence of cardiac source of thrombus. Lipid panel was checked and Lescol was increased as lipids were above goal. She was evaluated by speech and swallow, who felt that she would need a PEG for long term nutrition. This was discussed with her family, who felt that she would not want such an invasive procedure and said that they would want her care to focus on comfort. . Pulmonary: Pt. was noted to have stridor on exam and was tachypneic on the floor to the 40s. She was transferred to the ICU for close monitoring. CTA Chest was performed and showed no evidence of PE. She was seen by Pulmonary, who felt that she most likely had laryngeal edema causing her symptoms. She was evaluated by ENT who confirmed supraglottic edema, and she was treated with racemic epinephrine and a Decadron pulse with improvement in her respiratory status. . CV: Pt. was noted to go into a HR of 140s-160s intermittently on the floor. She was controlled with Metoprolol. | Mild (1+) aorticregurgitation is seen. abd softly distended, BS+. Wall motion.Height: (in) 66Weight (lb): 152BSA (m2): 1.78 m2BP (mm Hg): 177/46HR (bpm): 64Status: InpatientDate/Time: at 15:15Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: SalineTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Physiologic MR (within normal limits).TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs ofagitated normal saline at rest. CXR results pending.CVS - Sinus rhythm no ectopy. Cx sent.GI: Abd soft, NT, ND. Mild mitral annularcalcification. The mitral valve leaflets are mildly thickened.Physiologic mitral regurgitation is seen (within normal limits). BUN/Creatinine WNL, K 3.9, Mg 2.4, Ca 8.2, Phos 1.8 (awaiting repletion). Pressure areas intact.Social - No family contact.A - Continues with upper airway obstruction despite steroids, heliox. SC heparin and pneumoboots for DVT prophylaxis.Resp - Obvious upper airway obstruction. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. BUN/Creatinine WNL, K 3.5, Mg 1.9, Ca 8.7, Phos 2.7. Maintenance fluids 80ml/hr NS.Neuro - Unresponsive. There is an anterior spacewhich most likely represents a fat pad.IMPRESSION: Mild aortic regurgitation with mild aortic valve sclerosis. Focal calcifications inaortic root.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Normal regional LV systolic function. Maintenance fluid 80ml/hr NS.Neuro - Unresponsive, GCS 8 (e2v1m5), pupils 4mm/4mm brisk reactive, localising with left to sternal rub, withdrawing with right. Sinus bradycardiaRight bundle branch blockEarly precordial QRS transition -is nonspecificSince previous tracing of , no significant change Pt ordered for dextamethasone Q6, and PRN epi nebs. Occasional coughing-scant amt oral secretions sxn. Respiratory Care:Patient was placed on heliox with little airway resistance change noted. HCT 36.7%, Hb 13.0, Platelets 190, WCC 12.1. Protonix.GU: Foley draining less than adquate amts of clear yellow urine 10-40cc/hr (HO aware, and to monitor) Kphos repleted.Skin/IV: Skin remains intact. The IVC is normal in diameterwith collapse during respiration (estimated RAP 0-5mmHg).LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). WAS COMBATIVE/AGGITATED/LETARGIC IN ED. Suboptimal image quality - poor subcostal views.Conclusions:The left atrium is mildly dilated. LS with rhonchi in bilat lobes, dim in bilat bases. Withdrawing to nailbed pressure in all 4 ext. (F/U with Lactulose). soft/nontender/positive bowel sounds. soft/nontender/positive bowel sounds. Breath sounds coarse RUL/LUL, diminished RLL/LLL. F/U with cx results. SHE WAS UNABLE TO UNDERGO MRI DUE TO AGGITATION.ON ARRIVAL SHE RESPONDS TO VOICE, FOLLOWS SIMPLE COMMANDS, ABLE TO EXPRSS YES/NO WITH HEAD NODS AND SOUNDS.HAS R.SIDE WEAKNESS, PERL 4MM, NO SEIZURES NOTED.GETTING AGGITATED AT TIMES, AND SOMNOLENT MOST OF THE TIMESYSTEMS OVERVUE:ASSESSMENT AS NOTED IN CAREVUECV: GOAL TO KEEP SBP 120-200 PER MEUROMED, IN NSR, NO ECTOPYGU: FOLEY 14FR LEAKING, TRYING TO PUT A NEW ONE 18FR:STILL LEAKING, PT HAS NOW DIAPER ON-INCONTINENTGI: +BS NPO, NGT WAS INCERTED FOR MEDSSOCIAL: PT IS DNR EXP FOR INTUBATIONS NEEDED FOR TESTS PROCEDURES-DECIDED BY FAMILY WHO WAS IN LAST NIGHT AND TALKED TO RESIDENTPLAN: TO CTA HEAD TODAY IF TOLERATES, MONITOR NEURO, CV, PLEASE ARRANGE FAMILY MEETING TODAY WITH THE TEAM, ?TRANFER Opens eyes to strong sternal rub. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. TF at goal with minimal residuals. Nasal airway inserted for suctioning, no sputum on Q2 suction with Q2 Chest PT. Sputum cx sent.Neuro: Pt arouses to pain/sternal rub. Left ventricular function. Now on cool mist face tent.GI - Abdomen obese, soft, + BS. Peripheral pulses palpable. +pp, +csm.Resp: Nasal trumpet removed, no secretions present during NT sxn. HR 60-90bpm, SBP 150-190, MAP 85-100, Tmax 99.8. The aortic valve leaflets (3)are mildly thickened but aortic stenosis is not present. TSICU NPN-0700-1900Event: pt was to be tx to (tx note complete) however at last minute following pulmonary consult it was decided that pt resp status should continue to be monitored in ICU setting-and to be started on steroid therapy epi nebs, and heli/O2 therapy.Neuro: Pt arousable by noxious stimuli and not following commands. CXR clear, no repeat ABGs overnight. cap refill < 3sec in all extremeties. Nodiscrete vegetation or definite cardiac source of embolism identified.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). PO Bisacodyl given with no effect. Tmax 99.8. Nursing Progress Note:Events: Pt sent for lung scan; ruled out for PE. HCT 37.5%, Hb 13.4, WCC 13.3, Platelets 177. LS diminished in bases. Peripherally warm/well perfused/palpable pedal pulses. Peripherally warm/well perfused/palpable pedal pulses. HR 70-90bpm, SBP 140-190, MAP 70-110, Tmax 100.1. No evidence of pain.GI - NGT clamped, for meds only. Spo2 >94%, RR 30-45bpm. 250cc NS bolus x1 for low UOP.Endo - BS > 200 at 0000, covered per SS.Skin - Skin tear right hand OTA. +BS. GCS 8 (e2v1m5). UO 40-80ml/hr. Nonpurposeful spontaneous movement with right side/localising to pain, withdrawing to pain on left. No IVABs.Renal - Foley inserted upon arrival in T/SICU, light yellow urine. BUBBLE STUDY /PFO. Cough/gag impaired. MAEs, pt doesn't appear to be in any pain (no changes in vitals/pt appearing comfortable).CV: NIBP 150's over 80's, HR 80's, NSR. SBP 130s to 160s by cuff. Breath sounds coarse to RUL/LUL, diminished to RLL/LLL, difficult to auscultate due to upper airway breathing. CT WAS NEG FOR BLEED, ? Blood glucose stable with ISS.Skin - Grossly intact. The estimated right atrial pressure is 0-5mmHg. No evidence of pain.GI - TF continue at goal rate 50ml/hr. UOP 30-40 ml/hr.Endo: FSBS per SS.ID. Pulm toilet. Pressure areas intact.Access - 1x18g PIV in left hand.Social - Very supportive family, will visit tomorrow.PLAN - Replete lytes Transfer back to 5 Monitor resp status SBP 150-170, maintaining <200. Right ventricularchamber size and free wall motion are normal. Abg's drawn x2, WNL. | 10 | [
{
"category": "Echo",
"chartdate": "2148-01-15 00:00:00.000",
"description": "Report",
"row_id": 102274,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Left ventricular function. Valvular heart disease. BUBBLE STUDY /PFO. Wall motion.\nHeight: (in) 66\nWeight (lb): 152\nBSA (m2): 1.78 m2\nBP (mm Hg): 177/46\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 15:15\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC is normal in diameter\nwith collapse during respiration (estimated RAP 0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Physiologic MR (within normal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\nagitated normal saline at rest. Patient was unable to cooperate with\nmaneuvers. Suboptimal image quality - poor subcostal views.\n\nConclusions:\nThe left atrium is mildly dilated. No right-to-left passage of microbubbles is\nidentified at rest. The estimated right atrial pressure is 0-5mmHg. Left\nventricular wall thickness, cavity size, and systolic function are normal\n(LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened.\nPhysiologic mitral regurgitation is seen (within normal limits). The pulmonary\nartery systolic pressure could not be determined. There is an anterior space\nwhich most likely represents a fat pad.\n\nIMPRESSION: Mild aortic regurgitation with mild aortic valve sclerosis. No\ndiscrete vegetation or definite cardiac source of embolism identified.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2148-01-14 00:00:00.000",
"description": "Report",
"row_id": 294336,
"text": "Sinus bradycardia\nRight bundle branch block\nEarly precordial QRS transition -is nonspecific\nSince previous tracing of , no significant change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-18 00:00:00.000",
"description": "Report",
"row_id": 1445138,
"text": "TSICU NPN-0700-1900\nEvent: pt was to be tx to (tx note complete) however at last minute following pulmonary consult it was decided that pt resp status should continue to be monitored in ICU setting-and to be started on steroid therapy epi nebs, and heli/O2 therapy.\n\nNeuro: Pt arousable by noxious stimuli and not following commands. Pt did open eyes briefly in response to grandaughters voice this afternoon.. PERRLA 4mm, briskly react. MAEs, pt doesn't appear to be in any pain (no changes in vitals/pt appearing comfortable).\n\nCV: NIBP 150's over 80's, HR 80's, NSR. +pp, +csm.\n\nResp: Nasal trumpet removed, no secretions present during NT sxn. Occasional coughing-scant amt oral secretions sxn. Pt's breathing continues to be rapid and shallow. RR 20's-40, O2 sats >96% on 40% FM. Pt ordered for dextamethasone Q6, and PRN epi nebs. Epi neb given at 1800 with good effect (briefly).\n\nGI: TF continues at 50cc/hr (goal) with residuals <20.\n abd softly distended, BS+. PO Bisacodyl given with no effect. (F/U with Lactulose). Protonix.\n\nGU: Foley draining less than adquate amts of clear yellow urine 10-40cc/hr (HO aware, and to monitor) Kphos repleted.\n\nSkin/IV: Skin remains intact. (2) PIV in Ue's-WNL.\n\nID: Tmax 99.9, continues on Cipro for ?pnemonia.\n\nEndo: BS controlled per RISS\n\nSocial: Multiple family members in to visit today and have been updated on POC. Family has decided to continue with DNR/DNI status.\n\nPOC: Continue to monitor resp status/tx as ordered\n Update family on POC\n replete lytes as needed\n tx to floor once resp status deemed \"stable\"\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-19 00:00:00.000",
"description": "Report",
"row_id": 1445139,
"text": "Respiratory Care:\nPatient was placed on heliox with little airway resistance change noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-19 00:00:00.000",
"description": "Report",
"row_id": 1445140,
"text": "TSICU Nursing Progress Note\nNeuro - PERRL. Pt opened eyes x1 when turning, did not track. Appeared to follow commands early in shift when asked to wiggle toes (moved on left) but unable to replicate through rest of shift. Purposeful movement with left arm.\n\nCV - SR with rare PACs. SBP 130s to 160s by cuff. Peripheral pulses palpable. SC heparin and pneumoboots for DVT prophylaxis.\n\nResp - Obvious upper airway obstruction. Heliox attempted with no change observed in upper airway noise, work of breathing, RR or O2 sat. LS diminished in bases. Now on cool mist face tent.\n\nGI - Abdomen obese, soft, + BS. TF at goal with minimal residuals. Lactulose with resulting large soft brown stool.\n\nGU - Borderline UOP. 250cc NS bolus x1 for low UOP.\n\nEndo - BS > 200 at 0000, covered per SS.\n\nSkin - Skin tear right hand OTA. Pressure areas intact.\n\nSocial - No family contact.\n\nA - Continues with upper airway obstruction despite steroids, heliox. Hyperglycemia on steroids.\n\nP - Continue to monitor resp status. Monitor and treat hyperglycemia. Discuss condition with family.\n\nP -\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-17 00:00:00.000",
"description": "Report",
"row_id": 1445136,
"text": "Nursing Progress Note:\nEvents: Pt sent for lung scan; ruled out for PE. Abg's drawn x2, WNL. Sputum cx sent.\n\nNeuro: Pt arouses to pain/sternal rub. Opens eyes to strong sternal rub. Withdrawing to nailbed pressure in all 4 ext. Localizing to pain with RUE. RUE stronger than LUE. Does not follow commands. Pt non-verbal. No s/s of pain.\n\nCV: NSR, no ectopy. HR 70-80. SBP 150-170, maintaining <200. cap refill < 3sec in all extremeties. +PP.\n\nResp: Pt on face tent, 50% FIO2. Sats 98-100%. RR 30-40. LS with rhonchi in bilat lobes, dim in bilat bases. Orally sx several times producing thick brown sputum. Cx sent.\n\nGI: Abd soft, NT, ND. +BS. TF at goal rate of 50ml/hr. Residuals <10ml.\n\nGU: FOley draining clear yellow urine. UOP 30-40 ml/hr.\n\nEndo: FSBS per SS.\n\nID. Tmax 99.8. Pt to start on ciprofloxacin this evening.\n\nSkin: no apparent issues.\n\nSocial: Pt's children in to visit today. spoke at length with family about plan of care.\n\nPlan: Neuro checks q4hrs. Pulm toilet. F/U with cx results. Abd and Head CT later tonight.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-18 00:00:00.000",
"description": "Report",
"row_id": 1445137,
"text": "T/SICU Shift Report 1900-0730\n89 Year Old Female Allergy - PCN DNR/DNI Universal Precautions\n\nAdm - MCA stroke\n\nPMH - CAD/Hypertension/Hypercholesterolemia/MI\n Hard of Hearing\n\nShift events - CTA Chest - No Pulmonary Embolism\n CT Head - No extension of stroke/hemorrhage\n\nReview of Systems:\n\nResp - SV on face tent FiO2 35%. Spo2 >94%, RR 30-45bpm. Breath sounds coarse RUL/LUL, diminished RLL/LLL. Nasal airway inserted for suctioning, no sputum on Q2 suction with Q2 Chest PT. CXR results pending.\n\nCVS - Sinus rhythm no ectopy. HR 70-90bpm, SBP 140-190, MAP 70-110, Tmax 100.1. HCT 37.5%, Hb 13.4, WCC 13.3, Platelets 177. Peripherally warm/well perfused/palpable pedal pulses. Started on Cipro for presumed pneumonia.\n\nRenal - UO 15-60ml/hr via foley, ?bypassing. Positive 1500ml in previous 24hours, positive 4000ml for LOS. BUN/Creatinine WNL, K 3.9, Mg 2.4, Ca 8.2, Phos 1.8 (awaiting repletion). Maintenance fluid 80ml/hr NS.\n\nNeuro - Unresponsive, GCS 8 (e2v1m5), pupils 4mm/4mm brisk reactive, localising with left to sternal rub, withdrawing with right. Nonpurposeful movement with Left. No evidence of pain.\n\nGI - TF continue at goal rate 50ml/hr. soft/nontender/positive bowel sounds. No BM since admission. Blood glucose stable with ISS.\n\nSkin - Full bed bath/hairwash overnight. Pressure areas intact. Side-side lying overnight.\n\nAccess - PIVx1\n\nSocial - Son called overnight, updated.\n\nPLAN - ?Transfer to floor\n Replete lytes\n Monitor respiratory status\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-15 00:00:00.000",
"description": "Report",
"row_id": 1445133,
"text": "THIS TEAM PT CAME IN FROM ED AFTER BEING ADMITTED FROM HOME WHERE SHE WAS FOUND WITH MS CHANGES AND WAS UNABLE TO SPEAK AND HAD FACIAL DROOP. WAS COMBATIVE/AGGITATED/LETARGIC IN ED. CT WAS NEG FOR BLEED, ? ISCHEMIC STROKE L.LACUNAR INFARCT. SHE WAS UNABLE TO UNDERGO MRI DUE TO AGGITATION.\nON ARRIVAL SHE RESPONDS TO VOICE, FOLLOWS SIMPLE COMMANDS, ABLE TO EXPRSS YES/NO WITH HEAD NODS AND SOUNDS.HAS R.SIDE WEAKNESS, PERL 4MM, NO SEIZURES NOTED.GETTING AGGITATED AT TIMES, AND SOMNOLENT MOST OF THE TIME\u0013\n\nSYSTEMS OVERVUE:ASSESSMENT AS NOTED IN CAREVUE\n\nCV: GOAL TO KEEP SBP 120-200 PER MEUROMED, IN NSR, NO ECTOPY\n\nGU: FOLEY 14FR LEAKING, TRYING TO PUT A NEW ONE 18FR:STILL LEAKING, PT HAS NOW DIAPER ON-INCONTINENT\n\nGI: +BS NPO, NGT WAS INCERTED FOR MEDS\n\nSOCIAL: PT IS DNR EXP FOR INTUBATIONS NEEDED FOR TESTS PROCEDURES-DECIDED BY FAMILY WHO WAS IN LAST NIGHT AND TALKED TO RESIDENT\n\nPLAN: TO CTA HEAD TODAY IF TOLERATES, MONITOR NEURO, CV, PLEASE ARRANGE FAMILY MEETING TODAY WITH THE TEAM, ?TRANFER\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-15 00:00:00.000",
"description": "Report",
"row_id": 1445134,
"text": "NPN:\n\nPlease refer to Transfer Note\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-01-17 00:00:00.000",
"description": "Report",
"row_id": 1445135,
"text": "T/SICU Admission Note\n89 Year Old Female DNR/DNI Allergy - PCN Universal Precautions\n\nAdmission - Ischemic stroke\nReadmission - Respiratory distress\n\nPMH - MI/Hypertension/Hyperlipidemia\n Diverticulitis\n\nPatient transferred to 5 with reduced mental status. ?aspiration of oral secretions, increased RR. CO2 35, O2 59 on RA. Neuromedicine concerned about impending respiratory failure.\n\nReview of Systems:\n\nResp - SV on 3l FiO2 via NC. SpO2>95%, RR 30-40bpm. Breath sounds coarse to RUL/LUL, diminished to RLL/LLL, difficult to auscultate due to upper airway breathing. CXR clear, no repeat ABGs overnight. No use of accessory muscles, no nasal flaring, no abdominal breathing.\n\nCVS - Sinus rhythm rare PVCs. HR 60-90bpm, SBP 150-190, MAP 85-100, Tmax 99.8. HCT 36.7%, Hb 13.0, Platelets 190, WCC 12.1. Peripherally warm/well perfused/palpable pedal pulses. No IVABs.\n\nRenal - Foley inserted upon arrival in T/SICU, light yellow urine. UO 40-80ml/hr. BUN/Creatinine WNL, K 3.5, Mg 1.9, Ca 8.7, Phos 2.7. Maintenance fluids 80ml/hr NS.\n\nNeuro - Unresponsive. GCS 8 (e2v1m5). Pupils 4mm/4mm brisk reactive. Nonpurposeful spontaneous movement with right side/localising to pain, withdrawing to pain on left. Cough/gag impaired. No evidence of pain.\n\nGI - NGT clamped, for meds only. soft/nontender/positive bowel sounds. No BM since admission. Blood glucose stable with ISS.\n\nSkin - Grossly intact. Given full bed bath/hairwash overnight. Pressure areas intact.\n\nAccess - 1x18g PIV in left hand.\n\nSocial - Very supportive family, will visit tomorrow.\n\nPLAN - Replete lytes\n Transfer back to 5\n Monitor resp status\n\n"
}
] |
91,086 | 102,972 | 27 year old male with a history of polysubstance abuse, depression with SIs, admitted after found down (obtuneded), with anoxic brain injury (per MRI/EEG). Hospital course complicated by Rhabdo, ARF, Aspiration PNA->respiratory failure/intubation. Medical issues stable, slow recovery from anoxic brain injury, going to rehab for PT/OT/speech therapy. 1)Anoxic brain injury/found down: The ultimate etiology of the patient's initial obtundation remains unclear. conflicting stories from the various interested parties (girlfriend, family, etc...) and conflicting reports about the patient's substance use prior to arrival at . Per notes patient received methadone at 8:00 pm and next seen 9:00 am next morning at which time he was unresponsive and hypoxic. Possible overdose vs seizure vs serotonin syndrome. Of course, given history of opioid abuse there is concern the patient may have overdosed. His drug screen was only positive for methadone. Of note, his mental status did not resolve after receiving naloxone, but it is possible that at that point anoxic brain injury was primary mechanism of obtundation. Other possible primary insults would include seizure (though not supported by EEG) or serotonin syndrome due to trazodone in addition to his SSRI. At presentation to the hospital as the patient was noted to have clonus, hypertension, and fever there was increased concern for serotonin syndrome so toxicology was consulted and on their recommendation the patient received a course of cyproheptidine (antidote to serotonin syndrome) with no clear improvement. In the ED tox screen was negative except for methadone and CT revealed only bilateral hypodensity in the globus pallidus. The patient did spike a fever so also had an LP, which showed no pleiocytosis or findings concerning for meningitis. Osmolality was also checked and the patient had no osmolal gap suggesting there had been no ingestion of non-ethanol alcohols. Over the following days the patient's other pathologies (respiratory distress/PNA, hypotension, ARF etc...) continued to resolve but he continued to have altered MS and not localize to noxious stimuli or follow commands. Repeat CT showed persistent hypodensity of the globus pallidus bilaterally. Neurology consult was called and thought this was most consistent with anoxic brain injury but recommended MRI/MRA and EEG. MRI/MRA showed findings consistent with anoxic brain injury and EEG revealed extensive areas of restricted diffusion involving the white matter, corpus callosum, both globus pallidus and right hippocampus indicative of acute infarct/ischemia likely due to global hypoxia. EEG showed findings consistent with global encephalopathy without lateralizing or epileptiform activity. The patient's family was informed of these findings and a likely unfavorable prognosis. Nevertheless, after extubation the patient did begin to answer simple questions appropriately and speak to his family though he did continue to not be aware of his name or situation intermittently and reported he was unable to move his extremities, but intermittently had reflexive movements. Upon transfer to the medical floor, his mental status continued to improve very slowly. He was able to speak coherently, raise his limbs against gravity, take POs w/o aspiration. He was evaluated by PT/OT and speech therapy who recommended rehabilitation for further regaining of mobility/speech therapy. His current MS waxes/wanes. He can be uncooperative when awake trying to climb out of bed. At other times, he is calm. Also on klonipin for tremors per neuro which has sedating effect, thus dose decreased 1mg -->0.5mg tid. . Other issues during hospitalization were: Hypoxemic respiratory failure, extubated , aspiration PNA/pneumonitis. sputum cx with OP flora supported aspiration Dx. initially broad Abx (vancomycin, pipercillin/tazobactam, and levofloxacin)---> unasyn until (7days). Currenlty doing well on RA. . Rhabdomyolisis with ARF/ATN, transamintitis. CKs up to 25K, Creat peak 4.8, initially anuric, s/p 7L fluids with improvement. Now creat plateued 24/1.6 (X5days) by time of discharge, likely his new baseline. LFTs and CKs also much improved, should have complete metabolic panel checked every few days for next couple weeks. Needs f/u PCP . . Fever of Unknown Origin: The patient was persistently febrile throughout first part of his hospital stay. Blood cultures persistently negative and no other localizing signs except possible aspiration pneumonia (thought unlikely as respiratory status was improving). Had some diarrhea (on lactulose), c-diff neg X2. He eventually defervesced without any intervention and has been afebrile for several days . Rashes: The patient had areas of erythema on his medial knees at presentation with some vesicles. These were cultured for herpes and were negative. Thought most likely due to pressure injury when found down. A wound care consult was called for concern for skin breakdown, and he was placed on a First Step mattress. . Tremors and diaphoresis: He was noted to be tremulous and diaphoretic during his stay. He had a normal TSH, and a resolving fever and WBC count. He was placed on Klonopin for tremors. this dose was reduced to 0.5mg tid on day of discharge given increased somnolence with 1mg dose. . Depression and polysubstance abuse. He was followed by psychiatry and social work during his stay. He did not express suicidal ideations during his stay. He was briefly on a one-to-one sitter. His celexa was not resumed on discharge, and he will require psychiatric follow up as an outpatient. | There isno pericardial effusion.IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavitysizes and regional/global biventricular systolic function. As before, there is partial opacification of the bilateral ethmoid sinuses. Mild pulmonary edema persists presumably neurogenic. Partial opacification of the bilateral ethmoid and right maxillary sinus. Mild PAsystolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor apical views.Conclusions:The left atrium and right atrium are normal in cavity size. There is partial opacification of the bilateral ethmoid sinuses and right maxillary sinus. Allowing the difference in positioning of the patient cardiomediastinal contours and small right pleural effusion are unchanged DR. Mild pulmonary edema, presumably neurogenic, persists. Mild pulmonary edema, presumably neurogenic, persists. Stable partial opacification of the bilateral ethmoid sinuses. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 72Weight (lb): 230BSA (m2): 2.26 m2BP (mm Hg): 161/96HR (bpm): 96Status: OutpatientDate/Time: at 10:57Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated.Cannot assess RA pressure.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). Noted post-methadone OD, now p/w AMS& fevers & now intubated. 8) Prophylaxis: Heparin SC, famotidine 9) FEN: NPO for now 10) Code Status: Presumed full 11) Dispo: ICU for moment RESPIRATORY FAILURE, ACUTE (NOT ARDS/) RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) RHABDOMYOLYSIS POISONING / OVERDOSE, OTHER ICU Care Nutrition: Glycemic Control: Lines: 16 Gauge - 05:19 PM Arterial Line - 07:00 PM 20 Gauge - 03:45 PM 18 Gauge - 04:00 PM Prophylaxis: DVT: SQ UF Heparin Stress ulcer: H2 blocker VAP: HOB elevation, Mouth care, Daily wake up, RSBI Comments: Communication: Comments: Code status: Full code Disposition:ICU He was transferred via ambulance to ED, where he received narcan w/ limited effect became febrile to Altered mental status (not Delirium) Assessment: Action: Response: Plan: Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: Renal failure, acute (Acute renal failure, ARF) Assessment: Action: Response: Plan: Rhabdomyolysis Assessment: Action: Response: Plan: Initial high FiO2/PEEP likely volume overload, now weaned down with diuresis. Initial high FiO2/PEEP likely volume overload, now weaned down with diuresis. Initial high FiO2/PEEP likely volume overload, now weaned down with diuresis. Initial high FiO2/PEEP likely volume overload, now weaned down with diuresis. Initial high FiO2/PEEP likely volume overload, now weaned down with diuresis. 8) Prophylaxis: Heparin SC, famotidine 9) FEN: NPO for now 10) Code Status: Presumed full 11) Dispo: ICU for moment ALTERED MENTAL STATUS (NOT DELIRIUM) RESPIRATORY FAILURE, ACUTE (NOT ARDS/) RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) RHABDOMYOLYSIS POISONING / OVERDOSE, OTHER ICU Care Nutrition: Glycemic Control: Lines: 16 Gauge - 05:19 PM Arterial Line - 07:00 PM 20 Gauge - 03:45 PM 18 Gauge - 04:00 PM Prophylaxis: DVT: SQ UF Heparin Stress ulcer: H2 blocker VAP: HOB elevation, Mouth care, Daily wake up, RSBI Comments: Communication: Comments: Code status: Full code Disposition:ICU -f/u EEG -regular assessment of mental status #) Hypoxemic respiratory failure: Most likely etiologies include aspiration pneumonitis vs PNA. ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 01:51 PM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: Not indicated VAP: Comments: Communication: Comments: Code status: Full code Disposition:C/O to floor ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 01:51 PM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: Not indicated VAP: Comments: Communication: Comments: Code status: Full code Disposition:C/O to floor ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 01:51 PM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: Not indicated VAP: Comments: Communication: Comments: Code status: Full code Disposition:C/O to floor Initial high FiO2/PEEP likely volume overload, now weaned down with diuresis. 8) Prophylaxis: Heparin SC, famotidine 9) FEN: NPO for now 10) Code Status: Presumed full 11) Dispo: ICU for moment ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 05:00 PM 16 Gauge - 05:19 PM Arterial Line - 07:00 PM Prophylaxis: DVT: heparin SC Stress ulcer: famotidine VAP: HOB elevation, chlorhexidine Comments: Communication: Comments: Code status: Full Disposition: ICU ------ Protected Section ------ MICU ATTENDING ADDENDUM I saw and examined the patient, and was physically present with the ICU team for the key portions of the services provided. 8) Prophylaxis: Heparin SC, famotidine 9) FEN: NPO for now 10) Code Status: Presumed full 11) Dispo: ICU for moment ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 05:00 PM 16 Gauge - 05:19 PM Arterial Line - 07:00 PM Prophylaxis: DVT: heparin SC Stress ulcer: famotidine VAP: HOB elevation, chlorhexidine Comments: Communication: Comments: Code status: Full Disposition: ICU Initial high FiO2/PEEP likely volume overload, now weaned down with diuresis. Initial high FiO2/PEEP likely volume overload, now weaned down with diuresis. Initial high FiO2/PEEP likely volume overload, now weaned down with diuresis. Initial high FiO2/PEEP likely volume overload, now weaned down with diuresis. -f/u EEG -regular assessment of mental status #) Hypoxemic respiratory failure: Most likely etiologies include aspiration pneumonitis vs PNA. Presumed etiology is ATN and rhabdomyoloysis. Now inclined toward hypertension but improved with up-titration of labetalol -Continue labetalol 3) Hypoxemic respiratory failure: Most likely etiologies include aspiration pneumonitis, vs PNA. #Hypoxemic respiratory failure: Likely aspiration PNA. In EW pt remained tachycardic, tachypneic, febrile w/ temp to 103, and diaphoretic. Also using levofloxacin to cover atypicals. Appearance of CXR could be consistent with aspiration pneumonitis, vs PNA, vs edema. | 116 | [
{
"category": "Echo",
"chartdate": "2162-03-09 00:00:00.000",
"description": "Report",
"row_id": 86760,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 72\nWeight (lb): 230\nBSA (m2): 2.26 m2\nBP (mm Hg): 161/96\nHR (bpm): 96\nStatus: Outpatient\nDate/Time: at 10:57\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated.\nCannot assess RA pressure.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size and\nregional/global systolic function (LVEF>55%). The estimated cardiac index is\nnormal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion\nare normal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. There is mild pulmonary artery systolic hypertension. There is\nno pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity\nsizes and regional/global biventricular systolic function. Mild pulmonary\nartery systolic hypertension.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1061689,
"text": " 11:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for head bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with ams\n REASON FOR THIS EXAMINATION:\n eval for head bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MBue MON 3:11 PM\n No hemorrhage. bilateral globus pallidus hypodensities, non specific finding\n for which MRI is rec to further characterize.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD DATED \n\n HISTORY: 27 yo male with overdose and seizure.\n\n COMPARISON: None.\n\n FINDINGS: Contiguous helical acquisition through the head was performed\n without intravenous contrast.\n\n There are bilaterally symmetric hypodensities in the region of the globus\n pallidus. The grey white matter differentiation is otherwise preserved. There\n is no hemorrhage, mass effect, shift of midline structures. Ventricles are\n normal in appearance. The calvarium is intact. There is partial opacification\n of the bilateral ethmoid sinuses and right maxillary sinus. The mastoid air\n cells are normally aerated. The soft tissues are normal.\n\n IMPRESSION: Bilateral hypodense appearance of the globus pallidus,\n nonspecific, but may be related to patient's history of drug overdose. An MRI\n is recommended for further evaluation.\n\n Partial opacification of the bilateral ethmoid and right maxillary sinus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-09 00:00:00.000",
"description": "P RENAL U.S. PORT",
"row_id": 1061857,
"text": " 7:39 AM\n RENAL U.S. PORT Clip # \n Reason: Evaluate for hydronephrosis.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with acute renal failue of unclear etiology.\n REASON FOR THIS EXAMINATION:\n Evaluate for hydronephrosis.\n ______________________________________________________________________________\n FINAL REPORT\n RENAL ULTRASOUND, PORTABLE.\n\n INDICATION: 27-year-old man with acute renal failure of unclear etiology,\n evaluate for hydronephrosis.\n\n RENAL ULTRASOUND: The right kidney measures 12.8 cm. The left kidney\n measures 11.7 cm. There is no hydronephrosis or stones. The bladder contains\n a Foley catheter. Incidental note is made of hyperechoic parenchyma of the\n liver consistent with fatty infiltration.\n\n IMPRESSION:\n 1. Normal examination of the kidneys. No evidence for hydronephrosis.\n 2. Echogenic liver consistent with fatty infiltration. Please note that\n other forms of liver disease including significant fibrosis/cirrhosis cannot\n be excluded on the basis of this study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1061782,
"text": " 6:25 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: EVAL LINES AND FOR ACUTE CARDIOPULMONARY PROCESS\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with hypoxia and right groin CVL.\n REASON FOR THIS EXAMINATION:\n Evaluate lines and for acute cardiopulmonary process\n ______________________________________________________________________________\n WET READ: DMFj MON 8:31 PM\n ETT terminates 3 cm above carina. NG tube in good position. Persistant\n perihilar opacities. New bilateral small pleural effusions. New left lower\n lobe atelectasis suspicious for aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Check tube placement.\n\n FINDINGS: In comparison with earlier study of this date, the endotracheal\n tube lies approximately 3 cm above the carina. Nasogastric tube is in good\n position, well into the stomach. Perihilar opacification persists. There is\n new blunting of the costophrenic angles with poor definition of the\n hemidiaphragms, suspicious for aspiration or effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1062495,
"text": " 8:44 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate for NGT placement\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with overdose, concern for anoxic brain injury\n REASON FOR THIS EXAMINATION:\n now concern for extubation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 27-year-old male after overdose with concern for anoxic brain\n injury. Referred for assessment of endotracheal tube position.\n\n COMPARISON: at 14:57.\n\n AP PORTABLE CHEST: The endotracheal tube terminates in the right mainstem\n bronchus. Mild pulmonary edema persists which may be neurogenic given history.\n Mild subsegmental atelectasis is noted at both lung bases. The right internal\n jugular central venous catheter remains with termination in the right atrium.\n Nasogastric tube tip and side hole are in the stomach.\n\n IMPRESSION:\n\n 1. Right mainstem bronchial intubation. Review of subsequent radiograph at\n 22:56 shows this has been properly repositioned with terminus 2.6 cm above the\n carina. Right IJ catheter tip in the right atrium, pullback 6cm suggested.\n 2. Persistent mild pulmonary edema may be neurogenic. Mild bibasilar\n atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1062916,
"text": " 11:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval new placement\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man s/p line retraction\n REASON FOR THIS EXAMINATION:\n eval new placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Status post line retraction.\n\n FINDINGS: The right IJ line tip is at the SVC/RA junction. The NG tube tip\n is in the proximal stomach with the proximal port at the GE junction. There\n is no focal infiltrate or effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1062501,
"text": " 9:50 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Reevaluate ET tube position\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with bronchial intubation, recheck after ET readjustment\n REASON FOR THIS EXAMINATION:\n Reevaluate ET tube position\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MPtb FRI 12:37 PM\n Endotracheal tube has been appropriately repositioned with tip now 2.6 cm\n above the carina. Mild pulmonary edema, presumably neurogenic, persists.\n Mild bibasilar subsegmental atelectasis unchanged. Right IJ CVL tip remains\n in the right atrium and pullback 6 cm recommended.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 27-year-old male after overdose.\n\n COMPARISON: Prior study at 21:09 on .\n\n AP PORTABLE CHEST: The endotracheal tube has been pulled back and is now in\n appropriate position with terminus 2.6 cm above the carina. The right IJ\n venous catheter is unchanged with tip in the right atrium and pullback 6 cm\n recommended. Nasogastric tube tip and side hole are in the stomach. Mild\n pulmonary edema persists presumably neurogenic. Subsegmental bibasilar\n atelectasis not significantly changed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1062502,
"text": ", F. MED 9:50 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Reevaluate ET tube position\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with bronchial intubation, recheck after ET readjustment\n REASON FOR THIS EXAMINATION:\n Reevaluate ET tube position\n ______________________________________________________________________________\n PFI REPORT\n Endotracheal tube has been appropriately repositioned with tip now 2.6 cm\n above the carina. Mild pulmonary edema, presumably neurogenic, persists.\n Mild bibasilar subsegmental atelectasis unchanged. Right IJ CVL tip remains\n in the right atrium and pullback 6 cm recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-12 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1062545,
"text": " 7:27 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Evaluate for focal abnormality.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man found down and with persistently altered mental status and\n unequal responsiveness (L>R)\n REASON FOR THIS EXAMINATION:\n Evaluate for focal abnormality.\n CONTRAINDICATIONS for IV CONTRAST:\n ;acute kidney injury\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN FRI 1:33 PM\n Extensive diffusion abnormalities in deep white matter, both cerebral\n hemispheres, corpus callosum, both globus pallidus and right hippocampus\n suggestive of ischemia/acute infarcts. Findings are indicative of global\n brain insult from metabolic abnormalities or hypoxia.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient was found down with persistent altered mental\n status and unequivocal responsiveness. Question of poisoning.\n\n TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and diffusion axial\n images of the brain were acquired. 3D time-of-flight MRA of the circle of\n obtained.\n\n FINDINGS: Multiple areas of restricted diffusion are identified, which\n include bilateral globus pallidus, corpus callosum, and white matter of both\n cerebral hemispheres, in the centrum semiovale. In addition, right\n hippocampus also demonstrates restricted diffusion. The findings are\n indicative of ischemia/acute infarcts. There is no midline shift seen or\n hydrocephalus identified. No evidence of herniation noted. No evidence of\n blood products seen.\n\n In the suprasellar region, an area of increased signal identified above the\n pituitary gland could be artifactual.\n\n IMPRESSION:\n 1. Extensive areas of restricted diffusion involving the white matter, corpus\n callosum, both globus pallidus and right hippocampus indicative of\n acute infarct/ischemia likely due to global hypoxia.\n\n 2. No evidence of midline shift or herniation.\n\n MRA OF THE HEAD:\n\n The head MRA demonstrates normal flow signal within the arteries of anterior\n and posterior circulation.\n\n IMPRESSION: Normal MRA of the head.\n (Over)\n\n 7:27 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Evaluate for focal abnormality.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-12 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1062546,
"text": ", F. MED 7:27 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Evaluate for focal abnormality.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man found down and with persistently altered mental status and\n unequal responsiveness (L>R)\n REASON FOR THIS EXAMINATION:\n Evaluate for focal abnormality.\n CONTRAINDICATIONS for IV CONTRAST:\n ;acute kidney injury\n ______________________________________________________________________________\n PFI REPORT\n Extensive diffusion abnormalities in deep white matter, both cerebral\n hemispheres, corpus callosum, both globus pallidus and right hippocampus\n suggestive of ischemia/acute infarcts. Findings are indicative of global\n brain insult from metabolic abnormalities or hypoxia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1062084,
"text": " 5:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with hypoxic respiratory failure and ?sepsis now s/p\n intubation.\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:02 A.M. ON \n\n HISTORY: Hypoxic respiratory failure and sepsis.\n\n IMPRESSION: AP chest compared to through 10:\n\n Mild pulmonary edema is new, accompanied by increasing moderate right pleural\n effusion. Mild cardiomegaly unchanged. Resolution of right paratracheal\n widening, left hilar enlargement, and perihilar consolidation suggests\n involution of pneumonia. ET tube in standard placement. Nasogastric tube\n passes into the stomach and out of view. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1062725,
"text": " 4:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ETT placement\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with resp failure, anoxic brain injury\n REASON FOR THIS EXAMINATION:\n ? ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 27-year-old man with respiratory failure. Evaluate placement of\n endotracheal tube.\n\n FINDINGS: Comparison is made to prior study from .\n\n The endotracheal tube has been removed. The side port of the nasogastric tube\n is at the GE junction and this could be advanced several centimeters for more\n optimal placement. The right-sided central venous catheter tip is again seen\n in the mid right atrium and could be pulled back slightly for more optimal\n placement. There is no signs for overt pulmonary edema. There are no\n pneumothoraces identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1061683,
"text": " 11:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube placement post intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with ams, intubated, + rhoncherous bs\n REASON FOR THIS EXAMINATION:\n eval for tube placement post intubation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY DATED .\n\n COMPARISON: None.\n\n HISTORY: 27-year-old male with seizure and altered mental status.\n\n FINDINGS: A single AP portable supine view of the chest was obtained. The\n cardiac silhouette is within normal limits. There are patchy airspace\n densities noted within the bilateral perihilar regions and within the left\n retrocardiac region. No pleural effusion or pneumothorax is identified. The\n osseous structures are intact. There is an endotracheal tube noted\n terminating approximately 1.8 cm above the carina.\n\n IMPRESSION: Patchy airspace opacities within the bilateral hilar and left\n basilar regions. Given the patient's history of intoxication, these findings\n are suspicious for aspiration. However, given the perihilar opacities, central\n pulmonary vascular congestion cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1063141,
"text": " 10:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate NG tube position, ? aspiration event\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with concern for NG tube displacement, tube feeds seen coming\n from nose\n REASON FOR THIS EXAMINATION:\n Evaluate NG tube position, ? aspiration event\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NGT placement with possible aspiration.\n\n FINDINGS: In comparison with the study of , there is now a nasogastric\n tube in place that extends to the distal stomach. No evidence of aspiration.\n The lungs remain clear.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2162-03-08 00:00:00.000",
"description": "Report",
"row_id": 241419,
"text": "Sinus rhythm. Compared to the previous tracing the rate is slower.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2162-03-08 00:00:00.000",
"description": "Report",
"row_id": 241420,
"text": "Sinus tachycardia. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1062341,
"text": " 9:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for cerebral edema, changes consistent with anoxic\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with persistent mental status changes after being found down.\n REASON FOR THIS EXAMINATION:\n Evaluate for cerebral edema, changes consistent with anoxic brain injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:35 PM\n Slight interval increase in the prominence of hypodensity in the bilateral\n globus pallidus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 27-year-old male with persistent mental status changes after\n being found down. Evaluate for edema or anoxic brain injury.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n COMPARISON: .\n\n FINDINGS: There has been interval increase in the hypodensity in the\n bilateral globus pallidus since the prior exam. The -white matter\n differentiation is otherwise preserved without evidence of diffuse cerebral\n edema or anoxic brain injury. No evidence of acute hemorrhage, mass, or mass\n effect. The ventricles and sulci are normal in size and configuration. As\n before, there is partial opacification of the bilateral ethmoid sinuses. The\n visualized mastoid air cells are well aerated. No osseous abnormality is\n identified.\n\n IMPRESSION:\n 1. Interval increase in the prominence of hypodensity in the bilateral globus\n pallidus.\n\n 2. Stable partial opacification of the bilateral ethmoid sinuses.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1062342,
"text": ", F. MED 9:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for cerebral edema, changes consistent with anoxic\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with persistent mental status changes after being found down.\n REASON FOR THIS EXAMINATION:\n Evaluate for cerebral edema, changes consistent with anoxic brain injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Slight interval increase in the prominence of hypodensity in the bilateral\n globus pallidus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1062428,
"text": " 2:56 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate line placement.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with new right sided IJ\n REASON FOR THIS EXAMINATION:\n evaluate line placement.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 5:47 PM\n PFI: Central venous line reaching mid portion of right atrium, suggest\n withdrawal by 5 cm for appropriate position. No complication identified.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Right-sided internal jugular approach central venous line\n placement. Check position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position and analysis is performed in direct comparison\n with a preceding similar study obtained nine hours earlier during the same\n date. The patient remains intubated, the ETT terminating in the trachea some\n 2 cm above the level of the carina. An NG tube is present and seen to reach\n far below the diaphragm. A right internal jugular approach central venous\n line has been placed seem to terminate within the heart shadow most likely\n reaching the central portion of the right atrium. A withdrawal by 5 cm is\n recommended to accomplish termination position within the lower SVC. No\n pneumothorax or any other new pulmonary abnormalities are identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1062312,
"text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with hypoxic respiratory failure and ?sepsis now s/p\n intubation.\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:35 AM\n No interval change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Hypoxic respiratory failure and sepsis.\n\n ET tube is in standard position. The NG tube tip is out of view below the\n diaphragm. Allowing the difference in positioning of the patient\n cardiomediastinal contours and small right pleural effusion are unchanged\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2162-03-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1062313,
"text": ", F. MED 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with hypoxic respiratory failure and ?sepsis now s/p\n intubation.\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n PFI REPORT\n No interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1061837,
"text": " 4:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate interval change\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man who was found down with hypoxic respiratory failure\n REASON FOR THIS EXAMINATION:\n Evaluate interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Found down hypoxic, respiratory failure.\n\n COMPARISON: .\n\n FINDINGS: The endotracheal tube terminates at 3.4 cm above the carina. An NG\n tube is seen passing the stomach, the tip is excluded. The right costophrenic\n angle is partially excluded. The retrocardiac opacity has increased since\n prior study. New right lung base opacity likely represent pneumonia and\n atelectasis. Perihilar opacificaties are unchanged.\n\n IMPRESSION: New right lung base opacity likely represents pneumonia.\n\n The findings were discussed with Dr. at the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-03-11 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1062429,
"text": ", F. MED 2:56 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate line placement.\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man with new right sided IJ\n REASON FOR THIS EXAMINATION:\n evaluate line placement.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Central venous line reaching mid portion of right atrium, suggest\n withdrawal by 5 cm for appropriate position. No complication identified.\n\n\n"
},
{
"category": "Respiratory ",
"chartdate": "2162-03-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658958,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 10 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient admitted to unit from EW, ABG\ns drawn.\n"
},
{
"category": "Social Work",
"chartdate": "2162-03-09 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 659119,
"text": "Family Information\n Next of : Father\n Health Proxy appointed: Proxy\n Family Spokesperson designated: Father\n Communication or visitation restriction: None\n Patient Information:\n Previous living situation: Homeless\n Previous level of functioning: Independent\n Previous or other hospital admissions: No admissions\n Past psychiatric history: Pt\ns family reports a HX of depression but\n gave few details. They did say that when he broke-up with the mother of\n his 9 y/o son 5-6 years ago, he became quite depressed. Their\n understanding is that pt had been sent to by another OSH\n because he was suicidal.\n Past addictions history: Pt has an extensive HX of drug use beginning\n perhaps 10 years ago, if not longer. He initially used cocaine and\n Oxycontin, but stopped 3-4 years ago. More recently, he has been using\n heroin, Xanax, methadone, and Percocet. His use of methadone is recent,\n according to pt's family. His girlfriend, and the mother of his \n month old female \"crack baby,\" introduced him to this drug. Pt's mo,\n from whom he has been estranged, is an \"addict,\" according to pt's\n father. Pt's paternal grandfather \"is an alcoholic.\"\n Employment status: Unemployed--Pt has had numerous jobs, but his work\n with his father in home improvement was of greatest duration. Following\n release from prison, he did carpentry.\n Legal involvement: Mr. was released from prison in . A\n judge incarcerated him for five months for robbery. He is currently on\n probation.\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment: This worker will meet further with pt\n family tomorrow in an effort to obtain more detailed HX.\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659173,
"text": "27 male w/ hx opiate abuse, s/p admision to pornwood yesterday for\n post-methadone overdose management. Pt found unresponsive at bornwood,\n tachypneic, tachycardic and hypertenisve. Pt given Narcan (total 2.8mg)\n w/ no improvement. Pt intubated and sedated in EW for airway\n protection. Urine tox positive for methadone\n Poisoning / Overdose, Other\n Assessment:\n Pt was found down and obtunded with urine pos for methadone. Pt is\n currently only responsive to suction. During suction pt body becomes\n rigid and he bites down on the oral airway and ett, opening eyes but\n not focusing. Does not react to sternal rub. Does not follow any\n commands.\n Action:\n Pt is not on any sedation.\n Response:\n Pending.\n Plan:\n Cont to assess neuro. No sedation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt lungs with rhonchi. Sputum in lg amts thick tannish/brownish in\n color. Sao2 96-99%. Pt probably aspirated.\n Action:\n Pt is intubated with cpap 40%/. suction every several hours for mod\n to lg amts of sputum. Pt is on vanco, ampicillin and levofloxacin.\n Response:\n Pt has a good cough with suction.\n Plan:\n Cont to provide resp support as needed. Cont with antibiotics\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt was oliguric on adm to micu. Creat 3.7 on the 10^th. Renal has been\n in tho see pt and feels rhabdo and atn are contributing factors. Pt has\n had a good urine output this shift.\n Action:\n Pt received 100mg of lasix iv at change of shift yesterday. Pt had been\n > 6000cc pos yesterday and is currently <1000cc pos. pt is also getting\n 1 liter of LR at 150hr.\n Response:\n U/O > 150/hr\n Plan:\n Goal is for u/o to be > 150cc hr. will recheck labs this am.\n"
},
{
"category": "Respiratory ",
"chartdate": "2162-03-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 659112,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 10 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt weaned to PSV ventilating well however needed to increased\n peep and fio2 breifly to maintain adequate sats abgs WNL\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Nasal aspiration (1620)\n Comments: for r/o flu\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659171,
"text": "27 male w/ hx opiate abuse, s/p admision to pornwood yesterday for\n post-methadone overdose management. Pt found unresponsive at bornwood,\n tachypneic, tachycardic and hypertenisve. Pt given Narcan (total 2.8mg)\n w/ no improvement. Pt intubated and sedated in EW for airway\n protection. Urine tox positive for methadone\n Poisoning / Overdose, Other\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659245,
"text": "Chief Complaint: Found down\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:34 AM\n ULTRASOUND - At 11:00 AM\n ultrasound of kidneys.\n MULTI LUMEN - STOP 05:01 PM\n placed in EW\n -contact by , attending physician at . She\n will accept the patient back when/if better. Phone number: \n -d/c acyclovir, cont vanco/unasyn/levo\n - gave lasix 100IV X1 in evening when UOP dropped to 80cc/hr. next hr\n was 1000\n -Per renal, ARF likely combo ATN and rhabdo\n - blister on inside left knee unroofed and sent for viral cx.\n -DFA for influenza and urine for legionella neg\n -labetalol started and uptitrated to 300mg PO TID\n - on PM labs, LFTS and CK trending down. Cr rising to 3.7 from 2.9\n - sedation shut off in am. Pt coughing but not consistently responding\n to pain\n -TTE: Mild symmetric left ventricular hypertrophy with normal cavity\n sizes and regional/global biventricular systolic function. Mild\n pulmonary artery systolic hypertension. LVEF >60%\n -plan to get peripherals then perhaps pull CVL\n - no further toxicology notes.\n - d/c'd cyproheptadine for serotonin sx\n -Midnight down 5.5L for the day- ordered 1L NS at 150cc/hr\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:18 PM\n Acyclovir - 11:18 PM\n Piperacillin/Tazobactam (Zosyn) - 11:18 PM\n Ampicillin - 10:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 07:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 81 (75 - 93) bpm\n BP: 116/75(84) {0/0(0) - 0/0(0)} mmHg\n RR: 14 (12 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 904 mL\n 1,062 mL\n PO:\n TF:\n IVF:\n 544 mL\n 1,062 mL\n Blood products:\n Total out:\n 6,490 mL\n 1,665 mL\n Urine:\n 6,490 mL\n 1,665 mL\n NG:\n Stool:\n Drains:\n Balance:\n -5,586 mL\n -603 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 816 (711 - 875) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 27\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: 7.39/41/99./25/0\n Ve: 10.2 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal), (S2:\n Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, Rash: unchanged erythematous areas on medial\n surface of knees\n Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone:\n Not assessed, clonus in ankles bilaterally, babinski on left (no reflex\n on right)\n Labs / Radiology\n 261 K/uL\n 13.0 g/dL\n 100 mg/dL\n 4.2 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 47 mg/dL\n 105 mEq/L\n 146 mEq/L\n 37.2 %\n 21.3 K/uL\n [image002.jpg]\n 06:01 PM\n 09:07 PM\n 10:19 PM\n 04:27 AM\n 04:40 AM\n 11:50 AM\n 12:01 PM\n 03:02 PM\n 04:02 PM\n 04:00 AM\n WBC\n 17.8\n 17.9\n 21.3\n Hct\n 35.9\n 35.8\n 37.2\n Plt\n 227\n 241\n 261\n Cr\n 2.5\n 2.9\n 3.7\n 4.2\n TropT\n 0.82\n <0.01\n TCO2\n 22\n 22\n 25\n 25\n 26\n Glucose\n 124\n 98\n 134\n 123\n 100\n Other labs: PT / PTT / INR:15.7/27.3/1.4, CK / CKMB /\n Troponin-T:/113/<0.01, ALT / AST:3708(4029)/2217(3673), Alk Phos /\n T Bili:123(118)/0.6(0.6), Amylase / Lipase:461/31,\n Differential-Neuts:85.5 %, Band:0.0 %, Lymph:9.6 %, Mono:4.5 %, Eos:0.2\n %, D-dimer: ng/mL, Fibrinogen:455 mg/dL, Lactic Acid:1.4 mmol/L,\n Albumin:3.2 g/dL, LDH:2137 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.8 mg/dL\n Imaging: Renal U/S:\n IMPRESSION:\n 1. Normal examination of the kidneys. No evidence for hydronephrosis.\n 2. Echogenic liver consistent with fatty infiltration. Please note that\n other forms of liver disease including significant fibrosis/cirrhosis\n cannot\n be excluded on the basis of this study.\n TTE:\n IMPRESSION: Mild symmetric left ventricular hypertrophy with normal\n cavity sizes and regional/global biventricular systolic function. Mild\n pulmonary artery systolic hypertension.\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now intubated for\n hypoxic respiratory failure and being broadly treated for serotonin\n syndrome and pneumonia.\n 1)Obtundation: Ultimate etiology is not clear at this time. Major\n concerns include serotonin syndrome, intoxication, or post-ictal\n state. Given extremely few cells in CSF will d/c empiric acyclovir\n therapy for HSV due to risk this poses to renal function. Will\n continue to treat empirically for serotonin syndrome and monitor.\n -cyproheptidine 4 mg Q6hrs for serotonin syndrome\n - STOP acyclovir empirically for consern HSV meningitis\n -F/U toxicology reccs\n -Attempt to wean sedation and reassess mental status\n 2)Shock: The patient was hypotensive in the ED but only after\n receiving propofol sedation. This completely resolved and he is in\n fact hypertensive off pressor support at this time. Presumably his\n initial hypotension was iatrogenic. In the short term we would prefer\n mild hypertension to hypotension in this gentleman but given MAP\ns >100\n we will treat.\n -labetalol given concern for past cocaine abuse and unapposed B\n blockade\n -Echocardiogram to evaluate EF\n 3) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis, vs PNA, vs edema. We will cover for aspiration\n pneumonia and CA-MRSA with antibiotics though there are definitely\n other potential etiologies for fever in this patient. Patient is\n currently oxygenating and ventilating well on reasonable ventilator\n settings particularly given previous need for 100% O2.\n -Wean FiO2 and then PEEP as tolerated\n -Vanco/Ampicillin-Sublactam for aspiration pneumonia, we will d/c\n levofloxacin as legionella antigen negative and this patient would not\n be typical epidemiology of this pathogen; we will also d/c pipercillin\n tazobactam as he seems to be improving with diuresis reducing concern\n pneumonia is the primary causative of pneumonia\n -sputum cultures\n -Rapid flu antigen test and viral culture\n 4) Renal failure: Patient was nearly anuric yesterday. Elevated CK\n and blood/rbc dissociation on UA suggestive or rhabdomyolysis\n particularly given this is an otherwise healthy young man with\n presumably a normal Cr before. He has responded to diuretic therapy\n with brisk urine output and we will continue this diuresis as long as\n possible to flush and protect the kidneys.\n -nephrology is following\n -bolus dose furosemide if UOP drops below 100 cc/hr\n -Avoid nephrotoxins, renally dose meds\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, etc...\n -Monitor fever and leukocytosis curves.\n -Consider CT to look for occult abcess if repeated fevers once stable\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -unroof vesicle and send for viral cutlure.\n 7) Neuro: Unclear on significance of bilateral clonus w/o other\n neurologic abnormalities. Ct head slightly abnormal and patient's MS\n is poor. Will await evaluation of non-sedated mental status before\n proceeding to neuro consult.\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: NPO for now\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RHABDOMYOLYSIS\n POISONING / OVERDOSE, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 05:19 PM\n Arterial Line - 07:00 PM\n 20 Gauge - 03:45 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659335,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. Per notes, the\n patient endorsed an 8 mo history of abusing multiple types of opiates\n including oxycontin, methadone, and heroin. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect became febrile to\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Rhabdomyolysis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2162-03-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 659332,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 10 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt weaned to PSV 5/5 tolerating well sats >96%\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: plan to continue to wean as tolerated awaiting pt to wake up\n appropriately and follow commands ? CT of head tomorrow\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659225,
"text": "27 male w/ hx opiate abuse, s/p admision to pornwood yesterday for\n post-methadone overdose management. Pt found unresponsive at bornwood,\n tachypneic, tachycardic and hypertenisve. Pt given Narcan (total 2.8mg)\n w/ no improvement. Pt intubated and sedated in EW for airway\n protection. Urine tox positive for methadone\n Poisoning / Overdose, Other\n Assessment:\n Pt was found down and obtunded with urine pos for methadone. Pt is\n currently only responsive to suction. During suction pt body becomes\n rigid and he bites down on the oral airway and ett, opening eyes but\n not focusing. Does not react to sternal rub. Does not follow any\n commands.\n Action:\n Pt is not on any sedation.\n Response:\n Pending. Hepatic enzymes remain very elevated this am. During suction\n left leg\ntremors\n Plan:\n Cont to assess neuro. No sedation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt lungs with rhonchi. Sputum in lg amts thick tannish/brownish in\n color. Sao2 96-99%. Pt probably aspirated.\n Action:\n Pt is intubated with cpap 40%/. suction every several hours for mod\n to lg amts of sputum. Pt is on vanco, ampicillin and levofloxacin.\n Response:\n Pt has a good cough with suction.\n Plan:\n Cont to provide resp support as needed. Cont with antibiotics\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt was oliguric on adm to micu. Creat 3.7 on the 10^th. Renal has been\n in tho see pt and feels rhabdo and atn are contributing factors. Pt has\n had a good urine output this shift.\n Action:\n Pt received 100mg of lasix iv at change of shift yesterday. Pt had been\n > 6000cc pos yesterday and is currently <1000cc pos. pt is also getting\n 1 liter of LR at 150hr.\n Response:\n U/O > 150/hr.\n Plan:\n Goal is for u/o to be > 150cc hr. will recheck labs this am.\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-10 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 659327,
"text": "Chief Complaint: Found down\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:34 AM\n ULTRASOUND - At 11:00 AM\n ultrasound of kidneys.\n MULTI LUMEN - STOP 05:01 PM\n placed in EW\n -contact by , attending physician at . She\n will accept the patient back when/if better. Phone number: \n -d/c acyclovir, cont vanco/unasyn/levo\n - gave lasix 100IV X1 in evening when UOP dropped to 80cc/hr. next hr\n was 1000\n -Per renal, ARF likely combo ATN and rhabdo\n - blister on inside left knee unroofed and sent for viral cx.\n -DFA for influenza and urine for legionella neg\n -labetalol started and uptitrated to 300mg PO TID\n - on PM labs, LFTS and CK trending down. Cr rising to 3.7 from 2.9\n - sedation shut off in am. Pt coughing but not consistently responding\n to pain\n -TTE: Mild symmetric left ventricular hypertrophy with normal cavity\n sizes and regional/global biventricular systolic function. Mild\n pulmonary artery systolic hypertension. LVEF >60%\n -plan to get peripherals then perhaps pull CVL\n - no further toxicology notes.\n - d/c'd cyproheptadine for serotonin sx\n -Midnight down 5.5L for the day- ordered 1L NS at 150cc/hr\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:18 PM\n Acyclovir - 11:18 PM\n Piperacillin/Tazobactam (Zosyn) - 11:18 PM\n Ampicillin - 10:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 07:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 81 (75 - 93) bpm\n BP: 116/75(84) {0/0(0) - 0/0(0)} mmHg\n RR: 14 (12 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 904 mL\n 1,062 mL\n PO:\n TF:\n IVF:\n 544 mL\n 1,062 mL\n Blood products:\n Total out:\n 6,490 mL\n 1,665 mL\n Urine:\n 6,490 mL\n 1,665 mL\n NG:\n Stool:\n Drains:\n Balance:\n -5,586 mL\n -603 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 816 (711 - 875) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 27\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: 7.39/41/99./25/0\n Ve: 10.2 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal), (S2:\n Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, Rash: unchanged erythematous areas on medial\n surface of knees\n Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone:\n Not assessed, clonus in ankles bilaterally, babinski on left (no reflex\n on right)\n Labs / Radiology\n 261 K/uL\n 13.0 g/dL\n 100 mg/dL\n 4.2 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 47 mg/dL\n 105 mEq/L\n 146 mEq/L\n 37.2 %\n 21.3 K/uL\n [image002.jpg]\n 06:01 PM\n 09:07 PM\n 10:19 PM\n 04:27 AM\n 04:40 AM\n 11:50 AM\n 12:01 PM\n 03:02 PM\n 04:02 PM\n 04:00 AM\n WBC\n 17.8\n 17.9\n 21.3\n Hct\n 35.9\n 35.8\n 37.2\n Plt\n 227\n 241\n 261\n Cr\n 2.5\n 2.9\n 3.7\n 4.2\n TropT\n 0.82\n <0.01\n TCO2\n 22\n 22\n 25\n 25\n 26\n Glucose\n 124\n 98\n 134\n 123\n 100\n Other labs: PT / PTT / INR:15.7/27.3/1.4, CK / CKMB /\n Troponin-T:/113/<0.01, ALT / AST:3708(4029)/2217(3673), Alk Phos /\n T Bili:123(118)/0.6(0.6), Amylase / Lipase:461/31,\n Differential-Neuts:85.5 %, Band:0.0 %, Lymph:9.6 %, Mono:4.5 %, Eos:0.2\n %, D-dimer: ng/mL, Fibrinogen:455 mg/dL, Lactic Acid:1.4 mmol/L,\n Albumin:3.2 g/dL, LDH:2137 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.8 mg/dL\n Imaging: Renal U/S:\n IMPRESSION:\n 1. Normal examination of the kidneys. No evidence for hydronephrosis.\n 2. Echogenic liver consistent with fatty infiltration. Please note that\n other forms of liver disease including significant fibrosis/cirrhosis\n cannot\n be excluded on the basis of this study.\n TTE:\n IMPRESSION: Mild symmetric left ventricular hypertrophy with normal\n cavity sizes and regional/global biventricular systolic function. Mild\n pulmonary artery systolic hypertension.\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now intubated for\n hypoxic respiratory failure and with persistently altered MS.\n 1)Obtundation: Ultimate etiology is not clear at this time. Major\n concerns include serotonin syndrome, intoxication, or post-ictal\n state. Given extremely few cells in CSF minimal concern for\n meningitis/encephalitis. Mental status mildly improved since last\n night but still not consistently purposeful. Concern for anoxic brain\n injury.\n -completed cyproheptidine treatment\n -off sedation\n -if mental status not consistently improving CT head to rule out edema\n or acute process, proceed to neuro consult and MRI/EEG\n 2)Shock: The patient was hypotensive in the ED but only after\n receiving propofol sedation. This completely resolved and he is in\n fact hypertensive off pressor support at this time. Presume\n hypotension was iatrogenic. .\n -labetalol given concern for past cocaine abuse and unapposed B\n blockade\n -Echocardiogram with normal EF\n 3) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis, vs PNA, vs edema. We will cover for aspiration\n pneumonia and CA-MRSA with antibiotics though there are definitely\n other potential etiologies for fever in this patient. Patient is\n currently oxygenating and ventilating well on reasonable ventilator\n settings particularly given previous need for 100% O2. Now doing well\n on pressure support. Primary reason for continued ventilation is\n mental status.\n -Vanco/Ampicillin-Sublactam for aspiration pneumonia\n -sputum cultures\n -Rapid flu antigen test negative\n 4) Renal failure: Patient with good urine output but Cr continues to\n rise. Presumed etiology is ATN and rhabdomyoloysis.\n -Goal UOP of 150-200cc/hr\n -D5W given free water deficit and careful to avoid hypovolemia in\n setting of self-diuresis\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, etc...\n -Monitor fever and leukocytosis curves.\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -f/u culture from vesicle\n 7) Neuro: Unclear on significance of bilateral clonus w/o other\n neurologic abnormalities. Ct head slightly abnormal and patient's MS\n is poor. Neuro consult in AM and imaging per above if not improving\n dramatically over course of day.\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: NPO for now\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 05:19 PM\n Arterial Line - 07:00 PM\n 20 Gauge - 03:45 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 27M polysubstance abuse, recent methadone OD,\n found down with shock, rhabdo, ARF, respiratory failure and likely\n aspiration pneumonia. Creatinine rising but excellent UOP. CK and LFTs\n trending down.\n Exam notable for Tm 98.2 BP 120/90 HR 90 RR 18 with sat 98 on PSV\n 0.4 7.46/38/112. -5L/24h. B ronchi. Hyperdynamic s1s2. +BS. 2+\n edema but not tense. Labs notable for WBC 21K, HCT 37, Cr 4.2. CXR with\n B ASD, progressive.\n Agree with plan to manage respiratory failure with PSV ventilation\n (reduced to at bedside) and fluid removal with lasix PRN only if\n UOP <100cc/h. Likely pneumonia due to nosocomial pathogens or\n aspiration; will continue vanco/unasyn and f/u cultures. Shock has\n resolved, will follow lactate, CK, LFTs and monitor with gentle\n hydration. Remains on labetalol for hypertension. ARF is worse based on\n creatinine but UOP is excellent. Likely ATN based upon sediment; will\n match I+O, RD meds, and follow closely. Will start FWB for evolving\n hypernatremia. Mental status remains poor, will recheck CT if he\n doesn't continue to improve. Will d/w SW re home situation. Remainder\n of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 16:30 ------\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659032,
"text": "27 male w/ hx opiate abuse, s/p admision to pornwood yesterday for\n post-methadone overdose management. Pt found unresponsive at bornwood,\n tachypneic, tachycardic and hypertenisve. Pt given Narcan (total 2.8mg)\n w/ no improvement. Pt intubated and sedated in EW for airway\n protection. Urine tox positive for methadone\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remained as intubated , vented, sedated with propofol 35mic/kg/min. pt\n received with levophed 0.052 mic/kg/min. pt unresponsive .withdraws\n sometimes for sternal rub.\n Action:\n Fio2 down to 40% from 100%. Other vent settings 16/ 650/ 10. BP > 130\n sys ,off levo without tapering as per team,pt tolerated well . PEEP\n weaned to 8 by am.\n Response:\n BP 130-150\ns sys ,sats 94-98%. Pt not awake, pupils 2mm / brisk. Blood\n gas satisfactory.\n Plan:\n Wean vent /sedations as tolerated. need to off propofol and to\n check his neuro status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n K 5.8 ,Renal functions elevated. Low urine output. Elevated trop ,\n CPK, ? rhabdo.\n Action:\n Keyoxelate 30gms PO x 1. lasix 100mg iv x 1. ekg done. Urine\n lytes,legionelle sent.\n Response:\n Repeat K 5.7. no other interventions done as EKG without any acute\n changes. Urine output improved.\n Plan:\n Echo today. F /u with renal team. need more fluids.\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659406,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. His BP increased to\n 220/systolic w/mouth care, turning & suctioning/coughing. His eyes do\n not focus or track. Patient stretches out legs & his legs have a\n tremor while his eyes remain closed each time he is turned or receives\n mouth care, sx\ning-- ? seizure activity. This activity was not seen\n when he was left alone.\n Action:\n Received propofol for a few minutes until his BP was back down to\n 160\ns/systolic.\n Response:\n No stimulation & IV propofol brought patient\ns BP back down to\n 160\ns/systolic.\n Plan:\n Head CT & EEG planned for today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On CPAP @ 40% w/5 PEEP & 5 PS. RR: 14-20 O2 sats: 97-98%\n Lungs were clear w/exp wheezes @ L base.\n Action:\n ABG: Sx\ned for small amount thick\n secretions.\n Response:\n RSBI:\n Plan:\n Wean from vent as patient tolerates.\n Renal failure, acute (Acute renal failure, ARF) from rhabdomyolysis\n Assessment:\n U/o 100cc/hr. Receiving 110cc/hr + abx/gastric meds. BUN\n ( Cr\n Action:\n Continue to finish 2400cc D5W (on 2^nd L) @ 100cc/hr.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659411,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. His BP increased to\n 220/systolic w/mouth care, turning & suctioning/coughing. His eyes do\n not focus or track. Patient stretches out legs & his legs have a\n tremor while his eyes remain closed each time he is turned or receives\n mouth care, sx\ning-- ? seizure activity. This activity was not seen\n when he was left alone.\n Action:\n Received propofol for a few minutes until his BP was back down to\n 160\ns/systolic.\n Response:\n No stimulation & IV propofol brought patient\ns BP back down to\n 160\ns/systolic.\n Plan:\n Head CT & EEG planned for today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On CPAP @ 40% w/5 PEEP & 5 PS. RR: 14-20 O2 sats: 97-98%\n Lungs were clear w/exp wheezes @ L base.\n Action:\n ABG: Sx\ned for small amount thick\n secretions.\n Response:\n RSBI:\n Plan:\n Wean from vent as patient tolerates.\n Renal failure, acute (Acute renal failure, ARF) from rhabdomyolysis\n Assessment:\n U/o 100cc/hr. Receiving 110cc/hr + abx/gastric meds. BUN\n (47) Cr (4.2)\n Action:\n Continue to finish 2400cc D5W (on 2^nd L) @ 100cc/hr.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659412,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. His BP increased to\n 220/systolic w/mouth care, turning & suctioning/coughing. His eyes do\n not focus or track. Patient stretches out legs & his legs have a\n tremor while his eyes remain closed each time he is turned or receives\n mouth care, sx\ning-- ? seizure activity. This activity was not seen\n when he was left alone.\n Action:\n Received propofol for a few minutes until his BP was back down to\n 160\ns/systolic.\n Response:\n No stimulation & IV propofol brought patient\ns BP back down to\n 160\ns/systolic.\n Plan:\n Head CT & EEG planned for today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On CPAP @ 40% w/5 PEEP & 5 PS. RR: 14-20 O2 sats: 97-98%\n Lungs were clear w/exp wheezes @ L base.\n Action:\n ABG: Sx\ned for small amount thick\n secretions.\n Response:\n RSBI:\n Plan:\n Wean from vent as patient tolerates.\n Renal failure, acute (Acute renal failure, ARF) from rhabdomyolysis\n Assessment:\n U/o 100cc/hr. Receiving 110cc/hr + abx/gastric meds. BUN\n (47) Cr (4.2) CK \n Action:\n Continue to finish 2400cc D5W (on 2^nd L) @ 100cc/hr.\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 659529,
"text": "Subjective\n Intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 102 kg\n 30.6\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 80.7 kg\n 126\n 86kg\n Diagnosis: AMS\n PMH : polysubstance abuse ?opiate, seisures\n Food allergies and intolerances: none noted.\n Pertinent medications: Vancomycin, pepcid.\n Labs:\n Value\n Date\n Glucose\n 119 mg/dL\n 04:12 AM\n BUN\n 45 mg/dL\n 04:12 AM\n Creatinine\n 4.2 mg/dL\n 04:12 AM\n Sodium\n 148 mEq/L\n 04:12 AM\n Potassium\n 3.4 mEq/L\n 04:12 AM\n Chloride\n 111 mEq/L\n 04:12 AM\n TCO2\n 26 mEq/L\n 04:12 AM\n PO2 (arterial)\n 114 mm Hg\n 04:31 AM\n PCO2 (arterial)\n 37 mm Hg\n 04:31 AM\n pH (arterial)\n 7.47 units\n 04:31 AM\n pH (urine)\n 5.5 units\n 04:59 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 04:31 AM\n Albumin\n 3.2 g/dL\n 04:27 AM\n Calcium non-ionized\n 8.0 mg/dL\n 04:12 AM\n Phosphorus\n 3.3 mg/dL\n 04:12 AM\n Ionized Calcium\n 1.07 mmol/L\n 12:01 PM\n Magnesium\n 2.0 mg/dL\n 04:12 AM\n ALT\n 3089 IU/L\n 04:12 AM\n Alkaline Phosphate\n 114 IU/L\n 04:12 AM\n AST\n 1277 IU/L\n 04:12 AM\n Amylase\n 461 IU/L\n 05:24 PM\n Total Bilirubin\n 0.7 mg/dL\n 04:12 AM\n WBC\n 14.0 K/uL\n 04:12 AM\n Hgb\n 11.7 g/dL\n 04:12 AM\n Hematocrit\n 33.3 %\n 04:12 AM\n Current diet order / nutrition support: NPO.\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: hx polysubstance abuse.\n Estimated Nutritional Needs\n Calories: 1720 - 2150 (BEE x or / 20 - 25 cal/kg)\n Protein: 86 - 129 (1 - 1.5 g/kg)\n Fluid: per team.\n Specifics:\n 27 YO Male with hx of polysubstance abuse. Noted post-methadone OD, now\n p/w AMS& fevers & now intubated. Noted elevated BUN/Creat; renal\n following ~2L free water deficit & renal recommending IVF\ns with\n BUN/Creat expected to trend down given good U/O. Recommend nutrition\n support if remains intubated in the next 24hrs. FS Fibersource HN at\n goal 65mL/hr, providing 1872Kcals & 83g protein (1g/kg protein).\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. IVF\ns as recommended by renal\n 2. If remains intubated in the next 24hrs, consider TF: FS\n Fibersource HN; start at 15mL/hr, advance by 10-15mL Q 4-6hrs to goal\n 65mL/hr\n 3. Check residuals Q 4hrs & hold X1hr if >150mL\n 4. Continue to monitor renal fxn\n 5. Monitor hydration & adjust free water flushes PRN\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659403,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. His BP increased to\n 220/systolic w/mouth care, turning & suctioning/coughing. His eyes do\n not focus or track.\n Action:\n Received propofol for a few minutes until his BP was back down to\n 160\ns/systolic.\n Response:\n No stimulation & IV propofol brought patient\ns BP back down to\n 160\ns/systolic.\n Plan:\n Head CT & EEG today most likely\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On CPAP @ 40% w/5 PEEP & 5 PS. RR: 14-20 O2 sats: 97-98%\n Lungs were clear w/exp wheezes @ L base.\n Action:\n ABG: Sx\ned for small amount thick\n secretions.\n Response:\n RSBI:\n Plan:\n Wean from vent as patient tolerates.\n Renal failure, acute (Acute renal failure, ARF) from rhabdomyolysis\n Assessment:\n U/o 100cc/hr. Receiving 110cc/hr + abx/gastric meds. BUN\n ( Cr\n Action:\n Continue to finishe 2400cc D5W (on 2^nd L).\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659402,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. His BP increased to\n 220/systolic w/mouth care, turning & suctioning/coughing. His eyes do\n not focus or track.\n Action:\n Received propofol for a few minutes until his BP was back down to\n 160\ns/systolic.\n Response:\n No stimulation & IV propofol brought patient\ns BP back down to\n 160\ns/systolic.\n Plan:\n Head CT & EEG today most likely\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On CPAP @ 40% w/5 PEEP & 5 PS. RR: 14-20 O2 sats: 97-98%\n Lungs were clear w/exp wheezes @ L base.\n Action:\n ABG: Sx\ned for small amount thick\n secretions.\n Response:\n RSBI:\n Plan:\n Wean from vent as patient tolerates.\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659492,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Events:\n Tmax 101.7 po @ 0400. BCX2, UA, C&S sent. Sputum Cx sent .\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. His BP increased to\n 220/systolic w/mouth care, turning & suctioning/coughing. His eyes do\n not focus or track. Patient stretches out legs & his legs have a\n tremor while his eyes remain closed each time he is turned or receives\n mouth care, sx\ning-- ? seizure activity. This activity was not seen\n when he was left alone.\n Action:\n Received propofol for a few minutes until his BP was back down to\n 160\ns/systolic.\n Response:\n No stimulation & IV propofol brought patient\ns BP back down to\n 160\ns/systolic.\n Plan:\n Head CT & EEG planned for today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On CPAP @ 40% w/5 PEEP & 5 PS. RR: 14-20 O2 sats: 97-98%\n Lungs were clear w/exp wheezes @ L base.\n Action:\n ABG: 7.47/37/114 Sx\ned for small amount thick tan secretions.\n Grm stain shows no bacteria ()\n Response:\n RSBI:\n Plan:\n Wean from vent as patient is able to protect his airway.\n Renal failure, acute (Acute renal failure, ARF) from rhabdomyolysis\n Assessment:\n U/o 100cc/hr. Receiving 110cc/hr + abx/gastric meds. BUN 45\n (47) Cr 4.2 (4.2) CK 5360 ()\n Action:\n Continue to finish 2400cc D5W (on 2^nd L) @ 100cc/hr.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659493,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Events:\n Tmax 101.7 po @ 0400. BCX2, UA, C&S sent. Sputum Cx sent .\n Tylenol given @ 0700. WBC 14 (\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. His BP increased to\n 220/systolic w/mouth care, turning & suctioning/coughing. His eyes do\n not focus or track. Patient stretches out legs & his legs have a\n tremor while his eyes remain closed each time he is turned or receives\n mouth care, sx\ning-- ? seizure activity. This activity was not seen\n when he was left alone.\n Action:\n Received propofol for a few minutes until his BP was back down to\n 160\ns/systolic.\n Response:\n No stimulation & IV propofol brought patient\ns BP back down to\n 160\ns/systolic.\n Plan:\n Head CT & EEG planned for today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On CPAP @ 40% w/5 PEEP & 5 PS. RR: 14-20 O2 sats: 97-98%\n Lungs were clear w/exp wheezes @ L base.\n Action:\n ABG: 7.47/37/114 Sx\ned for small amount thick tan secretions.\n Grm stain shows no bacteria ()\n Response:\n RSBI: 27\n Plan:\n Wean from vent as patient is able to protect his airway.\n Renal failure, acute (Acute renal failure, ARF) from rhabdomyolysis\n Assessment:\n U/o 100cc/hr. Receiving 110cc/hr + abx/gastric meds. BUN 45\n (47) Cr 4.2 (4.2) CK 5360 ()\n Action:\n Continue to finish 2400cc D5W (on 2^nd L) @ 100cc/hr.\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659494,
"text": "Chief Complaint: Found Down\n 24 Hour Events:\n SPUTUM CULTURE - At 08:00 AM\n FEVER - 101.7\nF - 04:00 AM\n -Put on PS 5/5 in a.m. Remained off sedation for near entirety of day\n (was briefly given propofol for agitation in evening)\n -Was initially minimally responsive in a.m. but gradually became\n slightly more responsive over course of day; still very sedated overall\n -Increased labetalol to 400 tid b/c of htn\n -BCx/UCx this a.m. for temp of 101.7\n Patient unable to provide history: Encephalopathy, intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:18 PM\n Acyclovir - 11:18 PM\n Piperacillin/Tazobactam (Zosyn) - 11:18 PM\n Ampicillin - 10:00 PM\n Vancomycin - 09:00 AM\n Ampicillin/Sulbactam (Unasyn) - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 AM\n Famotidine (Pepcid) - 07:38 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 38.7\nC (101.7\n HR: 81 (76 - 86) bpm\n BP: 116/75(84) {0/0(0) - 0/0(0)} mmHg\n RR: 17 (14 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 3,277 mL\n 858 mL\n PO:\n TF:\n IVF:\n 3,187 mL\n 778 mL\n Blood products:\n Total out:\n 2,555 mL\n 420 mL\n Urine:\n 2,555 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n 438 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 670 (670 - 777) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 27\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.47/37/114/26/3\n Ve: 8.8 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: Well nourished, Thin\n Eyes / Conjunctiva: PERRL, looks to left when opens spontaneously\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, Rash: stable\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Increased, clonus, possible posturing w/suctioning\n Labs / Radiology\n 265 K/uL\n 11.7 g/dL\n 119 mg/dL\n 4.2 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 45 mg/dL\n 111 mEq/L\n 148 mEq/L\n 33.3 %\n 14.0 K/uL\n [image002.jpg]\n 04:40 AM\n 11:50 AM\n 12:01 PM\n 03:02 PM\n 04:02 PM\n 04:00 AM\n 08:39 AM\n 10:48 AM\n 04:12 AM\n 04:31 AM\n WBC\n 21.3\n 14.0\n Hct\n 37.2\n 33.3\n Plt\n 261\n 265\n Cr\n 3.7\n 4.2\n 4.2\n TCO2\n 25\n 25\n 26\n 28\n 27\n 28\n Glucose\n 134\n 123\n 100\n 119\n Other labs: PT / PTT / INR:15.8/27.9/1.4, CK / CKMB / Troponin-T:5360\n ()/113/<0.01, ALT / AST:3089 (3708)/1277 (2217), Alk Phos / T\n Bili:114 (121)/0.7, Amylase / Lipase:461/31, Differential-Neuts:76.4 %,\n Band:0.0 %, Lymph:16.2 %, Mono:6.2 %, Eos:0.8 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:1.4 mmol/L, Albumin:3.2 g/dL,\n LDH:2137 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:3.3 mg/dL\n Microbiology: DFA for Influenza A and B is negative\n Legionella urinary antigen (-)\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now intubated for\n hypoxic respiratory failure and with persistently altered MS.\n 1)Obtundation: Ultimate etiology is not clear at this time. Major\n concerns include serotonin syndrome, intoxication, or post-ictal\n state. Given extremely few cells in CSF minimal concern for\n meningitis/encephalitis. Mental status mildly improved since last\n night but still not consistently purposeful. Concern for anoxic brain\n injury.\n -completed cyproheptidine treatment\n -off sedation\n -if mental status not consistently improving CT head to rule out edema\n or acute process, proceed to neuro consult and MRI/EEG\n 2)Shock: The patient was hypotensive in the ED but only after\n receiving propofol sedation. This completely resolved and he is in\n fact hypertensive off pressor support at this time. Presume\n hypotension was iatrogenic. .\n -labetalol given concern for past cocaine abuse and unapposed B\n blockade\n -Echocardiogram with normal EF\n 3) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis, vs PNA, vs edema. We will cover for aspiration\n pneumonia and CA-MRSA with antibiotics though there are definitely\n other potential etiologies for fever in this patient. Patient is\n currently oxygenating and ventilating well on reasonable ventilator\n settings particularly given previous need for 100% O2. Now doing well\n on pressure support. Primary reason for continued ventilation is\n mental status.\n -Vanco/Ampicillin-Sublactam for aspiration pneumonia\n -sputum cultures\n -Rapid flu antigen test negative\n 4) Renal failure: Patient with good urine output but Cr continues to\n rise. Presumed etiology is ATN and rhabdomyoloysis.\n -Goal UOP of 150-200cc/hr\n -D5W given free water deficit and careful to avoid hypovolemia in\n setting of self-diuresis\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, etc...\n -Monitor fever and leukocytosis curves.\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -f/u culture from vesicle\n 7) Neuro: Unclear on significance of bilateral clonus w/o other\n neurologic abnormalities. Ct head slightly abnormal and patient's MS\n is poor. Neuro consult in AM and imaging per above if not improving\n dramatically over course of day.\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: NPO for now\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RHABDOMYOLYSIS\n POISONING / OVERDOSE, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 05:19 PM\n Arterial Line - 07:00 PM\n 20 Gauge - 03:45 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659496,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Events:\n Tmax 101.7 po @ 0400. BCX2, UA, C&S sent. Sputum Cx sent .\n Tylenol given @ 0700. WBC 14 ( 21.3)\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. His BP increased to\n 220/systolic w/mouth care, turning & suctioning/coughing. His eyes do\n not focus or track. Patient stretches out legs & his legs have a\n tremor while his eyes remain closed each time he is turned or receives\n mouth care, sx\ning-- ? seizure activity. This activity was not seen\n when he was left alone.\n Action:\n Received propofol for a few minutes until his BP was back down to\n 160\ns/systolic.\n Response:\n No stimulation & IV propofol brought patient\ns BP back down to\n 160\ns/systolic.\n Plan:\n Head CT & EEG planned for today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On CPAP @ 40% w/5 PEEP & 5 PS. RR: 14-20 O2 sats: 97-98%\n Lungs were clear w/exp wheezes @ L base.\n Action:\n ABG: 7.47/37/114 Sx\ned for small amount thick tan secretions.\n Grm stain shows no bacteria ()\n Response:\n RSBI: 27\n Plan:\n Wean from vent as patient is able to protect his airway.\n Renal failure, acute (Acute renal failure, ARF) from rhabdomyolysis\n Assessment:\n U/o 100cc/hr. Receiving 110cc/hr + abx/gastric meds. BUN 45\n (47) Cr 4.2 (4.2)\n Action:\n Continue to finish 2400cc D5W (on 2^nd L) @ 100cc/hr.\n Response:\n CK down to 5360 from 12,746 yesterday. BUN & Cr unchanged.\n Plan:\n Continue to hydrate well & follow labs.\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659400,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. His BP increased to\n 220/systolic w/mouth care, turning & suctioning/coughing.\n Action:\n Received propofol for a few minutes until his BP was back down to\n 160\ns/systolic.\n Response:\n No stimulation & IV propofol brought patient\ns BP back down to\n 160\ns/systolic.\n Plan:\n Decrease noxious stimulation as much as possible. Provide periods of\n no stimulation after turning, mouth care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On CPAP @ 40% w/5 PEEP & 5 PS. RR: 14-20 O2 sats: 97-98%\n Action:\n ABG: Sx\ned for small amount thick\n tan secretions.\n Response:\n Lungs clear w/exp wheezes @ L base.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659401,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. His BP increased to\n 220/systolic w/mouth care, turning & suctioning/coughing. His eyes do\n not focus or track.\n Action:\n Received propofol for a few minutes until his BP was back down to\n 160\ns/systolic.\n Response:\n No stimulation & IV propofol brought patient\ns BP back down to\n 160\ns/systolic.\n Plan:\n Head CT & EEG today most likely\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On CPAP @ 40% w/5 PEEP & 5 PS. RR: 14-20 O2 sats: 97-98%\n Action:\n ABG: Sx\ned for small amount thick\n tan secretions.\n Response:\n Lungs clear w/exp wheezes @ L base.\n Plan:\n"
},
{
"category": "Social Work",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 659593,
"text": "Progress Note:\n This worked spent time meeting with Mr. \ns father and his brother\n . When told that the pt\ns girlfriend had visited last night and had\n been able to provide useful information, Mr. said,\nIf you can\n believe her,\n adding that she always lies. When trying to understand\n what she might gain from not being honest, he felt that she might being\n try to protect herself because she had been supplying the methadone.\n and pt\ns father thought that she would cheek the methadone when\n she got her daily dose at a clinic by putting cotton in her mouth that\n would absorb the liquid, which she would then spit out when she left\n the building. Mr. was very open about his dislike of her and\n considering not letting her visit, but quickly reconsidered and said\n that for the time being it was okay. In the two meetings with the\n family, Mr. has asked about getting information from \n to understand why they did not check him for 13 hours. He states that\n his aim is not to hold them liable, but to get answers to\nthis\n mystery.\n Neither pt\ns father nor brother are working with the exception of Mr.\n plowing snow. The poor economy has no negatively affected his\n home improvement business, which was making three-quarters of a million\n dollars 2-3 years ago, he has had to lay-off eight employees. has\n moved in with his father because he could no longer afford to pay rent\n to his fianc\ns parents, as he had been living with them.\n Assessment:\n Mr. seems concerned, angry, and anxious about \ns medical\n condition. It appears that he is trying to blame and pt\n girlfriend for \n and medical problems. This worker spent\n time discussing with him the tendency to try to lay blame as a way of\n dealing with one\ns feelings. He did acknowledge that no one had held a\n gun to \n as a way of getting him to use .\n Plan:\n 1. To continue meeting with family.\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 659747,
"text": "Chief Complaint: Altered MS, Respiratory failure\n 24 Hour Events:\n URINE CULTURE - At 12:16 PM\n MULTI LUMEN - START 01:51 PM\n PAN CULTURE - At 04:45 AM\n -Persistently altered mental status so got neuro consult, they are\n somewhat concerned about focality (left more responsive than right) and\n asked for EEG and MRI/MRA tomorrow\n -CT Head just showed increased signal in globus pallidus\n -Got right sided IJ\n -Bit through OG so traded out for NG\n -Bit through ET tube so replaced by anesthesiology and got bite block\n and more sedation for the night, put on assist control til about 5:00\n am then converted back to spontaneous breathing\n -Febrile in AM on (100.4 at 4:54) so cultured\n -Started on tube feeds and free water boluses\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Ampicillin - 04:02 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:03 PM\n Famotidine (Pepcid) - 08:30 PM\n Propofol - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38\nC (100.4\n HR: 77 (72 - 89) bpm\n BP: 146/71(92) {120/64(83) - 159/94(109)} mmHg\n RR: 15 (12 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 4 (0 - 9)mmHg\n Total In:\n 2,574 mL\n 934 mL\n PO:\n TF:\n 44 mL\n 119 mL\n IVF:\n 1,681 mL\n 315 mL\n Blood products:\n Total out:\n 1,490 mL\n 655 mL\n Urine:\n 1,490 mL\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,084 mL\n 279 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 751 (629 - 5,749) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.46/39/145/26/4\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: Well nourished, Thin\n Eyes / Conjunctiva: PERRL, pupils midline\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: bilateral rhonchi)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, Rash: stable\n Neurologic: Responds to: Not assessed, Movement: Non -purposeful, Tone:\n Not assessed, responds intermittently to noxious stimuli, clonus\n continues but less dramatic in feet (2-3 beats), babinski unclear.\n / Radiology\n 239 K/uL\n 10.9 g/dL\n 100 mg/dL\n 3.8 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 47 mg/dL\n 113 mEq/L\n 148 mEq/L\n 31.4 %\n 14.8 K/uL\n [image002.jpg]\n 03:02 PM\n 04:02 PM\n 04:00 AM\n 08:39 AM\n 10:48 AM\n 04:12 AM\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n WBC\n 21.3\n 14.0\n 14.8\n Hct\n 37.2\n 33.3\n 31.4\n Plt\n 261\n 265\n 239\n Cr\n 3.7\n 4.2\n 4.2\n 3.9\n 3.8\n TCO2\n 26\n 28\n 27\n 28\n 29\n Glucose\n 123\n 100\n 119\n 105\n 100\n Other : PT / PTT / INR:15.3/27.8/1.3, CK / CKMB /\n Troponin-T:2818(5360)/113/<0.01, ALT / AST:(3089)/446(1277), Alk\n Phos / T Bili:100 (114)/0.6, Amylase / Lipase:158/54,\n Differential-Neuts:76.4 %, Band:0.0 %, Lymph:16.2 %, Mono:6.2 %,\n Eos:0.8 %, D-dimer: ng/mL, Fibrinogen:455 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:3.0 g/dL, LDH:844 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now respiratory issues\n have largely resolved and doing well on pressure support, but no\n clearly purposeful movements and continuing to be encephalopathic.\n 1)Obtundation: Seen by neurology who agree his picture is most\n consistent with anoxic brain injury and prognosis is not favorable.\n Some concern for laterality of findings so we are obtaining an MRI head\n today and an EEG to rule out epileptiform activity.\n -f/u EEG and MRI\n -Presumably the primary injury is anoxic brain injury and expect\n minimal recovery. After final studies and neuro input will discuss\n with family implications of further decisions. Patient likely to\n continue to breathe adequately if extubated (though would probably be\n chronic aspiration risk) but will address whether to re-intubate and/or\n proceed with trach\n -Minimize sedation\n 2)Shock: The patient was hypotensive in the ED but only after\n receiving propofol sedation. This completely resolved and he is in\n fact hypertensive off pressor support at this time. Presume\n hypotension was iatrogenic. Now inclined toward hypertension but\n improved with up-titration of labetalol\n -Continue labetalol\n 3) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis, vs PNA. CXR currently resolving and patient is\n needing minimal respiratory support. Primary reason for continued\n ventilation is mental status.\n -Ampicillin-Sublactam for aspiration pneumonia for seven day course\n 4) Renal failure: Cr. Continuing to fall though urine output falling\n as well, expect resolution of injury from rhabdo/ATN but will continue\n to monitor.\n -Free water boluses to correct hypernatremia, repeat evening lytes\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, neurogenic fever, etc\n Given improving lung findings and\n broad abx coverage highest suspicion for central fever now.\n -Monitor fever and leukocytosis curves.\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -f/u culture from vesicle\n 7) Hypernatremia: Possibly due to free water deficit and saline\n repletion but given persistently high despite free water boluses\n yesterday and known intracranial injury we are concerned for SIADH.\n -Recheck serum and urine osms, urine lytes\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: Tube feeds\n 10)Access: R IJ, A-line, PIV\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:00 PM\n 18 Gauge - 04:00 PM\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 27M polysubstance abuse, recent methadone OD,\n found down with shock, rhabdo, ARF, respiratory failure and likely\n aspiration pneumonia. Remains febrile, neuro input appreciated, bit\n through OGT/ETT. Reintubated.\n Exam notable for Tm 102.2 BP 120/90 HR 90 RR 18 with sat 98\n on PSV 10/5 0.4 7.46/39/126. +1L/24h. B ronchi. Hyperdynamic s1s2. +BS.\n 2+ edema but not tense. Clonus. notable for WBC 14K, HCT 31,\n Cr 3.8 / falling. CXR with B ASD, improving.\n Agree with plan to manage respiratory failure with PSV ventilation\n (reduced to at bedside). Continue treatment for\n aspiration pneumonia with unasyn alone. Remains on labetalol for\n hypertension. ARF is improving; will match I+O, RD meds, and follow\n closely. Will increase FWB for ongoing hypernatremia. Mental status\n remains poor, will f/u MRI read, d/w neuro and check EEG though doubt\n subclincial status. Ongoing support for family by team and SW. Will\n notify NEOB and d/w family re overall prognosis. Family meeting today\n at 1500. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 16:20 ------\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 659961,
"text": "27 y/o M admitted from detox unit with unknown drug overdose, seizures\n (LP neg), likely aspiration PNA with severe rhabdo from being down.\n Intubated and briefly on pressors. Initial high FiO2/PEEP likely \n volume overload, now weaned down with diuresis. Remained intubated for\n mental status - MRI with diffuse anoxic brain injury - after family\n meeting decided to extubate yesterday before commiting to trach/peg.\n On unasyn for aspiration PNA, but persistently febrile.\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Pt will follow some simple commands. Pt will stick tongue out when\n asked\nwill try to show his thumb when asked.\n Action:\n Neuro checks Q4hr. Pt reoriented to unit/date/time. All meds/treatments\n explained to the pt.\n Response:\n No change in status.\n Plan:\n No change in pt status. Pt to be transferred to floor. PT/OT consult?\n Pt will need rehab service once discharged from Hospital.\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 659962,
"text": "27 y/o M admitted from detox unit with unknown drug overdose, seizures\n (LP neg), likely aspiration PNA with severe rhabdo from being down.\n Intubated and briefly on pressors. Initial high FiO2/PEEP likely \n volume overload, now weaned down with diuresis. Remained intubated for\n mental status - MRI with diffuse anoxic brain injury - after family\n meeting decided to extubate yesterday before commiting to trach/peg.\n On unasyn for aspiration PNA, but persistently febrile.\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Pt will follow some simple commands. Pt will stick tongue out when\n asked\nwill try to show his thumb when asked. MRI EEG show anoxic brain\n injury. Pt difficult to understand. Unable to move feet. Pt can move\n right upper arm on bed. No movement in left upper arm.\n Action:\n Neuro checks Q4hr. Pt reoriented to unit/date/time. All meds/treatments\n explained to the pt.\n Response:\n No change in status.\n Plan:\n No change in pt status. Pt to be transferred to floor. PT/OT consult?\n Pt will need rehab service once discharged from Hospital.\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-12 00:00:00.000",
"description": "ICU Event Note - Family Meeting",
"row_id": 659751,
"text": "TITLE: FAMILY MEETING\n Clinician: Attending\n Mr. case was reviewed in detail with multiple family members\n and friends, including his father, who is his HCP. The nature of his\n neurological injury, based on examination, imaging and the input of the\n neuro team was discussed, as was his current medical condition. Based\n upon all of the above, it is likely that he has sufferred a profound\n injury and is unlikely to return to his prior baseline. The family\n understand this, and remain hopeful that he will have some recovery. We\n will extubate him today and monitor his neurological and respiratory\n status in the ICU over the next few days. If he requires reintubation,\n we will meet again to discuss T+G versus redirection to comfort\n measures. Until then, his is full code. All questions answered.\n Total time spent: 60 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659809,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down unresponsive with pinpoint pupils at\n Hosp on . He was treated with narcan with minimal effect.\n Pt was taken to where he was intubated and admitted to M/SICU for\n further mgt of resp failure, ARF, and rhabdo.\n A family meeting was held on . pts extensive neurologic injury was\n explained to the family, and that would likely never\n recover to his baseline neurologic status. it was decided to trial\n extubation with the understanding that we would re-intubate if he\n developed any distress and then discuss the plan of care further (i.e.\n trach/PEG, etc.). Pt was placed on a SBT and extubated successfully on\n .\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to protect airway, pos gag and cough.\n Appears to respond to stimuli reflexively.\n Opens eyes spontaneously, PERRL, continued leftward gaze, no\n following/tracking.\n No purposeful movements noted, one episode of possible decorticate\n posturing noted, pos clonus.\n Occasionally groans, did say\n\n overnight several times, but did\n not appear in response to any interaction.\n Remains NPO, NGT in place.\n Action:\n Continued close monitoring of neuro status, airway, and resp status.\n Response:\n Continues to respond reflexively to stimuli, non purposeful movements.\n Plan:\n Cont to monitor neuro status and airway protection.\n f/u with neuro recs.\n Cont supportive care to pt and family.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt has has been febrile over past 24 hrs.\n Tmax overnight 101.1 oral.\n Cultures drawn within 24hrs.\n Action:\n 650mg Tylenol administered.\n MD team aware, no further cultures ordered.\n On IV abx.\n Response:\n Pt remains febrile.\n Plan:\n Cont to monitor pts temp.\n MD team ? source, possible infection or neuro fevers.\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 659957,
"text": "27 y/o M admitted from detox unit with unknown drug overdose, seizures\n (LP neg), likely aspiration PNA with severe rhabdo from being down.\n Intubated and briefly on pressors. Initial high FiO2/PEEP likely \n volume overload, now weaned down with diuresis. Remained intubated for\n mental status - MRI with diffuse anoxic brain injury - after family\n meeting decided to extubate yesterday before commiting to trach/peg.\n On unasyn for aspiration PNA, but persistently febrile.\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Rhabdomyolysis\n Assessment:\n Action:\n Response:\n Plan:\n Poisoning / Overdose, Other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 659959,
"text": "27 y/o M admitted from detox unit with unknown drug overdose, seizures\n (LP neg), likely aspiration PNA with severe rhabdo from being down.\n Intubated and briefly on pressors. Initial high FiO2/PEEP likely \n volume overload, now weaned down with diuresis. Remained intubated for\n mental status - MRI with diffuse anoxic brain injury - after family\n meeting decided to extubate yesterday before commiting to trach/peg.\n On unasyn for aspiration PNA, but persistently febrile.\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 659960,
"text": "27 y/o M admitted from detox unit with unknown drug overdose, seizures\n (LP neg), likely aspiration PNA with severe rhabdo from being down.\n Intubated and briefly on pressors. Initial high FiO2/PEEP likely \n volume overload, now weaned down with diuresis. Remained intubated for\n mental status - MRI with diffuse anoxic brain injury - after family\n meeting decided to extubate yesterday before commiting to trach/peg.\n On unasyn for aspiration PNA, but persistently febrile.\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Pt will follow some simple commands. Pt will stick tongue out when\n asked\nwill try to show his thumb when asked.\n Action:\n Neuro checks Q4hr. Pt reoriented to unit/date/time. All meds/treatments\n explained to the pt.\n Response:\n No change in status.\n Plan:\n No change in pt status. Pt to be transferred to floor. PT/OT consult?\n Pt will need rehab service once discharged from Hospital.\n"
},
{
"category": "Social Work",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 659589,
"text": "Family Information\n Next of : Father\n Health Proxy appointed: Proxy\n Family Spokesperson designated: Father\n Communication or visitation restriction: None\n Patient Information:\n Previous living situation: Homeless\n Previous level of functioning: Independent\n Previous or other hospital admissions: No admissions\n Past psychiatric history: Pt\ns family reports a HX of depression but\n gave few details. They did say that when he broke-up with the mother of\n his 9 y/o son 5-6 years ago, he became quite depressed. Their\n understanding is that a doctor at had recently sent Mr.\n to because he was suicidal. It was not clear if the\n pt was transported by ambulance or went independently.\n Past addictions history: Pt has an extensive HX of drug use beginning\n perhaps 10 years ago, if not longer. He initially used cocaine and\n Oxycontin, but stopped 3-4 years ago. More recently, he has been using\n heroin, Xanax, methadone, and Percocet. His use of methadone is recent,\n according to pt's family. His girlfriend, and the mother of his \n month old female \"crack baby,\" introduced him to this drug. Pt's mo,\n with whom he has no contact (she lives in FL), was an \"addict\"\n (Oxycontin) according to pt's father. Pt's paternal grandfather \"is an\n alcoholic.\"\n Employment status: Unemployed--Pt has had numerous jobs, but his work\n with his father in home improvement was of his longest period of\n employment. Following release from prison, he did carpentry.\n Legal involvement: Mr. was released from prison in . A\n judge incarcerated him for five months for robbery. He is currently on\n probation.\n Additional Information:\n Patient / Family Assessment: The family felt guarded re information\n concerning Mr. \ns current and former behavior, perhaps in an\n effort to protect him. They did say that there is DSS involvement re\n the pt\ns new baby, born addicted to crack. When the police took the pt\n to hospital following an apparent seizure, possibly due to drug use,\n DSS came over at 4:00 AM and aid that pt could not return to the hotel\n where the family has apparently been living.\n Plan / Follow up:\n 1. This worker will again meet with family for additional HX and to\n provide support.\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659590,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, he was also found\n to be febrile, hypertensive, & tachycardic. LP negative for menengitis\n and Urine tox only positive for methadone. was started on broad\n spectrum abx and transferred to the M/SICU for further management.\n All sedation has been off since , Mr. continues to only\n respond to painful stimuli by withdrawing.\n Events:\n Head CT this AM\n R IJ TLCL placed @ bedside\n Neuro Consulted\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. He becomes aggittated w/\n all nursing care and displays lateral lower extremity tremors some\n question of seizure activity. PEARL however he is unable to track or\n follow commands and is noted to have a left leaning gaze when his eyes\n are open.\n Action:\n Head CT to evaluate for anoxic injury, q 4hr neuro checks, neuro in to\n evaluate\n Response:\n Official read of CT pending @ this time however preliminary read showed\nhypodensities in the globus pallidus\n which may be consistent w/\n anoxic injury\n Plan:\n Cont to monitor neuro status per routine, probable EEG tomorrow, family\n meeting once neurology weighs in.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated for airway protection on CPAP 5/5 no vent changes\n made, ABGs are within normal limits\n Action:\n Suctioned q3-4hrs for small amounts thick tan secretions\n Response:\n No change in clinical presentation\n Plan:\n Monitor resp status, extubate when confident pt can protect airway.\n Renal failure, acute (Acute renal failure, ARF) from rhabdomyolysis\n Assessment:\n Cr stable @ 4.2, hypernatremic w/ a Na of 148\n Action:\n 250 cc free water q 3, trend lytes\n Response:\n Chemestries sent @ 1700 pending @ this time\n Plan:\n Cont w/ free water boluses, trend lytes and replete accordingly\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659887,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down unresponsive with pinpoint pupils at\n Hosp on . He was treated with narcan with minimal effect.\n Pt was taken to where he was intubated and admitted to M/SICU for\n further mgt of resp failure, ARF, and rhabdo.\n A family meeting was held on . pts extensive neurologic injury was\n explained to the family, and that would likely never\n recover to his baseline neurologic status. it was decided to trial\n extubation with the understanding that we would re-intubate if he\n developed any distress and then discuss the plan of care further (i.e.\n trach/PEG, etc.). Pt was placed on a SBT and extubated successfully on\n .\n Altered mental status (not Delirium)\n Assessment:\n Respiratory status remains stable w/ pt extubated. Pt awake though\n unresponsive w/ no response to nail bed stimuli. Eyes open, PERRLA,\n corneal reflex present; however, pt continues w/ left fixed gaze, does\n not track. No purposeful movement noted, pt does not follow commands.\n On occasion pt says\n;\n however, these verbalizations do not seem\n purposeful.\n Action:\n - Monitoring respiratory status closely.\n - FiO2 weaned to room air.\n - Monitoring neuro status closely and following q4hr neuro\n assessments.\n Response:\n BBS remain CTA. SPO2 remains >92% on RA. Initially no improvement in MS\ns brother and father came to visit and pt increasingly verbal w/\n oriented responses\n able to identify picture of his neice, family\n members, time remaining in basketball game on television. Purposeful\n movements noted to bilat upper extremities.\n Plan:\n Continue to monitor respiratory status. Monitor neuro status closely.\n Hypernatremia (high sodium)\n Assessment:\n NA 149 this am up from 148.\n Action:\n - Monitoring labs closely.\n - D5W IVF continued at 125ml/hr as ordered.\n Response:\n Repeat Na 153. D5W IVF increased to 200ml/hr as ordered. Free water\n boluses 250ml Q6hr via NGT started as ordered. Repeat Na pnd.\n Plan:\n Continue to monitor labs as ordered and continue IVF and free water\n boluses as ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659717,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down at Hosp. 9AM on found\n unresponsive with pinpoint pupils. He was treated with narcan with\n minimal effect. Today pt had MRI.MRA brain, and\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659723,
"text": "Chief Complaint: Altered MS, Respiratory failure\n 24 Hour Events:\n URINE CULTURE - At 12:16 PM\n MULTI LUMEN - START 01:51 PM\n PAN CULTURE - At 04:45 AM\n -Persistently altered mental status so got neuro consult, they are\n somewhat concerned about focality (left more responsive than right) and\n asked for EEG and MRI/MRA tomorrow\n -CT Head just showed increased signal in globus pallidus\n -Got right sided IJ\n -Bit through OG so traded out for NG\n -Bit through ET tube so replaced by anesthesiology and got bite block\n and more sedation for the night, put on assist control til about 5:00\n am then converted back to spontaneous breathing\n -Febrile in AM on (100.4 at 4:54) so cultured\n -Started on tube feeds and free water boluses\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Ampicillin - 04:02 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:03 PM\n Famotidine (Pepcid) - 08:30 PM\n Propofol - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38\nC (100.4\n HR: 77 (72 - 89) bpm\n BP: 146/71(92) {120/64(83) - 159/94(109)} mmHg\n RR: 15 (12 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 4 (0 - 9)mmHg\n Total In:\n 2,574 mL\n 934 mL\n PO:\n TF:\n 44 mL\n 119 mL\n IVF:\n 1,681 mL\n 315 mL\n Blood products:\n Total out:\n 1,490 mL\n 655 mL\n Urine:\n 1,490 mL\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,084 mL\n 279 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 751 (629 - 5,749) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.46/39/145/26/4\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: Well nourished, Thin\n Eyes / Conjunctiva: PERRL, pupils midline\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: bilateral rhonchi)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, Rash: stable\n Neurologic: Responds to: Not assessed, Movement: Non -purposeful, Tone:\n Not assessed, responds intermittently to noxious stimuli, clonus\n continues but less dramatic in feet (2-3 beats), babinski unclear.\n / Radiology\n 239 K/uL\n 10.9 g/dL\n 100 mg/dL\n 3.8 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 47 mg/dL\n 113 mEq/L\n 148 mEq/L\n 31.4 %\n 14.8 K/uL\n [image002.jpg]\n 03:02 PM\n 04:02 PM\n 04:00 AM\n 08:39 AM\n 10:48 AM\n 04:12 AM\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n WBC\n 21.3\n 14.0\n 14.8\n Hct\n 37.2\n 33.3\n 31.4\n Plt\n 261\n 265\n 239\n Cr\n 3.7\n 4.2\n 4.2\n 3.9\n 3.8\n TCO2\n 26\n 28\n 27\n 28\n 29\n Glucose\n 123\n 100\n 119\n 105\n 100\n Other : PT / PTT / INR:15.3/27.8/1.3, CK / CKMB /\n Troponin-T:2818(5360)/113/<0.01, ALT / AST:(3089)/446(1277), Alk\n Phos / T Bili:100 (114)/0.6, Amylase / Lipase:158/54,\n Differential-Neuts:76.4 %, Band:0.0 %, Lymph:16.2 %, Mono:6.2 %,\n Eos:0.8 %, D-dimer: ng/mL, Fibrinogen:455 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:3.0 g/dL, LDH:844 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now respiratory issues\n have largely resolved and doing well on pressure support, but no\n clearly purposeful movements and continuing to be encephalopathic.\n 1)Obtundation: Seen by neurology who agree his picture is most\n consistent with anoxic brain injury and prognosis is not favorable.\n Some concern for laterality of findings so we are obtaining an MRI head\n today and an EEG to rule out epileptiform activity.\n -f/u EEG and MRI\n -Presumably the primary injury is anoxic brain injury and expect\n minimal recovery. After final studies and neuro input will discuss\n with family implications of further decisions. Patient likely to\n continue to breathe adequately if extubated (though would probably be\n chronic aspiration risk) but will address whether to re-intubate and/or\n proceed with trach\n -Minimize sedation\n 2)Shock: The patient was hypotensive in the ED but only after\n receiving propofol sedation. This completely resolved and he is in\n fact hypertensive off pressor support at this time. Presume\n hypotension was iatrogenic. Now inclined toward hypertension but\n improved with up-titration of labetalol\n -Continue labetalol\n 3) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis, vs PNA. CXR currently resolving and patient is\n needing minimal respiratory support. Primary reason for continued\n ventilation is mental status.\n -Ampicillin-Sublactam for aspiration pneumonia for seven day course\n 4) Renal failure: Cr. Continuing to fall though urine output falling\n as well, expect resolution of injury from rhabdo/ATN but will continue\n to monitor.\n -Free water boluses to correct hypernatremia, repeat evening lytes\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, neurogenic fever, etc\n Given improving lung findings and\n broad abx coverage highest suspicion for central fever now.\n -Monitor fever and leukocytosis curves.\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -f/u culture from vesicle\n 7) Hypernatremia: Possibly due to free water deficit and saline\n repletion but given persistently high despite free water boluses\n yesterday and known intracranial injury we are concerned for SIADH.\n -Recheck serum and urine osms, urine lytes\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: Tube feeds\n 10)Access: R IJ, A-line, PIV\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:00 PM\n 18 Gauge - 04:00 PM\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659799,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down unresponsive with pinpoint pupils at\n Hosp on . He was treated with narcan with minimal effect.\n Pt was taken to where he was intubated and admitted to M/SICU for\n further mgt of resp failure, ARF, and rhabdo.\n A family meeting was held on . pts extensive neurologic injury was\n explained to the family, and that would likely never\n recover to his baseline neurologic status. it was decided to trial\n extubation with the understanding that we would re-intubate if he\n developed any distress and then discuss the plan of care further (i.e.\n trach/PEG, etc.). Pt was placed on a SBT and extubated successfully on\n .\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to protect airway, pos gag and cough.\n Appears to respond to stimuli reflexively.\n Opens eyes spontaneously, PERRL, continued leftward gaze, no\n following/tracking.\n No purposeful movements noted, one episode of possible decorticate\n posturing noted, pos clonus.\n Occasionally groans, did say\n\n overnight several times, but did\n not appear in response to any interaction.\n Remains NPO, NGT in place.\n Action:\n Continued close monitoring of neuro status, airway, and resp status.\n Response:\n Continues to respond reflexively to stimuli, non purposeful movements.\n Plan:\n Cont to monitor neuro status and airway protection.\n f/u with neuro recs.\n Cont to supportive care to pt and family.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt has has been febrile over past 24 hrs.\n Tmax overnight 100.5 oral.\n Cultures drawn within 24hrs.\n Action:\n 650mg Tylenol administered.\n MD team aware, no further cultures ordered.\n On IV abx.\n Response:\n Pt remains febrile.\n Plan:\n Cont to monitor pts temp.\n MD team ? source, possible infection or neuro fevers.\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659951,
"text": "Chief Complaint: Obtundation, found down\n 24 Hour Events:\n -was able to answer simple questions with \"OK,\" \"thanks,\" \".\" etc.\n -got free water to correct hypernatremia\n -IJ pulled back 2 cm (was previously in RA)\n -started on amlodipine for htn to 180s\n PAN CULTURE - At 12:00 PM\n FEVER - 101.3\nF - 12:00 PM\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 04:20 AM\n Ampicillin/Sulbactam (Unasyn) - 10:04 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.8\nC (100.1\n HR: 81 (70 - 92) bpm\n BP: 166/89(114) {155/82(103) - 179/98(123)} mmHg\n RR: 18 (12 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 6 (4 - 14)mmHg\n Total In:\n 4,894 mL\n 7 mL\n PO:\n TF:\n IVF:\n 4,314 mL\n 7 mL\n Blood products:\n Total out:\n 2,575 mL\n 220 mL\n Urine:\n 2,575 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,319 mL\n -213 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: 7.48/37/86./23/3\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, blood around mouth\n Head, Ears, Nose, Throat: Normocephalic, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Diminished: mostly due to effort)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, Rash: stable on medial knees\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement:\n Purposeful, Tone: Not assessed, clonus in ankles bilaterally persists,\n babinski upgoing bilaterally in toes\n Labs / Radiology\n 258 K/uL\n 10.5 g/dL\n 127 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 37 mg/dL\n 115 mEq/L\n 148 mEq/L\n 30.6 %\n 16.8 K/uL\n [image002.jpg]\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n 08:27 PM\n 04:07 AM\n 10:30 AM\n 10:47 AM\n 04:59 PM\n 04:20 AM\n WBC\n 14.8\n 14.5\n 16.8\n Hct\n 31.4\n 31.1\n 30.6\n Plt\n \n Cr\n 3.9\n 3.8\n 3.4\n 3.4\n 3.3\n 3.0\n TCO2\n 28\n 29\n 26\n 28\n Glucose\n 105\n 100\n 108\n 137\n 131\n 127\n Other labs: PT / PTT / INR:15.8/27.5/1.4, CK / CKMB /\n Troponin-T:1249/113/<0.01, ALT / AST:815/95, Alk Phos / T Bili:80/0.7,\n Amylase / Lipase:158/54, Differential-Neuts:76.4 %, Band:0.0 %,\n Lymph:16.2 %, Mono:6.2 %, Eos:0.8 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:3.0 g/dL, LDH:637\n IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL, PO4:3.0 mg/dL\n Fluid analysis / Other labs: Other Urine Chemistry:\n UreaN:679\n Creat:98\n Na:54\n K:25\n Cl:32\n Osmolal:410\n Imaging: IMPRESSION:\n 1. Extensive areas of restricted diffusion involving the white matter,\n corpus callosum, both globus pallidus and right hippocampus indicative\n of\n acute infarct/ischemia likely due to global hypoxia.\n 2. No evidence of midline shift or herniation.\n MRA OF THE HEAD:\n The head MRA demonstrates normal flow signal within the arteries of\n anterior\n and posterior circulation.\n IMPRESSION: Normal MRA of the head.\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presenting with obtundation\n and respiratory failure.\n #) Anoxic brain injury: Seen by neurology who agree his picture is most\n consistent with anoxic brain injury and prognosis is not favorable.\n MRI also showed extensive areas of restricted diffusion consistent with\n this diagnosis. Fortunately, was able to verbally respond to simple\n questions from family on afternoon of .\n -f/u EEG\n -regular assessment of mental status\n #) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis vs PNA. CXR currently resolving and patient is\n s/p extubation on and generally breathing comfortably. Had\n - respirations earlier today but now has normal breathing\n pattern.\n -Ampicillin-Sublactam for aspiration pneumonia for seven day course\n (day 1 = )\n #) Renal failure: Secondary to rhabdo and ATN. Creatinine falling.\n - renally dose meds\n - continue to monitor\n #) Fever: Concern for infection and culturing when patient spikes\n fevers. Also may be related to serotonin syndrome, vasculitis,\n neurogenic fever, etc\n Fever curve trending down.\n -Monitor fever and leukocytosis curves.\n #) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -f/u culture from vesicle\n #) Hypernatremia: Likely secondary to insensible losses but may also\n be related to intracranial injury. Free water deficit of 4.5 liters on\n .\n - correct sodium with free water boluses, D5W by mEq/day\n - check p.m. sodium level\n #)PPX: SC Heparin\n #) FEN: Tube feeds\n #) Code Status: Presumed full\n HYPERNATREMIA (HIGH SODIUM)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RHABDOMYOLYSIS\n POISONING / OVERDOSE, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659956,
"text": "Chief Complaint: Obtundation, found down\n 24 Hour Events:\n -was able to answer simple questions with \"OK,\" \"thanks,\" \".\" etc.\n -got free water to correct hypernatremia\n -IJ pulled back 2 cm (was previously in RA)\n -started on amlodipine for htn to 180s\n PAN CULTURE - At 12:00 PM\n FEVER - 101.3\nF - 12:00 PM\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 04:20 AM\n Ampicillin/Sulbactam (Unasyn) - 10:04 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.8\nC (100.1\n HR: 81 (70 - 92) bpm\n BP: 166/89(114) {155/82(103) - 179/98(123)} mmHg\n RR: 18 (12 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 6 (4 - 14)mmHg\n Total In:\n 4,894 mL\n 7 mL\n PO:\n TF:\n IVF:\n 4,314 mL\n 7 mL\n Blood products:\n Total out:\n 2,575 mL\n 220 mL\n Urine:\n 2,575 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,319 mL\n -213 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: 7.48/37/86./23/3\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, blood around mouth\n Head, Ears, Nose, Throat: Normocephalic, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Diminished: mostly due to effort)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, Rash: stable on medial knees\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement:\n Purposeful, Tone: Not assessed, clonus in ankles bilaterally persists,\n babinski upgoing bilaterally in toes\n Labs / Radiology\n 258 K/uL\n 10.5 g/dL\n 127 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 37 mg/dL\n 115 mEq/L\n 148 mEq/L\n 30.6 %\n 16.8 K/uL\n [image002.jpg]\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n 08:27 PM\n 04:07 AM\n 10:30 AM\n 10:47 AM\n 04:59 PM\n 04:20 AM\n WBC\n 14.8\n 14.5\n 16.8\n Hct\n 31.4\n 31.1\n 30.6\n Plt\n \n Cr\n 3.9\n 3.8\n 3.4\n 3.4\n 3.3\n 3.0\n TCO2\n 28\n 29\n 26\n 28\n Glucose\n 105\n 100\n 108\n 137\n 131\n 127\n Other labs: PT / PTT / INR:15.8/27.5/1.4, CK / CKMB /\n Troponin-T:1249/113/<0.01, ALT / AST:815/95, Alk Phos / T Bili:80/0.7,\n Amylase / Lipase:158/54, Differential-Neuts:76.4 %, Band:0.0 %,\n Lymph:16.2 %, Mono:6.2 %, Eos:0.8 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:3.0 g/dL, LDH:637\n IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL, PO4:3.0 mg/dL\n Fluid analysis / Other labs: Other Urine Chemistry:\n UreaN:679\n Creat:98\n Na:54\n K:25\n Cl:32\n Osmolal:410\n Imaging: IMPRESSION:\n 1. Extensive areas of restricted diffusion involving the white matter,\n corpus callosum, both globus pallidus and right hippocampus indicative\n of\n acute infarct/ischemia likely due to global hypoxia.\n 2. No evidence of midline shift or herniation.\n MRA OF THE HEAD:\n The head MRA demonstrates normal flow signal within the arteries of\n anterior\n and posterior circulation.\n IMPRESSION: Normal MRA of the head.\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presenting with obtundation\n and respiratory failure.\n #) Anoxic brain injury: Patient has presentation and symptoms most\n consistent with anoxic brain injury. Neurology in agreement and MRI\n and EEG consistent with that diagnosis. Had very minimal\n responsiveness while intubated but currently responding intermittently\n appropriately to simple questions. Still difficult to understand and\n reports unable to move hands or feets. Ventilating and oxygenating\n well since extubated.\n -follow mental status\n -will likely need placement to long term rehab/care facility\n #) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis vs PNA. CXR has progressively improved and\n patient is s/p extubation on and generally breathing\n comfortably.\n -Ampicillin-Sublactam for aspiration pneumonia for seven day course\n (day 1 = )\n #) Renal failure: Secondary to rhabdo and ATN. Continues to\n improve.\n - renally dose meds\n -avoid nephrotoxins\n #) FUO: Patient continues to have fevers despite generally improving\n clinical condition. Cultures have all been negative so far.\n Potentially, this is all neurogenic fever, drug fever, and/or resolving\n vasculitis but also possible line infection or choleycystitis (unlikely\n with falling LFT\ns). If cultures remain negative would probably\n proceed to CT chest to rule out complicated effusion/empyema.\n -Monitor fever and leukocytosis curves.\n -check WBC differential\n #) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Culture results benign.\n #) Hypernatremia: This has resolved with free water boluses and\n presumably was due to insensible losses.\n - check p.m. sodium level\n #)PPX: SC Heparin, no further indication for acid suppression so\n stopped\n #) FEN: Tube feeds\n #) Code Status: Presumed full\n #) Dispo: C/O to floor, will presumably need long term placement\n afterward.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:C/O to floor\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659796,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down unresponsive with pinpoint pupils at\n Hosp on . He was treated with narcan with minimal effect.\n Pt was taken to where he was intubated and admitted to M/SICU for\n further mgt of resp failure, ARF, and rhabdo.\n A family meeting was held on . pts extensive neurologic injury was\n explained to the family, and that would likely never\n recover to his baseline neurologic status. it was decided to trial\n extubation with the understanding that we would re-intubate if he\n developed any distress and then discuss the plan of care further (i.e.\n trach/PEG, etc.). Pt was placed on a SBT and extubated successfully on\n .\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659800,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down unresponsive with pinpoint pupils at\n Hosp on . He was treated with narcan with minimal effect.\n Pt was taken to where he was intubated and admitted to M/SICU for\n further mgt of resp failure, ARF, and rhabdo.\n A family meeting was held on . pts extensive neurologic injury was\n explained to the family, and that would likely never\n recover to his baseline neurologic status. it was decided to trial\n extubation with the understanding that we would re-intubate if he\n developed any distress and then discuss the plan of care further (i.e.\n trach/PEG, etc.). Pt was placed on a SBT and extubated successfully on\n .\n Altered mental status (not Delirium)\n Assessment:\n Pt continues to protect airway, pos gag and cough.\n Appears to respond to stimuli reflexively.\n Opens eyes spontaneously, PERRL, continued leftward gaze, no\n following/tracking.\n No purposeful movements noted, one episode of possible decorticate\n posturing noted, pos clonus.\n Occasionally groans, did say\n\n overnight several times, but did\n not appear in response to any interaction.\n Remains NPO, NGT in place.\n Action:\n Continued close monitoring of neuro status, airway, and resp status.\n Response:\n Continues to respond reflexively to stimuli, non purposeful movements.\n Plan:\n Cont to monitor neuro status and airway protection.\n f/u with neuro recs.\n Cont supportive care to pt and family.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt has has been febrile over past 24 hrs.\n Tmax overnight 100.5 oral.\n Cultures drawn within 24hrs.\n Action:\n 650mg Tylenol administered.\n MD team aware, no further cultures ordered.\n On IV abx.\n Response:\n Pt remains febrile.\n Plan:\n Cont to monitor pts temp.\n MD team ? source, possible infection or neuro fevers.\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659941,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down unresponsive with pinpoint pupils at\n Hosp on . He was treated with narcan with minimal effect.\n Pt was taken to where he was intubated and admitted to M/SICU for\n further mgt of resp failure, ARF, and rhabdo.\n A family meeting was held on . pts extensive neurologic injury was\n explained to the family, and that would likely never\n recover to his baseline neurologic status. it was decided to extubate\n with the understanding that we would re-intubate if he developed any\n distress and then discuss the plan of care further (i.e. trach/PEG,\n etc.). Pt was extubated successfully on .\n Altered mental status (not Delirium)\n Assessment:\n MS has been improving, pt oriented x1, knows and names family members\n from pictures, answers simple questions appropriately, sticks out\n tongue on command. Have not noted any spontaneous movement, could not\n move arms when asked. Cont w L gaze, not tracking. PERRL. LS clear,\n RR irreg, short periods of apnea but sats always > 93, usually > 95.\n Action:\n Reorient pt to time and place freq. Monitor resp and neuro status.\n Turn q2 hrs\n Response:\n Improving MS\n :\n Cont to monitor resp and neur status closely.\n Hypernatremia (high sodium)\n Assessment:\n Na improving from 153 to 150 with fluids.\n Action:\n D5W at 200mls/hr for 2L overnoc, also cont free water flushes via NG\n tube 250mls q4hrs.\n Response:\n Na 148 w am labs. Changed D5W to 100mls/hr at 0400 per team, last\n liter up. K 3.6. Cr steadily improving/.\n Plan:\n Replete K per team. Review fluid orders with team for day shift.\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659418,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. His BP increased to\n 220/systolic w/mouth care, turning & suctioning/coughing. His eyes do\n not focus or track. Patient stretches out legs & his legs have a\n tremor while his eyes remain closed each time he is turned or receives\n mouth care, sx\ning-- ? seizure activity. This activity was not seen\n when he was left alone.\n Action:\n Received propofol for a few minutes until his BP was back down to\n 160\ns/systolic.\n Response:\n No stimulation & IV propofol brought patient\ns BP back down to\n 160\ns/systolic.\n Plan:\n Head CT & EEG planned for today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On CPAP @ 40% w/5 PEEP & 5 PS. RR: 14-20 O2 sats: 97-98%\n Lungs were clear w/exp wheezes @ L base.\n Action:\n ABG: Sx\ned for small amount thick\n secretions.\n Response:\n RSBI:\n Plan:\n Wean from vent as patient tolerates.\n Renal failure, acute (Acute renal failure, ARF) from rhabdomyolysis\n Assessment:\n U/o 100cc/hr. Receiving 110cc/hr + abx/gastric meds. BUN\n (47) Cr (4.2) CK ()\n Action:\n Continue to finish 2400cc D5W (on 2^nd L) @ 100cc/hr.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659660,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, he was also found\n to be febrile, hypertensive, & tachycardic. LP negative for menengitis\n and Urine tox only positive for methadone. was started on broad\n spectrum abx and transferred to the M/SICU for further management.\n All sedation has been off since , Mr. continues to only\n respond to painful stimuli by withdrawing.\n EVENTS: RE INTUBATION.\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. He was off sedation for\n more than 48 hrs. but now he is again sedated with propofol. PEARL .\n Action:\n Head CT done yesterday to evaluate for anoxic injury, q 4hr neuro\n checks, neuro in to evaluate\n Response:\n Official read of CT pending @ this time however preliminary read showed\nhypodensities in the globus pallidus\n which may be consistent w/\n anoxic injury\n Plan:\n Cont to monitor neuro status per routine, probable EEG tomorrow, for\n MRI today .filled form already faxed. family meeting later.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Events during the shift : Beginning of shift pt remains intubated\n , off sedation , on CPAP 5/5 . initially RRT found that while he was\n suctioning the ETT, pt was coughing a lot ,having lot of secretions, pt\n not comfortable, a thin stream of water flowing from his mouth when he\n coughs. Myself informed to team and first thought of OGT misplaced.\n Feed stopped and OGT removed , propofol 20 mics given and re inserted\n NGT. But pt still not comfortable, coughing too much, Pt biting on\n ETT, airway inserted , able to hear air passing through the ETT. Sats\n maintained > 95% . called for anaesthesia ,propofol 20 mics given and\n tried to reinsert another ETT ith bouggie ,but unsuccessful,ambu bagged\n with hiflow O2 and sats maintained > 94%. .succs 5 cc iv given and re\n intubated the pt with 7.5 ETT and fixed at no: 26.repeat Xray showed\n ETT deep down ,so pulled out and fixed at no: 24 by RRT. . Connected\n to vent/ AC/14/600/5/50%. It was found that Old ETT got an open area\n inside ? due biting the tube.\n Action:\n Re intubated and vent settings changed to AC .\n Response:\n No change in clinical presentation\n Plan:\n Monitor resp status, Wean as tolerated.\n Renal failure, acute (Acute renal failure, ARF) from rhabdomyolysis\n Assessment:\n Cr stable @ 4.9 , hypernatremic w/ a Na of 148\n Action:\n Feed restarted at 15 cc/hr . goal @ 65 cc/hr free water 250cc q 3hr.\n Response:\n Am labs sent. Waiting for report.\n Plan:\n Cont w/ free water boluses, replete lytes as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659343,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Events:\n Increasingly responsive over course of shift\n Sputum Cx sent\n Temp curve trending up\n Altered mental status (not Delirium)\n Assessment:\n Unresponsive overnight, now becomes aggitated w/ nursing care,\n withdraws from painful stimuli, PEARL however unable to track or follow\n commands, moves all extremities on bed however spontaneous movement is\n non purposeful\n Action:\n Q4hr neuro checks, sedation off since @ 0700\n Response:\n Clinical presentation unchanged from above assessment\n Plan:\n Cont to monitor neuro status, if no further improvement plan for head\n CT and EEG in the AM.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, on CPAP 5/5, LS ronchi LUL otherwise clear.\n Action:\n Suctioned for scant\n small amounts thick tan secretions both oral and\n ett, no vent changes made\n Response:\n ABGs remain within normal limits\n Plan:\n Will remain intubated overnight, possible extubation tomorrow if able\n to protect airway\n Rhabdomyolysis\n Assessment:\n CPK, AST,ALT remain elevated and renal insufficiency persists but\n improving\n Action:\n Started on D\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659346,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Events:\n Increasingly responsive over course of shift\n Sputum Cx sent\n Temp curve trending up\n Altered mental status (not Delirium)\n Assessment:\n Unresponsive overnight, now becomes aggitated w/ nursing care,\n withdraws from painful stimuli, PEARL however unable to track or follow\n commands, moves all extremities on bed however spontaneous movement is\n non purposeful\n Action:\n Q4hr neuro checks, sedation off since @ 0700\n Response:\n Clinical presentation unchanged from above assessment\n Plan:\n Cont to monitor neuro status, if no further improvement plan for head\n CT and EEG in the AM.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, on CPAP 5/5, LS ronchi LUL otherwise clear.\n Action:\n Suctioned for scant\n small amounts thick tan secretions both oral and\n ett, no vent changes made\n Response:\n ABGs remain within normal limits\n Plan:\n Will remain intubated overnight, possible extubation tomorrow if able\n to protect airway\n Rhabdomyolysis\n Assessment:\n CPK, AST,ALT remain elevated and renal insufficiency persists but\n improving\n Action:\n Started on D5W maintenance @ 100cc/hr, renal consulted and is following\n Response:\n Plan:\n Monitor liver and renal function w/ morning labs, cont to monitor U/O.\n No indications for dialysis @ this time.\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659968,
"text": "Chief Complaint: Obtundation, found down\n 24 Hour Events:\n -was able to answer simple questions with \"OK,\" \"thanks,\" \".\" etc.\n -got free water to correct hypernatremia\n -IJ pulled back 2 cm (was previously in RA)\n -started on amlodipine for htn to 180s\n PAN CULTURE - At 12:00 PM\n FEVER - 101.3\nF - 12:00 PM\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 04:20 AM\n Ampicillin/Sulbactam (Unasyn) - 10:04 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.8\nC (100.1\n HR: 81 (70 - 92) bpm\n BP: 166/89(114) {155/82(103) - 179/98(123)} mmHg\n RR: 18 (12 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 6 (4 - 14)mmHg\n Total In:\n 4,894 mL\n 7 mL\n PO:\n TF:\n IVF:\n 4,314 mL\n 7 mL\n Blood products:\n Total out:\n 2,575 mL\n 220 mL\n Urine:\n 2,575 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,319 mL\n -213 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: 7.48/37/86./23/3\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, blood around mouth\n Head, Ears, Nose, Throat: Normocephalic, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Diminished: mostly due to effort)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, Rash: stable on medial knees\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement:\n Purposeful, Tone: Not assessed, clonus in ankles bilaterally persists,\n babinski upgoing bilaterally in toes\n Labs / Radiology\n 258 K/uL\n 10.5 g/dL\n 127 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 37 mg/dL\n 115 mEq/L\n 148 mEq/L\n 30.6 %\n 16.8 K/uL\n [image002.jpg]\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n 08:27 PM\n 04:07 AM\n 10:30 AM\n 10:47 AM\n 04:59 PM\n 04:20 AM\n WBC\n 14.8\n 14.5\n 16.8\n Hct\n 31.4\n 31.1\n 30.6\n Plt\n \n Cr\n 3.9\n 3.8\n 3.4\n 3.4\n 3.3\n 3.0\n TCO2\n 28\n 29\n 26\n 28\n Glucose\n 105\n 100\n 108\n 137\n 131\n 127\n Other labs: PT / PTT / INR:15.8/27.5/1.4, CK / CKMB /\n Troponin-T:1249/113/<0.01, ALT / AST:815/95, Alk Phos / T Bili:80/0.7,\n Amylase / Lipase:158/54, Differential-Neuts:76.4 %, Band:0.0 %,\n Lymph:16.2 %, Mono:6.2 %, Eos:0.8 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:3.0 g/dL, LDH:637\n IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL, PO4:3.0 mg/dL\n Fluid analysis / Other labs: Other Urine Chemistry:\n UreaN:679\n Creat:98\n Na:54\n K:25\n Cl:32\n Osmolal:410\n Imaging: IMPRESSION:\n 1. Extensive areas of restricted diffusion involving the white matter,\n corpus callosum, both globus pallidus and right hippocampus indicative\n of\n acute infarct/ischemia likely due to global hypoxia.\n 2. No evidence of midline shift or herniation.\n MRA OF THE HEAD:\n The head MRA demonstrates normal flow signal within the arteries of\n anterior\n and posterior circulation.\n IMPRESSION: Normal MRA of the head.\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presenting with obtundation\n and respiratory failure.\n #) Anoxic brain injury: Patient has presentation and symptoms most\n consistent with anoxic brain injury. Neurology in agreement and MRI\n and EEG consistent with that diagnosis. Had very minimal\n responsiveness while intubated but currently responding intermittently\n appropriately to simple questions. Still difficult to understand and\n reports unable to move hands or feets. Ventilating and oxygenating\n well since extubated.\n -follow mental status\n -will likely need placement to long term rehab/care facility\n #) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis vs PNA. CXR has progressively improved and\n patient is s/p extubation on and generally breathing\n comfortably.\n -Ampicillin-Sublactam for aspiration pneumonia for seven day course\n (day 1 = )\n #) Renal failure: Secondary to rhabdo and ATN. Continues to\n improve.\n - renally dose meds\n -avoid nephrotoxins\n #) FUO: Patient continues to have fevers despite generally improving\n clinical condition. Cultures have all been negative so far.\n Potentially, this is all neurogenic fever, drug fever, and/or resolving\n vasculitis but also possible line infection or choleycystitis (unlikely\n with falling LFT\ns). If cultures remain negative would probably\n proceed to CT chest to rule out complicated effusion/empyema.\n -Monitor fever and leukocytosis curves.\n -check WBC differential\n #) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Culture results benign.\n #) Hypernatremia: This has resolved with free water boluses and\n presumably was due to insensible losses.\n - check p.m. sodium level\n #)PPX: SC Heparin, no further indication for acid suppression so\n stopped\n #) FEN: Tube feeds\n #) Code Status: Presumed full\n #) Dispo: C/O to floor, will presumably need long term placement\n afterward.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:C/O to floor\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659969,
"text": "Chief Complaint: Obtundation, found down\n 24 Hour Events:\n -was able to answer simple questions with \"OK,\" \"thanks,\" \".\" etc.\n -got free water to correct hypernatremia\n -IJ pulled back 2 cm (was previously in RA)\n -started on amlodipine for htn to 180s\n -PAN CULTURE - At 12:00 PM\n -FEVER - 101.3\nF - 12:00 PM\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 04:20 AM\n Ampicillin/Sulbactam (Unasyn) - 10:04 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.8\nC (100.1\n HR: 81 (70 - 92) bpm\n BP: 166/89(114) {155/82(103) - 179/98(123)} mmHg\n RR: 18 (12 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 6 (4 - 14)mmHg\n Total In:\n 4,894 mL\n 7 mL\n PO:\n TF:\n IVF:\n 4,314 mL\n 7 mL\n Blood products:\n Total out:\n 2,575 mL\n 220 mL\n Urine:\n 2,575 mL\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,319 mL\n -213 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: 7.48/37/86./23/3\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, blood around mouth\n Head, Ears, Nose, Throat: Normocephalic, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Diminished: mostly due to effort)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, Rash: stable on medial knees\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement:\n Purposeful, Tone: Not assessed, clonus in ankles bilaterally persists,\n babinski upgoing bilaterally in toes\n Labs / Radiology\n 258 K/uL\n 10.5 g/dL\n 127 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 37 mg/dL\n 115 mEq/L\n 148 mEq/L\n 30.6 %\n 16.8 K/uL\n [image002.jpg]\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n 08:27 PM\n 04:07 AM\n 10:30 AM\n 10:47 AM\n 04:59 PM\n 04:20 AM\n WBC\n 14.8\n 14.5\n 16.8\n Hct\n 31.4\n 31.1\n 30.6\n Plt\n \n Cr\n 3.9\n 3.8\n 3.4\n 3.4\n 3.3\n 3.0\n TCO2\n 28\n 29\n 26\n 28\n Glucose\n 105\n 100\n 108\n 137\n 131\n 127\n Other labs: PT / PTT / INR:15.8/27.5/1.4, CK / CKMB /\n Troponin-T:1249/113/<0.01, ALT / AST:815/95, Alk Phos / T Bili:80/0.7,\n Amylase / Lipase:158/54, Differential-Neuts:76.4 %, Band:0.0 %,\n Lymph:16.2 %, Mono:6.2 %, Eos:0.8 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:3.0 g/dL, LDH:637\n IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL, PO4:3.0 mg/dL\n Fluid analysis / Other labs: Other Urine Chemistry:\n UreaN:679\n Creat:98\n Na:54\n K:25\n Cl:32\n Osmolal:410\n Imaging: IMPRESSION:\n 1. Extensive areas of restricted diffusion involving the white matter,\n corpus callosum, both globus pallidus and right hippocampus indicative\n of\n acute infarct/ischemia likely due to global hypoxia.\n 2. No evidence of midline shift or herniation.\n MRA OF THE HEAD:\n The head MRA demonstrates normal flow signal within the arteries of\n anterior\n and posterior circulation.\n IMPRESSION: Normal MRA of the head.\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presenting with obtundation\n and respiratory failure.\n #) Anoxic brain injury: Patient has presentation and symptoms most\n consistent with anoxic brain injury. Neurology in agreement and MRI\n and EEG consistent with that diagnosis. Had very minimal\n responsiveness while intubated but currently responding intermittently\n appropriately to simple questions. Still difficult to understand and\n reports unable to move hands or feets. Ventilating and oxygenating\n well since extubated.\n -follow mental status\n -will likely need placement to long term rehab/care facility\n #) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis vs PNA. CXR has progressively improved and\n patient is s/p extubation on and generally breathing\n comfortably.\n -Ampicillin-Sublactam for aspiration pneumonia for seven day course\n (day 1 = )\n #) Renal failure: Secondary to rhabdo and ATN. Continues to\n improve.\n - renally dose meds\n -avoid nephrotoxins\n #) FUO: Patient continues to have fevers despite generally improving\n clinical condition. Cultures have all been negative so far.\n Potentially, this is all neurogenic fever, drug fever, and/or resolving\n vasculitis but also possible line infection or choleycystitis (unlikely\n with falling LFT\ns). If cultures remain negative would probably\n proceed to CT chest to rule out complicated effusion/empyema.\n -Monitor fever and leukocytosis curves.\n -check WBC differential\n #) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Culture results benign.\n #) Hypernatremia: This has resolved with free water boluses and\n presumably was due to insensible losses.\n - check p.m. sodium level\n #)PPX: SC Heparin, no further indication for acid suppression so\n stopped\n #) FEN: Tube feeds\n #) Code Status: Presumed full\n #) Dispo: C/O to floor, will presumably need long term placement\n afterward.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:C/O to floor\n"
},
{
"category": "Respiratory ",
"chartdate": "2162-03-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658948,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 10 mL / Air\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-09 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 659005,
"text": "Chief Complaint: Found Down\n HPI:\n This is a 27 y.o. male with a history of polysubstance abuse,\n depressive disorder NOS, and GERD who presents after being found down\n at where he been admitted for detox. Per\n notes, the patient endorsed an 8 mo history of abusing\n multiple types of opiates including oxycontin, methadone, and heroin.\n He had decided to quit and thus had managed to obtain methadone with\n the intent to wean himself gradually from that medication.\n Unfortunately, on he accidentally overdosed on the methadone and\n was brought into hospital for treatment (it is unclear exactly\n what were the details of his overdose and how he was managed though it\n appears he was discharged from the emergency room). After discharge\n from the ED he self referred to for detox. He was admitted\n without incident and was alert, oriented, and appropriate. On the\n evening of he received his last dose of methadone at 8:00 pm.\n He also received his citalopram and omeprazole there by report and one\n dose of trazodone for sleep. The next morning he was found around 9:00\n am to be unresponsive and tachypneic with pinpoint pupils. Primary\n concern was for opioid overdose so the patient was given naloxone\n (total 0.8 mg) with no improvement in mental status by report but his\n miosis did resolve. He was then taken to the ED. Initially he was\n hypertensive, tachycardic, tachypnic, febrile, and diaphoretic. Though\n there was notable rigidity there was concern raised for serotonin\n syndrome given SSRI and trazodone use. Toxicologic screen was positive\n for methadone only and other labs were notable an elevated lactate and\n acute kidney injury. He was intubated and sedated with propofol and\n etomidate for for airway protection. Subsequently became hypotensive.\n Broad spectrum abx administered for suspected infectious etiology. He\n also received cyproheptidine to reverse possible serotonin syndrome and\n 6.8 L of fluid after an elevated CPK suggested rhabdomyolysis. LP was\n also performed to evaluate for meningitis.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated, intubated\n Allergies:\n Last dose of Antibiotics:\n Levofloxacin - 10:18 PM\n Acyclovir - 11:18 PM\n Piperacillin/Tazobactam (Zosyn) - 11:18 PM\n Infusions:\n Propofol - 35 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 10:18 PM\n Furosemide (Lasix) - 10:19 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1) GERD\n 2) Depressive disorder NOS\n 3) Polysubstance abuse\n 4) Hx of suicide attempt at age 15\n Unknown\n Occupation: Unemployed\n Drugs: Heroin, Oxycodone, and methadone for past three years and\n occasional cocaine\n Tobacco: Unknown\n Alcohol: Unknown\n Other:\n Review of systems:\n Flowsheet Data as of 05:29 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 79 (73 - 82) bpm\n BP: 116/75(84) {102/75(83) - 125/86(95)} mmHg\n RR: 16 (16 - 26) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 7,482 mL\n 239 mL\n PO:\n TF:\n IVF:\n 2,482 mL\n 169 mL\n Blood products:\n Total out:\n 1,040 mL\n 1,910 mL\n Urine:\n 340 mL\n 1,910 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,442 mL\n -1,671 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (650 - 650) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n SpO2: 97%\n ABG: 7.38/41/103/20/0\n Ve: 9.6 L/min\n PaO2 / FiO2: 258\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: left worse than right)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, Rash: erythematous, blanching spots on medial surfaces of\n knees, vesicles on right knee\n Neurologic: Responds to: Noxious stimuli, Movement: Purposeful,\n Sedated, Tone: Normal, 6 beat clonus bilaterally in feet, no clonus in\n upper extremities, DTR's couldn't be elicited\n Labs / Radiology\n 241 K/uL\n 12.3 g/dL\n 124 mg/dL\n 2.5 mg/dL\n 32 mg/dL\n 20 mEq/L\n 108 mEq/L\n 5.7 mEq/L\n 137 mEq/L\n 35.8 %\n 17.9 K/uL\n [image002.jpg]\n \n 2:33 A2/9/ 05:24 PM\n \n 10:20 P2/9/ 06:01 PM\n \n 1:20 P2/9/ 09:07 PM\n \n 11:50 P2/9/ 10:19 PM\n \n 1:20 A2/10/ 04:27 AM\n \n 7:20 P2/10/ 04:40 AM\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 20.8\n 17.8\n 17.9\n Hct\n 33.9\n 35.9\n 35.8\n Plt\n \n Cr\n 2.5\n 2.5\n TropT\n 0.82\n TC02\n 22\n 22\n 25\n Glucose\n 161\n 124\n Other labs: PT / PTT / INR:17.2/29.2/1.6, CK / CKMB /\n Troponin-T:/117/0.82, ALT / AST:3558/4323, Alk Phos / T\n Bili:102/0.5, Amylase / Lipase:461/31, Differential-Neuts:78.7 %,\n Lymph:14.5 %, Mono:6.2 %, Eos:0.4 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:2.7 mmol/L, LDH:5900 IU/L, Ca++:6.5\n mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Imaging: CT Head w/o contrast:\n IMPRESSION: Bilateral hypodense appearance of the globus pallidus,\n nonspecific, but may be related to patient's history of drug overdose.\n An MRI is recommended for further evaluation.\n Partial opacification of the bilateral ethmoid and right maxillary\n sinus.\n CXR:\n IMPRESSION: Patchy airspace opacities within the bilateral hilar and\n left basilar regions. Given the patient's history of intoxication,\n these findings are suspicious for aspiration. However, given the\n perihilar opacities, central pulmonary vascular congestion cannot be\n excluded.\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now intubated for\n hypoxic respiratory failure and being broadly treated for serotonin\n syndrome and pneumonia.\n 1)Obtundation: Ultimate etiology is not clear at this time. Major\n concerns include serotonin syndrome due to trazodone/SSRI (given\n diaphoresis, HTN, and clonus) vs drug intoxication (less likely given\n relatively unimpressive tox screen) vs infection. Seizure could also\n cause post-ictal mental status changes. Meningitis/encephalitis\n extremely unlikely given no pleiocytosis but cannot exclude HSV w/o PCR\n so will treat empirically for the moment. Finally, it is possible\n respiratory failure could have caused obtundation though seems unlikely\n in an otherwise healthy young man. Consumption of non ethanol alcohols\n was also considered but no osmolal gap suggesting this.\n -cyproheptidine 4 mg Q6hrs for serotonin syndrome\n -acyclovir empirically for consern HSV meningitis\n -vanc/zosyn/levo for possible PNA given bilateral infiltrates and fever\n in the ED in this critically ill gentlman\n -F/U tox reccs\n 2)Shock: The patient had hypotension today after receiving his propofol\n sedation. Possible etiologies of his shock would include vasodilation\n vs cardiogenic vs hypovolemic. Given the patient's appearance and\n bilateral infiltrates/enlarged hila it seems unlikely he is hypovolemic\n though he could have been initially. Cardiogenic shock also seems\n unlikely given he was quickly weaned off pressors after arrival to the\n floor and few etiologies of cardiogenic shock would resolve that\n quickly without specific management. Shock due to vasodilatory\n phenomena seem most likely given exclusion of other types. Propofol\n can cause profound hypotension in certain circumstances and the fact\n that hypotension didn't occur until sedation would support this.\n Autonomic instability due to serotonin syndrome could also potentially\n contribute to rapid transition from hypertension to hypotension.\n Finally, given fever/leukocytosis there is concern for septic shock.\n -blood cx, broad spectrum abx\n -cyprohepatidine\n -Echo in AM\n 3) Hypoxemic respiratory failure: Patient had an unwitnessed event\n leading to loss of consciousness. Most processed that cause this\n (intoxication, seizure, etc..) can lead to periods of decreased airway\n protection therefore high level of concern for aspiration. Appearance\n of CXR could be consistent with aspiration pneumonitis, vs PNA, vs\n edema. Will cover with antibiotics given fever and hold off on\n diuresis given hypotension earlier. Sputum cultures suggest aspiration\n (oropharyngeal flora in endotracheal specimen). Patient is currently\n oxygenating and ventilating well on reasonable ventilator settings\n particularly given previous need for 100% O2.\n -Wean FiO2 and then PEEP\n -Vanco/Pipercillin-Tazobactam for health care associated pneumonia\n (patient has spent around 48 hours in health care settings/borderline\n call but covering due to high acuity). Also using levofloxacin to\n cover atypicals.\n -sputum cultures\n -urine legionella\n -Rapid flu antigen test and viral culture\n 4) Renal failure: Patient nearly anuric since arrival to floor.\n Elevated CK and blood/rbc dissociation on UA suggestive or\n rhabdomyolysis particularly given this is an otherwise healthy young\n man with presumably a normal Cr before. Still, nephrology thinks CK\n not high enough for this degree of failure and time course not exactly\n appropriate. Granular casts of unclear significance.\n -Renal consult in AM\n -Urine lytes, protein\n -Attempt 100 mg IV furosemide * 1 for trial of diuresis on renal recc\n -Avoid nephrotoxins, renally dose meds\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, etc...\n -Monitor fever and leukocytosis curves.\n -Consider CT to look for occult abcess if repeated fevers once stable\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -unroof vesicle and send for viral cutlure.\n 7) Neuro: Unclear on significance of bilateral clonus w/o other\n neurologic abnormalities. Ct head slightly abnormal and patient's MS\n is poor.\n -Neuro consult in the AM\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: NPO for now, OG and tube feeds tomorrow\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:00 PM\n 16 Gauge - 05:19 PM\n Arterial Line - 07:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659399,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. His BP increased to\n 220/systolic w/mouth care, turning & suctioning/coughing.\n Action:\n Received propofol for a few minutes until his BP was back down to\n 160\ns/systolic.\n Response:\n No stimulation & IV propofol brought patient\ns BP back down to\n 160\ns/systolic.\n Plan:\n Decrease noxious stimulation as much as possible. Provide periods of\n no stimulation after turning, mouth care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On CPAP @ 40% w/5 PEEP & 5 PS. RR: O2 sats:\n Action:\n ABG: Sx\ned for small amount thick\n tan secretions.\n Response:\n Lungs clear w/exp wheezes @ L base.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659154,
"text": "27 male w/ hx opiate abuse, s/p admision to pornwood yesterday for\n post-methadone overdose management. Pt found unresponsive at bornwood,\n tachypneic, tachycardic and hypertenisve. Pt given Narcan (total 2.8mg)\n w/ no improvement. Pt intubated and sedated in EW for airway\n protection. Urine tox positive for methadone\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remained as intubated , vented, propofol off at 8am. Pt remained\n unresponsive until around115 30 to sternal rub now withdraws head\n from mouthcare.perla 3mm lt eye slighjtly less bsk than rt. With draws\n both legs touch remins with strong clonis.\n Action:\n Fio2 down to 40% from 100%. Other vent settings 16/ 650/ 10.\n Peep weaned to5 with drop in o2 sats from 98-91% peep increasedback to\n 8 with improvement insats to 95-97% and is now tolerating side to side\n positioning and maintaining sat greater than 95%.\n Being suctioned for large amounts thick tan beige blood tinged\n secretions q1-2.\n Hypertensive throughout shift received bolus of labetolol and po\n lobetolol increased to 300 mgs tid with min effect\n Response:\n BP 130-150\ns sys ,sats 94-98%. Pt not awake, pupils 2mm / brisk. Blood\n gas satisfactory.\n Plan:\n Wean vent as tolerated\n Continue to monitor neuro status closely.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n K 5.8 overnight down to 3.8 received 20 meq;s,Renal functions\n elevated. Urine output greater than 150 until 6pm received lasix 100\n mgs i.v.. Elevated trop , CPK, ? rhabdo.\n No bm as yet from given last night.\n Approx 6l pos con\n Action:\n . lasix 100mg iv x\n Ultrasound done today results pending\n Response:\n . Urine output improved. Goal u/o greater than 150 mls/hr\n Plan:\n Echo today. F /u with renal team. Continue to monitor fluid staus to\n make sure pt does not fall behind with lasix.\n Multiple family members into visit and updated with pt current\n condition referred to lissw\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659155,
"text": "27 male w/ hx opiate abuse, s/p admision to pornwood yesterday for\n post-methadone overdose management. Pt found unresponsive at bornwood,\n tachypneic, tachycardic and hypertenisve. Pt given Narcan (total 2.8mg)\n w/ no improvement. Pt intubated and sedated in EW for airway\n protection. Urine tox positive for methadone\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remained as intubated , vented, propofol off at 8am. Pt remained\n unresponsive until around115 30 to sternal rub now withdraws head\n from mouthcare.perla 3mm lt eye slighjtly less bsk than rt. With draws\n both legs touch remins with strong clonis.\n Action:\n Fio2 down to 40% from 100%. Other vent settings 16/ 650/ 10.\n Peep weaned to5 with drop in o2 sats from 98-91% peep increasedback to\n 8 with improvement insats to 95-97% and is now tolerating side to side\n positioning and maintaining sat greater than 95%.\n Being suctioned for large amounts thick tan beige blood tinged\n secretions q1-2.\n Hypertensive throughout shift received bolus of labetolol and po\n lobetolol increased to 300 mgs tid with min effect\n Response:\n BP 130-150\ns sys ,sats 94-98%. Pt not awake, pupils 2mm / brisk. Blood\n gas satisfactory.\n Plan:\n Wean vent as tolerated\n Continue to monitor neuro status closely.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n K 5.8 overnight down to 3.8 received 20 meq;s,Renal functions\n elevated. Urine output greater than 150 until 6pm received lasix 100\n mgs i.v.. Elevated trop , CPK, ? rhabdo.\n No bm as yet from given last night.\n Approx 6l pos con\n Action:\n . lasix 100mg iv x\n Ultrasound done today results pending\n Response:\n . Urine output improved. Goal u/o greater than 150 mls/hr\n Plan:\n Echo today. F /u with renal team. Continue to monitor fluid staus to\n make sure pt does not fall behind with lasix.\n Multiple family members into visit and updated with pt current\n condition referred to lissw with please see note.\n Next of : Father\n Health Proxy appointed: Proxy\n Family Spokesperson designated: Father\n Communication or visitation restriction: None\n"
},
{
"category": "Respiratory ",
"chartdate": "2162-03-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 658998,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 10 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments: Pt was suctioned for significant amount this shift. By end of\n shift, secretions had minimized.\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt continues to be stable on current support\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions; Comments: Pt is fully\n sedated and not breathing spontaneously over set rate. Pt has rhonchi\n Lung sounds but was suctioned for minimal by end of the shift.\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659442,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, and was febrile,\n hypertensive, tachycardic. LP negative for menengitis and Urine tox\n only positive for methadone. was started on broad spectrum abx\n and transferred to the M/SICU for further management.\n Events:\n Tmax 101.7 po @ 0400. BCX2, UA, C&S sent. Sputum Cx sent .\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. His BP increased to\n 220/systolic w/mouth care, turning & suctioning/coughing. His eyes do\n not focus or track. Patient stretches out legs & his legs have a\n tremor while his eyes remain closed each time he is turned or receives\n mouth care, sx\ning-- ? seizure activity. This activity was not seen\n when he was left alone.\n Action:\n Received propofol for a few minutes until his BP was back down to\n 160\ns/systolic.\n Response:\n No stimulation & IV propofol brought patient\ns BP back down to\n 160\ns/systolic.\n Plan:\n Head CT & EEG planned for today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On CPAP @ 40% w/5 PEEP & 5 PS. RR: 14-20 O2 sats: 97-98%\n Lungs were clear w/exp wheezes @ L base.\n Action:\n ABG: Sx\ned for small amount thick\n tan secretions. Grm stain shows no bacteria.\n Response:\n RSBI:\n Plan:\n Wean from vent as patient is able to protect his airway.\n Renal failure, acute (Acute renal failure, ARF) from rhabdomyolysis\n Assessment:\n U/o 100cc/hr. Receiving 110cc/hr + abx/gastric meds. BUN\n (47) Cr (4.2) CK ()\n Action:\n Continue to finish 2400cc D5W (on 2^nd L) @ 100cc/hr.\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 659572,
"text": "Chief Complaint: Found Down\n 24 Hour Events:\n SPUTUM CULTURE - At 08:00 AM\n FEVER - 101.7\nF - 04:00 AM\n -Put on PS 5/5 in a.m. Remained off sedation for near entirety of day\n (was briefly given propofol for agitation in evening)\n -Was initially minimally responsive in a.m. but gradually became\n slightly more responsive over course of day; still very sedated overall\n -Increased labetalol to 400 tid b/c of htn\n -BCx/UCx this a.m. for temp of 101.7\n Patient unable to provide history: Encephalopathy, intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:18 PM\n Acyclovir - 11:18 PM\n Piperacillin/Tazobactam (Zosyn) - 11:18 PM\n Ampicillin - 10:00 PM\n Vancomycin - 09:00 AM\n Ampicillin/Sulbactam (Unasyn) - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 AM\n Famotidine (Pepcid) - 07:38 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 38.7\nC (101.7\n HR: 81 (76 - 86) bpm\n BP: 116/75(84) {0/0(0) - 0/0(0)} mmHg\n RR: 17 (14 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 3,277 mL\n 858 mL\n PO:\n TF:\n IVF:\n 3,187 mL\n 778 mL\n Blood products:\n Total out:\n 2,555 mL\n 420 mL\n Urine:\n 2,555 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n 438 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 670 (670 - 777) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 27\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.47/37/114/26/3\n Ve: 8.8 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: Well nourished, Thin\n Eyes / Conjunctiva: PERRL, looks to left when opens spontaneously\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, Rash: stable\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Increased, clonus, possible posturing w/suctioning\n Labs / Radiology\n 265 K/uL\n 11.7 g/dL\n 119 mg/dL\n 4.2 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 45 mg/dL\n 111 mEq/L\n 148 mEq/L\n 33.3 %\n 14.0 K/uL\n [image002.jpg]\n 04:40 AM\n 11:50 AM\n 12:01 PM\n 03:02 PM\n 04:02 PM\n 04:00 AM\n 08:39 AM\n 10:48 AM\n 04:12 AM\n 04:31 AM\n WBC\n 21.3\n 14.0\n Hct\n 37.2\n 33.3\n Plt\n 261\n 265\n Cr\n 3.7\n 4.2\n 4.2\n TCO2\n 25\n 25\n 26\n 28\n 27\n 28\n Glucose\n 134\n 123\n 100\n 119\n Other labs: PT / PTT / INR:15.8/27.9/1.4, CK / CKMB / Troponin-T:5360\n ()/113/<0.01, ALT / AST:3089 (3708)/1277 (2217), Alk Phos / T\n Bili:114 (121)/0.7, Amylase / Lipase:461/31, Differential-Neuts:76.4 %,\n Band:0.0 %, Lymph:16.2 %, Mono:6.2 %, Eos:0.8 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:1.4 mmol/L, Albumin:3.2 g/dL,\n LDH:2137 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:3.3 mg/dL\n Microbiology: DFA for Influenza A and B is negative\n Legionella urinary antigen (-)\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now intubated for\n hypoxic respiratory failure and with persistently altered MS.\n 1)Obtundation: Patient continues to be altered and without clearly\n purposeful movements. Intermittent jerks consistent with myoclonus.\n Intoxication or serotonin syndrome would most likely resolve by now.\n Major concern is for long period down and hypoxic brain injury.\n -CT repeated this AM to look for edema post anoxic injury. Not a great\n deal of additional edema on our prelim eval.\n -off sedation as much as possible to assess mental status, propofol\n boluses PRN\n -Neuro consult\n 2)Shock: The patient was hypotensive in the ED but only after\n receiving propofol sedation. This completely resolved and he is in\n fact hypertensive off pressor support at this time. Presume\n hypotension was iatrogenic. Now consistently hypertensive.\n -labetalol given concern for past cocaine abuse and unapposed B\n blockade\n -Echocardiogram with normal EF\n 3) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis, vs PNA, vs edema. We will cover for aspiration\n pneumonia and CA-MRSA with antibiotics though there are definitely\n other potential etiologies for fever in this patient. Patient is\n currently oxygenating and ventilating well on reasonable ventilator\n settings particularly given previous need for 100% O2. Now doing well\n on pressure support. Primary reason for continued ventilation is\n mental status.\n -Ampicillin-Sublactam for aspiration pneumonia, stop vancomycin as no\n S. aureus on sputum cultures\n 4) Renal failure: Patient with good urine output but Cr continues to\n rise. Presumed etiology is ATN and rhabdomyoloysis.\n -Goal UOP of 150-200cc/hr\n -Free water boluses to correct hypernatremia, repeat evening lytes\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, neurogenic fever, etc\n -Monitor fever and leukocytosis curves.\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -f/u culture from vesicle\n 7) Neuro: Unclear on significance of bilateral clonus w/o other\n neurologic abnormalities. Ct head slightly abnormal and patient's MS\n is poor. Neuro consult in AM and imaging per above if not improving\n dramatically over course of day.\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: NPO for now, will get tube feeding recommendations/nutrition\n consult\n 10)Access: PIV\ns, A-line\n -given concern about stability of PIV\ns and inability to place PICC due\n to fevers will place CVL this afternoon\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 05:19 PM\n Arterial Line - 07:00 PM\n 20 Gauge - 03:45 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 27M polysubstance abuse, recent methadone OD,\n found down with shock, rhabdo, ARF, respiratory failure and likely\n aspiration pneumonia. Febrile, waking up but not following commands.\n Head CT pending.\n Exam notable for Tm 101.7 BP 120/90 HR 90 RR 18 with sat 98\n on PSV 5/5 0.4 7.47/37/136. +1L/24h. B ronchi. Hyperdynamic s1s2. +BS.\n 2+ edema but not tense. Clonus. Labs notable for WBC 14K, HCT 33,\n Cr 4.2 / stable. CXR with B ASD, progressive.\n Agree with plan to manage respiratory failure with PSV ventilation\n (reduced to at bedside) and fluid removal with lasix PRN only if\n UOP <100cc/h. Likely pneumonia due to nosocomial pathogens or\n aspiration; will continue vanco/unasyn and f/u cultures. Febrile on\n broad coverage, will reculture, check differential, amylase and lipase\n today. Remains on labetalol for hypertension. ARF is stable. Likely ATN\n based upon sediment; will match I+O, RD meds, and follow closely. Will\n increase FWB for evolving hypernatremia. Mental status remains poor,\n will f/u CT read, consult neuro and check EEG though doubt subclincial\n status. Needs CVL for access. Will d/w SW re home situation. Remainder\n of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 15:58 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 659457,
"text": "Demographics\n Day of intubation: 4\n Day of mechanical ventilation: 4\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 10 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing, High\n flow demand\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt most likely will go to CT today for a head scan. He remains\n unresponsive for the most part, except for spastic cough when\n suctioned. Secretions are thck yellow\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659067,
"text": "Chief Complaint: Found down\n 24 Hour Events:\n MULTI LUMEN - START 05:00 PM\n placed in EW\n INVASIVE VENTILATION - START 05:30 PM\n ARTERIAL LINE - START 07:00 PM\n -with furosemide began to increase UOP to >100 cc/hr\n -Able to wean FiO2 from 100% to 40%\n Patient unable to provide history: Sedated, Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Levofloxacin - 10:18 PM\n Acyclovir - 11:18 PM\n Piperacillin/Tazobactam (Zosyn) - 11:18 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:18 PM\n Furosemide (Lasix) - 10:19 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 80 (73 - 82) bpm\n BP: 116/75(84) {102/75(83) - 125/86(95)} mmHg\n RR: 15 (15 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 7,482 mL\n 302 mL\n PO:\n TF:\n IVF:\n 2,482 mL\n 232 mL\n Blood products:\n Total out:\n 1,040 mL\n 2,050 mL\n Urine:\n 340 mL\n 2,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,442 mL\n -1,748 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (650 - 650) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 26 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.38/41/103/23/0\n Ve: 11.6 L/min\n PaO2 / FiO2: 258\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 241 K/uL\n 12.3 g/dL\n 98 mg/dL\n 2.9 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 36 mg/dL\n 108 mEq/L\n 142 mEq/L\n 35.8 %\n 17.9 K/uL\n [image002.jpg]\n 05:24 PM\n 06:01 PM\n 09:07 PM\n 10:19 PM\n 04:27 AM\n 04:40 AM\n WBC\n 20.8\n 17.8\n 17.9\n Hct\n 33.9\n 35.9\n 35.8\n Plt\n \n Cr\n 2.5\n 2.5\n 2.9\n TropT\n 0.82\n <0.01\n TCO2\n 22\n 22\n 25\n Glucose\n 161\n 124\n 98\n Other labs: PT / PTT / INR:17.2/29.2/1.6, CK / CKMB /\n Troponin-T:/113/<0.01, ALT / AST:4257/6019, Alk Phos / T\n Bili:105/0.4, Amylase / Lipase:461/31, Differential-Neuts:81.0 %,\n Band:0.0 %, Lymph:14.0 %, Mono:5.0 %, Eos:0.0 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:2.7 mmol/L, Albumin:3.2 g/dL,\n LDH:5280 IU/L, Ca++:7.2 mg/dL, Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now intubated for\n hypoxic respiratory failure and being broadly treated for serotonin\n syndrome and pneumonia.\n 1)Obtundation: Ultimate etiology is not clear at this time. Major\n concerns include serotonin syndrome, intoxication, or post-ictal\n state. Given extremely few cells in CSF will d/c empiric acyclovir\n therapy for HSV due to risk this poses to renal function. Will\n continue to treat empirically for serotonin syndrome and monitor.\n -cyproheptidine 4 mg Q6hrs for serotonin syndrome\n - STOP acyclovir empirically for consern HSV meningitis\n -F/U toxicology reccs\n -Attempt to wean sedation and reassess mental status\n 2)Shock: The patient was hypotensive in the ED but only after\n receiving propofol sedation. This completely resolved and he is in\n fact hypertensive off pressor support at this time. Presumably his\n initial hypotension was iatrogenic. In the short term we would prefer\n mild hypertension to hypotension in this gentleman but given MAP\ns >100\n we will treat.\n -labetalol given concern for past cocaine abuse and unapposed B\n blockade\n -Echocardiogram to evaluate EF\n 3) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis, vs PNA, vs edema. We will cover for aspiration\n pneumonia and CA-MRSA with antibiotics though there are definitely\n other potential etiologies for fever in this patient. Patient is\n currently oxygenating and ventilating well on reasonable ventilator\n settings particularly given previous need for 100% O2.\n -Wean FiO2 and then PEEP as tolerated\n -Vanco/Ampicillin-Sublactam for aspiration pneumonia, we will d/c\n levofloxacin as legionella antigen negative and this patient would not\n be typical epidemiology of this pathogen; we will also d/c pipercillin\n tazobactam as he seems to be improving with diuresis reducing concern\n pneumonia is the primary causative of pneumonia\n -sputum cultures\n -Rapid flu antigen test and viral culture\n 4) Renal failure: Patient was nearly anuric yesterday. Elevated CK\n and blood/rbc dissociation on UA suggestive or rhabdomyolysis\n particularly given this is an otherwise healthy young man with\n presumably a normal Cr before. He has responded to diuretic therapy\n with brisk urine output and we will continue this diuresis as long as\n possible to flush and protect the kidneys.\n -nephrology is following\n -bolus dose furosemide if UOP drops below 100 cc/hr\n -Avoid nephrotoxins, renally dose meds\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, etc...\n -Monitor fever and leukocytosis curves.\n -Consider CT to look for occult abcess if repeated fevers once stable\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -unroof vesicle and send for viral cutlure.\n 7) Neuro: Unclear on significance of bilateral clonus w/o other\n neurologic abnormalities. Ct head slightly abnormal and patient's MS\n is poor. Will await evaluation of non-sedated mental status before\n proceeding to neuro consult.\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: NPO for now\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:00 PM\n 16 Gauge - 05:19 PM\n Arterial Line - 07:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: famotidine\n VAP: HOB elevation, chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-09 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 659097,
"text": "Chief Complaint: Found down\n 24 Hour Events:\n MULTI LUMEN - START 05:00 PM\n placed in EW\n INVASIVE VENTILATION - START 05:30 PM\n ARTERIAL LINE - START 07:00 PM\n -with furosemide began to increase UOP to >100 cc/hr\n -Able to wean FiO2 from 100% to 40%\n Patient unable to provide history: Sedated, Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Levofloxacin - 10:18 PM\n Acyclovir - 11:18 PM\n Piperacillin/Tazobactam (Zosyn) - 11:18 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:18 PM\n Furosemide (Lasix) - 10:19 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 80 (73 - 82) bpm\n BP: 116/75(84) {102/75(83) - 125/86(95)} mmHg\n RR: 15 (15 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 7,482 mL\n 302 mL\n PO:\n TF:\n IVF:\n 2,482 mL\n 232 mL\n Blood products:\n Total out:\n 1,040 mL\n 2,050 mL\n Urine:\n 340 mL\n 2,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,442 mL\n -1,748 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (650 - 650) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 26 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.38/41/103/23/0\n Ve: 11.6 L/min\n PaO2 / FiO2: 258\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 241 K/uL\n 12.3 g/dL\n 98 mg/dL\n 2.9 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 36 mg/dL\n 108 mEq/L\n 142 mEq/L\n 35.8 %\n 17.9 K/uL\n [image002.jpg]\n 05:24 PM\n 06:01 PM\n 09:07 PM\n 10:19 PM\n 04:27 AM\n 04:40 AM\n WBC\n 20.8\n 17.8\n 17.9\n Hct\n 33.9\n 35.9\n 35.8\n Plt\n \n Cr\n 2.5\n 2.5\n 2.9\n TropT\n 0.82\n <0.01\n TCO2\n 22\n 22\n 25\n Glucose\n 161\n 124\n 98\n Other labs: PT / PTT / INR:17.2/29.2/1.6, CK / CKMB /\n Troponin-T:/113/<0.01, ALT / AST:4257/6019, Alk Phos / T\n Bili:105/0.4, Amylase / Lipase:461/31, Differential-Neuts:81.0 %,\n Band:0.0 %, Lymph:14.0 %, Mono:5.0 %, Eos:0.0 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:2.7 mmol/L, Albumin:3.2 g/dL,\n LDH:5280 IU/L, Ca++:7.2 mg/dL, Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now intubated for\n hypoxic respiratory failure and being broadly treated for serotonin\n syndrome and pneumonia.\n 1)Obtundation: Ultimate etiology is not clear at this time. Major\n concerns include serotonin syndrome, intoxication, or post-ictal\n state. Given extremely few cells in CSF will d/c empiric acyclovir\n therapy for HSV due to risk this poses to renal function. Will\n continue to treat empirically for serotonin syndrome and monitor.\n -cyproheptidine 4 mg Q6hrs for serotonin syndrome\n - STOP acyclovir empirically for consern HSV meningitis\n -F/U toxicology reccs\n -Attempt to wean sedation and reassess mental status\n 2)Shock: The patient was hypotensive in the ED but only after\n receiving propofol sedation. This completely resolved and he is in\n fact hypertensive off pressor support at this time. Presumably his\n initial hypotension was iatrogenic. In the short term we would prefer\n mild hypertension to hypotension in this gentleman but given MAP\ns >100\n we will treat.\n -labetalol given concern for past cocaine abuse and unapposed B\n blockade\n -Echocardiogram to evaluate EF\n 3) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis, vs PNA, vs edema. We will cover for aspiration\n pneumonia and CA-MRSA with antibiotics though there are definitely\n other potential etiologies for fever in this patient. Patient is\n currently oxygenating and ventilating well on reasonable ventilator\n settings particularly given previous need for 100% O2.\n -Wean FiO2 and then PEEP as tolerated\n -Vanco/Ampicillin-Sublactam for aspiration pneumonia, we will d/c\n levofloxacin as legionella antigen negative and this patient would not\n be typical epidemiology of this pathogen; we will also d/c pipercillin\n tazobactam as he seems to be improving with diuresis reducing concern\n pneumonia is the primary causative of pneumonia\n -sputum cultures\n -Rapid flu antigen test and viral culture\n 4) Renal failure: Patient was nearly anuric yesterday. Elevated CK\n and blood/rbc dissociation on UA suggestive or rhabdomyolysis\n particularly given this is an otherwise healthy young man with\n presumably a normal Cr before. He has responded to diuretic therapy\n with brisk urine output and we will continue this diuresis as long as\n possible to flush and protect the kidneys.\n -nephrology is following\n -bolus dose furosemide if UOP drops below 100 cc/hr\n -Avoid nephrotoxins, renally dose meds\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, etc...\n -Monitor fever and leukocytosis curves.\n -Consider CT to look for occult abcess if repeated fevers once stable\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -unroof vesicle and send for viral cutlure.\n 7) Neuro: Unclear on significance of bilateral clonus w/o other\n neurologic abnormalities. Ct head slightly abnormal and patient's MS\n is poor. Will await evaluation of non-sedated mental status before\n proceeding to neuro consult.\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: NPO for now\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:00 PM\n 16 Gauge - 05:19 PM\n Arterial Line - 07:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: famotidine\n VAP: HOB elevation, chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 27M polysubstance abuse, recent methadone OD,\n found down with shock, rhabdo, respiratory failure and likely\n aspiration pneumonia. Good response to fluids overnight, off pressors\n with rising UOP.\n Exam notable for Tm 98.2 BP 150/100 HR 82 RR 18 with sat 98 on 650x16\n PEEP 8 0.4 7/38/41/103. B ronchi. Hyperdynamic s1s2. +BS. 2+ edema but\n not tense. Labs notable for WBC 17K, HCT 35, Cr 2.9 (from 2.5), ALT 4k,\n AST 6k, CK 25K. CXR with B ASD, progressive.\n Agree with plan to manage respiratory failure with PSV ventilation and\n fluid removal with lasix PRN only if UOP <100cc/h. Likely pneumonia\n due to nosocomial pathogens or aspiration. Will bronch for diagnosis\n and treat with vanco/unasyn. Shock has resolved, will follow lactate,\n CK, LFTs and monitor with gentle hydration. Will check echo today but\n doubt cardiogenic mechanism. Mental status change likely toxic in\n nature, will f/u HSV PCR and d/c acyclovir. ARF is worse based on\n creatinine but UOP is excellent. Likely ATN based upon sediment; will\n hold hydration, RD meds, and follow closely. Will d/c fem line today.\n Hold TFs for possible extubation. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 15:14 ------\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659637,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, he was also found\n to be febrile, hypertensive, & tachycardic. LP negative for menengitis\n and Urine tox only positive for methadone. was started on broad\n spectrum abx and transferred to the M/SICU for further management.\n All sedation has been off since , Mr. continues to only\n respond to painful stimuli by withdrawing.\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659638,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, he was also found\n to be febrile, hypertensive, & tachycardic. LP negative for menengitis\n and Urine tox only positive for methadone. was started on broad\n spectrum abx and transferred to the M/SICU for further management.\n All sedation has been off since , Mr. continues to only\n respond to painful stimuli by withdrawing.\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. He becomes aggittated w/\n all nursing care and displays lateral lower extremity tremors some\n question of seizure activity. PEARL however he is unable to track or\n follow commands and is noted to have a left leaning gaze when his eyes\n are open.\n Action:\n Head CT to evaluate for anoxic injury, q 4hr neuro checks, neuro in to\n evaluate\n Response:\n Official read of CT pending @ this time however preliminary read showed\nhypodensities in the globus pallidus\n which may be consistent w/\n anoxic injury\n Plan:\n Cont to monitor neuro status per routine, probable EEG tomorrow, family\n meeting once neurology weighs in.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated for airway protection on CPAP 5/5 no vent changes\n made, ABGs are within normal limits\n Action:\n Suctioned q3-4hrs for small amounts thick tan secretions\n Response:\n No change in clinical presentation\n Plan:\n Monitor resp status, extubate when confident pt can protect airway.\n Renal failure, acute (Acute renal failure, ARF) from rhabdomyolysis\n Assessment:\n Cr stable @ 4.2, hypernatremic w/ a Na of 148\n Action:\n 250 cc free water q 3, trend lytes\n Response:\n Chemestries sent @ 1700 pending @ this time\n Plan:\n Cont w/ free water boluses, trend lytes and replete accordingly\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659698,
"text": "Chief Complaint: Altered MS, Respiratory failure\n 24 Hour Events:\n URINE CULTURE - At 12:16 PM\n MULTI LUMEN - START 01:51 PM\n PAN CULTURE - At 04:45 AM\n -Persistently altered mental status so got neuro consult, they are\n somewhat concerned about focality (left more responsive than right) and\n asked for EEG and MRI/MRA tomorrow\n -CT Head just showed increased signal in globus pallidus\n -Got right sided IJ\n -Bit through OG so traded out for NG\n -Bit through ET tube so replaced by anesthesiology and got bite block\n and more sedation for the night, put on assist control til about 5:00\n am then converted back to spontaneous breathing\n -Febrile in AM on (100.4 at 4:54) so cultured\n -Started on tube feeds and free water boluses\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Ampicillin - 04:02 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:03 PM\n Famotidine (Pepcid) - 08:30 PM\n Propofol - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38\nC (100.4\n HR: 77 (72 - 89) bpm\n BP: 146/71(92) {120/64(83) - 159/94(109)} mmHg\n RR: 15 (12 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 4 (0 - 9)mmHg\n Total In:\n 2,574 mL\n 934 mL\n PO:\n TF:\n 44 mL\n 119 mL\n IVF:\n 1,681 mL\n 315 mL\n Blood products:\n Total out:\n 1,490 mL\n 655 mL\n Urine:\n 1,490 mL\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,084 mL\n 279 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 751 (629 - 5,749) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.46/39/145/26/4\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: Well nourished, Thin\n Eyes / Conjunctiva: PERRL, pupils midline\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: bilateral rhonchi)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, Rash: stable\n Neurologic: Responds to: Not assessed, Movement: Non -purposeful, Tone:\n Not assessed, responds intermittently to noxious stimuli, clonus\n continues but less dramatic in feet (2-3 beats), babinski unclear.\n / Radiology\n 239 K/uL\n 10.9 g/dL\n 100 mg/dL\n 3.8 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 47 mg/dL\n 113 mEq/L\n 148 mEq/L\n 31.4 %\n 14.8 K/uL\n [image002.jpg]\n 03:02 PM\n 04:02 PM\n 04:00 AM\n 08:39 AM\n 10:48 AM\n 04:12 AM\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n WBC\n 21.3\n 14.0\n 14.8\n Hct\n 37.2\n 33.3\n 31.4\n Plt\n 261\n 265\n 239\n Cr\n 3.7\n 4.2\n 4.2\n 3.9\n 3.8\n TCO2\n 26\n 28\n 27\n 28\n 29\n Glucose\n 123\n 100\n 119\n 105\n 100\n Other : PT / PTT / INR:15.3/27.8/1.3, CK / CKMB /\n Troponin-T:2818(5360)/113/<0.01, ALT / AST:(3089)/446(1277), Alk\n Phos / T Bili:100 (114)/0.6, Amylase / Lipase:158/54,\n Differential-Neuts:76.4 %, Band:0.0 %, Lymph:16.2 %, Mono:6.2 %,\n Eos:0.8 %, D-dimer: ng/mL, Fibrinogen:455 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:3.0 g/dL, LDH:844 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now respiratory issues\n have largely resolved and doing well on pressure support, but no\n clearly purposeful movements and continuing to be encephalopathic.\n 1)Obtundation: Seen by neurology who agree his picture is most\n consistent with anoxic brain injury\n -CT repeated this AM to look for edema post anoxic injury. Not a great\n deal of additional edema on our prelim eval.\n -off sedation as much as possible to assess mental status, propofol\n boluses PRN\n -Neuro consult\n 2)Shock: The patient was hypotensive in the ED but only after\n receiving propofol sedation. This completely resolved and he is in\n fact hypertensive off pressor support at this time. Presume\n hypotension was iatrogenic. Now consistently hypertensive.\n -labetalol given concern for past cocaine abuse and unapposed B blockad\n -Echocardiogram with normal EF\n 3) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis, vs PNA, vs edema. We will cover for aspiration\n pneumonia and CA-MRSA with antibiotics though there are definitely\n other potential etiologies for fever in this patient. Patient is\n currently oxygenating and ventilating well on reasonable ventilator\n settings particularly given previous need for 100% O2. Now doing well\n on pressure support. Primary reason for continued ventilation is\n mental status.\n -Ampicillin-Sublactam for aspiration pneumonia, stop vancomycin as no\n S. aureus on sputum cultures\n 4) Renal failure: Patient with good urine output but Cr continues to\n rise. Presumed etiology is ATN and rhabdomyoloysis.\n -Goal UOP of 150-200cc/hr\n -Free water boluses to correct hypernatremia, repeat evening lytes\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, neurogenic fever, etc\n -Monitor fever and leukocytosis curves.\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -f/u culture from vesicle\n 7) Neuro: Unclear on significance of bilateral clonus w/o other\n neurologic abnormalities. Ct head slightly abnormal and patient's MS\n is poor. Neuro consult in AM and imaging per above if not improving\n dramatically over course of day.\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: NPO for now, will get tube feeding recommendations/nutrition\n consult\n 10)Access: PIV\ns, A-line\n -given concern about stability of PIV\ns and inability to place PICC due\n to fevers will place CVL this afternoon\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RHABDOMYOLYSIS\n POISONING / OVERDOSE, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:00 PM\n 18 Gauge - 04:00 PM\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659701,
"text": "Chief Complaint: Altered MS, Respiratory failure\n 24 Hour Events:\n URINE CULTURE - At 12:16 PM\n MULTI LUMEN - START 01:51 PM\n PAN CULTURE - At 04:45 AM\n -Persistently altered mental status so got neuro consult, they are\n somewhat concerned about focality (left more responsive than right) and\n asked for EEG and MRI/MRA tomorrow\n -CT Head just showed increased signal in globus pallidus\n -Got right sided IJ\n -Bit through OG so traded out for NG\n -Bit through ET tube so replaced by anesthesiology and got bite block\n and more sedation for the night, put on assist control til about 5:00\n am then converted back to spontaneous breathing\n -Febrile in AM on (100.4 at 4:54) so cultured\n -Started on tube feeds and free water boluses\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Ampicillin - 04:02 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:03 PM\n Famotidine (Pepcid) - 08:30 PM\n Propofol - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38\nC (100.4\n HR: 77 (72 - 89) bpm\n BP: 146/71(92) {120/64(83) - 159/94(109)} mmHg\n RR: 15 (12 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 4 (0 - 9)mmHg\n Total In:\n 2,574 mL\n 934 mL\n PO:\n TF:\n 44 mL\n 119 mL\n IVF:\n 1,681 mL\n 315 mL\n Blood products:\n Total out:\n 1,490 mL\n 655 mL\n Urine:\n 1,490 mL\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,084 mL\n 279 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 751 (629 - 5,749) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.46/39/145/26/4\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: Well nourished, Thin\n Eyes / Conjunctiva: PERRL, pupils midline\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: bilateral rhonchi)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, Rash: stable\n Neurologic: Responds to: Not assessed, Movement: Non -purposeful, Tone:\n Not assessed, responds intermittently to noxious stimuli, clonus\n continues but less dramatic in feet (2-3 beats), babinski unclear.\n / Radiology\n 239 K/uL\n 10.9 g/dL\n 100 mg/dL\n 3.8 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 47 mg/dL\n 113 mEq/L\n 148 mEq/L\n 31.4 %\n 14.8 K/uL\n [image002.jpg]\n 03:02 PM\n 04:02 PM\n 04:00 AM\n 08:39 AM\n 10:48 AM\n 04:12 AM\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n WBC\n 21.3\n 14.0\n 14.8\n Hct\n 37.2\n 33.3\n 31.4\n Plt\n 261\n 265\n 239\n Cr\n 3.7\n 4.2\n 4.2\n 3.9\n 3.8\n TCO2\n 26\n 28\n 27\n 28\n 29\n Glucose\n 123\n 100\n 119\n 105\n 100\n Other : PT / PTT / INR:15.3/27.8/1.3, CK / CKMB /\n Troponin-T:2818(5360)/113/<0.01, ALT / AST:(3089)/446(1277), Alk\n Phos / T Bili:100 (114)/0.6, Amylase / Lipase:158/54,\n Differential-Neuts:76.4 %, Band:0.0 %, Lymph:16.2 %, Mono:6.2 %,\n Eos:0.8 %, D-dimer: ng/mL, Fibrinogen:455 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:3.0 g/dL, LDH:844 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now respiratory issues\n have largely resolved and doing well on pressure support, but no\n clearly purposeful movements and continuing to be encephalopathic.\n 1)Obtundation: Seen by neurology who agree his picture is most\n consistent with anoxic brain injury and prognosis is not favorable.\n Some concern for laterality of findings so we are obtaining an MRI head\n today and an EEG to rule out epileptiform activity.\n -CT repeated this AM to look for edema post anoxic injury. Not a great\n deal of additional edema on our prelim eval.\n -off sedation as much as possible to assess mental status, propofol\n boluses PRN\n -Neuro consult\n 2)Shock: The patient was hypotensive in the ED but only after\n receiving propofol sedation. This completely resolved and he is in\n fact hypertensive off pressor support at this time. Presume\n hypotension was iatrogenic. Now consistently hypertensive.\n -labetalol given concern for past cocaine abuse and unapposed B blockad\n -Echocardiogram with normal EF\n 3) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis, vs PNA, vs edema. We will cover for aspiration\n pneumonia and CA-MRSA with antibiotics though there are definitely\n other potential etiologies for fever in this patient. Patient is\n currently oxygenating and ventilating well on reasonable ventilator\n settings particularly given previous need for 100% O2. Now doing well\n on pressure support. Primary reason for continued ventilation is\n mental status.\n -Ampicillin-Sublactam for aspiration pneumonia, stop vancomycin as no\n S. aureus on sputum cultures\n 4) Renal failure: Patient with good urine output but Cr continues to\n rise. Presumed etiology is ATN and rhabdomyoloysis.\n -Goal UOP of 150-200cc/hr\n -Free water boluses to correct hypernatremia, repeat evening lytes\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, neurogenic fever, etc\n -Monitor fever and leukocytosis curves.\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -f/u culture from vesicle\n 7) Neuro: Unclear on significance of bilateral clonus w/o other\n neurologic abnormalities. Ct head slightly abnormal and patient's MS\n is poor. Neuro consult in AM and imaging per above if not improving\n dramatically over course of day.\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: NPO for now, will get tube feeding recommendations/nutrition\n consult\n 10)Access: PIV\ns, A-line\n -given concern about stability of PIV\ns and inability to place PICC due\n to fevers will place CVL this afternoon\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RHABDOMYOLYSIS\n POISONING / OVERDOSE, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:00 PM\n 18 Gauge - 04:00 PM\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659642,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, he was also found\n to be febrile, hypertensive, & tachycardic. LP negative for menengitis\n and Urine tox only positive for methadone. was started on broad\n spectrum abx and transferred to the M/SICU for further management.\n All sedation has been off since , Mr. continues to only\n respond to painful stimuli by withdrawing.\n EVENTS: RE INTUBATION.\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. He was off sedation for\n more than 48 hrs. but now he is again sedated with propofol. PEARL .\n Action:\n Head CT done yesterday to evaluate for anoxic injury, q 4hr neuro\n checks, neuro in to evaluate\n Response:\n Official read of CT pending @ this time however preliminary read showed\nhypodensities in the globus pallidus\n which may be consistent w/\n anoxic injury\n Plan:\n Cont to monitor neuro status per routine, probable EEG tomorrow, for\n MRI today .filled form already faxed. family meeting later.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Events during the shift : Beginning of shift pt remains intubated\n , off sedation , on CPAP 5/5 . initially RRT found that while he was\n suctioning the ETT, pt was coughing a lot ,having lot of secretions, pt\n not comfortable, a thin stream of water flowing from his mouth when he\n coughs. Myself informed to team and first thought of OGT misplaced.\n Feed stopped and OGT removed , propofol 20 mics given and re inserted\n NGT. But pt still not comfortable, coughing too much, Pt biting on\n ETT, airway inserted , able to hear air passing through the ETT. Sats\n maintained > 95% . called for anaesthesia ,propofol 20 mics given and\n tried to reinsert another ETT ith bouggie ,but unsuccessful,ambu bagged\n with hiflow O2 and sats maintained > 94%. .succs 5 cc iv given and re\n intubated the pt with 7.5 ETT and fixed at no: 26.repeat Xray showed\n ETT deep down ,so pulled out and fixed at no: 24 by RRT. . Connected\n to vent/ AC/14/600/5/50%\n Action:\n Re intubated and vent settings changed to AC .\n Response:\n No change in clinical presentation\n Plan:\n Monitor resp status, Wean as tolerated.\n Renal failure, acute (Acute renal failure, ARF) from rhabdomyolysis\n Assessment:\n Cr stable @ 4.9 , hypernatremic w/ a Na of 148\n Action:\n Feed restarted at 15 cc/hr . goal @ 65 cc/hr free water 250cc q 3hr.\n Response:\n Am labs sent. Waiting for report.\n Plan:\n Cont w/ free water boluses, replete lytes as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659675,
"text": "27 y.o. male w/ a PMH significant for polysubstance abuse, depressive\n disorder, and GERD who presents after being found down at where he been admitted for detox. On the evening of he\n received his last dose of methadone at 8:00 pm. He also received\n citalopram and omeprazole and one dose of trazodone for sleep. The\n next morning he was found around 9:00 am to be unresponsive and\n tachypneic with pinpoint pupils. He was transferred via ambulance to\n ED, where he received narcan w/ limited effect, he was also found\n to be febrile, hypertensive, & tachycardic. LP negative for menengitis\n and Urine tox only positive for methadone. was started on broad\n spectrum abx and transferred to the M/SICU for further management.\n All sedation has been off since , Mr. continues to only\n respond to painful stimuli by withdrawing.\n EVENTS: RE INTUBATION.\n Altered mental status (not Delirium)\n Assessment:\n Patient continues to open eyes to stimulation, move all extremities non\n purposefully & withdraws to painful stimuli. He was off sedation for\n more than 48 hrs. but now he is again sedated with propofol. PEARL .\n Action:\n Head CT done yesterday to evaluate for anoxic injury, q 4hr neuro\n checks, neuro in to evaluate\n Response:\n Official read of CT pending @ this time however preliminary read showed\nhypodensities in the globus pallidus\n which may be consistent w/\n anoxic injury\n Plan:\n Cont to monitor neuro status per routine, probable EEG tomorrow, for\n MRI today .filled form already faxed. family meeting later.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Events during the shift : Beginning of shift pt remains intubated\n , off sedation , on CPAP 5/5 . initially RRT found that while he was\n suctioning the ETT, pt was coughing a lot ,having lot of secretions, pt\n not comfortable, a thin stream of water flowing from his mouth when he\n coughs. Myself informed to team and first thought of OGT misplaced.\n Feed stopped and OGT removed , propofol 20 mics given and re inserted\n NGT. But pt still not comfortable, coughing too much, Pt biting on\n ETT, airway inserted , able to hear air passing through the ETT. Sats\n maintained > 95% . called for anaesthesia ,propofol 20 mics given and\n tried to reinsert another ETT ith bouggie ,but unsuccessful,ambu bagged\n with hiflow O2 and sats maintained > 94%. .succs 5 cc iv given and re\n intubated the pt with 7.5 ETT and fixed at no: 26.repeat Xray showed\n ETT deep down ,so pulled out and fixed at no: 24 by RRT. . Connected\n to vent/ AC/14/600/5/50%. It was found that Old ETT got an open area\n inside ? due biting the tube.\n Action:\n Re intubated and vent settings changed to AC .\n Response:\n No change in clinical presentation\n Plan:\n Monitor resp status, Wean as tolerated.\n Renal failure, acute (Acute renal failure, ARF) from rhabdomyolysis\n Assessment:\n Cr stable @ 4.9 , hypernatremic w/ a Na of 148\n Action:\n Feed restarted at 15 cc/hr . goal @ 65 cc/hr free water 250cc q 3hr.\n Response:\n Am labs sent. Waiting for report.\n Plan:\n Cont w/ free water boluses, replete lytes as needed.\n"
},
{
"category": "Respiratory ",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 659685,
"text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: ICU\n Reason: Re-intubation; Comments: Pt bite through original ETT\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 10 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Tenacious\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659689,
"text": "Chief Complaint: Altered MS, Respiratory failure\n 24 Hour Events:\n URINE CULTURE - At 12:16 PM\n MULTI LUMEN - START 01:51 PM\n PAN CULTURE - At 04:45 AM\n -Persistently altered mental status so got neuro consult, they are\n somewhat concerned about focality (left more responsive than right) and\n asked for EEG and MRI/MRA tomorrow\n -CT Head just showed increased signal in globus pallidus\n -Got right sided IJ\n -Bit through OG so traded out for NG\n -Bit through ET tube so replaced by anesthesiology and got bite block\n and more sedation for the night, put on assist control til about 5:00\n am then converted back to spontaneous breathing\n -Febrile in AM on (100.4 at 4.54) so cultured\n -Started on tube feeds and free water boluses\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Ampicillin - 04:02 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:03 PM\n Famotidine (Pepcid) - 08:30 PM\n Propofol - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 38\nC (100.4\n HR: 77 (72 - 89) bpm\n BP: 146/71(92) {120/64(83) - 159/94(109)} mmHg\n RR: 15 (12 - 23) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 4 (0 - 9)mmHg\n Total In:\n 2,574 mL\n 934 mL\n PO:\n TF:\n 44 mL\n 119 mL\n IVF:\n 1,681 mL\n 315 mL\n Blood products:\n Total out:\n 1,490 mL\n 655 mL\n Urine:\n 1,490 mL\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,084 mL\n 279 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 751 (629 - 5,749) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 37\n PIP: 11 cmH2O\n SpO2: 99%\n ABG: 7.46/39/145/26/4\n Ve: 9.7 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: Well nourished, Thin\n Eyes / Conjunctiva: PERRL, pupils midline\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: bilateral rhonchi)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, Rash: stable\n Neurologic: Responds to: Not assessed, Movement: Non -purposeful, Tone:\n Not assessed, responds intermittently to noxious stimuli, clonus\n continues but less dramatic in feet (2-3 beats), babinski unclear.\n / Radiology\n 239 K/uL\n 10.9 g/dL\n 100 mg/dL\n 3.8 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 47 mg/dL\n 113 mEq/L\n 148 mEq/L\n 31.4 %\n 14.8 K/uL\n [image002.jpg]\n 03:02 PM\n 04:02 PM\n 04:00 AM\n 08:39 AM\n 10:48 AM\n 04:12 AM\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n WBC\n 21.3\n 14.0\n 14.8\n Hct\n 37.2\n 33.3\n 31.4\n Plt\n 261\n 265\n 239\n Cr\n 3.7\n 4.2\n 4.2\n 3.9\n 3.8\n TCO2\n 26\n 28\n 27\n 28\n 29\n Glucose\n 123\n 100\n 119\n 105\n 100\n Other : PT / PTT / INR:15.3/27.8/1.3, CK / CKMB /\n Troponin-T:2818(5360)/113/<0.01, ALT / AST:(3089)/446(1277), Alk\n Phos / T Bili:100 (114)/0.6, Amylase / Lipase:158/54,\n Differential-Neuts:76.4 %, Band:0.0 %, Lymph:16.2 %, Mono:6.2 %,\n Eos:0.8 %, D-dimer: ng/mL, Fibrinogen:455 mg/dL, Lactic Acid:1.4\n mmol/L, Albumin:3.0 g/dL, LDH:844 IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now intubated for\n hypoxic respiratory failure and with persistently altered MS.\n 1)Obtundation: Patient continues to be altered and without clearly\n purposeful movements. Intermittent jerks consistent with myoclonus.\n Intoxication or serotonin syndrome would most likely resolve by now.\n Major concern is for long period down and hypoxic brain injury.\n -CT repeated this AM to look for edema post anoxic injury. Not a great\n deal of additional edema on our prelim eval.\n -off sedation as much as possible to assess mental status, propofol\n boluses PRN\n -Neuro consult\n 2)Shock: The patient was hypotensive in the ED but only after\n receiving propofol sedation. This completely resolved and he is in\n fact hypertensive off pressor support at this time. Presume\n hypotension was iatrogenic. Now consistently hypertensive.\n -labetalol given concern for past cocaine abuse and unapposed B blockad\n -Echocardiogram with normal EF\n 3) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis, vs PNA, vs edema. We will cover for aspiration\n pneumonia and CA-MRSA with antibiotics though there are definitely\n other potential etiologies for fever in this patient. Patient is\n currently oxygenating and ventilating well on reasonable ventilator\n settings particularly given previous need for 100% O2. Now doing well\n on pressure support. Primary reason for continued ventilation is\n mental status.\n -Ampicillin-Sublactam for aspiration pneumonia, stop vancomycin as no\n S. aureus on sputum cultures\n 4) Renal failure: Patient with good urine output but Cr continues to\n rise. Presumed etiology is ATN and rhabdomyoloysis.\n -Goal UOP of 150-200cc/hr\n -Free water boluses to correct hypernatremia, repeat evening lytes\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, neurogenic fever, etc\n -Monitor fever and leukocytosis curves.\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -f/u culture from vesicle\n 7) Neuro: Unclear on significance of bilateral clonus w/o other\n neurologic abnormalities. Ct head slightly abnormal and patient's MS\n is poor. Neuro consult in AM and imaging per above if not improving\n dramatically over course of day.\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: NPO for now, will get tube feeding recommendations/nutrition\n consult\n 10)Access: PIV\ns, A-line\n -given concern about stability of PIV\ns and inability to place PICC due\n to fevers will place CVL this afternoon\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RHABDOMYOLYSIS\n POISONING / OVERDOSE, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:00 PM\n 18 Gauge - 04:00 PM\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659792,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down unresponsive with pinpoint pupils at\n Hosp on . He was treated with narcan with minimal effect.\n Pt was taken to where he was intubated and admitted to M/SICU for\n further mgt\n . A family meeting was held this PM with the Attending Physician, .\n , LiCSW, this RN and Dr. . The extensive\n neurologic injury was explained to the family, and that \n would likely never recover to his baseline neurologic status. In this\n context, it was decided to trial extubation with the understanding that\n we would re-intubate if he developed any distress and then discuss the\n plan of care further (i.e. trach/PEG, etc.). Pt was placed on a SBT and\n extubated successfully.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-08 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 658978,
"text": "Chief Complaint: respiratory failure, overdose\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 27-year-old man presented to Caritas with methadone overdose\n (?other substances). Came to . Last dose of methadone\n 8pm.\n Found down at this morning () ~9a. Unresponsive,\n tachypneic, hypertensive, GCS 8. Rx naloxone. In ED: hypertensive,\n tachycardic, bilateral LE clonus, no rigidity. Lactate 3.4 --> 2.8. CK\n . Tox (+) methadone only. Intubated and sedated with propofol\n --> hypotense --> levophed.\n Rx ceftriaxone, vancomycin, cyproheptadine. Seen by toxicology. LP\n unrevealing.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Propofol - 34 mcg/Kg/min\n Other ICU medications:\n Other medications:\n see resident note (reviewed in detail)\n Past medical history:\n Family history:\n Social History:\n (limited by patient status)\n polysubstance abuse -- opiates, cocaine\n depressive disorder (limited details)\n GERD\n ??seizure disorder (one note in medical record, but not present per\n father)\n unable to obtain\n Occupation:\n Drugs: last drink unclear\n :\n Alcohol:\n Other: see resident note (reviewed in detail)\n Review of systems:\n Flowsheet Data as of 08:23 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 74 (73 - 82) bpm\n BP: 115/80(88) {102/78(83) - 125/86(95)} mmHg\n RR: 18 (16 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 6,913 mL\n PO:\n TF:\n IVF:\n 1,913 mL\n Blood products:\n Total out:\n 0 mL\n 780 mL\n Urine:\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,133 mL\n Respiratory\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (650 - 650) mL\n RR (Set): 16\n RR (Spontaneous): 7\n PEEP: 12 cmH2O\n FiO2: 100%\n PIP: 26 cmH2O\n Plateau: 24 cmH2O\n SpO2: 98%\n ABG: 7.33/40/59/22/-4\n Ve: 9.9 L/min\n PaO2 / FiO2: 59\n Physical Examination\n Sedated\n Pupils small. Normal doll\ns eye.\n Coarse breath sounds\n No murmur\n Abdomen soft\n No spontaneous movement. Scant withdrawal. Clonus in bilateral ankles\n but no other lower extremeity DTRs detectable.\n Careful compartment exam including turning\n no tense compartments\n Small red areas bilateral medial knees (looks like his knees were\n together when he was down), including vesicles on one side. Left hip\n with some small red areas.\n Labs / Radiology\n 216 K/uL\n 33.9 %\n 11.6 g/dL\n 161 mg/dL\n 2.5 mg/dL\n 28 mg/dL\n 22 mEq/L\n 107 mEq/L\n 5.8 mEq/L\n 137 mEq/L\n 20.8 K/uL\n [image002.jpg]\n 05:24 PM\n 06:01 PM\n WBC\n 20.8\n Hct\n 33.9\n Plt\n 216\n Cr\n 2.5\n TC02\n 22\n Glucose\n 161\n Other labs: PT / PTT / INR:19.4/33.5/1.8, CK / CKMB /\n Troponin-T://, Lactic Acid:2.7 mmol/L, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:2.5 mg/dL\n Fluid analysis / Other labs: labs reviewed in OMR\n ECG: NST with normal QRS interval\n Assessment and Plan\n 27-year-old man with\n Severe hypoxemic respiratory failure\n Shock on levophed\n Altered mental status\n Presumptive overdose\n Acute renal failure\n Rhabdomyolysis\n Fever (103 in ED rectal), leucocytosis (20; differential\n pending)\n The etiology of his obtundation/encephalopathy is not precisely\n certain.\n Serotenergic syndrome is in differential diagnosis, as are\n other overdoses.\n Osmolal gap is low, making ingestions like ethylene glycol\n unlikely\n LP adequately excludes bacterial meningitis and makes\n herpetic disease unlikely\n CT excludes large intracranial bleeding\n Although he may or may not be infected, we will cover pending results\n Recheck sputum culture, including virals (influenza unlikely\n but history quite limited) and Legionella\n Empiric coverage (pneumonia)\n o Vanco, Zosyn given 48 hours of exposure to healthcre\n o Levofloxacin to cover atypicals\n o Acyclovir to cover HSV encephalitis (discuss dosing with\n pharmacy given renal failure) given limited history at this point\n Check LFTs, pancreatic enzymes\n On careful exam, there is no evidence of tense compartments\n Treating empirically for serotenergic syndrome per\n toxicology\n For his respiratory railure\n Aspiration seems likely, though volume overload/CHF not\n excluded based on CXR. Pneumonia/etc. also possible.\n Trial of decreased FiO2. Seems to have responded to\n increased PEEP\n No clear risk factors for PE, and CXR makes this diagnosis\n substantially less likely\n For his renal failure\n He is quite oliguric. He has also received substantial\n volume already and is about 6L positive.\n Rhabdomyolysis seems fairly likely. Toxic alcohol\n ingestions seem less likely.\n Consult renal. Appreciate toxicology\ns help.\n For his shock\n be related to propofol, but could also be infection or\n other causes\n Assess stroke volume variation\n Echocardiogram (preferably with bubble given hypoxemia) if\n he does not come off of pressors very quickly\n Rash\n Looks most likely related to contact/being down\n Marked\n Swab vesicles\n Clonus\n In bilateral feet, but no hypertonia and no hyperreflexia\n more proximally therefore doubt SCI\n Given unusual CT finding, consult neurology\n ICU Care\n Nutrition: Gentle tube feeds in next day or so\n Lines / Intubation:\n Multi Lumen - 05:00 PM\n 18 Gauge - 05:18 PM\n 16 Gauge - 05:19 PM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB, CHG, etc.\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 80 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658987,
"text": "27 male w/ hx opiate abuse, s/p admision to pornwood yesterday for\n post-methadone overdose management. Pt found unresponsive at bornwood,\n tachypneic, tachycardic and hypertenisve. Pt given Narcan (total 2.8mg)\n w/ no improvement. Pt intubated and sedated in EW for airway\n protection. Urine tox positive for methadone\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658988,
"text": "27 male w/ hx opiate abuse, s/p admision to pornwood yesterday for\n post-methadone overdose management. Pt found unresponsive at bornwood,\n tachypneic, tachycardic and hypertenisve. Pt given Narcan (total 2.8mg)\n w/ no improvement. Pt intubated and sedated in EW for airway\n protection. Urine tox positive for methadone\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remained as intubated , vented, sedated with propofol 35mic/kg/min.\n received with levophed 0.052 mic/kg/min\n Action:\n Fio2 down to 40% from 100%. Other vent settings 16/ 650/ 10. BP > 130\n sys ,off levo without tapering as per team,pt tolerated well .\n Response:\n BP 130-150\ns sys ,sats 94-98%. Pt not awake, pupils 2mm / brisk.\n Plan:\n Wean vent /sedations as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n K\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2162-03-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 659193,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 10 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / None\n Comments: Pt was suctioned throughout shift for moderate/tan, but at\n last check, pt had no secreitons suctioned through ETT\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: Pt is stable on spontaneous settings\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Reduce PEEP as tolerated, Adjust Min.\n ventilation to control pH; Comments: Pt is stable on current vent\n settings. Pt showed a strong bedside RSBI and has good expiratory\n tidal volumes and resp rate.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Cannot manage\n secretions, Underlying illness not resolved; Comments: Pt remains on\n vent, although not sedated but unresponsive. Pt gets very\n agitated/combative when suctioned. Pt to continue current support\n BEDSIDE RSBI- 27\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659555,
"text": "Chief Complaint: Found Down\n 24 Hour Events:\n SPUTUM CULTURE - At 08:00 AM\n FEVER - 101.7\nF - 04:00 AM\n -Put on PS 5/5 in a.m. Remained off sedation for near entirety of day\n (was briefly given propofol for agitation in evening)\n -Was initially minimally responsive in a.m. but gradually became\n slightly more responsive over course of day; still very sedated overall\n -Increased labetalol to 400 tid b/c of htn\n -BCx/UCx this a.m. for temp of 101.7\n Patient unable to provide history: Encephalopathy, intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:18 PM\n Acyclovir - 11:18 PM\n Piperacillin/Tazobactam (Zosyn) - 11:18 PM\n Ampicillin - 10:00 PM\n Vancomycin - 09:00 AM\n Ampicillin/Sulbactam (Unasyn) - 10:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 AM\n Famotidine (Pepcid) - 07:38 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 38.7\nC (101.7\n HR: 81 (76 - 86) bpm\n BP: 116/75(84) {0/0(0) - 0/0(0)} mmHg\n RR: 17 (14 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 3,277 mL\n 858 mL\n PO:\n TF:\n IVF:\n 3,187 mL\n 778 mL\n Blood products:\n Total out:\n 2,555 mL\n 420 mL\n Urine:\n 2,555 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 722 mL\n 438 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 650 (650 - 650) mL\n Vt (Spontaneous): 670 (670 - 777) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 27\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: 7.47/37/114/26/3\n Ve: 8.8 L/min\n PaO2 / FiO2: 285\n Physical Examination\n General Appearance: Well nourished, Thin\n Eyes / Conjunctiva: PERRL, looks to left when opens spontaneously\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, Rash: stable\n Neurologic: Responds to: Noxious stimuli, Movement: Non -purposeful,\n Tone: Increased, clonus, possible posturing w/suctioning\n Labs / Radiology\n 265 K/uL\n 11.7 g/dL\n 119 mg/dL\n 4.2 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 45 mg/dL\n 111 mEq/L\n 148 mEq/L\n 33.3 %\n 14.0 K/uL\n [image002.jpg]\n 04:40 AM\n 11:50 AM\n 12:01 PM\n 03:02 PM\n 04:02 PM\n 04:00 AM\n 08:39 AM\n 10:48 AM\n 04:12 AM\n 04:31 AM\n WBC\n 21.3\n 14.0\n Hct\n 37.2\n 33.3\n Plt\n 261\n 265\n Cr\n 3.7\n 4.2\n 4.2\n TCO2\n 25\n 25\n 26\n 28\n 27\n 28\n Glucose\n 134\n 123\n 100\n 119\n Other labs: PT / PTT / INR:15.8/27.9/1.4, CK / CKMB / Troponin-T:5360\n ()/113/<0.01, ALT / AST:3089 (3708)/1277 (2217), Alk Phos / T\n Bili:114 (121)/0.7, Amylase / Lipase:461/31, Differential-Neuts:76.4 %,\n Band:0.0 %, Lymph:16.2 %, Mono:6.2 %, Eos:0.8 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:1.4 mmol/L, Albumin:3.2 g/dL,\n LDH:2137 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL, PO4:3.3 mg/dL\n Microbiology: DFA for Influenza A and B is negative\n Legionella urinary antigen (-)\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now intubated for\n hypoxic respiratory failure and with persistently altered MS.\n 1)Obtundation: Patient continues to be altered and without clearly\n purposeful movements. Intermittent jerks consistent with myoclonus.\n Intoxication or serotonin syndrome would most likely resolve by now.\n Major concern is for long period down and hypoxic brain injury.\n -CT repeated this AM to look for edema post anoxic injury. Not a great\n deal of additional edema on our prelim eval.\n -off sedation as much as possible to assess mental status, propofol\n boluses PRN\n -Neuro consult\n 2)Shock: The patient was hypotensive in the ED but only after\n receiving propofol sedation. This completely resolved and he is in\n fact hypertensive off pressor support at this time. Presume\n hypotension was iatrogenic. Now consistently hypertensive.\n -labetalol given concern for past cocaine abuse and unapposed B\n blockade\n -Echocardiogram with normal EF\n 3) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis, vs PNA, vs edema. We will cover for aspiration\n pneumonia and CA-MRSA with antibiotics though there are definitely\n other potential etiologies for fever in this patient. Patient is\n currently oxygenating and ventilating well on reasonable ventilator\n settings particularly given previous need for 100% O2. Now doing well\n on pressure support. Primary reason for continued ventilation is\n mental status.\n -Ampicillin-Sublactam for aspiration pneumonia, stop vancomycin as no\n S. aureus on sputum cultures\n 4) Renal failure: Patient with good urine output but Cr continues to\n rise. Presumed etiology is ATN and rhabdomyoloysis.\n -Goal UOP of 150-200cc/hr\n -Free water boluses to correct hypernatremia, repeat evening lytes\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, neurogenic fever, etc\n -Monitor fever and leukocytosis curves.\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -f/u culture from vesicle\n 7) Neuro: Unclear on significance of bilateral clonus w/o other\n neurologic abnormalities. Ct head slightly abnormal and patient's MS\n is poor. Neuro consult in AM and imaging per above if not improving\n dramatically over course of day.\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: NPO for now, will get tube feeding recommendations/nutrition\n consult\n 10)Access: PIV\ns, A-line\n -given concern about stability of PIV\ns and inability to place PICC due\n to fevers will place CVL this afternoon\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 05:19 PM\n Arterial Line - 07:00 PM\n 20 Gauge - 03:45 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659774,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down at Hosp. 9AM on found\n unresponsive with pinpoint pupils. He was treated with narcan with\n minimal effect. Today pt had MRI/MRA brain and EEG. A family meeting\n was held this PM with the Attending Physician, . , \n LiCSW, this RN and Dr. . The extensive neurologic injury\n was explained to the family, and that would likely never\n recover to his baseline neurologic status. In this context, it was\n decided to trial extubation with the understanding that we would\n re-intubate if he developed any distress and then discuss the plan of\n care further (i.e. trach/PEG, etc.). Pt was placed on a SBT and\n extubated successfully.\n Altered mental status (not Delirium)\n Assessment:\n Eyes to stimulation, moving extremities on bed\n PEARRL 2-4mm, not tracking or following commands, left leaning gaze\n Action:\n MRI/MRA of brain today\n EEG today\n Sedation stopped\n Extubated successfully\n Response:\n Remains extubated, initially breathing in a\nneurologic\n pattern\n intermittently holding breath, more regular now\n Continues respond to stimuli reflexively but it is unclear whether pt\n has any purposeful response\n Plan:\n Continue to supportive measures\n Close monitoring of airway/respiratory status\n Continue abx as ordered and follow micro data\n Follow-up with neurology\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659844,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down unresponsive with pinpoint pupils at\n Hosp on . He was treated with narcan with minimal effect.\n Pt was taken to where he was intubated and admitted to M/SICU for\n further mgt of resp failure, ARF, and rhabdo.\n A family meeting was held on . pts extensive neurologic injury was\n explained to the family, and that would likely never\n recover to his baseline neurologic status. it was decided to trial\n extubation with the understanding that we would re-intubate if he\n developed any distress and then discuss the plan of care further (i.e.\n trach/PEG, etc.). Pt was placed on a SBT and extubated successfully on\n .\n Altered mental status (not Delirium)\n Assessment:\n Respiratory status remains stable w/ pt extubated. Pt awake though\n unresponsive w/ no response to nail bed stimuli. Eyes open, PERRLA,\n corneal reflex present; however, pt continues w/ left fixed gaze, does\n not track. No purposeful movement noted, pt does not follow commands.\n On occasion pt says\n;\n however, these verbalizations do not seem\n purposeful.\n Action:\n - monitoring respiratory status closely.\n - FiO2 weaned to room air.\n - Monitoring neuro status closely and following q4hr neuro\n assessments.\n - Monitoring labs as ordered.\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt continues w/ temp 99-101 range (see flowsheet). Multiple cultures\n have been sent and have been unrevealing. Last cultures sent . ?\n fevers infectious vs. neurological.\n Action:\n - Monitoring for s/s infection\n - Pt continues on unasyn as ordered.\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 659846,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 27 y/o M admitted from detox unit with unknown drug overdose, seizures\n (LP neg), likely aspiration PNA with severe rhabdo from being down.\n Intubated and briefly on pressors. Initial high FiO2/PEEP likely \n volume overload, now weaned down with diuresis. Remained intubated for\n mental status - MRI with diffuse anoxic brain injury - after family\n meeting decided to extubate yesterday before commiting to trach/peg.\n On unasyn for aspiration PNA, but persistently febrile.\n 24 Hour Events:\n EEG - At 01:43 PM - diffuse slowing\n INVASIVE VENTILATION - STOP 04:19 PM\n FEVER - 102.2\nF - 08:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 09:51 AM\n Ampicillin - 04:20 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:57 PM\n Heparin Sodium (Prophylaxis) - 10:12 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.9\nC (100.3\n HR: 73 (66 - 92) bpm\n BP: 160/84(106) {145/74(97) - 178/98(123)} mmHg\n RR: 17 (10 - 20) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 4 (2 - 10)mmHg\n Total In:\n 2,758 mL\n 1,135 mL\n PO:\n TF:\n 315 mL\n IVF:\n 772 mL\n 1,105 mL\n Blood products:\n Total out:\n 2,435 mL\n 1,300 mL\n Urine:\n 2,435 mL\n 1,300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 323 mL\n -165 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 878 (878 - 878) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 93%\n ABG: 7.48/37/86./24/3\n Ve: 11.2 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, Rash: Improving\n Neurologic: Responds to: Unresponsive, Movement: Non -purposeful, Tone:\n Not assessed, Blink reflex,\n Labs / Radiology\n 11.0 g/dL\n 249 K/uL\n 108 mg/dL\n 3.4 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 49 mg/dL\n 115 mEq/L\n 149 mEq/L\n 31.1 %\n 14.5 K/uL\n [image002.jpg]\n 08:39 AM\n 10:48 AM\n 04:12 AM\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n 08:27 PM\n 04:07 AM\n 10:47 AM\n WBC\n 14.0\n 14.8\n 14.5\n Hct\n 33.3\n 31.4\n 31.1\n Plt\n 265\n 239\n 249\n Cr\n 4.2\n 3.9\n 3.8\n 3.4\n TCO2\n 28\n 27\n 28\n 29\n 26\n 28\n Glucose\n 119\n 105\n 100\n 108\n Other labs: PT / PTT / INR:15.1/30.4/1.3, CK / CKMB /\n Troponin-T:2818/113/<0.01, ALT / AST:1287/201, Alk Phos / T\n Bili:98/0.6, Amylase / Lipase:158/54, Differential-Neuts:76.4 %,\n Band:0.0 %, Lymph:16.2 %, Mono:6.2 %, Eos:0.8 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:3.0 g/dL, LDH:831\n IU/L, Ca++:8.1 mg/dL, Mg++:2.6 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 27 y/o M admitted from detox unit with unknown drug overdose, seizures\n (LP neg), likely aspiration PNA with severe rhabdo from being down.\n Now with evidence of anoxic brain injury. Extubated overnight.\n #Anoxic brain injury: Possibly answering questions today, but unclear\n if responses are purposeful or random.\n -Continue to assess mental status\n - breathing pattern\n will follow gasses and reintubate if\n needed.\n #Hypoxemic respiratory failure: Likely aspiration PNA.\n - Continue Augmentin for aspiration PNA.\n - Stable off vent.\n # Fever: Unclear etiology\n aspiration pneumonia/pneumonitis vs\n neurogenic. No evidence of eosinophilia/drug rash.\n - Follow fever curve/ cultures\n # Renal failure: Likely ATN/rhabdo\n - Free water boluses to correct hypernatremia\n - Follow\n #Liver dysfunction: Presumed due to rhabo. Improving.\n - Follow.\n All other issues per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:00 PM\n 18 Gauge - 04:00 PM\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments: Aspiration precautions\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659848,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down unresponsive with pinpoint pupils at\n Hosp on . He was treated with narcan with minimal effect.\n Pt was taken to where he was intubated and admitted to M/SICU for\n further mgt of resp failure, ARF, and rhabdo.\n A family meeting was held on . pts extensive neurologic injury was\n explained to the family, and that would likely never\n recover to his baseline neurologic status. it was decided to trial\n extubation with the understanding that we would re-intubate if he\n developed any distress and then discuss the plan of care further (i.e.\n trach/PEG, etc.). Pt was placed on a SBT and extubated successfully on\n .\n Altered mental status (not Delirium)\n Assessment:\n Respiratory status remains stable w/ pt extubated. Pt awake though\n unresponsive w/ no response to nail bed stimuli. Eyes open, PERRLA,\n corneal reflex present; however, pt continues w/ left fixed gaze, does\n not track. No purposeful movement noted, pt does not follow commands.\n On occasion pt says\n;\n however, these verbalizations do not seem\n purposeful.\n Action:\n - monitoring respiratory status closely.\n - FiO2 weaned to room air.\n - Monitoring neuro status closely and following q4hr neuro\n assessments.\n - Monitoring labs as ordered.\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt continues w/ temp 99-101 range (see flowsheet). Multiple cultures\n have been sent and have been unrevealing. Last cultures sent . ?\n fevers infectious vs. neurological.\n Action:\n - Monitoring for s/s infection\n - Pt continues on unasyn as ordered.\n Response:\n Plan:\n Hypernatremia (high sodium)\n Assessment:\n NA 149 this am up from 148.\n Action:\n - Monitoring labs closely.\n - D5W IVF continued at 125ml/hr as ordered.\n Response:\n Repeat Na 153. D5W IVF increased to 200ml/hr as ordered. Free water\n boluses 250ml Q6hr via NGT started as ordered.\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 659864,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 27 y/o M admitted from detox unit with unknown drug overdose, seizures\n (LP neg), likely aspiration PNA with severe rhabdo from being down.\n Intubated and briefly on pressors. Initial high FiO2/PEEP likely \n volume overload, now weaned down with diuresis. Remained intubated for\n mental status - MRI with diffuse anoxic brain injury - after family\n meeting decided to extubate yesterday before commiting to trach/peg.\n On unasyn for aspiration PNA, but persistently febrile.\n 24 Hour Events:\n EEG - At 01:43 PM - diffuse slowing\n INVASIVE VENTILATION - STOP 04:19 PM\n FEVER - 102.2\nF - 08:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 09:51 AM\n Ampicillin - 04:20 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:57 PM\n Heparin Sodium (Prophylaxis) - 10:12 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.9\nC (100.3\n HR: 73 (66 - 92) bpm\n BP: 160/84(106) {145/74(97) - 178/98(123)} mmHg\n RR: 17 (10 - 20) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 4 (2 - 10)mmHg\n Total In:\n 2,758 mL\n 1,135 mL\n PO:\n TF:\n 315 mL\n IVF:\n 772 mL\n 1,105 mL\n Blood products:\n Total out:\n 2,435 mL\n 1,300 mL\n Urine:\n 2,435 mL\n 1,300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 323 mL\n -165 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 878 (878 - 878) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 93%\n ABG: 7.48/37/86./24/3\n Ve: 11.2 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, Rash: Improving\n Neurologic: Responds to: Unresponsive, Movement: Non -purposeful, Tone:\n Not assessed, Blink reflex,\n Labs / Radiology\n 11.0 g/dL\n 249 K/uL\n 108 mg/dL\n 3.4 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 49 mg/dL\n 115 mEq/L\n 149 mEq/L\n 31.1 %\n 14.5 K/uL\n [image002.jpg]\n 08:39 AM\n 10:48 AM\n 04:12 AM\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n 08:27 PM\n 04:07 AM\n 10:47 AM\n WBC\n 14.0\n 14.8\n 14.5\n Hct\n 33.3\n 31.4\n 31.1\n Plt\n 265\n 239\n 249\n Cr\n 4.2\n 3.9\n 3.8\n 3.4\n TCO2\n 28\n 27\n 28\n 29\n 26\n 28\n Glucose\n 119\n 105\n 100\n 108\n Other labs: PT / PTT / INR:15.1/30.4/1.3, CK / CKMB /\n Troponin-T:2818/113/<0.01, ALT / AST:1287/201, Alk Phos / T\n Bili:98/0.6, Amylase / Lipase:158/54, Differential-Neuts:76.4 %,\n Band:0.0 %, Lymph:16.2 %, Mono:6.2 %, Eos:0.8 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:3.0 g/dL, LDH:831\n IU/L, Ca++:8.1 mg/dL, Mg++:2.6 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 27 y/o M admitted from detox unit with unknown drug overdose, seizures\n (LP neg), likely aspiration PNA with severe rhabdo from being down.\n Now with evidence of anoxic brain injury. Extubated overnight.\n #Anoxic brain injury: answering questions today! Able to recognize\n family at bedside.\n -Continue to assess mental status, strict aspiration precautions\n - breathing pattern\n will follow gasses and reintubate if\n needed.\n #Hypoxemic respiratory failure: Likely aspiration PNA.\n - Continue Augmentin for aspiration PNA.\n - Stable off vent.\n # Fever: Unclear etiology\n aspiration pneumonia/pneumonitis vs\n neurogenic. No evidence of eosinophilia/drug rash.\n - Follow fever curve/ cultures\n # Renal failure: Likely ATN/rhabdo\n - Free water boluses to correct hypernatremia\n - Follow\n #Liver dysfunction: Presumed due to rhabo. Improving.\n - Follow.\n All other issues per resident note.\n ICU Care\n Nutrition: tube feeds for now will assess S/S early next week\n Glycemic Control:\n Lines:\n Arterial Line - 07:00 PM\n 18 Gauge - 04:00 PM\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments: Aspiration precautions\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is ill but improving!\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 658974,
"text": "27 male w/ hx opiate abuse, s/p admision to pornwood yesterday for\n post-methadone overdose management. Pt found unresponsive at bornwood,\n tachypneic, tachycardic and hypertenisve. Pt given Narcan (total 2.8mg)\n w/ no improvement. Pt intubated and sedated in EW for airway\n protection. Urine tox positive for methadone, otherwise negative. In\n EW pt remained tachycardic, tachypneic, febrile w/ temp to 103, and\n diaphoretic. Hypertension resolved w/ adaquete sedation, then w/ pt\n becoming hypotensive w/ SBP to 70's. Pt. was started on levophed.\n Received 6L IVF in EW, given vancomycin, acyclovir, and ceftriaxone.\n Given cyproheptadine ? serotonin syndrome. Lactate 3.4 on arrival\n to EW - trending down to 2.8. Pt transferred to MICU for further\n management.\n Poisoning / Overdose, Other\n Assessment:\n Pt found down at bornewood where he was being treated for\n post-methadone overdose management. P, urine tox positive for\n methadone, s/s ? serotonin syndrome\n pt given cyproheptadine in EW.\n CPK 20,769. WBC 20.1\n pt received abx in EW as above.\n Action:\n - Monitoring respiratory status closely.\n - Monitoring hemodynamic status closely.\n - Continued IVF as ordered.\n - Monitoring labs as ordered.\n Response:\n ABG 7.33/40/59 on vent settings AC 500/5 X18 FiO2 100%. BBS w/ rhonchi\n on L, otherwise CTA. SpO2 85-89%. Snx for copious thick tan secretions\n both via ETT and subglotal snx\n specimen sent for cx. PEEP increased\n to 12 by RT as ordered w/ improvement in SpO2 to 95%. Team in to place\n A-line. UOP remains low (see flowsheet) , creatanine 2.5, K 5.8. Pt\n received additional 1L IVF in MICU\n IVF stopped as ordered. Pt remains\n hemodynamically stable.\n Plan:\n Continue to monitor respiratory assessment closely and titrate vent\n settings. Monitor labs closely. Anticipate need for urgent HD. Wean\n pressor as able. Continue abx as ordered. Continue aggressive pulmonary\n toilet.\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659043,
"text": "Chief Complaint: Found down\n 24 Hour Events:\n MULTI LUMEN - START 05:00 PM\n placed in EW\n INVASIVE VENTILATION - START 05:30 PM\n ARTERIAL LINE - START 07:00 PM\n Patient unable to provide history: Sedated, Unresponsive\n Allergies:\n Last dose of Antibiotics:\n Levofloxacin - 10:18 PM\n Acyclovir - 11:18 PM\n Piperacillin/Tazobactam (Zosyn) - 11:18 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 10:18 PM\n Furosemide (Lasix) - 10:19 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.8\nC (98.2\n HR: 80 (73 - 82) bpm\n BP: 116/75(84) {102/75(83) - 125/86(95)} mmHg\n RR: 15 (15 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 7,482 mL\n 302 mL\n PO:\n TF:\n IVF:\n 2,482 mL\n 232 mL\n Blood products:\n Total out:\n 1,040 mL\n 2,050 mL\n Urine:\n 340 mL\n 2,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,442 mL\n -1,748 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 650 (650 - 650) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 18\n PIP: 26 cmH2O\n Plateau: 21 cmH2O\n SpO2: 98%\n ABG: 7.38/41/103/23/0\n Ve: 11.6 L/min\n PaO2 / FiO2: 258\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 241 K/uL\n 12.3 g/dL\n 98 mg/dL\n 2.9 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 36 mg/dL\n 108 mEq/L\n 142 mEq/L\n 35.8 %\n 17.9 K/uL\n [image002.jpg]\n 05:24 PM\n 06:01 PM\n 09:07 PM\n 10:19 PM\n 04:27 AM\n 04:40 AM\n WBC\n 20.8\n 17.8\n 17.9\n Hct\n 33.9\n 35.9\n 35.8\n Plt\n \n Cr\n 2.5\n 2.5\n 2.9\n TropT\n 0.82\n <0.01\n TCO2\n 22\n 22\n 25\n Glucose\n 161\n 124\n 98\n Other labs: PT / PTT / INR:17.2/29.2/1.6, CK / CKMB /\n Troponin-T:/113/<0.01, ALT / AST:4257/6019, Alk Phos / T\n Bili:105/0.4, Amylase / Lipase:461/31, Differential-Neuts:81.0 %,\n Band:0.0 %, Lymph:14.0 %, Mono:5.0 %, Eos:0.0 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:2.7 mmol/L, Albumin:3.2 g/dL,\n LDH:5280 IU/L, Ca++:7.2 mg/dL, Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now intubated for\n hypoxic respiratory failure and being broadly treated for serotonin\n syndrome and pneumonia.\n 1)Obtundation: Ultimate etiology is not clear at this time. Major\n concerns include serotonin syndrome due to trazodone/SSRI (given\n diaphoresis, HTN, and clonus) vs drug intoxication (less likely given\n relatively unimpressive tox screen) vs infection. Seizure could also\n cause post-ictal mental status changes. Meningitis/encephalitis\n extremely unlikely given no pleiocytosis but cannot exclude HSV w/o PCR\n so will treat empirically for the moment. Finally, it is possible\n respiratory failure could have caused obtundation though seems unlikely\n in an otherwise healthy young man. Consumption of non ethanol alcohols\n was also considered but no osmolal gap suggesting this.\n -cyproheptidine 4 mg Q6hrs for serotonin syndrome\n -acyclovir empirically for consern HSV meningitis\n -vanc/zosyn/levo for possible PNA given bilateral infiltrates and fever\n in the ED in this critically ill gentlman\n -F/U tox reccs\n 2)Shock: The patient had hypotension today after receiving his propofol\n sedation. Possible etiologies of his shock would include vasodilation\n vs cardiogenic vs hypovolemic. Given the patient's appearance and\n bilateral infiltrates/enlarged hila it seems unlikely he is hypovolemic\n though he could have been initially. Cardiogenic shock also seems\n unlikely given he was quickly weaned off pressors after arrival to the\n floor and few etiologies of cardiogenic shock would resolve that\n quickly without specific management. Shock due to vasodilatory\n phenomena seem most likely given exclusion of other types. Propofol\n can cause profound hypotension in certain circumstances and the fact\n that hypotension didn't occur until sedation would support this.\n Autonomic instability due to serotonin syndrome could also potentially\n contribute to rapid transition from hypertension to hypotension.\n Finally, given fever/leukocytosis there is concern for septic shock.\n -blood cx, broad spectrum abx\n -cyprohepatidine\n -Echo in AM\n 3) Hypoxemic respiratory failure: Patient had an unwitnessed event\n leading to loss of consciousness. Most processed that cause this\n (intoxication, seizure, etc..) can lead to periods of decreased airway\n protection therefore high level of concern for aspiration. Appearance\n of CXR could be consistent with aspiration pneumonitis, vs PNA, vs\n edema. Will cover with antibiotics given fever and hold off on\n diuresis given hypotension earlier. Sputum cultures suggest aspiration\n (oropharyngeal flora in endotracheal specimen). Patient is currently\n oxygenating and ventilating well on reasonable ventilator settings\n particularly given previous need for 100% O2.\n -Wean FiO2 and then PEEP\n -Vanco/Pipercillin-Tazobactam for health care associated pneumonia\n (patient has spent around 48 hours in health care settings/borderline\n call but covering due to high acuity). Also using levofloxacin to\n cover atypicals.\n -sputum cultures\n -urine legionella\n -Rapid flu antigen test and viral culture\n 4) Renal failure: Patient nearly anuric since arrival to floor.\n Elevated CK and blood/rbc dissociation on UA suggestive or\n rhabdomyolysis particularly given this is an otherwise healthy young\n man with presumably a normal Cr before. Still, nephrology thinks CK\n not high enough for this degree of failure and time course not exactly\n appropriate. Granular casts of unclear significance.\n -Renal consult in AM\n -Urine lytes, protein\n -Attempt 100 mg IV furosemide * 1 for trial of diuresis on renal recc\n -Avoid nephrotoxins, renally dose meds\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, etc...\n -Monitor fever and leukocytosis curves.\n -Consider CT to look for occult abcess if repeated fevers once stable\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -unroof vesicle and send for viral cutlure.\n 7) Neuro: Unclear on significance of bilateral clonus w/o other\n neurologic abnormalities. Ct head slightly abnormal and patient's MS\n is poor.\n -Neuro consult in the AM\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: NPO for now, OG and tube feeds tomorrow\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RHABDOMYOLYSIS\n POISONING / OVERDOSE, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:00 PM\n 16 Gauge - 05:19 PM\n Arterial Line - 07:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659772,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down at Hosp. 9AM on found\n unresponsive with pinpoint pupils. He was treated with narcan with\n minimal effect. Today pt had MRI/MRA brain and EEG. A family meeting\n was held this PM with the Attending Physician, . , \n LiCSW, this RN and Dr. . The extensive neurologic injury\n was explained to the family, and that would likely never\n recover to his baseline neurologic status. In this context, it was\n decided to trial extubation with the understanding that we would\n re-intubate if he developed any distress and then discuss the plan of\n care further (i.e. trach/PEG, etc.). Pt was placed on a SBT and\n extubated successfully.\n Altered mental status (not Delirium)\n Assessment:\n Eyes to stimulation, moving extremities on bed\n PEARRL 2-4mm, not tracking or following commands, left leaning gaze\n Action:\n MRI/MRA of brain today\n EEG today\n Sedation stopped\n Extubated successfully\n Response:\n Remains extubated, initially breathing in a\nneurologic\n pattern\n intermittently holding breath, more regular now\n Continues respond to stimuli reflexively but it is unclear whether pt\n has any purposeful response\n Plan:\n Continue to supportive measures\n Close monitoring of airway/respiratory status\n Continue abx as ordered and follow micro data\n Follow-up with neurology\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659825,
"text": "Chief Complaint: 27 y.o. male with hx of polysubstance abuse\n presentinng with obtundations, respiratory failure, and hypotension in\n the context of fever and some indications of increased tone. Now\n respiratory issues have largely resolved and doing well on pressure\n support, but no clearly purposeful movements and continuing to be\n encephalopathic.\n 24 Hour Events:\n EEG - At 01:43 PM\n INVASIVE VENTILATION - STOP 04:19 PM\n FEVER - 102.2\nF - 08:00 AM\n -Fam mtg- explained gravity of anoxic brain injury.\n -Extubated in pm. Plan for reintubation PRN then would d/w family trach\n vs CMO. Post extubation gas 7.41/40/118/26\n -MRI head : Extensive areas of restricted diffusion involving the white\n matter, corpus callosum, both globus pallidus and right hippocampus\n indicative of acute infarct/ischemia likely due to global hypoxia.\n -EEG prelim with diffuse slowing, nothing focal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Ampicillin/Sulbactam (Unasyn) - 09:51 AM\n Ampicillin - 04:20 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:57 PM\n Heparin Sodium (Prophylaxis) - 10:12 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 38.4\nC (101.1\n HR: 85 (66 - 85) bpm\n BP: 172/90(115) {139/71(90) - 172/94(118)} mmHg\n RR: 14 (10 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 4 (2 - 10)mmHg\n Total In:\n 2,758 mL\n 929 mL\n PO:\n TF:\n 315 mL\n IVF:\n 772 mL\n 899 mL\n Blood products:\n Total out:\n 2,435 mL\n 740 mL\n Urine:\n 2,435 mL\n 740 mL\n NG:\n Stool:\n Drains:\n Balance:\n 323 mL\n 189 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 878 (878 - 878) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: 7.41/40/118//0\n Ve: 11.2 L/min\n PaO2 / FiO2: 295\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 249 K/uL\n 11.0 g/dL\n 100 mg/dL\n 3.8 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 47 mg/dL\n 114 mEq/L\n 149 mEq/L\n 31.1 %\n 14.5 K/uL\n [image002.jpg]\n 04:00 AM\n 08:39 AM\n 10:48 AM\n 04:12 AM\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n 08:27 PM\n 04:07 AM\n WBC\n 21.3\n 14.0\n 14.8\n 14.5\n Hct\n 37.2\n 33.3\n 31.4\n 31.1\n Plt\n 261\n 265\n 239\n 249\n Cr\n 4.2\n 4.2\n 3.9\n 3.8\n TCO2\n 28\n 27\n 28\n 29\n 26\n Glucose\n 100\n 119\n 105\n 100\n Other labs: PT / PTT / INR:15.3/27.8/1.3, CK / CKMB /\n Troponin-T:2818/113/<0.01, ALT / AST:/446, Alk Phos / T\n Bili:100/0.6, Amylase / Lipase:158/54, Differential-Neuts:76.4 %,\n Band:0.0 %, Lymph:16.2 %, Mono:6.2 %, Eos:0.8 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:3.0 g/dL, LDH:844\n IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now respiratory issues\n have largely resolved and doing well on pressure support, but no\n clearly purposeful movements and continuing to be encephalopathic.\n 1)Obtundation: Seen by neurology who agree his picture is most\n consistent with anoxic brain injury and prognosis is not favorable.\n Some concern for laterality of findings so we are obtaining an MRI head\n today and an EEG to rule out epileptiform activity.\n -f/u EEG and MRI\n -Presumably the primary injury is anoxic brain injury and expect\n minimal recovery. After final studies and neuro input will discuss\n with family implications of further decisions. Patient likely to\n continue to breathe adequately if extubated (though would probably be\n chronic aspiration risk) but will address whether to re-intubate and/or\n proceed with trach\n -Minimize sedation\n 2)Shock: The patient was hypotensive in the ED but only after\n receiving propofol sedation. This completely resolved and he is in\n fact hypertensive off pressor support at this time. Presume\n hypotension was iatrogenic. Now inclined toward hypertension but\n improved with up-titration of labetalol\n -Continue labetalol\n 3) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis, vs PNA. CXR currently resolving and patient is\n needing minimal respiratory support. Primary reason for continued\n ventilation is mental status.\n -Ampicillin-Sublactam for aspiration pneumonia for seven day course\n 4) Renal failure: Cr. Continuing to fall though urine output falling as\n well, expect resolution of injury from rhabdo/ATN but will continue to\n monitor.\n -Free water boluses to correct hypernatremia, repeat evening lytes\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, neurogenic fever, etc\n Given improving lung findings and\n broad abx coverage highest suspicion for central fever now.\n -Monitor fever and leukocytosis curves.\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -f/u culture from vesicle\n 7) Hypernatremia: Possibly due to free water deficit and saline\n repletion but given persistently high despite free water boluses\n yesterday and known intracranial injury we are concerned for SIADH.\n -Recheck serum and urine osms, urine lytes\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: Tube feeds\n 10)Access: R IJ, A-line, PIV\n 11) Code Status: Presumed full\n 11) Dispo: ICU for moment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:00 PM\n 18 Gauge - 04:00 PM\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659908,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down unresponsive with pinpoint pupils at\n Hosp on . He was treated with narcan with minimal effect.\n Pt was taken to where he was intubated and admitted to M/SICU for\n further mgt of resp failure, ARF, and rhabdo.\n A family meeting was held on . pts extensive neurologic injury was\n explained to the family, and that would likely never\n recover to his baseline neurologic status. it was decided to extubate\n with the understanding that we would re-intubate if he developed any\n distress and then discuss the plan of care further (i.e. trach/PEG,\n etc.). Pt was extubated successfully on .\n Altered mental status (not Delirium)\n Assessment:\n MS has been improving, pt oriented x1, knows and names family members\n from pictures, answers simple questions appropriately, sticks out\n tongue on command. Have not noted any spontaneous movement, could not\n move arms when asked. Cont w L gaze, not tracking. PERRL. LS clear,\n RR irreg, short periods of apnea but sats always > 93, usually > 95.\n Action:\n Reorient pt to time and place freq. Monitor resp and neuro status.\n Turn q2 hrs\n Response:\n Improving MS\n :\n Cont to monitor resp and neur status closely.\n Hypernatremia (high sodium)\n Assessment:\n Na improving from 153 to 150 with fluids.\n Action:\n D%W at 200mls/hr for 2L overnoc, also cont free water flushes via NG\n tube 250mls q4hrs.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 659990,
"text": "27 y/o M admitted from detox unit with unknown drug overdose, seizures\n (LP neg), likely aspiration PNA with severe rhabdo from being down.\n Intubated and briefly on pressors. Initial high FiO2/PEEP likely \n volume overload, now weaned down with diuresis. Remained intubated for\n mental status - MRI with diffuse anoxic brain injury - after family\n meeting decided to extubate yesterday before commiting to trach/peg.\n On unasyn for aspiration PNA, but persistently febrile.\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt temp 100.5 this am. Pt pan cultured last night. VSS. Pt denies pain.\n Action:\n Pt given tylenol. MD updated during rounds that the pt spiked last\n night. ? C-diff. Order for stool to be sent for s-diff done. Pt had\n brown/gold liquid stool 5 times today. Placed flexseal.\n Response:\n Pt tolerated flexseal placement. Pt continues to have liquid stool.\n Plan:\n Follow up with c-diff culture sent. Flush flexiseal per hospital\n policy. Monitor area for signs of redness or breakdown.\n Altered mental status (not Delirium)\n Assessment:\n Pt will follow some simple commands. Pt will stick tongue out when\n asked\nwill try to show his thumb when asked. MRI EEG show anoxic brain\n injury. Pt difficult to understand. Unable to move feet. Pt can move\n right upper arm on bed. No movement in left upper arm.\n Action:\n Neuro checks Q4hr. Pt reoriented to unit/date/time. All meds/treatments\n explained to the pt.\n Response:\n No change in status.\n Plan:\n No change in pt status. Pt to be transferred to floor. PT/OT consult?\n Pt will need rehab service once discharged from Hospital.\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 659993,
"text": "27 y/o M admitted from detox unit with unknown drug overdose, seizures\n (LP neg), likely aspiration PNA with severe rhabdo from being down.\n Intubated and briefly on pressors. Initial high FiO2/PEEP likely \n volume overload, now weaned down with diuresis. Remained intubated for\n mental status - MRI with diffuse anoxic brain injury - after family\n meeting decided to extubate yesterday before commiting to trach/peg.\n On unasyn for aspiration PNA, but persistently febrile.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt temp 100.5 this am. Pt pan cultured last night. VSS. Pt denies pain.\n Action:\n Pt given tylenol. MD updated during rounds that the pt spiked last\n night. ? C-diff. Order for stool to be sent for s-diff done. Pt had\n brown/gold liquid stool 5 times today. Placed flexseal.\n Response:\n Pt tolerated flexseal placement. Pt continues to have liquid stool.\n Plan:\n Follow up with c-diff culture sent. Flush flexiseal per hospital\n policy. Monitor area for signs of redness or breakdown.\n Altered mental status (not Delirium)\n Assessment:\n Pt will follow some simple commands. Pt will stick tongue out when\n asked\nwill try to show his thumb when asked. MRI EEG show anoxic brain\n injury. Pt difficult to understand. Unable to move feet. Pt can move\n right upper arm on bed. No movement in left upper arm.\n Action:\n Neuro checks Q4hr. Pt reoriented to unit/date/time. All meds/treatments\n explained to the pt.\n Response:\n No change in status.\n Plan:\n No change in pt status. Pt to be transferred to floor. PT/OT consult?\n Pt will need rehab service once discharged from Hospital.\n Impaired Skin Integrity\n Assessment:\n Noted bruses on pt extremities. Noted L knee abrasion 4cm by 3.5cm. R\n knee abrasion 2.5cm by 2cm. Both red base. Blister on L hand 4cm by 4cm\n in size. Abrasion to lower lip with large scab. Anasarca to R arm, 8cm\n by 8cm deep tissue injury on coccyx/gludeal area.\n Action:\n Blister cleaned with NS and dry gauze applied to it. Both abrasions\n cleaned with foam cleanser and open to air. Blister cleaned with mouth\n care. Cream applied to coccyx area and pt turned Q2hr and Prn. Pt kept\n off back. Flexiseal placed do to frequent stool and redness to gluteal\n area.\n Response:\n No change in pt status at this time.\n Plan:\n Continue to turn pt Q2hr and prn. Wound care consult placed. ?\n specialty bed for pt. Monitor for signs of deep tissue injury.\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 659995,
"text": "27 y/o M admitted from detox unit with unknown drug overdose, seizures\n (LP neg), likely aspiration PNA with severe rhabdo from being down.\n Intubated and briefly on pressors. Initial high FiO2/PEEP likely \n volume overload, now weaned down with diuresis. Remained intubated for\n mental status - MRI with diffuse anoxic brain injury - after family\n meeting decided to extubate yesterday before commiting to trach/peg.\n On unasyn for aspiration PNA, but persistently febrile.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt temp 100.5 this am. Pt pan cultured last night. VSS. Pt denies pain.\n Action:\n Pt given tylenol. MD updated during rounds that the pt spiked last\n night. ? C-diff. Order for stool to be sent for s-diff done. Pt had\n brown/gold liquid stool 5 times today. Placed flexseal.\n Response:\n Pt tolerated flexseal placement. Pt continues to have liquid stool.\n Plan:\n Follow up with c-diff culture sent. Flush flexiseal per hospital\n policy. Monitor area for signs of redness or breakdown.\n Altered mental status (not Delirium)\n Assessment:\n Pt will follow some simple commands. Pt will stick tongue out when\n asked\nwill try to show his thumb when asked. MRI EEG show anoxic brain\n injury. Pt difficult to understand. Unable to move feet. Pt can move\n right upper arm on bed. No movement in left upper arm.\n Action:\n Neuro checks Q4hr. Pt reoriented to unit/date/time. All meds/treatments\n explained to the pt.\n Response:\n No change in status.\n Plan:\n No change in pt status. Pt to be transferred to floor. PT/OT consult?\n Pt will need rehab service once discharged from Hospital.\n Impaired Skin Integrity\n Assessment:\n Noted bruses on pt extremities. Noted L knee abrasion 4cm by 3.5cm. R\n knee abrasion 2.5cm by 2cm. Both red base. Blister on L hand 4cm by 4cm\n in size. Abrasion to lower lip with large scab. Anasarca to R arm, 8cm\n by 8cm deep tissue injury on coccyx/gludeal area.\n Action:\n Blister cleaned with NS and dry gauze applied to it. Both abrasions\n cleaned with foam cleanser and open to air. Blister cleaned with mouth\n care. Cream applied to coccyx area and pt turned Q2hr and Prn. Pt kept\n off back. Flexiseal placed do to frequent stool and redness to gluteal\n area.\n Response:\n No change in pt status at this time.\n Plan:\n Continue to turn pt Q2hr and prn. Wound care consult placed. ?\n specialty bed for pt. Monitor for signs of deep tissue injury.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 102 kg\n Daily weight:\n 92 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Seizures\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:159\n D:96\n Temperature:\n 98.9\n Arterial BP:\n S:174\n D:90\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 76 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 3,863 mL\n 24h total out:\n 1,480 mL\n Pertinent Lab Results:\n Sodium:\n 146 mEq/L\n 02:14 PM\n Potassium:\n 3.6 mEq/L\n 02:14 PM\n Chloride:\n 113 mEq/L\n 02:14 PM\n CO2:\n 25 mEq/L\n 02:14 PM\n BUN:\n 34 mg/dL\n 02:14 PM\n Creatinine:\n 2.8 mg/dL\n 02:14 PM\n Glucose:\n 140 mg/dL\n 02:14 PM\n Hematocrit:\n 30.6 %\n 04:20 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 660002,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PAN CULTURE - At 12:00 PM\n FEVER - 101.3\nF - 12:00 PM\n CALLED OUT\n Self d/c'ed a.line\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 04:20 AM\n Ampicillin/Sulbactam (Unasyn) - 09:41 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Heparin Sodium - 08:02 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.7\nC (99.8\n HR: 80 (65 - 90) bpm\n BP: 149/88(102) {148/78(94) - 158/88(102)} mmHg\n RR: 20 (8 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 7 (4 - 14)mmHg\n Total In:\n 4,892 mL\n 1,870 mL\n PO:\n TF:\n IVF:\n 4,312 mL\n 1,590 mL\n Blood products:\n Total out:\n 2,575 mL\n 1,100 mL\n Urine:\n 2,575 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,317 mL\n 770 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: 7.48/37/86./23/3\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Intermittently follows simple commands, answers yes/no\n questions, but unclear accuracy of responses\n / Radiology\n 10.5 g/dL\n 258 K/uL\n 127 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 37 mg/dL\n 115 mEq/L\n 148 mEq/L\n 30.6 %\n 16.8 K/uL\n [image002.jpg]\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n 08:27 PM\n 04:07 AM\n 10:30 AM\n 10:47 AM\n 04:59 PM\n 04:20 AM\n WBC\n 14.8\n 14.5\n 16.8\n Hct\n 31.4\n 31.1\n 30.6\n Plt\n \n Cr\n 3.9\n 3.8\n 3.4\n 3.4\n 3.3\n 3.0\n TCO2\n 28\n 29\n 26\n 28\n Glucose\n 105\n 100\n 108\n 137\n 131\n 127\n Other : PT / PTT / INR:15.8/27.5/1.4, CK / CKMB /\n Troponin-T:1249/113/<0.01, ALT / AST:815/95, Alk Phos / T Bili:80/0.7,\n Amylase / Lipase:158/54, Differential-Neuts:76.4 %, Band:0.0 %,\n Lymph:16.2 %, Mono:6.2 %, Eos:0.8 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:3.0 g/dL, LDH:637\n IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL, PO4:3.0 mg/dL\n Imaging: CXR ordered.\n Microbiology: No new micro data.\n Assessment and Plan\n 27 y/o M admitted from detox unit with unknown drug overdose, seizures\n (LP neg), likely aspiration PNA with severe rhabdo from being down.\n Now with evidence of anoxic brain injury. .\n #Anoxic brain injury: Waxing/ responsiveness.\n -Continue to assess mental status, strict aspiration precautions\n - breathing pattern, but no need for reintubation\n #Hypoxemic respiratory failure: Likely aspiration PNA.\n - Continue Augmentin for aspiration PNA\n day .\n - Stable off vent.\n # Fever: Unclear etiology\n aspiration pneumonia/pneumonitis vs\n neurogenic. No evidence of eosinophilia/drug rash.\n - Follow fever curve/ cultures\n # Renal failure: Likely ATN/rhabdo\n improving.\n - Free water boluses to correct hypernatremia\n - Follow creatinine\n #Liver dysfunction: Presumed due to rhabo. Improving.\n - Follow.\n All other issues per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659291,
"text": "Chief Complaint: Found down\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:34 AM\n ULTRASOUND - At 11:00 AM\n ultrasound of kidneys.\n MULTI LUMEN - STOP 05:01 PM\n placed in EW\n -contact by , attending physician at . She\n will accept the patient back when/if better. Phone number: \n -d/c acyclovir, cont vanco/unasyn/levo\n - gave lasix 100IV X1 in evening when UOP dropped to 80cc/hr. next hr\n was 1000\n -Per renal, ARF likely combo ATN and rhabdo\n - blister on inside left knee unroofed and sent for viral cx.\n -DFA for influenza and urine for legionella neg\n -labetalol started and uptitrated to 300mg PO TID\n - on PM labs, LFTS and CK trending down. Cr rising to 3.7 from 2.9\n - sedation shut off in am. Pt coughing but not consistently responding\n to pain\n -TTE: Mild symmetric left ventricular hypertrophy with normal cavity\n sizes and regional/global biventricular systolic function. Mild\n pulmonary artery systolic hypertension. LVEF >60%\n -plan to get peripherals then perhaps pull CVL\n - no further toxicology notes.\n - d/c'd cyproheptadine for serotonin sx\n -Midnight down 5.5L for the day- ordered 1L NS at 150cc/hr\n Patient unable to provide history: intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 10:18 PM\n Acyclovir - 11:18 PM\n Piperacillin/Tazobactam (Zosyn) - 11:18 PM\n Ampicillin - 10:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 07:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 81 (75 - 93) bpm\n BP: 116/75(84) {0/0(0) - 0/0(0)} mmHg\n RR: 14 (12 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 904 mL\n 1,062 mL\n PO:\n TF:\n IVF:\n 544 mL\n 1,062 mL\n Blood products:\n Total out:\n 6,490 mL\n 1,665 mL\n Urine:\n 6,490 mL\n 1,665 mL\n NG:\n Stool:\n Drains:\n Balance:\n -5,586 mL\n -603 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 816 (711 - 875) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 27\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: 7.39/41/99./25/0\n Ve: 10.2 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal), (S2:\n Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, Rash: unchanged erythematous areas on medial\n surface of knees\n Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone:\n Not assessed, clonus in ankles bilaterally, babinski on left (no reflex\n on right)\n Labs / Radiology\n 261 K/uL\n 13.0 g/dL\n 100 mg/dL\n 4.2 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 47 mg/dL\n 105 mEq/L\n 146 mEq/L\n 37.2 %\n 21.3 K/uL\n [image002.jpg]\n 06:01 PM\n 09:07 PM\n 10:19 PM\n 04:27 AM\n 04:40 AM\n 11:50 AM\n 12:01 PM\n 03:02 PM\n 04:02 PM\n 04:00 AM\n WBC\n 17.8\n 17.9\n 21.3\n Hct\n 35.9\n 35.8\n 37.2\n Plt\n 227\n 241\n 261\n Cr\n 2.5\n 2.9\n 3.7\n 4.2\n TropT\n 0.82\n <0.01\n TCO2\n 22\n 22\n 25\n 25\n 26\n Glucose\n 124\n 98\n 134\n 123\n 100\n Other labs: PT / PTT / INR:15.7/27.3/1.4, CK / CKMB /\n Troponin-T:/113/<0.01, ALT / AST:3708(4029)/2217(3673), Alk Phos /\n T Bili:123(118)/0.6(0.6), Amylase / Lipase:461/31,\n Differential-Neuts:85.5 %, Band:0.0 %, Lymph:9.6 %, Mono:4.5 %, Eos:0.2\n %, D-dimer: ng/mL, Fibrinogen:455 mg/dL, Lactic Acid:1.4 mmol/L,\n Albumin:3.2 g/dL, LDH:2137 IU/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.8 mg/dL\n Imaging: Renal U/S:\n IMPRESSION:\n 1. Normal examination of the kidneys. No evidence for hydronephrosis.\n 2. Echogenic liver consistent with fatty infiltration. Please note that\n other forms of liver disease including significant fibrosis/cirrhosis\n cannot\n be excluded on the basis of this study.\n TTE:\n IMPRESSION: Mild symmetric left ventricular hypertrophy with normal\n cavity sizes and regional/global biventricular systolic function. Mild\n pulmonary artery systolic hypertension.\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presentinng with\n obtundations, respiratory failure, and hypotension in the context of\n fever and some indications of increased tone. Now intubated for\n hypoxic respiratory failure and with persistently altered MS.\n 1)Obtundation: Ultimate etiology is not clear at this time. Major\n concerns include serotonin syndrome, intoxication, or post-ictal\n state. Given extremely few cells in CSF minimal concern for\n meningitis/encephalitis. Mental status mildly improved since last\n night but still not consistently purposeful. Concern for anoxic brain\n injury.\n -completed cyproheptidine treatment\n -off sedation\n -if mental status not consistently improving CT head to rule out edema\n or acute process, proceed to neuro consult and MRI/EEG\n 2)Shock: The patient was hypotensive in the ED but only after\n receiving propofol sedation. This completely resolved and he is in\n fact hypertensive off pressor support at this time. Presume\n hypotension was iatrogenic. .\n -labetalol given concern for past cocaine abuse and unapposed B\n blockade\n -Echocardiogram with normal EF\n 3) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis, vs PNA, vs edema. We will cover for aspiration\n pneumonia and CA-MRSA with antibiotics though there are definitely\n other potential etiologies for fever in this patient. Patient is\n currently oxygenating and ventilating well on reasonable ventilator\n settings particularly given previous need for 100% O2. Now doing well\n on pressure support. Primary reason for continued ventilation is\n mental status.\n -Vanco/Ampicillin-Sublactam for aspiration pneumonia\n -sputum cultures\n -Rapid flu antigen test negative\n 4) Renal failure: Patient with good urine output but Cr continues to\n rise. Presumed etiology is ATN and rhabdomyoloysis.\n -Goal UOP of 150-200cc/hr\n -D5W given free water deficit and careful to avoid hypovolemia in\n setting of self-diuresis\n 5)Fever: Concern for infection of course is primarily and will be\n worked up per above. Also possibly from serotonin syndrome,\n vasculitis, etc...\n -Monitor fever and leukocytosis curves.\n 6) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -f/u culture from vesicle\n 7) Neuro: Unclear on significance of bilateral clonus w/o other\n neurologic abnormalities. Ct head slightly abnormal and patient's MS\n is poor. Neuro consult in AM and imaging per above if not improving\n dramatically over course of day.\n 8) Prophylaxis: Heparin SC, famotidine\n 9) FEN: NPO for now\n 10) Code Status: Presumed full\n 11) Dispo: ICU for moment\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 05:19 PM\n Arterial Line - 07:00 PM\n 20 Gauge - 03:45 PM\n 18 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659770,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down at Hosp. 9AM on found\n unresponsive with pinpoint pupils. He was treated with narcan with\n minimal effect. Today pt had MRI/MRA brain and EEG. A family meeting\n was held this PM with the Attending Physician, . , \n LiCSW, this RN and Dr. . The extenive neurologic injury\n was explained to the family, as well as the difficulty\n predicting whether will recover or to what extent. In this\n context, it was decided to trial extubation with the understanding that\n we would re-intubate if he developed any distress and then discuss the\n plan of care further (i.e. trach/PEG, etc.). Pt was placed on a SBT and\n extubated successfully.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-03-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 659896,
"text": "27 uo M with PMH: polysubstance abuse, depressive disorder and GERD who\n presents after being found down unresponsive with pinpoint pupils at\n Hosp on . He was treated with narcan with minimal effect.\n Pt was taken to where he was intubated and admitted to M/SICU for\n further mgt of resp failure, ARF, and rhabdo.\n A family meeting was held on . pts extensive neurologic injury was\n explained to the family, and that would likely never\n recover to his baseline neurologic status. it was decided to trial\n extubation with the understanding that we would re-intubate if he\n developed any distress and then discuss the plan of care further (i.e.\n trach/PEG, etc.). Pt was placed on a SBT and extubated successfully on\n .\n Altered mental status (not Delirium)\n Assessment:\n Respiratory status remains stable w/ pt extubated. Pt awake though\n unresponsive w/ no response to nail bed stimuli. Eyes open, PERRLA,\n corneal reflex present; however, pt continues w/ left fixed gaze, does\n not track. No purposeful movement noted, pt does not follow commands.\n On occasion pt says\n;\n however, these verbalizations do not seem\n purposeful.\n Action:\n - Monitoring respiratory status closely.\n - FiO2 weaned to room air.\n - Monitoring neuro status closely and following q4hr neuro\n assessments.\n Response:\n BBS remain CTA. SPO2 remains >92% on RA. Initially no improvement in MS\ns brother and father came to visit and pt increasingly verbal w/\n oriented responses\n able to identify picture of his neice, family\n members, time remaining in basketball game on television. Purposeful\n movements noted to bilat upper extremities.\n Plan:\n Continue to monitor respiratory status. Monitor neuro status closely.\n Hypernatremia (high sodium)\n Assessment:\n NA 149 this am up from 148.\n Action:\n - Monitoring labs closely.\n - D5W IVF continued at 125ml/hr as ordered.\n Response:\n Repeat Na 153. D5W IVF increased to 200ml/hr as ordered. Free water\n boluses 250ml Q4hr via NGT started as ordered. Repeat Na pnd.\n Plan:\n Continue to monitor labs as ordered and continue IVF and free water\n boluses as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 659900,
"text": "Chief Complaint: 27 y.o. male with hx of polysubstance abuse\n presentinng with obtundations, respiratory failure, and hypotension in\n the context of fever and some indications of increased tone. Now\n respiratory issues have largely resolved and doing well on pressure\n support, but no clearly purposeful movements and continuing to be\n encephalopathic.\n 24 Hour Events:\n EEG - At 01:43 PM\n INVASIVE VENTILATION - STOP 04:19 PM\n FEVER - 102.2\nF - 08:00 AM\n -Fam mtg- explained gravity of anoxic brain injury.\n -Extubated in pm. Plan for reintubation PRN then would d/w family trach\n vs CMO. Post extubation gas 7.41/40/118/26\n -MRI head : Extensive areas of restricted diffusion involving the white\n matter, corpus callosum, both globus pallidus and right hippocampus\n indicative of acute infarct/ischemia likely due to global hypoxia.\n -EEG prelim with diffuse slowing, nothing focal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Ampicillin/Sulbactam (Unasyn) - 09:51 AM\n Ampicillin - 04:20 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:57 PM\n Heparin Sodium (Prophylaxis) - 10:12 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39\nC (102.2\n Tcurrent: 38.4\nC (101.1\n HR: 85 (66 - 85) bpm\n BP: 172/90(115) {139/71(90) - 172/94(118)} mmHg\n RR: 14 (10 - 20) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 4 (2 - 10)mmHg\n Total In:\n 2,758 mL\n 929 mL\n PO:\n TF:\n 315 mL\n IVF:\n 772 mL\n 899 mL\n Blood products:\n Total out:\n 2,435 mL\n 740 mL\n Urine:\n 2,435 mL\n 740 mL\n NG:\n Stool:\n Drains:\n Balance:\n 323 mL\n 189 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 878 (878 - 878) mL\n PS : 5 cmH2O\n RR (Spontaneous): 13\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 97%\n ABG: 7.41/40/118//0\n Ve: 11.2 L/min\n PaO2 / FiO2: 295\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 249 K/uL\n 11.0 g/dL\n 100 mg/dL\n 3.8 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 47 mg/dL\n 114 mEq/L\n 149 mEq/L\n 31.1 %\n 14.5 K/uL\n [image002.jpg]\n 04:00 AM\n 08:39 AM\n 10:48 AM\n 04:12 AM\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n 08:27 PM\n 04:07 AM\n WBC\n 21.3\n 14.0\n 14.8\n 14.5\n Hct\n 37.2\n 33.3\n 31.4\n 31.1\n Plt\n 261\n 265\n 239\n 249\n Cr\n 4.2\n 4.2\n 3.9\n 3.8\n TCO2\n 28\n 27\n 28\n 29\n 26\n Glucose\n 100\n 119\n 105\n 100\n Other labs: PT / PTT / INR:15.3/27.8/1.3, CK / CKMB /\n Troponin-T:2818/113/<0.01, ALT / AST:/446, Alk Phos / T\n Bili:100/0.6, Amylase / Lipase:158/54, Differential-Neuts:76.4 %,\n Band:0.0 %, Lymph:16.2 %, Mono:6.2 %, Eos:0.8 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:3.0 g/dL, LDH:844\n IU/L, Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 27 y.o. male with hx of polysubstance abuse presenting with obtundation\n and respiratory failure.\n #) Anoxic brain injury: Seen by neurology who agree his picture is most\n consistent with anoxic brain injury and prognosis is not favorable.\n MRI also showed extensive areas of restricted diffusion consistent with\n this diagnosis. Fortunately, was able to verbally respond to simple\n questions from family on afternoon of .\n -f/u EEG\n -regular assessment of mental status\n #) Hypoxemic respiratory failure: Most likely etiologies include\n aspiration pneumonitis vs PNA. CXR currently resolving and patient is\n s/p extubation on and generally breathing comfortably. Had\n - respirations earlier today but now has normal breathing\n pattern.\n -Ampicillin-Sublactam for aspiration pneumonia for seven day course\n (day 1 = )\n #) Renal failure: Secondary to rhabdo and ATN. Creatinine falling.\n - renally dose meds\n - continue to monitor\n #) Fever: Concern for infection and culturing when patient spikes\n fevers. Also may be related to serotonin syndrome, vasculitis,\n neurogenic fever, etc\n Fever curve trending down.\n -Monitor fever and leukocytosis curves.\n #) Skin: Rashes on medial knees appear most consistent with\n friction/pressure induced injury. Vesicles could suggest herpes but\n are not typical and not particularly painful it seems.\n -f/u culture from vesicle\n #) Hypernatremia: Likely secondary to insensible losses but may also\n be related to intracranial injury. Free water deficit of 4.5 liters on\n .\n - correct sodium with free water boluses, D5W by mEq/day\n - check p.m. sodium level\n #) FEN: Tube feeds\n #) Code Status: Presumed full\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 07:00 PM\n 18 Gauge - 04:00 PM\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2162-03-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 659963,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PAN CULTURE - At 12:00 PM\n FEVER - 101.3\nF - 12:00 PM\n CALLED OUT\n Self d/c'ed a.line\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 04:20 AM\n Ampicillin/Sulbactam (Unasyn) - 09:41 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Heparin Sodium - 08:02 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.7\nC (99.8\n HR: 80 (65 - 90) bpm\n BP: 149/88(102) {148/78(94) - 158/88(102)} mmHg\n RR: 20 (8 - 21) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 102 kg\n Height: 72 Inch\n CVP: 7 (4 - 14)mmHg\n Total In:\n 4,892 mL\n 1,870 mL\n PO:\n TF:\n IVF:\n 4,312 mL\n 1,590 mL\n Blood products:\n Total out:\n 2,575 mL\n 1,100 mL\n Urine:\n 2,575 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,317 mL\n 770 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: 7.48/37/86./23/3\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Intermittently follows simple commands, answers yes/no\n questions, but unclear accuracy of responses\n / Radiology\n 10.5 g/dL\n 258 K/uL\n 127 mg/dL\n 3.0 mg/dL\n 23 mEq/L\n 3.6 mEq/L\n 37 mg/dL\n 115 mEq/L\n 148 mEq/L\n 30.6 %\n 16.8 K/uL\n [image002.jpg]\n 04:31 AM\n 05:03 PM\n 04:41 AM\n 05:22 AM\n 08:27 PM\n 04:07 AM\n 10:30 AM\n 10:47 AM\n 04:59 PM\n 04:20 AM\n WBC\n 14.8\n 14.5\n 16.8\n Hct\n 31.4\n 31.1\n 30.6\n Plt\n \n Cr\n 3.9\n 3.8\n 3.4\n 3.4\n 3.3\n 3.0\n TCO2\n 28\n 29\n 26\n 28\n Glucose\n 105\n 100\n 108\n 137\n 131\n 127\n Other : PT / PTT / INR:15.8/27.5/1.4, CK / CKMB /\n Troponin-T:1249/113/<0.01, ALT / AST:815/95, Alk Phos / T Bili:80/0.7,\n Amylase / Lipase:158/54, Differential-Neuts:76.4 %, Band:0.0 %,\n Lymph:16.2 %, Mono:6.2 %, Eos:0.8 %, D-dimer: ng/mL,\n Fibrinogen:455 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:3.0 g/dL, LDH:637\n IU/L, Ca++:8.1 mg/dL, Mg++:2.5 mg/dL, PO4:3.0 mg/dL\n Imaging: CXR ordered.\n Microbiology: No new micro data.\n Assessment and Plan\n 27 y/o M admitted from detox unit with unknown drug overdose, seizures\n (LP neg), likely aspiration PNA with severe rhabdo from being down.\n Now with evidence of anoxic brain injury. .\n #Anoxic brain injury: Waxing/ responsiveness.\n -Continue to assess mental status, strict aspiration precautions\n - breathing pattern, but no need for reintubation\n #Hypoxemic respiratory failure: Likely aspiration PNA.\n - Continue Augmentin for aspiration PNA\n day .\n - Stable off vent.\n # Fever: Unclear etiology\n aspiration pneumonia/pneumonitis vs\n neurogenic. No evidence of eosinophilia/drug rash.\n - Follow fever curve/ cultures\n # Renal failure: Likely ATN/rhabdo\n improving.\n - Free water boluses to correct hypernatremia\n - Follow creatinine\n #Liver dysfunction: Presumed due to rhabo. Improving.\n - Follow.\n All other issues per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 01:51 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 25 minutes\n"
}
] |
11,634 | 173,398 | Briefly, Mr. is a 51-year- old gentleman with metastatic esophageal cancer with obstructive nephropathy caused by bulky lymphadenopathy with bilateral nephrostomy tubes admitted for weakness, tremor and hypocalcemia. 1. HYPOCALCEMIA: The etiology was thought to be multifactorial; including hypomagnesemia, induced hypoparathyroidism, decreased p.o. intake, and possibly recent increased renal excretion of potassium/magnesium secondary to loop diuretic. The patient was started on calcium gluconate drip which was continued for 3 days. His Lasix was held. He received Calcitrol empirically which was stopped after 2 days upon the endocrinology team recommendation. After 3 days of IV repletion of calcium he was switched to large doses of p.o. calcium. Magnesium and potassium were also repleted daily IV. His electrolytes - including calcium, magnesium and phosphorous - were checked daily and repleted appropriately. His tremor and myoclonic jerking-like movements improved with the repletion of the calcium and magnesium. His voice also improved somewhat. On the day of discharge his calcium was 8.0, magnesium was 1.3, phosphorous was 3.7 and potassium was 4.4. 1. ESOPHAGEAL CANCER: His oncologist Dr. was consulted at this time. He did not receive any chemotherapy during this hospitalization; however, upon discharge he was planned to receive once again Taxol. An x- ray of his lungs revealed bilateral pleural effusion as already suspected from his physical exam. However, after consultation with Dr. it was thought that a diagnostic thoracentesis was not necessary since the patient did not have any symptoms of dyspnea or hypoxia, and finding malignant cells in the pleural fluid would not have changed his prognosis or management at this time. 1. PROPHYLAXIS: During his hospital stay the patient received physical therapy to walk, PPI for gastric ulcer prophylaxis and heparin for DVT prophylaxis. | wbc 5.3.heme: hct 31.5 and plts of 238.gi: abdomin soft/distended with + bowel sounds. wbc 9.0 urine cultures pending.gi: abdomin soft/distended. TAKING FRAPPES AND NEPRO.RENAL: NEPH. if pt's head ct due to mental status, spoke with ho about this.CV: HR 100-110'S st, no ectopy noted, bp stable, 140's/80's.RESP: On room air with sats 97-100%, no ectopy noted, Pt has audible wheezes at times, other times lung sounds are diminished.GI: Abd. Nephrostomies irrigated q8h. pmicu nursing progress notecardiac: bp 154-160/92-99 with pulse of 98-108 sr/st, with an occasional pvc. Baseline artifactSinus tachycardiaBorderline short P-R interval - is nonspecificDiffuse nonspecific ST-T wave changesBorderline low voltageSince previous tracing of : ST-T wave changes are present MS CONTIN WELL, BUT BECOMES QUITE LETHARGIC WHILE ON OPIATES/PER WIFE.SKIN INTEGRITY: OPEN AREAS ON BUTTUCKS CLEANED WITH SALINE AND DUODERM REAPPLIED. K+ PHOS INFUSING NOW. Baseline artifactSinus tachycardiaBorderline low voltageMinor nonspecific lateral T wave abnormalities - although baseline artifactmakes assessment difficultSince previous tracing of : T wave appear to have decreased appetite poor.gu: dsgs changed on both right and left nephrostomy sites. pmicu nursing progress noteneuro: this morning pt's extremities were tremulous and making jerking/spasm-like movements. Check for effusions. Evaluate for palpable ascites. Denies shortness of breath.GU/GI: Patient with bilateral nephrostomies. Status post bilateral nephrostomy. Pulses palpable.RESP: LS clear, no distress on room air.GI: Took in sipps of H2O with meds, declined other intake. NO COUGH NOTED.C/V: ST UP TO 150'S NO PVC'S.BP 130'S -160'S W/ TREMORS.ATTEMPTED EKG, UNABLE TO GET ADEQUATE .F/E/N: AM LABS IMPROVED,K+ 3.6,NA 141, CA 7.5, MAG 2.2 BILAT NEPHROSOTMY TUBES DRAINING CLEAR YELLOW URINE.FLUSHED W/ 10 CC NSS EACH.ABD LARGE ADENOPATHY.SKIN: 3 SMALL OPEN AREAS ON R BUTTOCK AND ONE AREA ON L BUTTOCK W/ OPEN AREA AT BASE OF SACRUM ~ .5CM LONG. APPETITE SLIGHTLY IMPROVED.RENAL: NEPHRO. MICU NPN 3PM-11PM:Neuro: Pt still tremulous but reported to be less than on admission. ON CA+ DRIP. URINE CLEAR.ENDOC; K+ REPLETED THIS AM.PAIN CONTROL: C/O BACK PAIN TODAY FOR THE FIRST TIME. hypoactive bowel sounds. PLEURAL EFFUSION PER CXR. Patient with duoderm in place to apparent area of breakdown on coccyx. pt having audible "stridor-like sounds/wheezing" on expiration. ALSO WENT OVER DNR AND HOSPICE. lung sounds clear.id: temp 97.9po. SPEECH IMPROVED.PAIN: PT. down for an abdominal ultrasound---small pockets, on left and right abdomin, of fluid, but too small to tap---not even marked to dissuade from tapping.gu: right and left nephrostomy tubes--both flushed with normal saline q8 hrs---passing equal amts of cloudy urine (urine fom left tube was slightly pink). Magnesium repleted during the night.Respiratory: Lung sounds are clear with diminished bases. troponin and cpk sent.resp: on room air with resp rate of 18-24 and o2 sats of 95-98%. Tremulous tetany noted to upper and lower extremities which is reportedly improved since admission.CV: Heart rate regular with cardiac monitor showing sinus rhythm to sinus tach with rare PVC's. slilghtly more lethargic this afternoon.cardiac: bp 137-163/70-99 with a pulse of 113-144 st, no ectopy noted. Sinus tachycardiaLateral T wave changes are nonspecific - baseline artifact makes assessmentdifficultLow QRS voltages in limb leadsSince last ECG, no significant change IMPRESSION: Normal-sized heart and marked pulmonary edema suggest a renal cause or possibly circulation overload. npo until later this afternoon---tolerating liquids and soft solids. MUCH IMPROVED.NEURO: LEGS STILL RIGID. RECIEVED 2 MG ATIVAN W/ NO RESPONSE.EYES BECOMING CROSSED AT TIMES.NO IMPROVEMENT IN NEURO STATUS EVEN AFTER ELECTROLYTE REPLETION. MS CONTIN GRADUALLY KICKED IN. He finished the K-phos dose and still has calcium and mag drips hanging.GU: Both nephrostomy tubes flush easily and are draining good amts clear urine. Oriented to self and hospital. There is now evidence of bilateral diffuse loss of translucency suggestive of pulmonary edema, associated with bilateral moderate-sized pleural effusions with obscuration of the costophrenic angles and diaphragms. urine lytes were sent.heme: hct was 32 and plts 179. cxr done.id: temp 98.2po and 96 axillary. Pt was given trazadone 25mg along with tylenol 650mg at that time.CV: Vital signs are stable. appears sob when speaking or doing any physicacl activity. Passed mod amt brown liquid stool once this shift.Skin: Both buttocks cheeks are open and excoriated. Dressing in place to bilateral flank areas at nephrostomy sites.Plan: Patient remains a full code. There is a small amount of ascites in the right upper quadrant and trace ascites in the left lower quadrant. UNABLE TO REORIENT.RECIEVED DEMEROL 12.5 AND 25 MG W/ NO REPSONSE. the left insertion site draining more then the right. Both are irrigated with 10cc 0.9% NaCl q8 hours and irrigate easily this pm. MG+ 2.4. SATS 95-97 % ON ROOM AIR.CXR SHOWED POSSIBLE INFILTRATES SOME FLUID IN BASES BILATERALLY. KPhos 44mEq given over 6 hours for PO4 1.9.GU: Bilateral nephrostomy tubes draining ~100ml/3-4 hours; irrigated as ordered with NS 10mL withou issue.SKIN: Coccyx dressing intasct; skin pink around right edges of duoderm. repeat lytes pending. See carevue for vital sign specifics. soft, no bm's.GU: Right and left nephrostomy tubes flushed q 8h with saline, 24 hour urine is in progress until 4pm today.LABS: Midnight k+ was 3.6, ca+8.3, phos 2.3, and mag 2.5. given 4gms of mag at 7a and another 2gms at approx 12p. Has required encouragement in coughing/deep breathing. Bil NT dressings intact.A/P1. This could reflect acute renal insufficiency. at approx 12p pt began to have less "jerking" movements, stayed more focused---even got more angry with being in the hospital. both flushed with 10cc of normal saline--no resistance noted with flushing. Renal insufficiency. eyes would intermittently cross and he had a nystagmus. SOME DISCHARGE TEACHING DONE RE: NEW MEDICATIONS AND DIET. GIVEN TYLENOL, BUT NEED BETTER PAIN CONTROL. (?BRAIN METS)RESP: SOUNDS LIKE STRIDOR BUT IS BASICALLY CLEAR, W DIMINISHED BASES. LAST K+ 3.6. Episode of dry heaves after asleep for ~ 45 minutes => compazine 10mg PO given with positive effect.FEN: Current labs pending. bun 14 and creat 1.0. pt does have urges of using the urinal and will pass a small amt of urine via the urinal. | 17 | [
{
"category": "Radiology",
"chartdate": "2167-07-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 797599,
"text": " 11:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate bilateral pleural effusions\n Admitting Diagnosis: DECREASE CALCIUM/MAGNISIUM/K+\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with metastatic esophogeal CA, renal insufficiency s/p\n b/l nephrostomy with decreased breath sounds and dullness to percussion\n REASON FOR THIS EXAMINATION:\n please evaluate bilateral pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient in renal failure, twitching.\n\n ; A portable semi-upright chest. Comparison is made with a comparable\n film taken yesterday at 5:33. There is gross pulmonary edema, bilateral\n effusions extending along the chest wall, particularly on the right side over\n the right apex. The patient is now more rotated to the left, which accounts\n for the shift of the heart and mediastinum to the left.\n\n IMPRESSION: Normal-sized heart and marked pulmonary edema suggest a renal\n cause or possibly circulation overload.\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 797476,
"text": " 5:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for effusions\n Admitting Diagnosis: DECREASE CALCIUM/MAGNISIUM/K+\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with metastatic esophogeal CA, renal insufficiency s/p\n b/l nephrostomy with decreased breath sounds and dullness to percussion\n REASON FOR THIS EXAMINATION:\n evaluate for effusions\n ______________________________________________________________________________\n FINAL REPORT\n , CHEST\n\n INDICATION: Metastatic esophageal carcinoma. Renal insufficiency. Status\n post bilateral nephrostomy. Decreased breath sounds and dullness to\n percussion. Check for effusions.\n\n FINDINGS: A single AP semi-upright view. Comparison study dated . There is now evidence of bilateral diffuse loss of translucency\n suggestive of pulmonary edema, associated with bilateral moderate-sized\n pleural effusions with obscuration of the costophrenic angles and diaphragms.\n However, the heart shows minimaleft, if any, enlargement and the upper zone\n pulmonary vessels which are not well displayed, do not show upper zone\n redistribution.\n\n IMPRESSION: The appearances suggest pulmonary edema without evidence of\n cardiomegaly or left heart failure. Bilateral pleural effusions are also\n noted. This could reflect acute renal insufficiency. No focal metastatic\n lesions can be identified. Clinical correlation is recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2167-07-27 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 797501,
"text": " 10:41 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: please evaluate for tappable ascites\n Admitting Diagnosis: DECREASE CALCIUM/MAGNISIUM/K+\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with metastatic SC esophageal CA, admitted for hypocalcemia\n REASON FOR THIS EXAMINATION:\n please evaluate for tappable ascites\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic esophageal CA, admitted for hypocalcemia. Evaluate\n for palpable ascites.\n\n FOUR-QUADRANT ABDOMINAL ULTRASOUND was performed. There is a small amount of\n ascites in the right upper quadrant and trace ascites in the left lower\n quadrant. The skin was not marked for location, as there is only a small\n amount of ascites present.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-07-28 00:00:00.000",
"description": "Report",
"row_id": 166920,
"text": "Sinus tachycardia\nLateral T wave changes are nonspecific - baseline artifact makes assessment\ndifficult\nLow QRS voltages in limb leads\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2167-07-27 00:00:00.000",
"description": "Report",
"row_id": 166921,
"text": "Baseline artifact\nSinus tachycardia\nBorderline low voltage\nMinor nonspecific lateral T wave abnormalities - although baseline artifact\nmakes assessment difficult\nSince previous tracing of : T wave appear to have decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2167-07-26 00:00:00.000",
"description": "Report",
"row_id": 166922,
"text": "Baseline artifact\nSinus tachycardia\nBorderline short P-R interval - is nonspecific\nDiffuse nonspecific ST-T wave changes\nBorderline low voltage\nSince previous tracing of : ST-T wave changes are present\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-31 00:00:00.000",
"description": "Report",
"row_id": 1414527,
"text": "Nursing Progress Note\n -> 0730\n\nS/O\n\nNEURO: Denies pain at rest, fear of pain with turning in bed. MS Contin 15mg given as scheduled. Requested trazodone, given, and patient slept quietly through night.\n\nCV: ST 100's, SBP 140's. Pulses palpable.\n\nRESP: LS clear, no distress on room air.\n\nGI: Took in sipps of H2O with meds, declined other intake. Episode of dry heaves after asleep for ~ 45 minutes => compazine 10mg PO given with positive effect.\n\nFEN: Current labs pending. KPhos 44mEq given over 6 hours for PO4 1.9.\n\nGU: Bilateral nephrostomy tubes draining ~100ml/3-4 hours; irrigated as ordered with NS 10mL withou issue.\n\n\nSKIN: Coccyx dressing intasct; skin pink around right edges of duoderm. Bil NT dressings intact.\n\nA/P\n1. Follow up in lytes.\n2. Continue current care.\n3. Prepare for chemo and discharge.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-31 00:00:00.000",
"description": "Report",
"row_id": 1414528,
"text": "pmicu nursing progress note\ncardiac: bp 154-160/92-99 with pulse of 98-108 sr/st, with an occasional pvc. given 4gms of mag at 7a and another 2gms at approx 12p. k+ was 4.4.\n\nresp: res rat of with o2 sats of 96%. lung sounds clear.\n\nid: temp 97.9po. wbc 5.3.\n\nheme: hct 31.5 and plts of 238.\n\ngi: abdomin soft/distended with + bowel sounds. appetite poor.\n\ngu: dsgs changed on both right and left nephrostomy sites. the left insertion site draining more then the right. good output--almost equal output from both drains. both flushed with 10cc of normal saline--no resistance noted with flushing. bun 18 and creat .8.\n\nmisc: spoke with from intake dept of the partners home care, office. also the inform was faxed to number . prescriptions were given to pt in wife's presence. supplies given to pt for dsg changes and also plugs and flushes (for at least 4 days) for nephrostomy tubes. pt's wife, , states she knows how to flush the tubeing. pt and family also given instructions to notify pcp/dr or even the call the unit if pt experiencing the slightest symptoms---low tolerance with symptoms--- with electolyte imbalance.\nafter being discharged from the unit pt will go to 9 and receive chemo\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-29 00:00:00.000",
"description": "Report",
"row_id": 1414523,
"text": "7p-7a nursing note\nNeuro: Patient has been asleep except when awakened thus far tonight. When awakened patient responds to questioning. Oriented to self and hospital. Patient is unsure of day,month,year. Answers yes and no questions but does not engage in any other conversation. Speech is clear. Follows commands and MAE equally. Tremulous tetany noted to upper and lower extremities which is reportedly improved since admission.\n\nCV: Heart rate regular with cardiac monitor showing sinus rhythm to sinus tach with rare PVC's. See carevue for vital sign specifics. Consistently denies chest pain or pressure. Pm labs with potassium 3.8, calcium 8.2, magnesium 2.0 Calcium drip completed, magnesium drip continues to infuse.\n\nRespiratory: Lung sounds are clear throughout. SpO2 in high 90's on room air. No cough noted. Denies shortness of breath.\n\nGU/GI: Patient with bilateral nephrostomies. Both are irrigated with 10cc 0.9% NaCl q8 hours and irrigate easily this pm. Urine is yellow and faintly cloudy. Has not voided urine tonight (had done so on previous shift). Abdomen is soft and non-tender with normal active bowel sounds in all four quadrants. Patient reportedly requires moderate amounts of encouragement with food as he has been anorexic over the past few weeks.\n\nID: Afebrile throughout the night. in place to right forearm and left AC. There is duoderm dressing covering broken skin area to coccyx.\n\nSocial: No contact with family this night.\n\nPlan: Continue to follow electrolytes closely and replete as appropriate. Awaiting results of am labs. Patient remains a full code.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-30 00:00:00.000",
"description": "Report",
"row_id": 1414524,
"text": "7p-7a nursing note\nNeuro: Oriented X3 throughout night. Converses appropriately, utilizes call bell to request assistance for such things as beverages, turning, etc. MAE equally and weakly. PERRL\n\nCardiovascular: Heart rate regular with cardiac monitor showing sinus tach to sinus rhythm with rare PVC's. Denies chest pain or pressure. Palpable peripheral pulses to all extremities. Magnesium repleted during the night.\n\nRespiratory: Lung sounds are clear with diminished bases. Has required encouragement in coughing/deep breathing. SpO2 >95% on room air throughout the night. Denies shortness of breath.\n\nGU/GI: Bilateral Nephrostomies are patent with clear yellow urine. Patient attempted to void in urinal X1 with <5cc urine realized. Nephrostomies irrigated q8h. Abdomen is softly distended with active bowel sounds in all four quadrants. Patient continent of small brown formed stool using bedpan.\n\nID: Temp 98.3max. to right wrist/hand and left AC. Patient with duoderm in place to apparent area of breakdown on coccyx. Dressing in place to bilateral flank areas at nephrostomy sites.\n\nPlan: Patient remains a full code. Has been called out and awaiting bed on floor. Continue to monitor electrolyte levels closely and replete as appropriate. Awaiting results of am labs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-28 00:00:00.000",
"description": "Report",
"row_id": 1414521,
"text": "RESP: BS'S CLEAR. BIL. PLEURAL EFFUSION PER CXR. PLAN FOR DIAGNOSTIC TAP HAS BEEN CANCELLED. O2 SATS IN HIGH 90'S WITHOUT O2.\nGI: INCONT. 2X OF SMALL AMTS OF STOOL. TAKING FRAPPES AND NEPRO.\nRENAL: NEPH. TUBES FUNCTIONING WELL. IRRIGATED X1. 24 HR URINE BEING SAVED TIL 16PM.\nENDOC: CONT. ON CA+ DRIP. MG+ CONCENTRATION DECREASED. K+ PHOS INFUSING NOW. LAST K+ 3.6. MG+ 2.4. CA+ 8.2. MUCH IMPROVED.\nNEURO: LEGS STILL RIGID. CONT. WITH TREMORS, BUT THEY HAVE IMPROVED. ACTUALLY MUCH BETTER AFTER HAVING SLEPT. ORIENTATED TO PERSON AND PLACE AND TIME THIS PM. SPEECH IMPROVED.\nPAIN: PT. C/O BACK PAIN THIS AFTERNOON. GIVEN TYLENOL, BUT NEED BETTER PAIN CONTROL. TOL. MS CONTIN WELL, BUT BECOMES QUITE LETHARGIC WHILE ON OPIATES/PER WIFE.\nSKIN INTEGRITY: OPEN AREAS ON BUTTUCKS CLEANED WITH SALINE AND DUODERM REAPPLIED. THEY APPEAR CLEAN.\nCV: CONTINUES TO BE TACHYCARDIC WITH ANY EXERTION.\nSALINE SPRAY TO BOTH NARES FOR DRYNESS AND BLEEDING.\nSOCIAL: FAMILY HAS SPOKEN WITH MED STUDENT. PT. ONLY WANTS TO GO HOME.\nACCESS: B2X PERIPHS. FUNCT. WELL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-28 00:00:00.000",
"description": "Report",
"row_id": 1414522,
"text": "MICU NPN 3PM-11PM:\nNeuro: Pt still tremulous but reported to be less than on admission. Speech is clearer, still hoarse but stronger. MAE, follows commands. He c/o nausea and was given compazine 25mg PR with good effect and then at 2130 pt requested sleeping pill and something for pain. Pt was given trazadone 25mg along with tylenol 650mg at that time.\n\nCV: Vital signs are stable. Awaiting 8PM labs sent earlier in the shift. He finished the K-phos dose and still has calcium and mag drips hanging.\n\nGU: Both nephrostomy tubes flush easily and are draining good amts clear urine. 24hr urine completed and sent at 4PM. Pt also passing small amts urine in urinal on his own. I did notify the team of this.\n\nGI: Pt with poor appetite. Does not like hospital food but did eat for his family this afternoon. Passed mod amt brown liquid stool once this shift.\n\nSkin: Both buttocks cheeks are open and excoriated. Duoderm applied. Pt should be transferred to first step mattress if possibe tomorrow.\n\nSocial: Pt's family visited this afternoon and seem very concerned and attentive. They spoke to intern for update.\n\nPlan: Please follow labs that were sent at 8PM and pt also has AM labs to be drawn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-30 00:00:00.000",
"description": "Report",
"row_id": 1414525,
"text": "RESP; BS'S CLEAR. O2 SATS OVER 98%.\nGI: LARGE BM THIS AM. GU NEG. APPETITE SLIGHTLY IMPROVED.\nRENAL: NEPHRO. TUBES IRRIGATED. URINE CLEAR.\nENDOC; K+ REPLETED THIS AM.\nPAIN CONTROL: C/O BACK PAIN TODAY FOR THE FIRST TIME. MEDICATED WITH MS , BUT REQUIRED IVP MS TO BRIDGE HIS PAIN. MS CONTIN GRADUALLY KICKED IN. PAIN HAS IMPROVED.\nSOCIAL: PLAN IS TO GO HOME TOMORROW AFTER CHEMO. WIFE AWARE AND WILL COME IN EARLY TOMORROW. SOME DISCHARGE TEACHING DONE RE: NEW MEDICATIONS AND DIET. ALSO WENT OVER DNR AND HOSPICE. WIFE NOT READY FOR THIS. SHE FEELS HE WASN'T TREATED WELL AT REHAB AND THAT HE'S DOING MUCH BETTER NOW.\nACTIVITY: REMAINED IN BED-REFUSED TO GET OOB TO CHAIR D/T BACK PAIN. HOPEFULLY PT WILL COME TO SEE HIM THIS AFTERNOON.\nNEURO: NO TREMORS NOTED TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-30 00:00:00.000",
"description": "Report",
"row_id": 1414526,
"text": "MICU 3P-7P\nSee previous note, no further changes in condition, pt. to be discharged to home tomorrow, disharged summary done. Pt. wife's was in earlier and mother has called. Nephrostomy tubes in place to gravity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-27 00:00:00.000",
"description": "Report",
"row_id": 1414518,
"text": "NPN 1900-0700 SEE CAREVIEW FOR DETAILS\n\nNEURO: SEVERE TREMORS OF ALL EXTREMITIES,HALLUCINATING, CONSTANT MOVEMENT, DIAPHORETIC.DISORIENTED BUT FOLLOWS COMMANDS. UNABLE TO REORIENT.RECIEVED DEMEROL 12.5 AND 25 MG W/ NO REPSONSE. RECIEVED 2 MG ATIVAN W/ NO RESPONSE.EYES BECOMING CROSSED AT TIMES.NO IMPROVEMENT IN NEURO STATUS EVEN AFTER ELECTROLYTE REPLETION.(?BRAIN METS)\n\nRESP: SOUNDS LIKE STRIDOR BUT IS BASICALLY CLEAR, W DIMINISHED BASES. SATS 95-97 % ON ROOM AIR.CXR SHOWED POSSIBLE INFILTRATES SOME FLUID IN BASES BILATERALLY. NO COUGH NOTED.\n\nC/V: ST UP TO 150'S NO PVC'S.BP 130'S -160'S W/ TREMORS.ATTEMPTED EKG, UNABLE TO GET ADEQUATE .\n\nF/E/N: AM LABS IMPROVED,K+ 3.6,NA 141, CA 7.5, MAG 2.2 BILAT NEPHROSOTMY TUBES DRAINING CLEAR YELLOW URINE.FLUSHED W/ 10 CC NSS EACH.ABD LARGE ADENOPATHY.\n\nSKIN: 3 SMALL OPEN AREAS ON R BUTTOCK AND ONE AREA ON L BUTTOCK W/ OPEN AREA AT BASE OF SACRUM ~ .5CM LONG. ALL AREAS COVERED W/ DUEODERM.\n\nPLAN: CONT AGGRESSIVE ELECTROLYTE REPLETION , MONITOR TREMORS, MONITOR SATS\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-27 00:00:00.000",
"description": "Report",
"row_id": 1414519,
"text": "pmicu nursing progress note\nneuro: this morning pt's extremities were tremulous and making jerking/spasm-like movements. legs very rigid and toes pointing upwards (feet very sensitive to stimulation). pt appeared to be hallucinating (eyes bug-eyed and pt stretching hands/arms outwards and making motions as if he were pulling on a rope). eyes would intermittently cross and he had a nystagmus. occasionally smiling while staring off across the room. But pt followed commands and answered questions appropriately--didn't really appear to be confused. at approx 12p pt began to have less \"jerking\" movements, stayed more focused---even got more angry with being in the hospital. less hallucinations--interacting with family. slilghtly more lethargic this afternoon.\n\ncardiac: bp 137-163/70-99 with a pulse of 113-144 st, no ectopy noted. K+ at 5a was 3.6, repeated at 12p and k+ was 3.2---pt rec'd 40 meq of kcl po x 2. pt also rec'd 4gms of calcium gluconate and 4gms of magnesium. iv of ns with 10gms of calcium is infusing at 50cc/hr, as well as a maintenance iv of ns at 125cc/hr. repeat lytes pending. troponin and cpk sent.\n\nresp: on room air with resp rate of 18-24 and o2 sats of 95-98%. lung sounds deminished at the bases and clear in left upper lobe. pt having audible \"stridor-like sounds/wheezing\" on expiration. appears sob when speaking or doing any physicacl activity. cxr done.\n\nid: temp 98.2po and 96 axillary. wbc 9.0 urine cultures pending.\n\ngi: abdomin soft/distended. hypoactive bowel sounds. npo until later this afternoon---tolerating liquids and soft solids. passing small amt of foul smelling liquidy golden stool. down for an abdominal ultrasound---small pockets, on left and right abdomin, of fluid, but too small to tap---not even marked to dissuade from tapping.\n\ngu: right and left nephrostomy tubes--both flushed with normal saline q8 hrs---passing equal amts of cloudy urine (urine fom left tube was slightly pink). bun 14 and creat 1.0. pt does have urges of using the urinal and will pass a small amt of urine via the urinal. started on a 24 hour urine at 4p---to continue until at 4p. urine lytes were sent.\n\nheme: hct was 32 and plts 179.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2167-07-28 00:00:00.000",
"description": "Report",
"row_id": 1414520,
"text": "MICU NPN 7P-7A\nNeuro: Very confused and disorientated all noc. Continues with jerking/spasms like movements. Med. for sleep with ambian 10mg with poor effect awake most of the night, pulled out 2 iv's, he is not appropriate reaching for things that are not there. ? if pt's head ct due to mental status, spoke with ho about this.\n\nCV: HR 100-110'S st, no ectopy noted, bp stable, 140's/80's.\n\nRESP: On room air with sats 97-100%, no ectopy noted, Pt has audible wheezes at times, other times lung sounds are diminished.\n\nGI: Abd. soft, no bm's.\n\nGU: Right and left nephrostomy tubes flushed q 8h with saline, 24 hour urine is in progress until 4pm today.\n\nLABS: Midnight k+ was 3.6, ca+8.3, phos 2.3, and mag 2.5. Receiving k+phos now over 6 hours, also has a 20 hour infusion of d5w with 10gms of calcium, also pt. has a 20h infusion of mag which should be done this am.\n\n"
}
] |
22,095 | 114,542 | . # CAD: She was diagnosed with a non-ST elevation MI and was started on IV heparin and loaded with clopidogrel. As she was asymptomatic at the time, the plan was made to stabilize her with antiplatelet agents and plan for catheterization on . She had recurrent chest pain the next day and was started on integrilin, after which time she was chest pain-free. Her peak CK was 347, MB 49, and troponin T 1.68. She underwent cardiac catheterization on , with PCI to the an 80% stenotic lesion of the ostial RCA. She was continued on ASA 325, Plavix, lipitor 80, and beta blocker. She had no further chest pain. She was discharged to PCP follow up with establishment of Cardiology follow up. . # CHF: TTE on with EF 50%, mild LVH, mildly dilated ascending aorta with no AI. She was volume overloaded on exam after her procedure and was diuresed with IV Lasix. She was maintained on a beta blocker, ACE-inhibitor, and oral Lasix. She was euvolemic on discharge. . # Atrial fibrillation: She has a history of paroxysmal atrial fibrillation with RVR at the outside hospital that converted with diltiazem. She had an episode of RVR in CCU, that was treated with diltiazem gtt, after which she converted to NSR. She was maintained on a beta blocker and was in sinus rhythm on discharge. She was not started on anticoagulation due to her recent GI bleed. . # HTN: She is not adherent to her medication regimen as an outpatient. Her hypertension was thought to be a likely trigger for her AF w/ RVR. She was severely hypertensive in the CCU to the 230s/100s. Her blood pressure was controlled in the CCU with labetalol and nifedipine gtt. She was hypertensive off the drips on the floor. Her severe renal artery stenosis was thought to be the main cause for her refractory hypertension. She was discharged on carvedilol, lisinopril, and furosemide. She was discharged to follow up with her PCP for further titration of her medications. . # GI bleed: She had melenic stools in the cath holding area on while on aspirin, clopidogrel, IV heparin, and integrilin. She had patent celiac and mesenteric arteries on angiography, so ischemic bowel was thought to be unlikely. GI was consulted and performed an EGD that showed gastric erosions and duodenitis as the only sources of upper GI bleed. She was started on IV pantoprazole and carafate with close monitoring of her hematocrit. She required a total of 8U PRBC. Her hematocrit stabilized and her diet was advanced. She had no further episodes of melena during her stay. She was encouraged to have a colonoscopy as an outpatient as she has never had one before. . # RP bleed: She had severe hypertension during the cardiac catheterization requiring nitroprusside. Her renal arteries were engaged during the cath, and she was found to have severe in-stent restenosis of her right renal artery, but attempts at intervention were unsuccessful. In the cath holding area, she became hypotensive and had a large melenic stool. She was taken back to the cath lab where she was found to have patent celiac and superior mesenteric arteries, but had bleeding from the right kidney which was stopped with balloon tamponade. No further chest pain. A CT abdomen was performed that showed a large perinephric hematoma extending into the retroperitoneum. Transplant Surgery was following. Surgical intervention was not indicated as she was hemodynamically stable. Repeat CT showed stable hematoma and her hematocrit stabilized. . # ARF: She has known RAS s/p stenting, and was thought to likely have some hypertensive nephropathy as well. Her baseline creatinine was unknown. Her creatinine was 1.5 on the day of cath, and her FENa was 0.9%, indicating a prerenal state. Angiography showed right renal artery in-stent restenosis. She likely had some hypoperfusion to the R kidney in setting of bleed. She also received a large dye load for aniography of coronaries, mesenterics, renals, and iliacs. Her left kidney appeared atrophic on imaging. Her creatinine increased to 1.6 and was then stable for several days. She was discharged on an ACE-inhibitor, with PCP follow up for further management. . # Glucose intolerance: She was hyperglycemic throughout her stay. She has no known diagnosis of diabetes. Her HgA1C was 6.7. She was maintained on an insulin sliding scale. . # Code status: FULL . | Dilt and Nipride gtt d/c'd. Physiologic mitral regurgitation is seen(within normal limits). Cont Mucomyst doses. pneumoboots/ SC heparin given Afib. Give final dose of mucomist and d/c. While in holding area pt ^ hypertensive and + melena. Posttransfusion HCT 33.6. DP +2 bilaterally/ PT dopplerable. BUN/Cr 31/1.6.ID: Afebrile. But found to have restenotic R renal artery. K-4.0, Mag-2.5 post repletion.Resp: Lungs clr in apices c dim bases and faint crackles in R. RR-20's. Compared to the previous tracing atrial fibrillation is nolonger present. Abd is obses with +bs. Pt cont on post cath/ MI regimen of Lipitor/ASA and Plavix. pt with 1uprbc's. Another tx absorbed this pm and hct is pnd.ID - T max 99.4CV - HR 60'- 70's NSR with no vea. diuresis for ? Probable left ventricular hypertrophy with secondary ST-T waveabnormalities. Q waves in the inferior leadsconsistent with prior infarction. Cont on Labetolol 2mg/min. + RP bld. + smoker, DM2, HTN, PVD (s/p bilateral renal stents), ^chol and familiar hx of early onset CAD. Cont melena in sm-med amts. Left atrial abnormality. BUN/creat - 31/1.6. Physiologic MR (withinnormal limits).TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor apical views. Dilated ascending aorta.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a low risk (prophylaxis not recommended). R radial arterial line placed w/o difficulty.Endo: BS 149-223. Probable old inferior myocardialinfarction. +1.2L for day, +2.4L for LOS. Pt was in Afib at OSH but converted to NSR following Diltiazem IVP/gtt. Based on AHA endocarditis prophylaxis recommendations, the echo findings indicate a lowrisk (prophylaxis not recommended). Repleted K+ 3.8/ Mg 1.7 w/ 20 meq KCL and 2 gm MGSO4.Resp: Received pt on 5L NC. Admitted for NSTEMI, found re-stenosis of RA stent, unsuccessful d/t RA perf-RP bleed. RIJ TLC residual ooze less significant. Afib w/ decreased incidence following administration of Diltiazem. RP bleedP: monitor hct, bp nipride if pt becomes hypertensive. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. F/C to gravity draining cyu. Pantoprazole cont 8mg/hr IV and Sucralfate slurry . Tmax 98.5. Intraventricular conductiondelay. Tx to CCU for further mgmt.MS: AAOx3. Placed pt on Conc mask w/ some improvement. There is mild symmetric left ventricularhypertrophy with normal cavity size. Tolerating po meds. Left ventricular hypertrophy with secondary ST-T wave changes.Compared to the previous tracing of no significant change. BP 109-140's/50-60.Resp - ls have faint crackles at r base. Occ needs 2L via nc. Regional left ventricular wall motion isnormal. Compared to the previous tracing of the T wave inversionsin the inferior and lateral leads are less prominent.TRACING #1 Slept w/ minimal interuption.CV: Initially NSR 70-80s w/ PACs. Sinus bradycardia. Sinus bradycardia. Non-specific lateral and anterolateralST-T wave changes. O2 off-Sats 92-100. Pt requiring titration of Nipride gtt to maintain SBP goal. Labetalol 600mg/200ml gtt started and titrated to 1mg/min for SBP 120-160. HCT immediately post this tx was 36.3 and is not reflective of this tx. Unchanged large right retroperitoneal hematoma as previously described. The right adrenal is obscured by the hematoma. CT OF THE ABDOMEN WITHOUT CONTRAST: There is interval development of a small right pleural effusion. The abdominal aorta is of normal caliber, with peripheral calcification. There appear to be hyperdense areas within the right retroperitoneal hematoma, which may represent contrast excreted from the prior catheterization. Cardiac shadow is unremarkable, however, there is mild prominence of the hila and of pulmonary interstitial markings, suggesting an element of cardiac failure. T waveinversions in leads I, aVL and V4-V6 suggest possible anterolateral ischemia.Compared to the previous tracing of no diagnostic interval change.TRACING #1 Renal angioplasty with subsequent angiographic evidence of renal artery perforation, now sealed. Patchy cortical enhancement of the right kidney, suggesting medical renal disease. Small right pleural effusion and atelectasis, as seen on CT scan of . CT OF THE ABDOMEN WITHOUT CONTRAST: There is mild atelectasis at the lung bases. Cortical enhancement is patchy and some areas, indicating renal disease. TECHNIQUE: Contiguous axial images through the abdomen and pelvis were obtained without oral or IV contrast. The new right internal jugular central venous catheter tip is in the distal SVC. There is elevation of the right hemidiaphragm, and suggestion of a pleural effusion and/or atelectasis, as seen on CT scan of . There is associated atelectasis at the right base posteriorly. CT OF THE PELVIS WITH CONTRAST: Contrast material is noted within the bladder, which contains a Foley catheter and is partially collapsed. Non-specificST-T wave abnormalities. Small stents are noted at the origins of the renal arteries bilaterally. CT OF THE PELVIS WITHOUT CONTRAST: Again noted is a Foley catheter within the bladder, with air likely related to instrumentation. Continued enhancement suggests impaired renal function. Mild cardiac failure. The left kidney is atrophic. The left kidney is atrophic. The right retroperitoneal hematoma extends into the right lower quadrant of the pelvis, in the pericolic gutter. Intraventricular conduction defect. Now s/p coronary cath and stent placement as well as mesenteric angiography and renal angioplasty developed melena and angiographic evidence of renal artery perforation, now sealed. Normal sinus rhythm with prominent T wave inversions in I, II, III, aVF, aVLand V3-V6 which are unchanged compared to the previous tracing of . The right kidney continues to enhance with contrast from yesterday's catheterization. Q waves in leads III and aVF suggest possible priorinferior myocardial infarction. The right kidney continues to demonstrate cortical enhancement and excretion of contrast from the recent cardiac catheterization. The proximal end of a right iliac stent is noted at the proximal right common iliac artery, extending into the right external iliac artery to approximately the level of the right common femoral artery. TECHNIQUE: Contiguous axial images through the abdomen and pelvis were obtained without contrast. Right precordial leads are presented and do not show any evidence of acuteischemia.TRACING #3 Normal sinus rhythm with prominent T wave inversions in I, II, III, aVF, aVLand leads V3-V6. | 24 | [
{
"category": "Nursing/other",
"chartdate": "2151-01-06 00:00:00.000",
"description": "Report",
"row_id": 1552095,
"text": "CCU Nursing Progress Note 7pm-7am\nS: I would really like a sleeping pill\n\nO: Pt takes Tylenol pm qhs and was administered Ambien 5mg with good effect. Pt slept most of night.\n\n pt with 1uprbc's. HCT immediately post this tx was 36.3 and is not reflective of this tx. Another tx absorbed this pm and hct is pnd.\n\nID - T max 99.4\n\nCV - HR 60'- 70's NSR with no vea. Cont on Labetolol 2mg/min. BP 109-140's/50-60.\n\nResp - ls have faint crackles at r base. Pt has non productive cough. O2 on 2ln/p with O2 sats 97%.\n\n Pt passing much flatus and dose c/o some abd pain which is improved this am. No stool. Abd is obses with +bs. Pantoprazole cont 8mg/hr IV and Sucralfate slurry . Kept NPO with the exception of meds and ice chips\n\nGU - Foley draining clear yellow urine 50-70cc/hr.\n\nSkin - Skin around rectal area is reddened and excoriated. Washed carefully with soap an water and covered with doubleguard.\n\nA: No stool this shift. HCT bumped to 36 between units.\n\nP: Monitor am hcts and through the day, increase activity as tolerated, increase diet per GI, med teaching stressing importance of compliance, case management and social work for consults if pt amenable, keep pt and family informed of poc per multidisiciplinary rounds.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-01-04 00:00:00.000",
"description": "Report",
"row_id": 1552090,
"text": "CCU NPN\nplease see carevue for all objective data\n\nEGD performed showing erythema w/ erosions in stomach, multiple non bleeding ulders in duodonum. Tolerated procedure well.\nCT scan of abdomen done results pnd.\n\nFourth unit of blood is presently hanging. TLC placed, awaiting confirmation of placement. When confirmed bicarb gtt to be started, needs protonix and bloods.\nA: GIB, ? RP bleed\nP: monitor hct, bp nipride if pt becomes hypertensive.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-01-05 00:00:00.000",
"description": "Report",
"row_id": 1552091,
"text": "CCU Nursing Progress Note 1900-0700\nS: \" I feel better than yesterday\".\n\nO: Please see careview for complete VS/additional objective data.\n 54 yr old female w/ CAD s/p 4 stents. + smoker, DM2, HTN, PVD (s/p bilateral renal stents), ^chol and familiar hx of early onset CAD. Pt presented to OSH w/ SS to L CP w/ radiation to L arm and jaw. + SOB. No relief w/ SL Ntg at home. Tx to OSH via EMS. Pt was in Afib at OSH but converted to NSR following Diltiazem IVP/gtt. Tx to for cath. S/P successful PTCA/ stent to RCA. But found to have restenotic R renal artery. Unable to deploy RA stent and intervention c/b RA perforation. While in holding area pt ^ hypertensive and + melena. Tx to CCU for further mgmt.\n\nMS: AAOx3. Pleasant and cooperative. Requiring frequent instruction not to bend L groin following sheath pull and given RP bld. Pt restless at times moving all over bed. Otherwise MAE. PEARL. Denied any pain . Slept w/ minimal interuption.\n\nCV: Initially NSR 70-80s w/ PACs. Requiring titration of Nipride gtt to 5 mcg/kg/min to maintain SBP goal of <160. Around 2230 pt entered Afib w/ HR ^ 160s. Pt also notable for bigeminy and then slowing down to 90s. Runs of RAF increased in incidence. Received Diltiazem IVP and started on Dilt gttat 5 mg/min. As noc progressed runs of Afib stopped until approx 0530. Titrated Diltiazem gtt to 10 mg/min. No further runs of Afib since 0600. Nipride weaned to 4 mcq/mg/min. R radial aline extremely labile. Any stop in treatment and ABP rises quickly. Pt cont on post cath/ MI regimen of Lipitor/ASA and Plavix. R groin site stable. DP +2 bilaterally/ PT dopplerable. Posttransfusion HCT 33.6. Repeat this am 30.2. Currently receiving UPRBC #5. Repleted K+ 3.8/ Mg 1.7 w/ 20 meq KCL and 2 gm MGSO4.\n\nResp: Received pt on 5L NC. As noc progressed O2 sats decreased. Pt apneic at times and a significant mouth breather. Placed pt on Conc mask w/ some improvement. LS diminished in bases. This am ? faint left lower lobe bibasilar crackles. Pt denies SOB/ difficulty breathing/\n\nGI/GU: NPO except for icechips. Tolerating po meds. No N/V. Cont melena in sm-med amts. F/C to gravity draining cyu. Output 45-180 cc/hr. No diuresis. Cont Bicarb gtt at 75cc/hr. Cont Mucomyst doses. Pt received 210cc contrast in cath lab. Pt + 1.9L LOS. BUN/Cr 31/1.6.\n\nID: Afebrile. Tmax 98.5. WBC 18.8. U/A sent. No abx regimen at present.\n\nAccess: LUE PIV. RIJ TLC residual ooze less significant. R radial arterial line placed w/o difficulty.\n\nEndo: BS 149-223. Pt received 4 units coverage per RISS.\n\nSkin: Buttocks becoming reddened w/ frequent washings d/t frequent episodes of melena. Barrier cream applied to area.\n\nSocial: No calls or visitors .\n\nA: S/P PTCA/ stent RCA. Course c/b perforation of R renal artery during PTCA of restenotic artery. + RP bld. Pt requiring titration of Nipride gtt to maintain SBP goal. Afib w/ decreased incidence following administration of Diltiazem. Cont GIB and HCT drop to 30.2.\n\nP: Cont transfusion #5 and to receive #6. Follow seri\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-01-05 00:00:00.000",
"description": "Report",
"row_id": 1552092,
"text": "CCU Nursing Progress Note 1900-0700\n(Continued)\n HCT. ? diuresis for ? LLL crackles. Monitor BS and follow RISS. ? pneumoboots/ SC heparin given Afib. Currently NPO. ? resuming diet and changing over to oral antihypertensives and antiarrhythmics. Cont supportive care. Keep pt and family updated in POC.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-01-05 00:00:00.000",
"description": "Report",
"row_id": 1552093,
"text": "Nursing Progress Note 0700-1900\nS: \"I didn't sleep at all last night-I usually take tylenol PM.\"\n\nO: Please see carevue for complete objective data.\n\nCV: Pt in rapid A-fib @ 0730. HR 140-150's. Increased dilt gtt to 15mg/hr c no effect. SBP remained stable 120-140's, titrated Nipride to 1.0mcg/kg/min. Spon converted to NSR, rate 60-70's, during echo. No bursts of A-fib since 1030. Dilt and Nipride gtt d/c'd. Labetalol 600mg/200ml gtt started and titrated to 1mg/min for SBP 120-160. ABP wave form dampened, not improved with repositioning or flushing. Unable to draw back blood and unsuccessfully attempted to change it over the wire, d/c'd.\nRec'd total of 6 unts PRBC's, last crit 29.4, trending down from 38.3 despite transfusions. Team aware. K-4.0, Mag-2.5 post repletion.\n\nResp: Lungs clr in apices c dim bases and faint crackles in R. RR-20's. O2 off-Sats 92-100. Occ needs 2L via nc.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-01-05 00:00:00.000",
"description": "Report",
"row_id": 1552094,
"text": "Cont Nursing Progress Note 0700-1900\nCV: To receive 2 units PRBC's, first bag hung at 1830.\n\nGI/GU/Endo: NPO except for meds, freq incontinence liquid melena stool. fecal bag attempted, but irritated skin severly and did not remain intact. C/o of intermittent abd pain resembling \"gas pains\", passing flatus. Went for abd/pelvic CT scan, no increase in blood from RP bleed. Endoscopy @ 1730, revealed multiple ischemic ulcers, no active bleeding. Protonix gtt @ 8mg/hr and on sucralfate po.\nFoley draining clr, light yellow urine. +1.2L for day, +2.4L for LOS. BUN/creat - 31/1.6. Rec'd 210cc of dye in cath lab, on mucomist.\nFS q4h, cov'd by reg insulin ss.\n\nSKIN: RIJ trip lumen-WNL, one R PIV-WNL. Bottom extremely sore, applying double guard after every stool.\n\nNeuro/Social: A&O x 3, cooperative. Likes to do things herself, seems down-wanted to out in time for her birthday, requesting meds for sleep. Rec'd 100mcg fent and 3mg versed for endoscopy. Husband visited today and daughter called.\n\nA: 57 yo female spon converted from rapid Afib to NSR. Started on labetalol gtt for BP management. Admitted for NSTEMI, found re-stenosis of RA stent, unsuccessful d/t RA perf-RP bleed. Requiring multiple transfusions.\n\nP: Monitor BP and titrate labetalol gtt to SBP 120-160. Cont to adm second unit of PRBC's and follow crit. Increase O2 to maintain sats > 90. Give final dose of mucomist and d/c. Emotionally support pt and family.\n"
},
{
"category": "Echo",
"chartdate": "2151-01-05 00:00:00.000",
"description": "Report",
"row_id": 66416,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 67\nWeight (lb): 230\nBSA (m2): 2.15 m2\nBP (mm Hg): 122/60\nHR (bpm): 138\nStatus: Inpatient\nDate/Time: at 11:12\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe patient had paroxysms of atrial fibrillation during the study with a rapid\nventricular response (ventricular rate >130/min).\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Normal regional LV\nsystolic function. Low normal LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Based on \nAHA endocarditis prophylaxis recommendations, the echo findings indicate a low\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is mildly elongated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. Regional left ventricular wall motion is\nnormal. Overall left ventricular systolic function is low normal (LVEF 50%).\nRight ventricular cavity size and free wall motion are normal. The ascending\naorta is mildly dilated. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve leaflets are mildly thickened. Physiologic mitral regurgitation is seen\n(within normal limits). The pulmonary artery systolic pressure could not be\ndetermined. There is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with low normal global\nsystolic function (?related to tachycardia). Dilated ascending aorta.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2151-01-02 00:00:00.000",
"description": "Report",
"row_id": 137325,
"text": "Normal sinus rhythm. Left atrial abnormality. Intraventricular conduction\ndelay. Probable left ventricular hypertrophy with secondary ST-T wave\nabnormalities. Compared to the previous tracing of the T wave inversions\nin the inferior and lateral leads are less prominent.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2151-01-09 00:00:00.000",
"description": "Report",
"row_id": 137267,
"text": "Sinus bradycardia. Long QTc interval. Probable old inferior myocardial\ninfarction. Left ventricular hypertrophy with secondary ST-T wave changes.\nCompared to the previous tracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2151-01-08 00:00:00.000",
"description": "Report",
"row_id": 137268,
"text": "Sinus bradycardia. The QTc interval is prolonged. Q waves in the inferior leads\nconsistent with prior infarction. Non-specific lateral and anterolateral\nST-T wave changes. Compared to the previous tracing atrial fibrillation is no\nlonger present.\n\n"
},
{
"category": "ECG",
"chartdate": "2151-01-05 00:00:00.000",
"description": "Report",
"row_id": 137269,
"text": "Atrial fibrillation with a rapid ventricular response. No diagnostic change\ncompared to tracing #3.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2151-01-04 00:00:00.000",
"description": "Report",
"row_id": 137270,
"text": "Atrial fibrillation with a rapid ventricular response. Compared to tracing #2,\natrial fibrillation is new.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2151-01-04 00:00:00.000",
"description": "Report",
"row_id": 137271,
"text": "Normal sinus rhythm. Compared to tracing #1, no diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2151-01-04 00:00:00.000",
"description": "Report",
"row_id": 137272,
"text": "Normal sinus rhythm. Q waves in leads III and aVF suggest possible prior\ninferior myocardial infarction. Intraventricular conduction defect. T wave\ninversions in leads I, aVL and V4-V6 suggest possible anterolateral ischemia.\nCompared to the previous tracing of no diagnostic interval change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2151-01-02 00:00:00.000",
"description": "Report",
"row_id": 137273,
"text": "Normal sinus rhythm with prominent T wave inversions in I, II, III, aVF, aVL\nand V3-V6 which are unchanged compared to the previous tracing of .\n\n"
},
{
"category": "ECG",
"chartdate": "2151-01-02 00:00:00.000",
"description": "Report",
"row_id": 137274,
"text": "Normal sinus rhythm with prominent T wave inversions in I, II, III, aVF, aVL\nand leads V3-V6. Compared to tracing #2, the anterolateral T wave abnormalities\nare more prominent. Clinical correlation is suggested.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2151-01-02 00:00:00.000",
"description": "Report",
"row_id": 137275,
"text": "Right precordial leads are presented and do not show any evidence of acute\nischemia.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2151-01-02 00:00:00.000",
"description": "Report",
"row_id": 137276,
"text": "Normal sinus rhythm. Intraventricular conduction delay. T wave inversions in\nleads I, aVL and V6 suggetive of anterolateral ischemia. Non-specific\nST-T wave abnormalities. No major change from tracing #1.\nTRACING #2\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-01-04 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 900657,
"text": " 4:23 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Evaluate for renal capsular hematoma size, and extent of RP\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with severe PVD and CAD. Now s/p coronary cath and stent\n placement as well as mesenteric angiography and renal angioplasty developed\n melena and angiographic evidence of renal artery perforation, now sealed.\n REASON FOR THIS EXAMINATION:\n Evaluate for renal capsular hematoma size, and extent of RP bleed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe PED and coronary artery disease. Now status post\n catheterization and stent placement as well as mesenteric angiography. Renal\n angioplasty with subsequent angiographic evidence of renal artery perforation,\n now sealed. Evaluate for hematoma.\n\n No prior studies are available for comparison.\n\n TECHNIQUE: Contiguous axial images through the abdomen and pelvis were\n obtained without contrast. IV contrast was not administered due to cardiac\n catheterization of the same day and elevated patient creatinine.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: There is mild atelectasis at the lung\n bases. The liver is of low attenuation, consistent with fatty infiltration.\n No focal liver lesions are identified on this non-contrast enhanced study. The\n patient is post cholecystectomy. The spleen, pancreas, and left adrenal are\n unremarkable. There is a large right perinephric hematoma, with hemorrhage\n surrounding the right kidney extending into the posterior pararenal space and\n along the lateral conal fascia into pouch. The right kidney\n continues to demonstrate cortical enhancement and excretion of contrast from\n the recent cardiac catheterization. Cortical enhancement is patchy and some\n areas, indicating renal disease. The left kidney is quite atrophic. The\n stomach and bowel loops are unremarkable. No free air in the abdomen. No\n pathologically enlarged mesenteric or retroperitoneal lymph nodes are seen.\n The abdominal aorta is of normal caliber, with peripheral calcification. Small\n stents are noted at the origins of the renal arteries bilaterally. The\n proximal end of a right iliac stent is noted at the proximal right common\n iliac artery, extending into the right external iliac artery to approximately\n the level of the right common femoral artery.\n\n CT OF THE PELVIS WITH CONTRAST: Contrast material is noted within the\n bladder, which contains a Foley catheter and is partially collapsed. There is\n air present likely related to instrumentation. The patient is post-\n hysterectomy. The rectum and sigmoid are unremarkable. The right\n retroperitoneal hematoma extends into the right lower quadrant of the pelvis,\n in the pericolic gutter. No pathologically enlarged pelvic or inguinal lymph\n nodes. Stranding is noted within the fat of the left groin, which may be\n related to the recent intervention.\n\n BONE WINDOWS: There are no suspicious osteolytic or sclerotic lesions.\n (Over)\n\n 4:23 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Evaluate for renal capsular hematoma size, and extent of RP\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Large right retroperitoneal hematoma surrounding the right kidney and\n extending into the right posterior pararenal space and along the lateral conal\n fascia into pouch. IV contrast could not be administered due to\n the patient's elevated creatinine and recent contrast administration, thus the\n examination cannot assess the presence or absence active extravasation. There\n appear to be hyperdense areas within the right retroperitoneal hematoma, which\n may represent contrast excreted from the prior catheterization.\n 2. Continued excretion from the right kidney. Patchy cortical enhancement of\n the right kidney, suggesting medical renal disease. The left kidney is\n atrophic.\n 3. Stents noted at the origins of the renal arteries bilaterally, and within\n the right common iliac artery extending to the distal external iliac artery.\n 4. Fatty infiltration of the liver.\n\n The findings were discussed with Dr. and a member of cardiology service\n immediately following the examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-01-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 900671,
"text": " 6:39 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: placement\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with NSTEMI and cough, new right IJ TLC\n\n REASON FOR THIS EXAMINATION:\n placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post central line placement. Myocardial infarction and\n cough.\n\n COMPARISON: .\n\n CHEST: AP supine portable view. The new right internal jugular central\n venous catheter tip is in the distal SVC. There is no pneumothorax. There is\n mild cardiomegaly without evidence of pulmonary edema. While the right\n costophrenic angle is not fully included on the image, no pleural effusion is\n visualized. The lungs are clear.\n\n IMPRESSION: Satisfactory central line position. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-01-05 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 900783,
"text": " 3:16 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval interval change in RP hematoma\n Admitting Diagnosis: CHEST PAIN\n Field of view: 44\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 y/o F with severe PVD and CAD. Lg R perinephric RP hematoma renal artery\n perforation.\n REASON FOR THIS EXAMINATION:\n eval interval change in RP hematoma\n CONTRAINDICATIONS for IV CONTRAST:\n dye nephropathy;Cr 1.6, severe RAS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Large right perinephric retroperitoneal hematoma secondary to\n renal artery perforation. Evaluate for interval change.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images through the abdomen and pelvis were\n obtained without oral or IV contrast.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: There is interval development of a small\n right pleural effusion. There is associated atelectasis at the right base\n posteriorly. There is new atelectasis within the basilar right middle lobe as\n well. The liver is of low attenuation, consistent with fatty infiltration.\n The patient is post cholecystectomy. The spleen, pancreas, and left adrenal\n gland are normal. Again seen is a large right perinephric hematoma extending\n into the posterior pararenal space, unchanged in size and appearance compared\n to 1 day previous. The right adrenal is obscured by the hematoma. The right\n kidney continues to enhance with contrast from yesterday's catheterization.\n Continued enhancement of the renal cortex suggests impaired renal function.\n The left kidney is atrophic. Bowel loops remain unremarkable. Stents are\n again noted at the origins of the renal arteries bilaterally, and within the\n right common iliac artery extending into the right external iliac artery.\n\n CT OF THE PELVIS WITHOUT CONTRAST: Again noted is a Foley catheter within the\n bladder, with air likely related to instrumentation. Some free fluid is now\n layering within the pelvis. Rectum and sigmoid are unremarkable. No\n pathologically enlarged lymph nodes. Post-procedure changes with stranding in\n the left groin are again seen.\n\n BONE WINDOWS: No suspicious osteolytic or sclerotic lesions.\n\n IMPRESSION:\n 1. Unchanged large right retroperitoneal hematoma as previously described.\n 2. Continued enhancement of the right kidney from contrast administered\n during yesterday's catheterization. Continued enhancement suggests impaired\n renal function.\n 3. Stents noted at the origins of the renal arteries bilaterally and within\n the right common iliac artery extending to the distal external iliac artery.\n 4. Fatty infiltration of the liver.\n (Over)\n\n 3:16 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval interval change in RP hematoma\n Admitting Diagnosis: CHEST PAIN\n Field of view: 44\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-01-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 900466,
"text": " 8:33 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?pulmonary edema\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with NSTEMI and cough, with new chest heaviness, SOB\n\n REASON FOR THIS EXAMINATION:\n ?pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 20:49\n\n INDICATION: Cough, dyspnea, and heaviness in the chest.\n\n COMPARISON: at 05:24.\n\n FINDINGS:\n\n The current study is in a much more lordotic projection. The left lateral\n costophrenic sulcus was obscured from view. There is no new consolidation or\n evidence for worsening of fluid status. The heart size appears slightly\n smaller than prior, but the projection technique may be influencing this.\n More prominence of the right hilum is seen on the current study, but again,\n this could be due to projection. PA and lateral views are recommended when\n feasible.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-01-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 900958,
"text": " 5:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: upright filmplease eval for CHF/infiltrate and free air unde\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with CAD w/NSTEMI, duodenal ulcers, perinephric hematoma,\n with rales, abdominal tenderness and rebound\n REASON FOR THIS EXAMINATION:\n upright filmplease eval for CHF/infiltrate and free air under the diaphragm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old woman with recent MI, now with rales.\n\n PORTABLE CHEST: Comparison with . The right IJ line remains\n in place. There are low lung volumes. There is elevation of the right\n hemidiaphragm, and suggestion of a pleural effusion and/or atelectasis, as\n seen on CT scan of . Cardiac shadow is unremarkable,\n however, there is mild prominence of the hila and of pulmonary interstitial\n markings, suggesting an element of cardiac failure. Bony structures are\n unremarkable.\n\n IMPRESSION:\n 1. Mild cardiac failure.\n 2. Small right pleural effusion and atelectasis, as seen on CT scan of\n .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-01-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 900391,
"text": " 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna, CHF.\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with NSTEMI and cough\n REASON FOR THIS EXAMINATION:\n eval for pna, CHF.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Recent MRI and cough.\n\n STUDY: AP upright portable chest at 5:24 a.m. on .\n\n FINDINGS:\n\n No comparison is available.\n\n FINDINGS:\n\n There is cardiomegaly. There is medial bibasilar opacities consistent with\n atelectasis. No findings to suggest pneumonia. No frank pulmonary edema.\n\n Clip overlying the right upper quadrant is of uncertain significance. No\n suspicious bone lesions.\n\n IMPRESSION:\n\n Cardiomegaly, without evidence of frank pulmonary edema or pneumonia.\n\n\n"
}
] |
20,236 | 151,904 | 46 yo man with history of cervical spinal cord injury, s/p C3-6 ACDF and remaining quadriplegia, indwelling suprapubic catheter/recurrent UTIs, baclofen pump, COPD, OSA who presented to OSH with after his wife noted seizure like activity with subsequent unresponsiveness, s/p 1 day intubation. Admission complicated by hypotension, bradycardia, hypoventillation. . # Hypotension, bradycardia, hypopnea: Patient presented hypotensive to SBP high 70-80 without reflex tachycardia (HRs as low as 40s). Hypotension was not responsive to extensive volume challenge (given 7.5 L NS in 24 hours). The etiology appears to be a combination of increased vagal tone and medication effect. The HR and BP responded to atropine challenge, indicating increased vagal tone from some offending process. Started on scopalomine patch. He was later also started on midodrine for further pressure support. The etiology of the increased vagal tone was most likely related to the UTI. The other major factors contributing was probably excess benzodiazepine and opioid. He had pinpoint pupils when he first came in. On his home doses of medications the patient had a low respiratory rate, and retained CO2 on ABG. The chronic hypopnea may lead to increased bradycardia. The patient's diazepam and methadone doses were decreased as below. . # Complicated UTI (enterococcus and serratia): Patient presented with foul smelling urine which is consistent with prior UTIs. He never had a fever, but he may have been unable to mount fever due to level of spinal cord lesion. Patient was initially on broad spectrum antibiotics but was narrowed based upon OSH culture data. Following 4 days of IV antibiotics, the patient was narrowed to PO amoxicillin for enterococcus plus cipro for serratia. Will receive a total of 14 days of abx for complicated UTI. Last dose of Abx to be given on . . # Toxic/metabolic encephalopathy. The patient was admitted following sustained altered mental status after an episode of clonic movements, thought by wife to represent seizure activity. Resolved per wife on admission to the ICU, but patient continued to be sedated with flat affect. Now much improved once decreased opiates, likely medication effect, as well as encephalopathy related to the UTI. Methadone dose was decreased. Diazepam dose was decreased. EEG was negative for seizure activity. Unclear if patient actually had seizure leading up to original presentation but no evidence during this hospitalization. More likely patient had toxic/metabolic derangements described above. Of note, the patient's wife was very concerned that the movements she saw (eyes rolling back in head, patient becoming confused) had happened a previous time when the patient received cymbalta. Cymbalta was stopped. . # ? Syringx: Patient had been recently diagnosed with cervical syringx per OSH records. However repeat MRI here did not show syringx but did show diffuse cervical spinal cord atrophy with cystic myelomalacia at C4-5 at the site of prior contusion. This was conveyed to one of the patient's primary neurologists, Dr. . . # COPD. On albuterol at home. Chronically retaining CO2. Decreased diazepam and methadone to increase respiratory drive. Continue albuterol PRN. . # DVT. After discussion with patient's PCP . , it does not appear that any documentation of DVT exists. The patient had IVC filter placed at the time of his spinal cord injury, and has been on anticoagulation since then. Current recommendations are that patients with IVF filters be anticoagulated if there are no contraindications (since IVC thrombi can develop). Given absence of contraindications, the patient's coumadin was continued. . # OSA: Patient has previous diagnosis of OSA however he has declined CPAP at home and here due to discomfort. Nasal cannula at night to maintain O2 sats | Retrocardiac opacity obscures the left hemidiaphragm. At C5-C6, uncovertebral and facet osteophytes result in mild left neural foraminal narrowing. The visualized pre- and paravertebral soft tissues appear unremarkable. As compared to the prior study from , the spinal cord appears diffusely and uniformly atrophic. At C4-C5, there are changes from prior anterior cervical discectomy and fusion, posterior spinal decompression. TECHNIQUE: Sagittal T1, T2, IDEAL and axial T2 and gradient echo sequences through the cervical spine were obtained without contrast. After intravenous administration of contrast, sagittal T1- and axial T1-weighted images were obtained. At C3-C4, there are changes from prior anterior cervical discectomy and fusion, and status laminectomy. There are expected susceptibility artifacts seen from anterior instrumentation from the C3 through C5 level. The spinal canal is adequately decompressed. At C6-C7, there is mild disc bulge, but no significant spinal canal narrowing is seen. Post-operative changes from prior C3-C6 laminectomies are seen. FINDINGS: Supine portable view of the chest demonstrates ET tube terminating 2.5 cm above the carina. Endotracheal tube terminates 2.5 cm above the carina. Post-surgical changes from anterior cervical fusion and instrumentation at C3-C5 levels and C3-C6 laminectomies. Uncovertebral and facet joint osteophytes cause moderate narrowing of the left neural foramen. COMPARISON: MRI cervical spine from . FINDINGS: Cervical vertebrae show normal height and alignment. There is a focal area of signal abnormality seen within the cervical spinal cord at C4-C5 level at the site of prior contusion, consistent with established cystic myelomalacic changes. Uncovertebral and facet joint osteophytes are causing mild narrowing of the left neural foramen. At C2-C3, posterior disc-osteophyte complex indents the thecal sac, but no spinal canal or neural foraminal narrowing is seen. seizure, PNA REASON FOR THIS EXAMINATION: please eval PNA, eval tube placement No contraindications for IV contrast FINAL REPORT INDICATION: Patient with possible seizure. Sinus rhythm. Bibasilar opacities, likely reflect atelectasis. Within normal limits. A nasogastric tube is positioned in the stomach. Hilar and mediastinal silhouettes are unremarkable. Partially imaged upper abdomen is notable for air-filled prominent stomach and bowel loops. Low lung volumes. No large pleural effusion or pneumothorax. 6:29 AM CHEST (PORTABLE AP) Clip # Reason: please eval PNA, eval tube placement MEDICAL CONDITION: History: 46M intubated, ? Right lung base opacity is also noted. Severe diffuse atrophy of the cervical spinal cord, with established cystic myelomalacia at the C4-5 level, the site of prior hemorrhagic contusion. At C7-T1, there is no disc herniation, spinal canal or neural foraminal (Over) 10:07 AM MR W& W/O CONTRAST Clip # Reason: assess for extent of syrinx, hematoma, paraspinal abcess, wi Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: GADAVIST Amt: 8 FINAL REPORT (Cont) narrowing. Multilevel degenerative changes in the cervical spine, most prominent at the C4-C5 and C5-C6 level. IMPRESSION: 1. IMPRESSION: 1. REASON FOR THIS EXAMINATION: assess for extent of syrinx, hematoma, paraspinal abcess, with contrast No contraindications for IV contrast FINAL REPORT INDICATION: 46-year-old man status post C3-C6 laminectomy and C3-C6 fusion in following cervical injury. MRI C-spine to evaluate for syrinx formation. Heart size is normal. There is no pulmonary edema. No abnormal enhancement is seen. COMPARISONS: None available. Assess for pneumonia and ET tube placement. No previous tracing available forcomparison. 2. 2. There is no abnormal enhancement seen within this area of signal abnormality. There is no canal or neural foraminal narrowing. 3. | 3 | [
{
"category": "Radiology",
"chartdate": "2136-05-19 00:00:00.000",
"description": "MR C-SPINE W& W/O CONTRAST",
"row_id": 1237734,
"text": " 10:07 AM\n MR W& W/O CONTRAST Clip # \n Reason: assess for extent of syrinx, hematoma, paraspinal abcess, wi\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: GADAVIST Amt: 8\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with C3 and C4/C5, now with worsening hypoventilation.\n REASON FOR THIS EXAMINATION:\n assess for extent of syrinx, hematoma, paraspinal abcess, with contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old man status post C3-C6 laminectomy and C3-C6 fusion in\n following cervical injury. MRI C-spine to evaluate for syrinx formation.\n\n COMPARISON: MRI cervical spine from .\n\n TECHNIQUE: Sagittal T1, T2, IDEAL and axial T2 and gradient echo sequences\n through the cervical spine were obtained without contrast. After intravenous\n administration of contrast, sagittal T1- and axial T1-weighted images were\n obtained.\n\n FINDINGS: Cervical vertebrae show normal height and alignment. There are\n expected susceptibility artifacts seen from anterior instrumentation from the\n C3 through C5 level. Post-operative changes from prior C3-C6 laminectomies\n are seen.\n\n As compared to the prior study from , the spinal cord appears diffusely\n and uniformly atrophic. There is a focal area of signal abnormality seen\n within the cervical spinal cord at C4-C5 level at the site of prior contusion,\n consistent with established cystic myelomalacic changes. There is no abnormal\n enhancement seen within this area of signal abnormality.\n\n At C2-C3, posterior disc-osteophyte complex indents the thecal sac, but no\n spinal canal or neural foraminal narrowing is seen.\n\n At C3-C4, there are changes from prior anterior cervical discectomy and\n fusion, and status laminectomy. There is no canal or neural foraminal\n narrowing.\n\n At C4-C5, there are changes from prior anterior cervical discectomy and\n fusion, posterior spinal decompression. Uncovertebral and facet joint\n osteophytes cause moderate narrowing of the left neural foramen.\n\n At C5-C6, uncovertebral and facet osteophytes result in mild left neural\n foraminal narrowing. The spinal canal is adequately decompressed.\n\n At C6-C7, there is mild disc bulge, but no significant spinal canal narrowing\n is seen. Uncovertebral and facet joint osteophytes are causing mild narrowing\n of the left neural foramen.\n\n At C7-T1, there is no disc herniation, spinal canal or neural foraminal\n (Over)\n\n 10:07 AM\n MR W& W/O CONTRAST Clip # \n Reason: assess for extent of syrinx, hematoma, paraspinal abcess, wi\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: GADAVIST Amt: 8\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n narrowing.\n\n The visualized pre- and paravertebral soft tissues appear unremarkable.\n\n IMPRESSION:\n 1. Severe diffuse atrophy of the cervical spinal cord, with established\n cystic myelomalacia at the C4-5 level, the site of prior hemorrhagic\n contusion. No abnormal enhancement is seen.\n\n 2. Post-surgical changes from anterior cervical fusion and instrumentation at\n C3-C5 levels and C3-C6 laminectomies.\n\n 3. Multilevel degenerative changes in the cervical spine, most prominent at\n the C4-C5 and C5-C6 level.\n\n"
},
{
"category": "ECG",
"chartdate": "2136-05-16 00:00:00.000",
"description": "Report",
"row_id": 200184,
"text": "Sinus rhythm. Within normal limits. No previous tracing available for\ncomparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-05-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1237261,
"text": " 6:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval PNA, eval tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 46M intubated, ? seizure, PNA\n REASON FOR THIS EXAMINATION:\n please eval PNA, eval tube placement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with possible seizure. Assess for pneumonia and ET tube\n placement.\n\n COMPARISONS: None available.\n\n FINDINGS:\n\n Supine portable view of the chest demonstrates ET tube terminating 2.5 cm\n above the carina. A nasogastric tube is positioned in the stomach. Low lung\n volumes. Retrocardiac opacity obscures the left hemidiaphragm. Right lung\n base opacity is also noted. No large pleural effusion or pneumothorax.\n Hilar and mediastinal silhouettes are unremarkable. Heart size is normal.\n There is no pulmonary edema. Partially imaged upper abdomen is notable for\n air-filled prominent stomach and bowel loops.\n\n IMPRESSION:\n\n 1. Endotracheal tube terminates 2.5 cm above the carina.\n\n 2. Bibasilar opacities, likely reflect atelectasis.\n\n"
}
] |
8,249 | 104,756 | The patient was initially given extensive medical treatment including Swan-Ganz catheter, arterial line, Aspirin, Plavix, ACE inhibitors, Nitroglycerin, and Lasix. On , the patient was taken to the Operating Room by Dr. for acute stent failure status post acute myocardial infarction. Coronary artery bypass grafting times three was performed, LIMA to left anterior descending, saphenous vein graft to LPD and OM. The patient initially appeared to tolerate the procedure and was transferred to the Cardiothoracic Intensive Care Unit with chest tubes and pacing wires in place. He required an intravenous drip of Neo-Synephrine and Levophed. He was also initially on a drip of Propofol. Over the next few ensuing days, the patient needed additional drips of Nitroglycerin. He was also given Lasix for his positive fluid status. On , the patient's T-max was noted to 101.5??????. The patient was pancultured. Over the next few days, the patient continued to have low-grade fevers, although his cultures persistently were read as negative. As the patient was allowed to be awakened, it became evident that he was very confused, and the patient frequently required Haldol. Also on the Intensive Care Unit, it was noted that the patient developed a sternal click although the sternum was not erythematous and did not express any pus. The Heart Failure Service was also consulted to evaluate the patient's heart failure and large positive fluid balance. The patient was started on Natrecor. His Lasix was discontinued. He was started on Bumex. His Diltiazem was discontinued. He was restricted to a 2 g sodium diet and restricted to a 1500 cc fluid intake. The patient was also put on p.o. Flagyl empirically for possible C-diff. Over the next few days, the patient's Bumex and .................. were adjusted as needed. The patient was then discharged from the Intensive Care Unit and sent to the regular floor. Also while on the unit, the patient was placed on Vancomycin, which was discontinued shortly after coming to the floor and dosed intermittently due to the high creatinine. The patient received a PICC line for future antibiotic and blood draw needs. Shortly after arriving to the floor, the patient had a blood culture that was done in the Intensive Care Unit which came back with a single bottle read of Staphylococcus coagulase negative, for which the patient continued to be treated. Over the course of the next few days, the patient continued to diurese, although he began to have increasing creatinine, more so than previously. His diuretics were revised, and he was finally left on a regimen simply of Bumex 1 mg b.i.d. On , it was noted that the patient's other leg wounds had partially dehisced, approximately 2 cm. Steri-Strips were placed on either side of the incision to prevent the dehiscence from expanding. The area had no erythema and no pus expressed. Also the lower leg incision demonstrated increased erythema indicative of a cellulitis. No pus was ever expressed. The patient was continued on Vancomycin 1 g dosed as needed. He was also placed on Cipro 500 p.o. b.i.d. He was also kept on Flagyl for unconfirmed C-diff. Over the next couple of days, the patient's positive fluid status continued to decrease. His creatinine finally started to fall. The patient experienced periodic hypokalemia which required replacement. At the present date of , the patient has remained afebrile for a number of days. His white count has slowly begun to improve. He remains on Vancomycin, Cipro and Flagyl. His leg erythema is improving. It is anticipated that he will be discharged tomorrow to a rehabilitation facility. He is to follow-up with Dr. in six weeks. He is to follow-up with his primary care physician weeks. He is to follow-up with his cardiologist in weeks. The patient should strenuous activity. He should also not drive while on pain medication. The patient may shower, although he should avoid baths. It is felt at this time that the patient no longer needs diuretics and therefore will not be discharged on any diuretics. He will however be discharged on Vancomycin 1 g q.d. He is to have a trough level drawn tomorrow night prior to his fourth consecutive dosing. He will be discharged on Ciprofloxacin 500 mg p.o. q.12, Potassium 20 mEq p.o. q.d., Flagyl 500 mg p.o. t.i.d., Albuterol nebulizer treatment q.6 hours p.r.n., Insulin sliding scale, Fluticasone 110 mcg 2 puffs b.i.d., Atorvastatin 20 mg p.o. q.d., Albuterol 1-2 puffs q.6 hours p.r.n., .................. 2-5 mg IM t.i.d. p.r.n., Multivitamin 1 cap p.o. q.d., Folic Acid 1 mg p.o. q.d., Thiamin 100 mg p.o. q.d., Lansoprazole 30 mg p.o. q.d., Diphenhydramine 25 mg p.o. q.h.s. p.r.n. sleep, Dulcolax suppositories 10 mg p.r. q.d. p.r.n. constipation, Milk of Magnesia 30 mg p.o. q.h.s. p.r.n. constipation, Percocet p.o. q.4 p.r.n. pain, Tylenol 650 mg p.o. q.4 hours p.r.n., enteric coated Aspirin 325 mg p.o. q.d., Colace 100 mg p.o. b.i.d. , M.D. Dictated By: MEDQUIST36 D: 13:07 T: 13:21 JOB#: , | There is marked calcification of the coronary arteries and minimal calcification of the aorta. There is left ventricular enlargement and slight upper zone redistribution, indicative of mild cardiac decompensation. There is moderate tosevere regional left ventricular systolic dysfunction. There is noaortic valve stenosis.MITRAL VALVE: The mitral valve leaflets are mildly thickened. The aorticroot is mildly dilated. There is focalhypokinesis of the apical free wall of the right ventricle.AORTA: The aortic root is mildly dilated. IMPRESSION: Status post CABG with mild atelectasis in the left lower lobe and small left pleural effusion. The left ventricular inflow pattern suggests impairedrelaxation.TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. There is moderateregional left ventricular systolic dysfunction.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal anterior - akinetic; mid anterior - akinetic;basal anteroseptal - akinetic; mid anteroseptal - akinetic; basal inferoseptal- akinetic; mid inferoseptal - akinetic; anterior apex - akinetic; septalapex- akinetic; inferior apex - akinetic; lateral apex - akinetic;RIGHT VENTRICLE: The right ventricular free wall is hypertrophied. There is a persistent small left pleural effusion, and there are minor atelectatic changes present at the left lung base. There is probable focal hypokinesis of theapical free wall of the right ventricle (not fully visualized). Sinus rhythmMarked left axis deviationRBBB with left anterior fascicular blockProbable anteroseptal myocardial infarction with anterolateral ST-Tconfiguration suggests acute processSince previous tracing of : lateral ST-T wave changes slightly lessprominent There is a small right sided pleural effusion. A small right-sided pleural effusion is present, but the left costophrenic angle is excluded from the examination. Mildtricuspid [1+] regurgitation is seen. The mitral valve leaflets are mildlythickened. Left ventricular wall thicknesses arenormal. There isfocal hypokinesis of the apical free wall of the right ventricle.AORTIC VALVE: The aortic valve leaflets are mildly thickened. The ascending aorta is mildly dilated. The ascending aorta is mildly dilated. Occasional ventricular ectopy. There is a small left pleural effusion. Nodefinite left ventricular thrombus identified but cannot exclude. There is moderate pulmonary arterysystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Conclusions:The left atrium is mildly dilated. K 3.4, repleted w/ additional 60mEq IV KCL. EPI/NEO/NTG/PROPOFOL GTTS. nebs per rt. Becomes bronchospastic w/ stimulation. R upper thigh cont with sm amt serous dng-DSD changed X1. NEO/NTG TITRATED FOR LABILE BP. Will change to CPAP @ 0600.GI/GU: +BS, abd soft and obese. cont etoh gtt. Captopril dc'd. rec'ing combivent by rt.gi: ogt in place.gu: rec'd lasix 20mg x2. r fem pa line in place. bs with scatt exp wheezes. ct's d/c'd. hypokalemia.p: follow volume status, filling pressures. Notched P waves inlead II. diurese as indicated. C-D-I-. EPI DCD FOR CO/CI > 2.5 IABP 1:1. neb tx's given by rt. + BS, + belching and + flatus. MIN->MOD. 1+ edema bil hands and feet. INTERMITTENT BOLUSES REQ'D FOR TRANSIENT HYPERTENSION. CKs cont to trend up-1785/274.Pulm: LS CTA, orally intubated. Clot to BB. +BS and flatus. plan to wean and extubate in am. chf. PA pressures 21-35/16-19, PCWP 13-14. NEURO-SEDATED ON PROPOFOL 30MCGKGMIN. started on po lopressor. fs qid. + palp pp bilaterally. +bs. paps 30s/22-26. At 1400 pt noted to have lg amt serosang drainage from lower third of sternal incision. post extubation abg's acceptable. K+ repleated. uop>30cc/hr. Last numbers 6.3/2.8/813. cont to replete. Cont amb per cardiac rehab. DSD applied and changed X3. Vent settings SIMV 650/12/40/5 PS 8, RR 12-20. BOUNDING PP. Cath revealed thrombosed stent LAD. Sinus rhythm. Sinus rhythm. Sinus rhythm. AMT. IABP WAS ON 1:2 AND WAS REMOVED AT 1530.REMAINS ON NTG AND NEO FOR BP CONTROL.TEMP WAS ELEVATED TO 101 MEDICATED WITH TYLENOL .SYSTOLIC BP 110 TO 130,DIASTOLIC BP 60 TO 70.PCWP 30,MD AWARE.ATRIAL WIRES RETESTED AND DO NOT WORK,VWIRES WORK, IN VVI MODE RATE OF 60 V OUTPUT 10 AND V SESITIVITY 0.8.NEW LEFT RADIAL ALINE INSERTED,RIGHT RADIAL ALINE DAMPENED.RIGHT FEMORAL SITE DSG INTACT BIL DP PULSES AND PT PULSES PRESENT PALPABLE AND BY DOPPLER ALSO.RESP:REMAINS INTUBATED ON SIMV AND PS OF 5 WITH PEEP OF 5CM,TV 800,RESP RATE OF 12,FIO2 40%.BREATH SOUNDS COARSE AND RHONCHOROUS BUT DIMINISHED ALSO ESPECIALLY AT RIGHT BASE.CHEST XRAY DONE.WHEN PT AWOKEN HE BECAME TACYPNIC AND DESATURATED.SP02 98 TO 100%.GI:ABD LARGE AND SOFT WITH QUESTIONABLE FAINT BOWEL SOUNDS PRESENT.OGT TO LCS DRAINING BILIOUS GREEN DRAINAGE.GU:FOLEY TO CD DRAINING LOW URINE OUTPUTS AROUND 20CC/HR.TEAM AWARE,NO LASIX AS YET.ENDOCRINE REMAINS ON INSULIN GTT .SOCIAL:GRANDSON VISITED,UPDATED PTS SON AND DAUGHTER ON PHONE CHANGED TO CPAP W IPS W ACCEPTABLE SPONT. RESEDATED W PROPOFOL. K+ & CA REPLEATED. tolerating po liquids. pt encouraged to cdb.gi/gu: +bs. Good resluts with 0600 lasix. ?extubate when appropriate. stated then corrected self by saying . ?EXTUBATE. ogt->lws with billious drainage. Recieved resp tx. nebs/inhalers as ordered. GI SM. STRENUM CLEA/DRY, MEDIASTINAL DSG D/I, RUPPER LEG LOTS OF SEROUS FLUID REDRESSED X4 ... Occ upper airway wheezes. ATTEMPT MADE AGAIN TO WAKE & WEAN. neo titrated to keep sbp~110. NEO TITRATED TO KEEP SBP~110. Breath sounds essent clear, but RR=28-32 w/ wheezes, DOE. +BS. +flatus. +pp bilaterally. SOFT,+ BOWEL SOUNDS. CI>2.0. right leg incision with ss drainage->dsd changed. SUCTIONED FOR THIN->THICK WHITE SECREATIONS.GI/GU: OG->LWS WITH BILLIOUS DRAINAGE. propofol slowly weaned to off. REMAINS ON ALCOHOL GTT.? WHEEZY W EXERTION,COUGHING,MDI'S CONTINUE.REMAINS NSR W 1 6 BT RUN VT. MG++ & KCL REPLETED,NO FURTHER ECTOPY OBSERVED.EXCELLENT HEMODYNAMICS W CONTINUED NEO REQUIREMENT.SEE FLOW SHEET. pearl.cardiac: nsr with rare pvc noted. sternal incision with mod amt ss drainage->dsd changed. k+ repleated.resp: rr 20-30's. haldol prn for agitation. COMING DOWN NICELY, AM LASIX GIVEN , K REPLACED X2 WITH 40MEQ KCL PO. will cont to monitor. Neo weaned off cont to monitor b/p, denies pain. denies pain.cardiac: nsr. haldol given prn with good effect. RARE PVC'S NOTED. shift update:neuro: oriented to self. Medicated for cough induced incision pain with 1 percocetX2 with effect noted.CV: Stable bp/hr. MIDAZ 2MG GIVEN X1. SEE FLOW SHEET.PLAN: CONT TO WEAN PROPOFOL. FINALLY RESTING MORE BY 1AM. ?need for sitter. SUCTIONED FOR THIN WHITE SECXRETIONS. sbp 90-120's. abg's acceptable. ABG'S ACCEPTABLE. ?? ABD. he still was anxious given haldol x2 doses with good response now. PATIENT IMPROVING, IN VOICE STRENTGH, COUGHING UP THIN WHITE SECRETIONS THISAM, WGT. Follows commands well, such as using the IS correctly to almost 1 liter. ntg cont at 0.25mcg/kg/min. NTG CONT AT 0.25MCG/KG/MIN. insulin gtt per protocol. Remains on ETOH gtt at 2.5cc/hr. | 42 | [
{
"category": "Radiology",
"chartdate": "2111-02-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 784935,
"text": " 5:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please check baseline CXR, ETT tube placement, assess for pu\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with STEMI s/p LAD stent in CHF\n REASON FOR THIS EXAMINATION:\n please check baseline CXR, ETT tube placement, assess for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77 y/o male s/p myocardial infarction and angioplasty. Assess ETT\n placement.\n\n TECHNIQUE: Portable AP chest.\n\n COMPARISON: None.\n\n FINDINGS: The ETT is in satisfactory position approximately 5 cm above the\n level of the carina. NG tube is seen coursing below the level of the\n hemidiaphragm, but the tip cannot be seen. There is a Swan-Ganz catheter via\n the femoral approach which terminates within the left pulmonary artery. There\n is cardiac enlargement with a left ventricular configuration and unfolding of\n the aorta. There are low lung volumes, and no definite evidence of congestive\n heart failure. There are no pleural effusions. The lungs appear grossly clear.\n\n IMPRESSION: 1) Satisfactory placement of ETT and Swan-Ganz catheter. The\n termination of the NG tube cannot be assessed. 2) No definite congestive heart\n failure pattern.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-02-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 785006,
"text": " 1:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with STEMI s/p LAD stent in CHF, now w/ fever\n\n REASON FOR THIS EXAMINATION:\n ?PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post anterior descending coronary artery stent, CHF, now\n with fever, ? pneumonia.\n\n A single frontal chest radiograph dated and compared with the\n prior chest radiograph dating .\n\n The ET tube, NG tube, and Swan-Ganz catheter has been intervally removed.\n There is left ventricular enlargement and slight upper zone redistribution,\n indicative of mild cardiac decompensation. There is a small focal area of\n increased opacity in the left retrocardiac region, which could represent\n aspiration or pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-16 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 786681,
"text": " 1:58 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man S/P cabg x3\n\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 77 y/o man status post CABG.\n\n CHEST, 2 VIEWS: Comparison is made to a prior study of . The heart\n size is in the upper limits of normal. The mediastinal and hilar contours are\n unremarkable. The pulmonary vasculature is normal. There is some atelectasis\n at the left lung base. A small left pleural effusion is present. A PICC line\n is identified with its tip in the mid SVC.\n\n IMPRESSION: Status post CABG with mild atelectasis in the left lower lobe and\n small left pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-11 00:00:00.000",
"description": "CVL/PICC",
"row_id": 786250,
"text": " 11:41 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: double lumen PICC line for access & blood draws please\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with s/p CABG, low LVEF\n REASON FOR THIS EXAMINATION:\n double lumen PICC line for access & blood draws please\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Difficult IV access in a 77 year old male after CABG. The IV\n nurse team attempted PICC line placement at the bedside and were unsuccessful.\n\n RADIOLOGIST: Drs. , , and . Dr. , the attending\n radiologist, was present and supervising throughout the entire procedure.\n\n PROCEDURE: There were no superficial veins identified suitable for PICC line\n placement. A patent and compressible left brachial vein was identified under\n ultrasound guidance. A 21 gauge needle was used to gain access to the left\n brachial vein. A .018 guidewire was advanced into the SVC. A peel away\n sheath was exchanged for the 21 gauge needle. The distance between the\n puncture site and the SVC was determined to be 43 cm and the PICC line was\n trimmed to the appropriate length and then advanced over the 0.018 wire. The\n distal tip of the PICC line was confirmed with fluoroscopy to be in the mid\n SVC. The PICC line withdrew and flushed appropriately and was Statlocked. The\n patient tolerated the procedure well without immediate post-procedural\n complication. The line is ready for use.\n\n IMPRESSION: Successful placement of 43 cm single lumen PICC line from the\n left brachial vein to the mid SVC.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-06 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 785870,
"text": " 4:28 PM\n CHEST (PA & LAT) Clip # \n Reason: R/O EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man S/P cabg x3\n REASON FOR THIS EXAMINATION:\n R/O EFFUSION\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEWS CHEST: Compared to 1 day earlier.\n\n CLINICAL INDICATION: Status post coronary artery bypass surgery.\n\n The patient is status post median sternotomy and coronary artery bypass\n surgery. The cardiac and mediastinal contours are stable compared to the\n previous post operative radiograph. There is a persistent small left pleural\n effusion, and there are minor atelectatic changes present at the left lung\n base. No pneumothorax is identified.\n\n As compared to the pre-operative film of there has been interval\n enlargement of the cardiac silhouette which may reflect a component of\n paracardial fluid.\n\n With regard to the sternal wires, there has been interval rotation of the\n lowest right sternal wire.\n\n IMPRESSION:\n 1) Interval rotation of lowest right sternal wire. This finding can be a\n sign of sternal dehiscence. Findings have been communicated with clinical\n service caring for the patient.\n 2) Persistent small left pleural effusion. Adjacent minor atelectasis at the\n left lung base, which is improved in the interval.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 785946,
"text": " 7:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man s/p cabg with sternal click\n\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG with sternal click.\n\n Chest, single AP view. Please note that the film is considerably degraded by\n respiratory motion, such that the sternal wires are not distinctly visible on\n this film. There is moderately severe cardiomegaly, unchanged. The left hemi-\n diaphragm is obscured and there is increased retrocardiac density, but the\n significance given the marked degree of motion is unclear. Please note that\n the report from the chest x-ray described interval rotation of one of\n the sternal wires which can be seen as a sign of dehiscence. No lateral view\n is provided at the time of the examination.\n\n IMPRESSION: Film markedly degraded by motion, limiting assessment. No CHF, but\n left lower lobe collapse and consolidation cannot be excluded. Please see\n report describing change in position of lower sternal wire.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-08 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 785986,
"text": " 10:59 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess stability of sternum,r/o effusion\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man s/p CABGx3\n REASON FOR THIS EXAMINATION:\n assess stability of sternum,r/o effusion\n CONTRAINDICATIONS for IV CONTRAST:\n creat\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG with dehiscence of sternotomy wires. Question\n effusion or abscess.\n\n TECHNIQUE: Contiguous axial images are obtained from the thoracic inlet to\n the lung bases without IV contrast.\n\n FINDINGS: There is no axillary, mediastinal, or hilar lymphadenopathy. There\n is a small paracardial effusion. There is marked calcification of the\n coronary arteries and minimal calcification of the aorta. There is a small\n right sided pleural effusion. There is some ground glass opacity anterior to\n the heart in the left upper lobe, with a small 4 mm nodule. Additionally, in\n the left lung base laterally, as well as a focus more medially at the left\n base, there are areas of opacification, which represent foci of subsegmental\n atelectasis. There are no pulmonary opacities at the right lung.\n\n Note is made of dehiscence of the sternotomy wires starting at the lower edge\n of the fourth sternotomy wire, and involving the 5th and 6th ones as well.\n There is a small fluid collection measuring 34 x 22 mm in size at the greatest\n axial dimension extending from the level of the fourth sternotomy wire to the\n lower edge of the sternum. This fluid collection appears to extend to the\n paracardium. There are no areas of stranding around this.\n\n Limited examination of the abdomen demonstrates an unremarkable appearance of\n the liver, gallbladder, spleen, adrenal glands, pancreas, and stomach.\n\n Review of osseous structures demonstrates mild degenerative change of the\n thoracic spine. As described above, there is dehiscence of sternotomy wires\n of the lower three sternotomy wires with an interposed fluid collection.\n\n IMPRESSION:\n 1) Dehiscence of the lower three sternotomy wires.\n 2) Small associated fluid collection.\n 3) Small left sided pleural effusion with focal opacities at the left lung\n base which may represent subsegmental atelectasis.\n 4) Ground glass opacity of the anterior right upper lobe is in the region of\n the sternotomy, is nonspecific; inflammatory change cannot be excluded.\n (Over)\n\n 10:59 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess stability of sternum,r/o effusion\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 785709,
"text": " 8:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess sternal wire placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man s/p cabg with sternal click\n REASON FOR THIS EXAMINATION:\n assess sternal wire placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CABG. Assess sternal wire placement.\n\n PORTABLE CHEST: The sternal wires are noted to be in appropriate alignment.\n The heart is enlarged. There is a small left effusion. However, there is no\n evidence of frank failure.\n\n IMPRESSION: Sternal wires in good position.\n\n Cardiomegaly and small left effusion, unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-02-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 785087,
"text": " 9:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O EFFUSION, CHECK iabp PLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with STEMI s/p LAD stent in CHF, now w/ fever\n\n REASON FOR THIS EXAMINATION:\n R/O EFFUSION, CHECK iabp PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 77-year-old male status post CABG. Assess intra-aortic\n balloon pump placement.\n\n TECHNIQUE: Portable AP chest.\n\n COMPARISON: .\n\n FINDINGS: The patient is status post median sternotomy and CABG. The\n endotracheal tube and nasogastric tube are in satisfactory position. A single\n left-sided chest tube is visible. The right IJ Swan-Ganz catheter terminates\n within the right pulmonary artery. The intra-aortic balloon pump tip is at the\n level of the carina, approximately 4 cm below the roof of the aortic knob. A\n small right-sided pleural effusion is present, but the left costophrenic angle\n is excluded from the examination. There is stable cardiac enlargement. No\n definite evidence of congestive heart failure.\n\n IMPRESSION:\n 1. Satisfactory placement of intra-aortic balloon pump and Swan-Ganz catheter.\n 2. No evidence of congestive heart failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-03-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 785603,
"text": " 7:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/sternal wound drainage\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with STEMI s/p LAD stent in CHF,\n REASON FOR THIS EXAMINATION:\n s/p CABG w/sternal wound drainage\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sternal wound drainage.\n\n PORTABLE AP CHEST: The exam is limited by respiratory motion. The heart is\n enlarged. Median sternotomy wires and CABG clips are noted. There is patchy\n bibasilar atelectasis which appears increased on the left in the six day\n interval. There is a small left pleural effusion. The aorta is unfolded.\n There has been interval removal of the Swan-Ganz catheter and ETT. There is\n mild cephalization of the pulmonary vessels suggesting improving CHF. Healed\n left rib fractures are noted.\n\n IMPRESSION: Patchy bibasilar atelectasis.\n\n"
},
{
"category": "Echo",
"chartdate": "2111-03-12 00:00:00.000",
"description": "Report",
"row_id": 74922,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function.\nHeight: (in) 67\nWeight (lb): 213\nBSA (m2): 2.08 m2\nBP (mm Hg): 100/70\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 11:37\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anteroseptal - hypokinetic; mid anteroseptal -\nakinetic; mid inferoseptal - akinetic; anterior apex - akinetic; septal apex-\nakinetic; inferior apex - akinetic; lateral apex - akinetic; apex -\ndyskinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. There is focal\nhypokinesis of the apical free wall of the right ventricle.\n\nAORTA: The aortic root is mildly dilated. There are focal calcifications in\nthe aortic root. The ascending aorta is mildly dilated. The aortic arch is\nnormal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\naortic valve stenosis.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen. The left ventricular inflow pattern suggests impaired\nrelaxation.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Mild\ntricuspid [1+] regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. There is moderate to\nsevere regional left ventricular systolic dysfunction. Resting regional wall\nmotion abnormalities include anteroseptal and apical akinesis/dyskinesis. No\ndefinite left ventricular thrombus identified but cannot exclude. Right\nventricular chamber size is normal. There is probable focal hypokinesis of the\napical free wall of the right ventricle (not fully visualized). The aortic\nroot is mildly dilated. The ascending aorta is mildly dilated. The aortic\nvalve leaflets are mildly thickened. There is no aortic valve stenosis. The\nmitral valve leaflets are mildly thickened. Trivial mitral regurgitation is\nseen. The left ventricular inflow pattern suggests impaired relaxation. The\ntricuspid valve leaflets are mildly thickened. There is moderate pulmonary\nartery systolic hypertension.\n\nCompared to the prior study fo , there is no significant change.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2111-02-24 00:00:00.000",
"description": "Report",
"row_id": 74923,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nBP (mm Hg): 140/80\nStatus: Inpatient\nDate/Time: at 15:11\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. There is moderate\nregional left ventricular systolic dysfunction.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anterior - akinetic; mid anterior - akinetic;\nbasal anteroseptal - akinetic; mid anteroseptal - akinetic; basal inferoseptal\n- akinetic; mid inferoseptal - akinetic; anterior apex - akinetic; septal\napex- akinetic; inferior apex - akinetic; lateral apex - akinetic;\n\nRIGHT VENTRICLE: The right ventricular free wall is hypertrophied. There is\nfocal hypokinesis of the apical free wall of the right ventricle.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\naortic valve stenosis. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Trivial mitral regurgitation is seen.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left ventricular cavity size is normal. There is moderate to severe\nregional left ventricular systolic dysfunction. Resting regional wall motion\nabnormalities include septal, anterior, and apical akinesis. No thrombus is\nseen but cannot exclude. The right ventricular free wall is hypertrophied.\nThere is focal hypokinesis of the apical free wall of the right ventricle. The\naortic valve leaflets are mildly thickened. There is no aortic valve stenosis.\nNo aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Trivial mitral regurgitation is seen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2111-03-18 00:00:00.000",
"description": "Report",
"row_id": 168652,
"text": "Sinus rhythm. Right bundle-branch block. Left axis deviation. Prior\nanteroseptal myocardial infarction. Occasional ventricular ectopy. Compared to\nthe previous tracing of there is no longer ST segment elevation in\nleads VI-V6 and the repolarizaetion abnormalities of right bundle-branch block\nare more appropriate. However, the initial portion of the ST segment in\nleads VI-V3 remains slightly elevated. These findings are consistent with\nrecent or interim anterolateral myocardial infarction. Clinical correlation is\nsuggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2111-02-26 00:00:00.000",
"description": "Report",
"row_id": 168653,
"text": "Sinus rhythm\nMarked left axis deviation\nRBBB with left anterior fascicular block\nProbable anteroseptal myocardial infarction with anterolateral ST-T\nconfiguration suggests acute process\nSince previous tracing of : lateral ST-T wave changes slightly less\nprominent\n\n"
},
{
"category": "ECG",
"chartdate": "2111-02-25 00:00:00.000",
"description": "Report",
"row_id": 168654,
"text": "Sinus rhythm\nMarked left axis deviation\nRBBB with left anterior fascicular block\nAnterior myocardial infarction with anterolateral ST-T configuration suggests\nacute process- clinical correlation is suggested\nSince previous tracing of the same date: further ST-T wave changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2111-02-25 00:00:00.000",
"description": "Report",
"row_id": 168655,
"text": "Sinus rhythm. Compared to the previous tracing the rate has increased. Right\nbundle-branch block and left anterior hemiblock persist. Anterior ST segment\nelevations also persist.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2111-02-24 00:00:00.000",
"description": "Report",
"row_id": 168656,
"text": "Sinus rhythm. Compared to the previous tracing no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2111-02-24 00:00:00.000",
"description": "Report",
"row_id": 168657,
"text": "Sinus rhythm. Broad QRS interval. Axis to the left. Notched P waves in\nlead II. Marked ST segment elevations in leads V2-V5. INT: Right bundle-branch\nblock. Left axis deviation. Left anterior hemiblock. Acute anterior injury\nwhich might represent an early phase of an infarction or a cardiac contusion.\nNo previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-03-04 00:00:00.000",
"description": "Report",
"row_id": 1371759,
"text": "NPN:\n\nNeuro: Alert and oriented to self, place, OR, month and year. Cont sl off at times--asking to go home but more appropriate today. Dozing intermittently-Haldol decreased to 1mg . MAE. Equal strength.\n\nCV: 90-100's SR with occ APC's-Cont on Cardizem 60mg QID, Bp-90-110/ 50-60's. Palp pedal pulses. 1+ edema bil hands and feet. Skin cool and dry.\n\nResp: Lungs coarse with wheezes intermittently-being treated with alb nebs, and flovent and combivent inhalers. Cont with lasix. Cough strong prod of mod amts thick white secretions. O2 sats> 94% on 2l nc.\nwheezes improve after nebs.\n\nGU: Voiding good amts of yellow urine. Cr stable.\n\nGI: Abd softly distended, Obese and round. +BS and flatus. No N/V. Tol sm amts of solids but good liquid intake.\n\nEndo: Covered with ss insulin for glucoses 130-160 per protocol.\n\nIncisions: Upper sternum C/D with Steristrips. Lower third with serosang dng- decreased from yest. Betadine and DSD applied at 10am and remains intact. R upper thigh cont with sm amt serous dng-DSD changed X1. Started on Levofoxacin po this am.\n\nActivity: OOB to chair all day--Does not find bed comfortable. Ambulated X2 with W/C and O2 at 3l approx 300ft- tol well in am-in afternoon with increased wheezes.\n\nComfort: Pt with increased c/o of incisional chest pain in afternnon after increased coughing--Tylenol given with little help-treated with percocet 1 with some effect.\n\nA: Remained in CSRU r/t sternal wound dng/click and pulmonary status.\n\nP: Cont sternal wound precautions with sterilt DSD-Change PRN. NPO after MN for possible OR. Clot to BB. Cont pulmonary toilet-inhalers and nebs. Cont amb per cardiac rehab. Case manager following for discharge planning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-03-03 00:00:00.000",
"description": "Report",
"row_id": 1371756,
"text": "PATIENT SLEEPING PEACEFULLY THRU THE NIGHT, INCREASED WHEEZING WITH COUGHING, ALBUTEROL NEB GIVEN WITH GOOD RESULTS. ALCOHOL DRIP OFF 630AM. REMAINS SR IN THE 90'S ON CAPTOPRIL/DILTIAZEM FOR UNLOADING. SAO2 07% ON 3LNP. PLEASANTLY CONFUSED NEEDS TO BE REORIENTED TO TIME/PLACE ??? CLEAR WITH SUN UP. ON DIAMX PRESENTLY FOR DIURESIS, K 4.2 THIS AM AFTER 40MEQ KCL IV. CA LOW THIS AM CA 2GMS GIVEN. STRENUM LOOKS GOOD, DSD PLACED OVER CTS SITES. RLEG OOZING SEROUS FLUID DSD CHANGED X3 THRU THE NIGHT.ENCOURAGE INCREASE DIET, OOB TO CHAIR , AMBULATION. MONITOR STATUS WITH DRIP OFF.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-03-03 00:00:00.000",
"description": "Report",
"row_id": 1371757,
"text": "NPN:\n\nNeuro: ETOH gtt stopped in early am. Pt oriented to self, place, month and year. Occassionally with some confusion and sl agitation requesting to go home now, asking for wife. Reorients easily. placed on haldol 2mg po BID. MAE. Follows commands and ambulated with PT. Bil hands with edema and some discoordination. PERRLA.\n\nCV: 90-100's SR-ST without VEA. On Cardizem. Captopril dc'd. BP 80-100's/ 40-60. Palp pedal pulses. A line and RIJ dc'd.\n\nResp: Lungs coarse with marked insp/exp wheezes at times--treated with ALB nebs, Combivent inhaler, diuresis and restated on Flovent inhaler. Strong cough productive of white secretions. RR 28- 36 most of day with swallow abd breathing. O2 sats> 95% on 3l nc O2.\n\nGI: Abd obese, round and softly distended. + BS, + belching and + flatus. Tol reg diet in sm amts- No N/V. Sm formed brown stool g-.\n\nGU: Foley to gd with good uo. Foley dc'd at 12n--DTV 20pm.\n\nEndo: Given ss reg insulin per protocol for glucoses 120's -160's.\n\nIncisions: Upper Sternal incision with S/S--clean and dry. At 1400 pt noted to have lg amt serosang drainage from lower third of sternal incision. and evaluated. DSD applied and changed X3. R upper thigh with sm serous dngDSD changed X2.\n\nComfort: Denies pain. No narcs given.\n\nActivity: OOB to chair X2-tol well. Ambulated with PT with W/C and O2 with 1 assist to doors of unit--See PT note.\n\nA: Clearing mental status-off gtts.\n\nP: Observe overnight, monitor sternal wound dng and WBC, If remains stable -transfer to 2 in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-25 00:00:00.000",
"description": "Report",
"row_id": 1371738,
"text": "CCU NPN 7P-7A\nNeuro: Propofol increased to 60mcg, requiring occ boluses for bronchospasm. Prior to increase pt had been open eyes and following commands, now is responding to pain only.\n\nCV: Tele SR 70s-80s, 1 9-beat run of AIVR. K 3.4, repleted w/ additional 60mEq IV KCL. BP 106-126/55-70. Nitro weaned off, given 25mg captopril-tol well but unsure if POs are being absorbed. PA pressures 21-35/16-19, PCWP 13-14. Last numbers 6.3/2.8/813. R groin C/D/I, no hematoma, palp pulses. CKs cont to trend up-1785/274.\n\nPulm: LS CTA, orally intubated. Ccc suctioning thick white sputum. Vent settings SIMV 650/12/40/5 PS 8, RR 12-20. Becomes bronchospastic w/ stimulation. Will change to CPAP @ 0600.\n\nGI/GU: +BS, abd soft and obese. Suctioned 530cc liquid w/ undigested meds from OGtube (had PO potassium earlier in the day which was ). Reglan started, HO still wants to cont some PO meds. Foley patent, draining cl yellow urine. Given 40mg IV lasix w/ good effect. -1.5L .\n\nSocial: son and daughter-in-law in to visit, updated by RN. Son expressing concern over his mother who was supposed to be d/c to home w/ services yesterday after being hospitalized for a perforated bowel. Emotional support given.\n\nA/P: S/P ant MI, VF arrest, LAD stent, hypokalemia. Lighten sedation and wean to extubate later this morning. Cont K repletion as needed, reglan, start beta blocker. Emotional support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-26 00:00:00.000",
"description": "Report",
"row_id": 1371740,
"text": "NEURO-SEDATED ON PROPOFOL 30MCGKGMIN. INTERMITTENT BOLUSES REQ'D FOR TRANSIENT HYPERTENSION. PERLA @ 2MM. REVERSALS GIVEN AS PT BEGINNING TO FLUTTER EYES.PROPOFOL WEANED TO 20MCGKGMIN.PT BECAME EXTREMELY ANXIOUS AND TACHYPNEIC,DESATTING TO 85%. UNABLE TO FOLLLOW COMMANDS TO ANXIETY R/T ETT. SPONTANEOUSLY MAE.MEDICTED WITH 4MG IVP MS04 & PROPOFOL INCREASED BACK TO 30MCGKGMIN.\n\nCV-NSR 75-85 NO ECTOPY. EPI/NEO/NTG/PROPOFOL GTTS. NEO/NTG TITRATED FOR LABILE BP. 3L LR. EPI DCD FOR CO/CI > 2.5 IABP 1:1. BOUNDING PP. EXTREMITIES COOL WITH +CSM.\n\nRESP-IMV 800x60x10 . SATS=98-100%. WEANED TO 50% WITH SATS=98%.\nREVERSALS GIVEN.PROPOFOL WEANED TO 20MCGKGMIN. WHEN AWAKE PT BECAME VERY ANXIOUS,TACHYPNEIC DE-SATTING TO 85%. SXD FOR SMALL AMT THIS WHITE SPUTUM. PT CONTINUED TO BREATH AGAINST THE VENT,GAGGING ON ETT. MEDICATED WITH 4MG IVP MSO4 AND PROPOFOL INCREASED TO 30MCGKGMIN. PT SEDATED TO INCREASE VENTIALTION.SATS INCREASED TO 100%. LS COURSE AT BASES. MIN->MOD. AMT. SANG DRG FROM CT WHEN GAGGING/COUGHING DECREASING~ 15CC/HR. WILL ATTEMPT VENT WEAN LATER IN SHIFT.\n\nG.I.-ABD OBESE,SOFT. ABSENT BS. OGT PLACEMENT COMFIRMED WITH BILIOUS DRG.\n\nG.U.- ADEQ AMT CLEAR YELLOW URINE FROM FOLEY.\n\nSKIN- STERNUM/RT LEG WITH STERI-STRIPS. C-D-I-. DSGS CHANGED.\n\nENDO-INSULIN GTT STARTED FOR 2 GLUCOSE LEVELS > 150.\n\nI.D.-CONTINUES ON VANCO 1 GM Q12H.\n\nPLAN-WEAN PROPOFOL,ATTEMPT VENT WEAN TO EXTUBATE. TITRATE NEO FOR BP.\nGLUCOSE LEVELS Q1H. CONTINUE WITH HEMODYMANIC MONITORING AND CSRU PROTOCOLS.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-26 00:00:00.000",
"description": "Report",
"row_id": 1371741,
"text": "ADDENDUM: VENT SETTINGS =IMV 40% 800X10X5/5. SATS=99%.PROPOFOL WEANED TO 20MCGGKMIN WITH PT AWAKENING & BECOMING WILD, THRASHING SIDE TO SIDE,CLAMPING DOWN ON ETT, & DISCOORDINATED BREATHING AND CLENCHED FISTS. ATTEMPTED CPAP WITH TV==250-350. PT WITH 20MCG PROPOFOL BOLUS AND 4MG IVP MS04. WILL NEED PRECEDEX GTT IN ORDER TO EXTUBATE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-25 00:00:00.000",
"description": "Report",
"row_id": 1371739,
"text": "CCU Nursing Progress Note\nS-\"I can't get rid of this back pain and now I have chest pain\"\nO-Neuro- Propofol at 20mcg/kg and pt very anxious and apprehensive pre extubation with rr 30's requiring haldol 2.5mg IVB x2 with good effect. Alert and oriented x3 post ETT very pleasant and cooperative.\nCV-Received captopril 25mg po at 0830 with SBP drop 68 30 minutes later, received 250cc NS bolus with good response but pt had first episode of chest pain. 3 episodes of mid back pain and SSCP elevations ant and TW flip V5-6. Relieved with restarting IV NTG at .70mcg/kg and MSO4 2mg IVB each time. Right fem venous sheath removed at 1300 and heparin started at 1200u/hr at 1400. The last chest pain at 1430 pt also c/o not feeling \"right\" with a 12 beat run AIVR. Defib pads applied and pt sent to the cath lab emergently. Please see careview for VS/rx. Cath revealed thrombosed stent LAD. Consult CSRUG and IABP placed and to OR at 1600 for CABG.\nCPK at 1400 3293/mb 243 has not peaked.\nResp-extubated succ at 0900 with RISB 70 although rr 30. Tolerated well and O2 weaned to 5lnp. LS coarse with congested NPC. Occ exp wheeze h/o asthma on MDI's. O2 sats 97%.\nID temp 101.6R with elevated WBC 19, started on levo po. One set BC sent. Urine cloudy.\nGU- urine output fair. Cr 1.2\nGI- +gag post ETT taking sips of water without nausea.\nSkin-Right groin no hematoma post sheath removal. Pedal pulses 2+/2+\nSocial-son and daughter into visit and daughter is pt helath care proxy copy in the chart.\nAccess-3 PIV\nFull code\nA/P Ant MI s/p LAD stent now thrombosed for CABG\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-26 00:00:00.000",
"description": "Report",
"row_id": 1371742,
"text": "NURSING PROGRESS NOTE SEE CAREVIEW FOR DETAILS\n\nNEURO:PT DID AWAKEN ,EXTREMELY AGITATED AND VERY TACHYPNIC .PUPILS 1MM TO 2MM AND PERL.PT MOVED ALL EXTREMITIES BUT NOT TO COMMAND.PT DID NOD APPROPRIATELY WHEN ASKED QUESTIONS.REQUIRED SEDATION WITH MS .USED PRECEDEX FOR SEDATION STILL AWOKEN ON MAX DOSE WAS CHANGED BACK TO PROPOFOL.\n\nCV:REMAINS IN NSR WITHOUT ECTOPY,HR FROM 70 TO 80. IABP WAS ON 1:2 AND WAS REMOVED AT 1530.REMAINS ON NTG AND NEO FOR BP CONTROL.TEMP WAS ELEVATED TO 101 MEDICATED WITH TYLENOL .SYSTOLIC BP 110 TO 130,DIASTOLIC BP 60 TO 70.PCWP 30,MD AWARE.ATRIAL WIRES RETESTED AND DO NOT WORK,VWIRES WORK, IN VVI MODE RATE OF 60 V OUTPUT 10 AND V SESITIVITY 0.8.NEW LEFT RADIAL ALINE INSERTED,RIGHT RADIAL ALINE DAMPENED.RIGHT FEMORAL SITE DSG INTACT BIL DP PULSES AND PT PULSES PRESENT PALPABLE AND BY DOPPLER ALSO.\n\nRESP:REMAINS INTUBATED ON SIMV AND PS OF 5 WITH PEEP OF 5CM,TV 800,RESP RATE OF 12,FIO2 40%.BREATH SOUNDS COARSE AND RHONCHOROUS BUT DIMINISHED ALSO ESPECIALLY AT RIGHT BASE.CHEST XRAY DONE.WHEN PT AWOKEN HE BECAME TACYPNIC AND DESATURATED.SP02 98 TO 100%.\n\nGI:ABD LARGE AND SOFT WITH QUESTIONABLE FAINT BOWEL SOUNDS PRESENT.OGT TO LCS DRAINING BILIOUS GREEN DRAINAGE.\n\nGU:FOLEY TO CD DRAINING LOW URINE OUTPUTS AROUND 20CC/HR.TEAM AWARE,NO LASIX AS YET.\n\nENDOCRINE REMAINS ON INSULIN GTT .\n\nSOCIAL:GRANDSON VISITED,UPDATED PTS SON AND DAUGHTER ON PHONE\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-24 00:00:00.000",
"description": "Report",
"row_id": 1371737,
"text": "ccu nursing progress note\ns: orally intubated. comm via nodding\no: pls see carevue flowsheet for complete vs/data/events\narrived from cath lab at 9:30am.\nneuro: awake this afternoon. intermittently sedated w fent/versed then propofol gtt this eve for sheath pull. when awake pt is cooperative. has diff w ett/gagging coughing vigorously. mae w purpose. denies discomfort.\n\ncv: hr 70-90s sr, no vea. noted. k 2.6 on arrival. cont to replete. last k 3.6 . another 40 infusing. bp 130-170/60-70. ntg started and ^'d to keep sbp <140. also started on captopril, rec'd 2 doses at 12.5mg. next dose will be 25mg.\nr fem aline dc'd at 6:30pm. r fem pa line in place. paps 30s/22-26. cvp 11-14. co 5.3, ci 2.4. mv sat 74.\nck 1250 at 4pm, 3rd due 10p-12m\nfem site d/i, pulses palp.\n\nresp: imv 650 x12, 40%, 5peep. did well on ps (, tv 300-350, rr low 20s) and were planning on extubating but then had fem art line dc'd and plan to sedate for hemostasis x sev hours, will wean and extubate in am after further diuresis.\nsxn'd for clear to white secretions. bs with scatt exp wheezes. rec'ing combivent by rt.\n\ngi: ogt in place.\ngu: rec'd lasix 20mg x2. currently 500cc neg. post cath ivf now dc'd after 400cc infused.\nsocial: family visited. left numbers. haven't called this eve.\n\na: s/p ant mi, stent to lad. chf. hypokalemia.\np: follow volume status, filling pressures. diurese as indicated. monitor for bleeding precautions. sedate overnoc. plan to wean and extubate in am. d/c fem pa line tomorrow. support to pt and family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-03-01 00:00:00.000",
"description": "Report",
"row_id": 1371751,
"text": "shift update:\n\nneuro: cont on etoh gtt at 10cc/hr. alert. oriented to self & aware in hospital. mae. following commands. calm & cooperative. haldol given x1 for restlessness with fair effect. denies pain.\n\ncardiac: nsr. hr 80-90's. no vea. sbp>140. started on po lopressor. ct's d/c'd. epi wires secured. + palp pp bilaterally. K+ repleated. swan d/c'd. cordus intact.\n\nresp: extubated at 8am. post extubation abg's acceptable. lungs clear with expiratory wheezes note at times. neb tx's given by rt. strong/productive cough=>thick white sputum. sat's>96% on 4l nc.\n\ngi/gu: ogt d/c'd. +bs. tolerating diet w/o difficulty. uop>30cc/hr. lasix given as ordered.\n\nendo: fs covered with ss reg insulin. see flow sheet.\n\nplan: monitor neuro status. cont etoh gtt. pulmonary toilet. nebs per rt. fs qid. monitor labs. pain management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-03-02 00:00:00.000",
"description": "Report",
"row_id": 1371752,
"text": "PATIENT INTIALLY VERY RESTLESS, BATHED, ENCOURAGED TO SLEEP, REPOSTIONED SEVERAL TIMES, RAISING THICK WHITE SPUTUM, GOOD SATS 97% ON 3LNP. SR IN THE 90'S, AFEBRILE. FINALLY RESTING MORE BY 1AM. GOOD U/O THRU THE NIGHT, K2.8 POKCL GIVEN 40MEQ. AM LABS TO BE SENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-03-02 00:00:00.000",
"description": "Report",
"row_id": 1371753,
"text": "PATIENT IMPROVING, IN VOICE STRENTGH, COUGHING UP THIN WHITE SECRETIONS THISAM, WGT. COMING DOWN NICELY, AM LASIX GIVEN , K REPLACED X2 WITH 40MEQ KCL PO. RESP-- ON 3LNP WITH SATS 97%. GI__ SM. BM THIS AM INCREASE DIET THIS AM, ??? OOB TO CHAIR THIS AM. PATIENT HAD STARTED ON LOPRESSOR LAST NIGHT PLAN TO CHANGE TO DILTIAZEM THIS AM, PLAN TO D/C LOPRESSOR. ORIENTATION CONTINUES TO IMPROVE. STRENUM CLEA/DRY, MEDIASTINAL DSG D/I, RUPPER LEG LOTS OF SEROUS FLUID REDRESSED X4 ...\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-03-02 00:00:00.000",
"description": "Report",
"row_id": 1371754,
"text": "NEURO ALERT BUT CONFUSED IN AM UNABLE TO STATE TIME OR PLACE STATES \" GET MY WIFE OFF THE CEILING \" C/O OF THE THINGS MOVING ON THE WALL ETOH DRIP WEANING DOWN HALDOL X 2 DOSES WITH LITTLE EFFECT ETOH DRIP DOWN TO 2.5 IMPROVED MENTAL STATUS 6PM ABLE TO STATE TIME VAGUE REGARDING MOVES ALL EXTREMETIES\n\nC/V NSR TO ST CAPTOPRIL AND CARDIZEM STARTED TOL WELL B/P MAP < 90 UNLESS AGTITATED HR 90-100 GOOD PEDAL PULSES EPI WIRES ATTACHED AND SECURED\n\nRESP INCREASE SOB WITH EXERTION LUNGS WHEEZES AT TIMES O2 4L NC SATS 97-99% INCREASE CONGESTION COARSE WITH CRACKLES IN BASES 1400 EXTRA LASIX GIVEN WITH IMPROVED RESP STATUS USING IS WELL WITH ENCOURAGMENT PRODUCTIVE FOR MOD AMTS WHITE SECRETIONS\n\nGU/GI ABD SOFT MOD FORMED STOOL X1 COMMODE TODAY GUIAC NEGATIVE ADEQUATE URINE OUTPUT TOL PO DIET WELL WITH ASSIST EATING\n\nPLAN CONTINUE TO WEAN ETOH TO OFF CONTINUE TO ASSESS MENTAL AND RESP STATUS\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-03-02 00:00:00.000",
"description": "Report",
"row_id": 1371755,
"text": "7p-11p\n\n\nNuero status unchanged - conversation is confused, speaking giberish, but when you ask him a question, he can answer it - Knows the month, but not the day, knows the year, the president, knew he was in , but didn't know exactly where. Follows commands well, such as using the IS correctly to almost 1 liter. Breath sounds essent clear, but RR=28-32 w/ wheezes, DOE. Recieved resp tx. Remains on ETOH gtt at 2.5cc/hr. Resting comfortably at this time.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-28 00:00:00.000",
"description": "Report",
"row_id": 1371747,
"text": "Neuro; Increased agitation throughout noc. Prop up to 30 and pt is still restless.PERRL Alcohol drip at 10cc/hr\nRESP;No vent changes made, sats99% on CPAP course lung sounds, SX for thick phlem CT possibly removed today\nCARDIO; SR NEO weened to .5,NTG .25,SBP>90 Cardiac profile WNL Pacer wires attached\nGI;ABd soft, NG to LIS Possibly start TF today BS active\nGU; F/C draining cl yellow urine. Good resluts with 0600 lasix. K replacement given\nSkin; R leg healing, Groins eechmotic from IABP site.Chest drsg D/I\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-28 00:00:00.000",
"description": "Report",
"row_id": 1371748,
"text": "shift update:\n\nneuro: cont on etoh gtt at 10cc/hr. propofol slowly weaned to off. haldol given prn with good effect. alert. mae. inconsistantly following commands. appears agitated at times but calms easily. pearl.\n\ncardiac: nsr with rare pvc noted. K+ repleated no further pvc's noted. hr 70-90's. hr>115 prior to haldol. ntg cont at 0.25mcg/kg/min. neo titrated to keep sbp~110. ci>2.5. ct drainage minimal. epi wires attached to pacer/pacer off. +pp bilaterally.\n\nresp: cont on cpap 40%fio2 10ps/5peep. abg's acceptable. lungs coarse. suctioned for thick white sputum.\n\ngi/gu: +bs. +flatus. ogt->lws with billious drainage. uop<30cc/hr foley irrigated & ballon deflated unable to aspirate irrigant. foley changed without difficulty. uop>30cc/hr.\n\nendo: insulin gtt titrated per protocol.\n\nplan: cont to monitor neuro status. haldol prn for agitation. monitor hemodynamics. pulmonary toilet. ?extubate when appropriate. insulin gtt per protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-28 00:00:00.000",
"description": "Report",
"row_id": 1371749,
"text": "Anxious, thrashing a round in bed resp ratew 30-35 with vt 300, attempted to increase ps to 15 vt remain 300-400 with resp rate 28-34, cont to be restless - if ambued calmed down - changed to imv rate 12 with vt 800 ps 10 and peep 5 to rest - seemed effective he calmed down resp rate 16-24, but at times became agitated again. having some discomfort in chest from incision - treated with morphine and then percocet with relief. he still was anxious given haldol x2 doses with good response now. he is calm presents as sleeping - but b/p decreased and neo restarted for b/p. will cont to monitor closely. He is appropriate when asked questions nods yes/no, follows commands and has generalized weakness but can lift and hold up all extremeties. Restraints removed to decrease agitation with good effect - RN at bedside and he has been cooperative and reinforced multiple times not to touch tubes. will cont to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-03-01 00:00:00.000",
"description": "Report",
"row_id": 1371750,
"text": "Received multiple doses of haldol with some effect did need frequent reassurance - currently on CPAP 5/5 - ABG good - plan to possibly extubate. Neo weaned off cont to monitor b/p, denies pain. Penis is eccymotic - was very swollen and foreskin up last evening - pulled down by md - need to monitor closely. following commands calms with verbal reassurance and holding his hand - no family calls/visits this shift\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-26 00:00:00.000",
"description": "Report",
"row_id": 1371743,
"text": "UPDATE.PT WAS STARTED ON COMBIVENT INHALER WHICH HAS IMPROVED WHEEZES AND BREATH SOUNDS.DAUGHTER WAS CALLED AND ASKED IF HER FATHER DRANK SHE SAID, ONE BEER AND A SHOT EVERY DAY.PLAN TO START PT ON ALCOHOL GTT THEN WEAN PROPOFOL AS TOLERATED.TEAM HAS SEEN AND EVALUATED PT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-03-05 00:00:00.000",
"description": "Report",
"row_id": 1371760,
"text": "NEURO: A+Ox3. Pt slept in chair for most of the night. Medicated for cough induced incision pain with 1 percocetX2 with effect noted.\n\nCV: Stable bp/hr. no ectopy.\n\nRESP: Lung are clear. Occ upper airway wheezes. resolved with albuterol inh/nebs.\n\nGU: Voided 300 cyu.\n\nSKIN: No drainage from chest incision site. DSD intact.\n\nASSESS: STABLE.\n\nPLAN: Start Diet. Transfer to 2 when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-27 00:00:00.000",
"description": "Report",
"row_id": 1371744,
"text": " B:\n\nNeuro: alert while on 30 of prop and etoh gtt,-though does not follow commands consistantly and is very agitated and is kicking and waving hands around and arching himself while in bed in bed. pearl, mae, lightly sedated while on 40 of prop.\n\nCardiac: nsr in the 70's no ectopy noted, sbp's in the 110's, while on nitro per dr. , and neo for bp support. running temps throughout night md aware tx with tylenol with little results, was cultured on earlier shift for temp. does have weak palpible pulses in both feet bilat, +3 edema in extremities. 2 a and 2 w wires -a wires do not sense or capture.\n\nSkin: chest with dsd that is cdi, right leg ace cdi, let fem old ballon site with dsd is cdi, right fem site with dsd cdi, ct insertion sites with dsd's that are cdi.\n\nResp: remains on vent, abg's good rhonchi in upper lungs dim in lower, no leak in ct system.\n\nGi/gu: npo,og-tube to lws with billeous drainage, hypo-active bowel sounds, on insulin gtt per protocall, 30cc/hr or greater of urine.\n\nplan: ween to extubate if pt is not agitated, monitor i/o's monitor hr,rhythm and bp's, monitor blood sugar levals, calm pt down when needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-27 00:00:00.000",
"description": "Report",
"row_id": 1371745,
"text": "SHIFT UPDATE:\n\nNEURO: CONT ON ALCOHOL GTT AT 10CC/HR. PROPOFOL WEANED TO 10MCG/KG/MIN. MAE, OPENS EYES, NOT FOLLOWING COMMANDS. MIDAZ 2MG GIVEN X1. MSO4 4MG GIVEN Q2H WITH GOOD EFFECT.\n\nCARDIAC: NSR. HR 60-70'S. RARE PVC'S NOTED. K+ & CA REPLEATED. CI>2.0. NTG CONT AT 0.25MCG/KG/MIN. NEO TITRATED TO KEEP SBP~110. PACER SET FOR V-DEMAND AT RATE OF 60. CT DRAINAGE MINIMAL. +PP BILATERALLY.\n\nRESP: CONT ON SIMV+PS AT RATE OF 12 40%FIO2. ABG'S ACCEPTABLE. SUCTIONED FOR THIN->THICK WHITE SECREATIONS.\n\nGI/GU: OG->LWS WITH BILLIOUS DRAINAGE. +BS. UOP>50CC/HR AFTER LASIX.\n\nENDO: CONT ON INSULIN GTT PER PROTOCOL. SEE FLOW SHEET.\n\nPLAN: CONT TO WEAN PROPOFOL. MONITOR NEURO STATUS. ?EXTUBATE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-27 00:00:00.000",
"description": "Report",
"row_id": 1371746,
"text": "ATTEMPT MADE AGAIN TO WAKE & WEAN. PROPOFOL OFF W EPISODIC SEVERE AGITATION,THRASHING LIMBS,ATTEMPTING TO TURN OVER ETC.TACHYPNEIC,DIAPHORETIC. NO EYE CONTACT,NOT FOLLWING COMMANDS. RESEDATED W PROPOFOL. REMAINS ON ALCOHOL GTT.? NEED FOR CT/NEURO EXAM IN INTUBATED PT. S/P VF ARREST W CPR PRE CABG.FEBRILE->APAP & BC X 2. PANCULTURED ,RESULTS PENDING. CHANGED TO CPAP W IPS W ACCEPTABLE SPONT. TV'S,INCREASED COMFORT. SUCTIONED FOR THIN WHITE SECXRETIONS. WHEEZY W EXERTION,COUGHING,MDI'S CONTINUE.REMAINS NSR W 1 6 BT RUN VT. MG++ & KCL REPLETED,NO FURTHER ECTOPY OBSERVED.EXCELLENT HEMODYNAMICS W CONTINUED NEO REQUIREMENT.SEE FLOW SHEET. ABD. SOFT,+ BOWEL SOUNDS. PLAN BEGIN TF'S IN A.M.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-03-04 00:00:00.000",
"description": "Report",
"row_id": 1371758,
"text": "shift update:\n\nneuro: oriented to self. not oriented to place. stated then corrected self by saying . forgetful yelling that he asked for a neb tx & didn't recieve one when he did. mae. following commands. transfered to commonde/chair with assist. gait unsteady. denies pain.\n\ncardiac: nsr. no vea. hr 90's. sbp 90-120's. epi wires secured. sternal incision with mod amt ss drainage->dsd changed. right leg incision with ss drainage->dsd changed. +pp bilaterally. k+ repleated.\n\nresp: rr 20-30's. lungs wheezy at times. sat's 92-98% on 3lnc. +thick white sputum. pt encouraged to cdb.\n\ngi/gu: +bs. tolerating po liquids. x1 small stool. voided on commode 250cc x1.\n\nendo: fs tx's with ss reg insulin per protocol.\n\nsocial: family into visit & called.\n\nplan: transfer to 2 in am. ?need for sitter. nebs/inhalers as ordered. monitor neuro status. monitor incisions.\n"
}
] |
28,315 | 108,486 | This is a 76 year old female admitted with persistent abdominal pain and bloating from Rehab. By CT - shows stricture in the sigmoid region as well as an upper R lung mass. On patient underwent a tranverse loop colostomy for small bowel obstruction. Postoperative course complicated by tachycardia, respiratory failure, nonoperative lung mass, urinary tract infection, several admissions to ICU for tachycardia and respiratory difficulty. Cardiology Consult - Postoperatively patient had several periods where she became tachycardic 130's she remained tachycardic after fluid resuscitation and no longer febrile. They continue to feel that her tachycardia is related to fluid shifts and normal physiologic response. Geriatric Consult - Patient is somewhat angry regarding diagnosis and need for colostomy. Geriatric service was helpful prior to patient's surgery in helping her through her anger. Social Work - Patient has been followed throughout hospital course. Working with patient and family. Thoracics Consult - nonoperative lung mass, small cell lung cancer to be followed up with radiation/oncologist - Dr. for radiation treatments. Problems 1. Respiratory - Saddle PE/sm. cell lung cancer/CHF/Asthma - postoperative course as above. Current respiratory status - Bilateral breath sounds clear with few exp. wheeze and fine crax. in R base. For last 4 days patient has been running 95-100% oxygen saturations. 2. Cardiac - tachycardia/hypertension - postoperative course as above. Echo normal RV size amd free wall motion. LVEF 45-50%, septal hypokinesis, No asd/vsd seen. Mild pulmonary artery hypertension. No effusion. Currently patient remains tachycardic 100-120. Blood pressures ranging 100-140 systolic. Remains on lopressor 25mg . 3. Anticoagulation - Currently patient on coumadin 5mg po daily and fondaparinux sc. INR today = 1.7. Fondaparinux should be discontinued when INR . Then titrate coumadin to maintain. 4. Infectious Disease - MRSA - via nasal swab, VRE - via rectal swab 5. Malnutrition - Currently patient on soft diet with cycled TPN. Needs much encouragement with PO intake. 6. Fluid Shifts - Patient continues to have a large amount of ostomy output. Will need strict monitoring of intake and output to ensure balance. 7. Follow up - Dr. (surgeon) in one week. Dr. (radiation oncologist) for radiation therapy for lung ca. Will fax this discharge summary to PCP . in for continuation of care. | Pt HIT +; has IVC filter, venodynes, and lovenox for DVT prophylaxis.NEURO: Pt lethargic, yet arouses to voice/stimulation. Once pt was admitted to TSICU, was placed on NIMV, with improvement in respiratory status. sepsis.Pt admitted to from Hosp. : Wean off supplemental O2, hemodynamics, give fluid boluses PRN for hypotension as long as pt tols fluid, bld cultures pnding, cont anbx as ordered, I/Os, ? CXR obtained/ABG sent- revealed resp acidosis. Pt receiving vanco, zosyn, and flagyl for anbx coverage. SOAP NoteSee Carevue for significant data.Significant Events: TPN discontinued, CVL removed, continues to wait for transfer to 9.Neuro: A&O x3, follows commands, pleasant. assessment as noted in carevueres: RISBI 36 this am, ls clear, remains on CPAP , ABG wnl, succtioned for scant amntcv: sedation was increased which helped to keep sbp<150, in NSR/S.tachl.leg is swallen,warm, +pulseslabs: hct 25, bs scale covered with ,neuro: off sedation follows simple commands, open eyes to name, on fentanyl and versed gttgi: ngt placement was confirmed with x-ray: pospyloric. Please refer to chart for rest of home medicationsPt has multiple allergies- Iodine, heparin (HIT positive), erythromycin, PCN, ASA, NSAIDS, Sulfa, doxycycline, neurontin, vioxx, singular, and latex.Pt remains full code and universal precautions.SHIFT EVENTS: Pan cultured, arterial and central lines placed for closer monitoring, CXR x2, and ECHO performed.ROS:RESP: Pt transfered from 9 in 'resp distress'- pt on non-rebreather at that time, however continued to experience respiratory acidosis/SOB, whereupon pt placed on NIMV for a period of time with minimal improvement in acidosis. PICC RAC new small sang drainage.Endo: , adequate coverage.ID: Afebrile, WBC 6.6, cont on flagyl, vanco.Psychosocial: mo family contact .P: OOB, start PT severe deconditioning. +BS, softly distended abdomen. Oriented to place only.PLAN: Cont to monitor GI status, HD status and fluid balance. Left SC TC C/D; L radial a-line C/D, intact. Sputum cx if pt able to raise. Hypoactive BS. Foley patent clear to cloudy urine. IVF KVO.Skin: grossly intact w/o pressure areas. IVC filter in place.Resp: Clear lung sounds bilaterally in upper lobes, diminished in bases. Pt placed on NIMV as documented. + pedal pulses, cap refill < 3sec. Pt saturation remained >98%, no longer tachypenic or c/o SOB- team decided to place pt on NC. BUN 28, creatinine 0.5, Na 134, K 5.1, Ca 7.4, Mg 2.1, Phos 4.8. Rsbi 29, placed on cpap. CT revealed SBO /? Pt taken off for central line placement. re-start b-blockers in light of MAT. Follow up ABG showed resp acidosis. Pt tachypenic/tachycardic with + wheezing. HR 120 this am at 0600 and SPB stable at 100-120 range, 0600 meoprolol dose held. Patient remains unresponsive to external stim in spite of propofol wean to 10mcg.PLAN: cont vent support and pressors/sedation; wean to extubate as tol, monitor HD status. Abd soft, BOS +, ngt cont to draing pale bilious secretions. Pulses palpable 2+throughout; 2+ anasarca. Pt remains afebrile; temperature is 95-97 at baseline. Admission Note, 0700-(Continued) #7 for transverse loop colostomy, abd softly distended, +BS, abd NT, colostomy intact- stoma protruding and pink, moderate amts of thick liquid greenish brown stool draining from colostomy. Mild (1+) mitral regurgitation is seen. Trivial mitral regurgitation is seen. Mild [1+] TR. Mild [1+] TR. Mild mitralannular calcification. Normal interatrial septum. Normal tricuspid valvesupporting structures. Goal SVO2>65.Remains tachy in 120' aware. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Temp 103.6 rectal. Low normal LVEF. ?sigmoid stricture. Right PICC dc'd in ED. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild (1+) MR. LV inflow uninterpretable due totachycardia and/or fusion of spectral Doppler E and A wavesTRICUSPID VALVE: Normal tricuspid valve leaflets. Right ventricular sizeand function now appear normal. Mildly dilated ascending aorta. BP labile. Otherwise, within normal limits. Lactate 0.7. Abdomen firmly distended. Left ventricular wall thicknesses arenormal. Non-specificST-T wave changes. Non-specific anterior ST-T wave changes. Trace aortic regurgitation isseen. There is no pericardial effusion.Compared with the findings of the prior study (images reviewed) of , the interventricular septum is now hypokinetic. Noresting LVOT gradient. Mild thickening of mitral valve chordae. There is mild pulmonaryartery systolic hypertension. NoASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness and cavity size. Levophed gtt started, fluid boluses given. Mildly depressedLVEF. PERSISTANT SINUS TACH 100-116, BP TOLERATING LOPRESSOR WELL. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. ?dilutional.Type and cross sent from ED. Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. Theascending aorta is mildly dilated. BP stable 120's-140's. There is mild pulmonary arterysystolic hypertension. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Focal calcifications inaortic root. K+ REPLETED THIS AM. Left ventricular wallthicknesses and cavity size are normal. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. Pt tachy to 130's, hypotensive 80's/30's. Small LV cavity. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 67Weight (lb): 217BSA (m2): 2.10 m2BP (mm Hg): 110/65HR (bpm): 134Status: InpatientDate/Time: at 10:04Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. Abd firm and distended with hyperactive/high-pitched BS. Fluid bolus given x 2. Transfer to floor in am if pt remains stable. The aortic valve leaflets (3) are mildly thickened butaortic stenosis is not present. Hct 25.4. Very prominent resting sinus tachycardia. Right ventricular chamber size and free wallmotion are normal. Right ventricular chamber size and free wall motion are normal. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Current Hct 23.4. SVO2 80's. Thetricuspid valve leaflets are mildly thickened. There isno ventricular septal defect. The left ventricular cavity is unusually small. There is no pericardial effusion.Compared with the prior study (images reviewed) of , no change (thepatient is less tachycardic). ALERT AND ORIENTED X3, DENIES PAIN. 500cc NS fluid bolus given without effect. CT revealed SBO. Re-checked at -19.8. PRBC's now transfusing. CVP 5-11. PreSep cath placed in ED. SBP 120s. Tx to floor when appropriate. | 25 | [
{
"category": "Radiology",
"chartdate": "2125-10-22 00:00:00.000",
"description": "US GUID FOR VAS. ACCESS",
"row_id": 982603,
"text": " 9:54 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Needs TPN and will need at least a double lumen because she\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p transverse loop colostomy with poor nutrition\n\n REASON FOR THIS EXAMINATION:\n Needs TPN and will need at least a double lumen because she will need IV ascess\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for TPN, with history of colostomy.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Drs. and , the attending\n radiologist, who was present and supervising.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the basilic vein was\n punctured under direct ultrasound guidance using a micropuncture set. Hard\n copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guide wire and a double lumen catheter measuring 35 cm in length was\n then placed through the peel-away sheath with its tip positioned in the SVC\n under fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guide wire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double lumen\n 5 French catheter placement via the basilic venous approach. Final\n internal length is 35 cm, with the tip positioned in the junction of SVC and\n right atrium. The line is ready to use.\n\n\n\n\n\n (Over)\n\n 9:54 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Needs TPN and will need at least a double lumen because she\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-26 00:00:00.000",
"description": "Report",
"row_id": 1631990,
"text": "SOAP Note\nSee Carevue for significant data.\n\nSignificant Events: TPN discontinued, CVL removed, continues to wait for transfer to 9.\n\nNeuro: A&O x3, follows commands, pleasant. MAE, opens eyes spontaneously. Frequently found resting in bed.\n\nPain: Continues to have constant \"squashing\" pain in left shoulder which goes all the way to her back. Given .25mg Dilaudid IVP with acceptable pain relief.\n\nCV: Hr 90-110, BP WNL. Rare ectopy (PVC's). Continues on Fondaparin Sodium sc, refuses to wear multipodus, occasionally wears PBoots. IVC filter in place.\n\nResp: Clear lung sounds bilaterally in upper lobes, diminished in bases. No sputum. Did well with IS but needs encouragement to do more frequently. Tolerated activity well, but requires persuasion.\n\nSkin: Intact. Saccrum has redness from old yeast infection.\n\nGI: Ileocolostomy in left lower quadrant draining bilious/ brown stool that is less fluid than yesterday to a drainage bag to gravity. Stoma is large and pink. +BS, softly distended abdomen. TPN stopped, pt taking some POs-not much appetite.\n\nGU: Adequate clear to cloudy yellow urine with some sediment draining from foley catheter.\n\nEndo: Minimal coverage needed per .\n\nEndo: continues on vanco, flagyl, and Zosyn.\n\nSocial: Son visited today; night nurse described pt as getting a little agitated/restless, but appropriate behavior during this shift.\n\nPlan: Transfer to 9 when bed is available. Continue to monitor hemodynamics, replete lytes as needed. Monitor PO intake-encourage eating (soft foods only--dentures still missing at nursing home). Monitor respiratory status closely, manage pain. Activity as tolerated, encourage IS frequently. Continue to support pt and family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-25 00:00:00.000",
"description": "Report",
"row_id": 1631987,
"text": "NPPN, 1900-0700\nneuro: AAO x 3; lethargic, awakens to voice. PERRLa, no focal deficits. Has denied any pain until OOB when she c/o point tenderness over cervical neck area, no deficits.\n\nCV: ST, variable AEA, rate 100-120's. ~0300 pt developed MAT to 130's, responsive to single dose lopressor 5 mg SIV. MAP>60. Pulses palpable 2+throughout; 2+ anasarca. Pboots DVT prophy.\n\nPulm: sats > 95% on Np 2l. BS CTA upper lobes, dim left base, crackels right base. Non-productive cough; IS to 50cc w/ coaching.\n\nGI: abd soft, non-tender. Hypoactive BS. Large volume green-black liquid stool via colostomy;stoma pink. NPO, no nausea. TPN infusing.\n\nGU: F/C uirne clear yellow, adeaute OP. 24 hr -500cc, 2 liters. Lytes repleted aggressively. IVF KVO.\n\nSkin: grossly intact w/o pressure areas. MP boots prophy. Left SC TC C/D; L radial a-line C/D, intact. PICC RAC new small sang drainage.\n\nEndo: , adequate coverage.\n\nID: Afebrile, WBC 6.6, cont on flagyl, vanco.\n\nPsychosocial: mo family contact .\n\nP: OOB, start PT severe deconditioning. ? re-start b-blockers in light of MAT. Sputum cx if pt able to raise. ? image c-spine r/t new pain, unknown etiology. ? transfer to 9 later in day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-26 00:00:00.000",
"description": "Report",
"row_id": 1631988,
"text": "THIS NOTE WAS WRITTEN ON THE WRONG PATIENT. IT IS NOT FOR .\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-26 00:00:00.000",
"description": "Report",
"row_id": 1631989,
"text": "assessment as noted in carevue\n\nres: RISBI 36 this am, ls clear, remains on CPAP , ABG wnl, succtioned for scant amnt\n\ncv: sedation was increased which helped to keep sbp<150, in NSR/S.tach\nl.leg is swallen,warm, +pulses\n\nlabs: hct 25, bs scale covered with ,\n\nneuro: off sedation follows simple commands, open eyes to name, on fentanyl and versed gtt\n\ngi: ngt placement was confirmed with x-ray: pospyloric. T feeding was started last night goal 75/h, +bs, no bm, abd soft\n\ngi: icteric urine via foley\n\nskin: VAC drains to L.leg intact/patent, drained 700cc overnight, skin is warm/pink\n\nid: temp >100.5ax, remains on vanco\n\nsocial: family was in last night and was updated on pt comdition\n\npaln: maintain VAC/skin care, try to wean off vent and extubate, pain control, monotor ID/temp\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-19 00:00:00.000",
"description": "Report",
"row_id": 1631983,
"text": "Nursing Progress Note\n Please see carevue for details of care. Remains extubated requiring no sedation or pressor support. Maint MAP> 65 w/lopressor maint to control HR to 100-110 range, no effecxt noted on BP post lopressor dose. Remains off vent support overnight. BS clear, able to raise minimal secretions. Frequent mouthcare required.\n Colostomy draining light brown liquid stool. Also incontinent of large amt liquid brown stool this pm. Abd soft, BOS +, ngt cont to draing pale bilious secretions. Foley patent clear to cloudy urine.\n Has not required pain med. Denies pain or need for pain med. Answering questions in simple/one word answers appropriately. Oriented to place only.\n\nPLAN: Cont to monitor GI status, HD status and fluid balance. Monitor labs and replete lytes as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-24 00:00:00.000",
"description": "Report",
"row_id": 1631984,
"text": "Respiratory Care\n\n\n Pt received from floors in \"respiratory distress\" on a 100% non rebreather. ABG showed resp acidosis. Pt placed on NIMV as documented. Follow up ABG showed resp acidosis. Pt taken off for central line placement. ABG on 2lnc normal Pt continues on 2lnc. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-24 00:00:00.000",
"description": "Report",
"row_id": 1631985,
"text": "Admission Note, 0700-\n76 y.o.f. with long significant PMH/PSH triggered on 9 for respiratory distress. Pt called nurses station early this morning c/o SOB. Pt tachypenic/tachycardic with + wheezing. Sats 75% on 2L N.C., pt placed on non-rebreather with improvement in saturation. CXR obtained/ABG sent- revealed resp acidosis. Primary team felt that the patient required further monitoring for resp distress and unstable hemodynamics. Once pt was admitted to TSICU, was placed on NIMV, with improvement in respiratory status. Pt lined and cultured. ECHO performed this afternoon for evaluation of cardiac function. Team unable to diagnosis pt at this time, ? sepsis.\nPt admitted to from Hosp. 2 weeks ago w/ abd distention. CT revealed SBO /? stricture. Pt went to OR on for transverse loop colostomy.\nPt has significant PMH/PSH- includes saddle PE in of ', s/p IVC filter, spinal stenosis, PUD, mult ileuses, basal cell CA (newly diagnosed), cerebrovascular disease w/ sm vessel infarcts, migraines, OA, L eye blindness, depression, renal insufficiency, and OA. s/p choley, hysterectomy, skin lesion removal x4.\nPre-admission medications include HCTZ, lipitor, lisinopril, nystatin, verapamil, zyrtec, zofran, atrovent, and albuterol. Please refer to chart for rest of home medications\nPt has multiple allergies- Iodine, heparin (HIT positive), erythromycin, PCN, ASA, NSAIDS, Sulfa, doxycycline, neurontin, vioxx, singular, and latex.\nPt remains full code and universal precautions.\n\nSHIFT EVENTS: Pan cultured, arterial and central lines placed for closer monitoring, CXR x2, and ECHO performed.\n\nROS:\n\nRESP: Pt transfered from 9 in 'resp distress'- pt on non-rebreather at that time, however continued to experience respiratory acidosis/SOB, whereupon pt placed on NIMV for a period of time with minimal improvement in acidosis. Pt saturation remained >98%, no longer tachypenic or c/o SOB- team decided to place pt on NC. Pt remained on 2-3L NC the entire shift, maintained SBP >98%, RR 20s, and denied SOB. Respiratory acidosis corrected itself- pt no longer retaining CO2. LS clear with dim bases. No cough or secretions noted. Sputum culture ordered however unable to collect sample. CXR obtained this morning for confirmation of line placement.\n\nCVS: NSR to ST, no ectopy noted. HR 90-120s. ABP 84-113/44-56, MAP 58-78, CVP 3-12 (cvp positional). Pt remains afebrile; temperature is 95-97 at baseline. Pt pan cultured for ? sepsis. Pt receiving vanco, zosyn, and flagyl for anbx coverage. L ulnar aline and LSC CVL placed for additional monitoring/access. Pt also has R PICC, which was placed on . Pt occasionally hypotensive with SBP in low 80s- pt given 500cc of LR x2 with resolution in BP. Cardiac enzymes cycled. Results pnding. + pedal pulses, cap refill < 3sec. Pt HIT +; has IVC filter, venodynes, and lovenox for DVT prophylaxis.\n\nNEURO: Pt lethargic, yet arouses to voice/stimulation. Oriented x3. Neuro status intact. Pt denies pain/discomfort.\n\nGI: POD\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-24 00:00:00.000",
"description": "Report",
"row_id": 1631986,
"text": "Admission Note, 0700-\n(Continued)\n #7 for transverse loop colostomy, abd softly distended, +BS, abd NT, colostomy intact- stoma protruding and pink, moderate amts of thick liquid greenish brown stool draining from colostomy. Pt receiving TPN for nutrition.\n\nENDO: FS 122-144, pt given insulin per . stim test performed at noon, results pnding.\n\nGU: Foley draining moderate to lg amts c/y/u. + UTI. Maintenance fluid stopped once TPN started. BUN 28, creatinine 0.5, Na 134, K 5.1, Ca 7.4, Mg 2.1, Phos 4.8. Calcium repleted with 3gm calcium gluconate.\n\nSOCIAL: Pt lives at home with son who is pts HCP. Dr. spoke with son and updated him as to .\n\n: Wean off supplemental O2, hemodynamics, give fluid boluses PRN for hypotension as long as pt tols fluid, bld cultures pnding, cont anbx as ordered, I/Os, ? ID consult, cont to provide pt with emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-17 00:00:00.000",
"description": "Report",
"row_id": 1631978,
"text": "1400-1900\nadmitted from OR, transverse loop colostomy done, intubated, propofol, neo gtts on admission\n\nneuro: sedated on propofol gtt, no response to command, PERL\n\ncv: hr st(110-123), no ectopy, sbp 83-127, continues on neo gtt, now @ .5 mic/kg/, iv lopressor q 4 hrs\n\nresp: on 40%/AC 12/5 peep, bs+ all lobes, clear, sux sm amt yellow, no resp distress noted, sat 100\n\ngi: npo, ntg to low wall sux draining sm amt bilious material, colostomy pink, copious amts golden stool from colostomy, stoma nurse in, bag placed to gravity drainage, iv protonix\n\ngu: foley patent, clear yellow urine, good uo\n\nother: medicated with iv dilaudid x 2 for increased hr, no drop in hr noted after dilaudid, post op labs sent, K+ 3.8 & repleated\n\nplan: continue ventilatory support, wean vent as tolerated, wean neo as tolerated keeping map > 65, iv antibiotics as ordered\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-18 00:00:00.000",
"description": "Report",
"row_id": 1631979,
"text": "Nursing Progress Note\n Please see carevue for details of care. Remains intubated and sedated with propofol. Weaning propofol in attempt to wake patient and extubate. Neo also cont to maint MAP>65, was weaned down to 0.25mcg tol well early in shift then titrated back to 0.75mcg. Lopressor doses given for HR to 140's w/ good response and minimal effect on BP. HR 120 this am at 0600 and SPB stable at 100-120 range, 0600 meoprolol dose held.\n Vent weaned to CPAP 5/5 then increased to CPAP , repeat ABG pending. BS remain clear w/minimal secretions noted.\n Maint NPO, ngt to draining bilious gastric contents, sl blood tinged this am which cleared after tube irrigated. Colostomy draining golden brown liquid stool, foley patent clear-cloudy yellow urine.\n MED w/dilaudid 1m IV x2 overnight w/no effect on BP or HR noted. Patient remains unresponsive to external stim in spite of propofol wean to 10mcg.\n\nPLAN: cont vent support and pressors/sedation; wean to extubate as tol, monitor HD status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-18 00:00:00.000",
"description": "Report",
"row_id": 1631980,
"text": "resp Care\npt remains on vent. Rsbi 29, placed on cpap. Increasing Ps based on abgs. Suctioning for mod amt of thick white secretions. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-18 00:00:00.000",
"description": "Report",
"row_id": 1631981,
"text": "Respiratory Care\nPt weaned and extubated without complications.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-18 00:00:00.000",
"description": "Report",
"row_id": 1631982,
"text": "Nursing Progress Note\nSee Carevue for specifics\n\nEvents: Extubated without incident. Post-extub ABG's WNL.\n\nPt now resting comfortably, sleepy but , denies pain.\nContinues to have persistant tachyardia. Cardiac echo, EKG done today. Cycling enzymes. Next due at 20:00. Fluid bolus given x 2. BP labile. Attempting to wean off Neo-currently at 0.25. BP 100-117/40's. MAP 60's. CVP 5-11. Albumin 5% given. Lytes repleted.\nNGT to CLWS draining lge amts bilious drainage. Abdomen soft, +BS colostomy stoma pink draining large amts golden liquid stool.\nFoley draining minimal amts 30-40cc/hr CYU.\nSkin intact.\n\nPlan: Attempt wean pressors, keep MAP>65, fluid status, monitor stool/NGT output, follow labs. Transfer to floor in am if pt remains stable.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-13 00:00:00.000",
"description": "Report",
"row_id": 1631974,
"text": "Nursing Admit Note\nSee Carevue for specifics\n\n76 year-old female presented to ED from with 2 week history of abdominal distention. CT revealed SBO. ?sigmoid stricture. Pt tachy to 130's, hypotensive 80's/30's. Levophed gtt started, fluid boluses given. Temp 103.6 rectal. lactate 1.4.\nSepsis protocol initiated. pan cultured. PreSep cath placed in ED. SVO2 80's. Right PICC dc'd in ED. Given 1 gram tylenol, vanco, levaquin, flagyl. Hct 25.4. Re-checked at -19.8. ?dilutional.\nType and cross sent from ED. Transferred to SICU for further management.\nCurrently, pt is Afebrile. Lactate 0.7. SVO2 65-70. Crimson team aware. Goal SVO2>65.\nRemains tachy in 120' aware. 500cc NS fluid bolus given without effect. PRBC's now transfusing. Current Hct 23.4. BP stable 120's-140's. Levophed off.\nNGT to CLWS draining small amts clear to bilious drainage. Placement confirmed by XRay. Abdomen firmly distended. Hyperactive BS.\nFoley draining CYU ~30cc/hr. Team aware.\n\nPlan: Likely non-surgical management per Crimson team. Continue monitor fluid status, hemodynamics, abd exams, NGT drainage, antibiotics, follow labs, report changes to HO.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-13 00:00:00.000",
"description": "Report",
"row_id": 1631975,
"text": "Nursing progress note 0700 - 1500\nSee Carevue for specifics\n\nTMAX: afebrile\nNEURO: A & O x 3, MAE, follows all commands, very pleasant, denies pain.\nCV: ST (baseline, per patient) around 115, lopressor started with + result. No ectopy. SBP 120s. Distal pulses palpable.\nRESP: Sats 99% on 3L NC, LS clear/diminished at bases.\nGI: NPO, NGT to LCS putting out clear/brown drainage. Abd firm and distended with hyperactive/high-pitched BS. Small stool x 1.\nGU: Foley draining clear yellow urine at 20-60cc/hr.\nSOCIAL: Son called earlier in shift.\n\nPLAN: Cont GI/abd assessment & NPO tx for bowel rest. Provide emotional support. Tx to floor when appropriate.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-14 00:00:00.000",
"description": "Report",
"row_id": 1631976,
"text": "NURSING UPDATE\n UNEVENTFUL NIGHT. PERSISTANT SINUS TACH 100-116, BP TOLERATING LOPRESSOR WELL. AFEBRILE, PRESEPT CATH IN PLACE, CONT SVO2 IN 80'S. K+ REPLETED THIS AM.\n REMAINS NPO, ABDOMEN DISTENDED AND FIRM, BOWEL SOUNDS ACTIVE-> HYPERACTIVE, NGT DRAINING GREEN BILE->LWS. NO BM.\n ALERT AND ORIENTED X3, DENIES PAIN. SPOKE TO SON ON PHONE, PLEASANT AND COOPERATIVE WITH CARE BUT DECLINED BATH WHEN OFFERED X2.\n\nPT MONITORED .\nDR IN CLOSE ICU ATTENDANCE.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-10-17 00:00:00.000",
"description": "Report",
"row_id": 1631977,
"text": "76 yr old female with PMHX:Basal cell ca,RUL mass,spinal stenosis.Admitted via ER from with diagnosis bowel obstruction.S/P (L) Colostomy,huge amount of evacuation.Attempted PSV patient does not done well;high rate and Ve patient is placed back on A/C\n"
},
{
"category": "Echo",
"chartdate": "2125-10-24 00:00:00.000",
"description": "Report",
"row_id": 99041,
"text": "PATIENT/TEST INFORMATION:\nIndication: eval for hypokinesis.\nHeight: (in) 67\nBP (mm Hg): 89/53\nHR (bpm): 111\nStatus: Inpatient\nDate/Time: at 14:50\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mildly depressed\nLVEF. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses and cavity size are normal. Overall left ventricular systolic\nfunction is mildly depressed (LVEF= 45-50 %) with septal hypokinesis. There is\nno ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , no change (the\npatient is less tachycardic).\n\n\n"
},
{
"category": "Echo",
"chartdate": "2125-10-18 00:00:00.000",
"description": "Report",
"row_id": 99042,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 67\nWeight (lb): 217\nBSA (m2): 2.10 m2\nBP (mm Hg): 110/65\nHR (bpm): 134\nStatus: Inpatient\nDate/Time: at 10:04\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Low normal LVEF. No\nresting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Focal calcifications in ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Mild (1+) MR. LV inflow uninterpretable due to\ntachycardia and/or fusion of spectral Doppler E and A waves\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. No TS. Mild [1+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is unusually small. Overall left\nventricular systolic function is low normal (LVEF 50%) secondary to\nhypokinesis of the interventricular septum. There is no ventricular septal\ndefect. Right ventricular chamber size and free wall motion are normal. The\nascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. Trace aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , the interventricular septum is now hypokinetic. Right ventricular size\nand function now appear normal.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2125-10-24 00:00:00.000",
"description": "Report",
"row_id": 287682,
"text": "Very prominent resting sinus tachycardia. Lateral ST-T wave abnormalities\nare non-diagnostic but may be due to ischemia. Compared with previous\ntracing of the heart rate is faster. ST-T wave changes are more\napparent. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2125-10-22 00:00:00.000",
"description": "Report",
"row_id": 287683,
"text": "Resting sinus tachycardia at about 120 beats per minute. Non-specific\nST-T wave changes. Compared with previous tracing of the heart rate\nis somewhat faster. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2125-10-19 00:00:00.000",
"description": "Report",
"row_id": 287684,
"text": "Sinus tachycardia. Non-specific anterior ST-T wave changes. Compared to the\nprior tracing there is no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2125-10-18 00:00:00.000",
"description": "Report",
"row_id": 287685,
"text": "Baseline artifact\nSinus tachycardia\nModest T wave changes inferiorly in lead V2 - could be in part positional/\nnormal variant but clinical correlation is suggested\nSince previous tracing of , sinus tachycardia rate slower and right\nprecordial lead T wave changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2125-10-12 00:00:00.000",
"description": "Report",
"row_id": 287686,
"text": "Sinus tachycardia. Otherwise, within normal limits.\n\n"
}
] |
26,931 | 170,370 | 1. Escherichia coli septicemia -- MICU course as follows: Ms. refused central line placement. Her systolic pressures were in the 70s, but improved to the 90s with crystalloid and IV antibiotics (vanco/cipro/flagyl). Abdominal source was suspected after CT scan, and labs were consistent. She underwent ERCP for evacuation of cholelithiasis. Stent placement was successful, no purulent drainage was appreciated, but sphincterotomy was not performed because of hypoxia during the procedure. Numerous stones were retained, and gastroenterology feels she should have repeat ERCP with sphincterotomy and lithotripsy in 2 months. Blood cultures grew E. coli resistant to floroquinolones. Therefore, antibiotic was switched to ceftriaxone. Given bacteremia, 14 day total course of antibiotics recommended. A midline was placed, as the E. coli was not sensitive to any tested oral antibiotics, and she will required 10 additional days of IV ceftriaxone. 2. heart murmur -- Given bacteremia, and no previous documented heart murmur, I felt obligated to have an echocardiogram prior to discharge. There was no evidence of vegetation, and only trivial mitral regurgitation to account for the murmur. Since it was a TTE, if any of her additional blood cultures turn positive, a transesophageal echocardiogram may be warranted, but I think it would be very unlikely she has endocarditis. Notably, she did not have any positive blood cultures subsequent to the first. 3. hypertension -- initially held antihypertensives, but reinitiated prior to discharge. 4. COPD -- hypoxia during ERCP/MAC anesthesia, but stable upon presentation on the floor on two liters. Home COPD meds were continued, and she did not require supplemental oxygen for >24 hours prior to discharge. | Suboptimal technical quality, a focal LV wall motion abnormalitycannot be fully excluded.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 60Weight (lb): 199BSA (m2): 1.86 m2BP (mm Hg): 160/80HR (bpm): 95Status: OutpatientDate/Time: at 14:22Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). Trivial MR.TRICUSPID VALVE: No TR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is normal in size. Sinus tachycardiaConsider prior inferior myocardial infarction although is nondiagnosticSince previous tracing of , sinus tachycardia present The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened.Trivial mitral regurgitation is seen. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. SINGLE VIEW CHEST, AP: There are low lung volumes when compared to previous study with slight elevation of the right hemidiaphragm. Noaortic regurgitation is seen. Scans of the upper abdomen show mild intrahepatic bile duct dilatation and massive dilatation of the common bile duct. The gallbladder is dilated with smaller stones, but no son evidence of cholecystitis. Preserved global biventricular systolic function.If clinical suspicion for endocarditis persists, a transesophageal study isrecommended.Compared with the prior study (images reviewed) of , the findingsare similar. There is an anterior space which mostlikely represents a fat pad.IMPRESSION: No valvular vegetations or clinically-significant regurgitantvalve disease seen, but the study is technically suboptimal to rule outendocarditis. Mild mitral annularcalcification. The gallbladder is moderately distended, but shows no wall thickening nor any other signs of acute cholecystitis. of a cellulitis, other causes of infection PNA ruled out by CXR and urine was clean per er report. There are small stones within the gallbladder, the largest measuring 1.1 cm. She continues on cipro, vanco and flagyl, is afebrile, was not making urine in ER but then after fluid making 30-100 cc per hour, was lt yellow now more concentrated looking. sepsis, hypotension, responded to fluid bolus and antibiotics. weaned o2 down to 1L from 4L, pt is former smoker has a few crackles and exp wheezes.a: Pt with ? NPO for US of gallbladder today.P: plan is to keep BP greater than MAP 60, follow labs, fever, A stent was put in at the end of the study per endoscopic report. Findings: Severe dilatation of the distal and mid common bile duct was visualized with common bile duct measuring up to 3 cm. CONCLUSION: Choledocholithiasis with massive dilatation of the common duct, 2.8 cm common bile duct with stone and sludge within the common duct. Left ventricular wall thickness, cavitysize, and systolic function are normal (LVEF>55%). NPN 0100 AM--7Ams: " I'm at the hospital because I have low blood pressure"o: please see nursing admit note for history and other data as well as vitals in careview.Pt came here with hypotension and fever in nursing home, has had venous stasis, and ? 8:04 AM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: Please assess for cholecystitis and cholangitis. she is in charge of her own healthcare decisions per DTR, and pt is DNR/DNI.Md ordered US of gallbladder this am as pt dtr reports pt had recent infection. IMPRESSION: Massively dilated CBD with multiple filling defects consistent with the stones. Technique:10 fluoroscopic images were obtained without presence of radiologist. The cardiac and mediastinal contours are stable with unfolding of the aorta. REASON FOR THIS EXAMINATION: Please assess for cholecystitis and cholangitis. The liver, spleen and pancreas are unremarkable. IMPRESSION: No radiographic evidence of pneumonia. Pt received 8 liters in ER and 500 cc up here for bp 84/50, after bolus pt bp has been stable and she has not required further fluid. Intrahepatic biliary system and gallbladder are not visualized on this study. Discoid atelectasis is seen within the left mid lung zone. 7:43 AM ERCP BILIARY&PANCREAS BY GI UNIT Clip # Reason: ERCP done Admitting Diagnosis: SEPSIS FINAL REPORT INDICATION: 75-year-old woman with elevated alkaline phosphatase level. Admitting Diagnosis: SEPSIS MEDICAL CONDITION: 75 year old woman with elevated alk phos and h/o cholecystitis. Rightventricular chamber size and free wall motion are normal. Multiple large filling defects are noted within the distal CBD consistent with stones. No focal pulmonary opacities identified to indicate pneumonia. Due to suboptimal technicalquality, a focal wall motion abnormality cannot be fully excluded. The right kidney measures 11.8 cm in length and the left kidney 11.7 cm. FINAL REPORT ABDOMINAL ULTRASOUND CLINICAL INDICATION: 75-year-old woman with elevated alkaline phosphatase and history of cholecystitis. The common hepatic duct measures 2.3 cm in diameter and there is sludge within the common duct as well as a large stone in the common bile duct, which measures approximately 2.6 x 2.8 cm. Portal vein is patent with forward flow. 7:06 PM CHEST (PORTABLE AP) Clip # Reason: 75 yo with fever MEDICAL CONDITION: 75 year old woman with fever REASON FOR THIS EXAMINATION: 75 yo with fever FINAL REPORT INDICATION: Fever. | 6 | [
{
"category": "Radiology",
"chartdate": "2193-07-31 00:00:00.000",
"description": "ERCP BILIARY&PANCREAS BY GI UNIT",
"row_id": 975188,
"text": " 7:43 AM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: ERCP done \n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 75-year-old woman with elevated alkaline phosphatase level.\n\n Technique:10 fluoroscopic images were obtained without presence of\n radiologist.\n\n Findings: Severe dilatation of the distal and mid common bile duct was\n visualized with common bile duct measuring up to 3 cm. Multiple large filling\n defects are noted within the distal CBD consistent with stones. Intrahepatic\n biliary system and gallbladder are not visualized on this study. A stent was\n put in at the end of the study per endoscopic report.\n\n IMPRESSION: Massively dilated CBD with multiple filling defects consistent\n with the stones.\n\n If further detail is required please refer to ERCP report in CCC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-07-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 974842,
"text": " 7:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 75 yo with fever\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with fever\n REASON FOR THIS EXAMINATION:\n 75 yo with fever\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever.\n\n COMPARISONS: .\n\n SINGLE VIEW CHEST, AP: There are low lung volumes when compared to previous\n study with slight elevation of the right hemidiaphragm. The lungs are clear.\n Discoid atelectasis is seen within the left mid lung zone. No focal pulmonary\n opacities identified to indicate pneumonia. The cardiac and mediastinal\n contours are stable with unfolding of the aorta.\n\n IMPRESSION: No radiographic evidence of pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-07-30 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 974899,
"text": " 8:04 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: Please assess for cholecystitis and cholangitis.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with elevated alk phos and h/o cholecystitis.\n REASON FOR THIS EXAMINATION:\n Please assess for cholecystitis and cholangitis.\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL ULTRASOUND\n\n CLINICAL INDICATION: 75-year-old woman with elevated alkaline phosphatase and\n history of cholecystitis.\n\n COMPARISON STUDY: .\n\n Scans of the upper abdomen show mild intrahepatic bile duct dilatation and\n massive dilatation of the common bile duct. The common hepatic duct measures\n 2.3 cm in diameter and there is sludge within the common duct as well as a\n large stone in the common bile duct, which measures approximately 2.6 x 2.8\n cm. The gallbladder is moderately distended, but shows no wall thickening nor\n any other signs of acute cholecystitis. There are small stones within the\n gallbladder, the largest measuring 1.1 cm. No tenderness was elicited during\n the scanning.\n\n The liver, spleen and pancreas are unremarkable. There is no ascites. Portal\n vein is patent with forward flow.\n\n The right kidney measures 11.8 cm in length and the left kidney 11.7 cm. Both\n are normal in appearance.\n\n CONCLUSION: Choledocholithiasis with massive dilatation of the common duct,\n 2.8 cm common bile duct with stone and sludge within the common duct. The\n gallbladder is dilated with smaller stones, but no son evidence of\n cholecystitis.\n\n Findings were relayed to Dr. by telephone at the completion of the\n study.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-07-30 00:00:00.000",
"description": "Report",
"row_id": 1614293,
"text": "NPN 0100 AM--7Am\n\ns: \" I'm at the hospital because I have low blood pressure\"\n\no: please see nursing admit note for history and other data as well as vitals in careview.\n\nPt came here with hypotension and fever in nursing home, has had venous stasis, and ? of a cellulitis, other causes of infection PNA ruled out by CXR and urine was clean per er report. Pt received 8 liters in ER and 500 cc up here for bp 84/50, after bolus pt bp has been stable and she has not required further fluid. She continues on cipro, vanco and flagyl, is afebrile, was not making urine in ER but then after fluid making 30-100 cc per hour, was lt yellow now more concentrated looking. Neuro wise pt is ox , cooperative. she is in charge of her own healthcare decisions per DTR, and pt is DNR/DNI.\nMd ordered US of gallbladder this am as pt dtr reports pt had recent infection. Pt is NPO. weaned o2 down to 1L from 4L, pt is former smoker has a few crackles and exp wheezes.\n\na: Pt with ? sepsis, hypotension, responded to fluid bolus and antibiotics. NPO for US of gallbladder today.\n\nP: plan is to keep BP greater than MAP 60, follow labs, fever,\n\n"
},
{
"category": "Echo",
"chartdate": "2193-08-02 00:00:00.000",
"description": "Report",
"row_id": 80869,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 60\nWeight (lb): 199\nBSA (m2): 1.86 m2\nBP (mm Hg): 160/80\nHR (bpm): 95\nStatus: Outpatient\nDate/Time: at 14:22\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR.\n\nTRICUSPID VALVE: No TR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nTrivial mitral regurgitation is seen. There is an anterior space which most\nlikely represents a fat pad.\n\nIMPRESSION: No valvular vegetations or clinically-significant regurgitant\nvalve disease seen, but the study is technically suboptimal to rule out\nendocarditis. Preserved global biventricular systolic function.\n\nIf clinical suspicion for endocarditis persists, a transesophageal study is\nrecommended.\n\nCompared with the prior study (images reviewed) of , the findings\nare similar.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2193-07-29 00:00:00.000",
"description": "Report",
"row_id": 202770,
"text": "Sinus tachycardia\nConsider prior inferior myocardial infarction although is nondiagnostic\nSince previous tracing of , sinus tachycardia present\n\n"
}
] |
145 | 138,459 | Briefly, this is a 55 yo F with MMP including stage IV sacral decub, PICC for chronic TPN, avascular necrosis with fluid in L sacroiliac joint, recent MRSA bacteremia, and GNR in blood from OSH, admitted with sepsis. Pt was found to have positive blood cx for Klebsiella, now afebrile on vanc and levoflox. . # Sepsis/ID: Likely Klebsiella line infection. Pt was hypotensive and febrile on admission to SBP 70s, requiring pressors in the ICU. Her WBC was 11.9 with 27% bands on admission. The pt has a h/o MRSA bacteremia from and now GNR in blood (now +for Klebsiella) from ED on . CXR was negative for acute cardiopulm process and UA was somewhat dirty but not grossly positive. The pt responded appropriately to stim test. Given it was the most likely source of infection, the pts PICC line was pulled on admission. Repeat RUQ US was wnl. TTE on was negative for vegetations. Levophed was weaned off and pts BP has been holding. Meropenem was d/c'd after blood cx from showed Klebsiella S to levoflox. ID was and has been following the pt. the patient was transferred to the medical floor once stable. It was decided to continue the levoflox for treatment of the Klebsiella line infection and Vancomycin for h/o MRSA until she saw ID in clinic for further f/u. . # Sacral Decub: Stage IV. Wound vac was discontinued PTA due to pain. Per one of pts prior hospitalizations, plastic surgery was considering a flap. Plastic surgery was and states decub appears to be healing well. Wound care was regarding decub care. The pt has been receiving pain meds with oxycodone and dilaudid prn. . #Hyponatremia: Na 132 on admission, with baseline 136-140. Likely hypovolemic in etiology. Na improved after fluids. . #URI sxs: --r/o with influenza DFA; droplet precautions . # Elevated LFTs: AST, ALT and alk phos are all down compared to discharge. These elevations have been present since prior to dissection. She had an open cholecystectomy in for cholecystitis. Previous workup has included: negative hepatitis B and C serologies x 2, nml HIDA scan , MRCP showed s/p cholecystectomy: normal biliary system, no evidence for retained stones, MRI with no explanation for abnormal liver enzymes, negative AMA, negative HIV. Abd pain is currently at baseline. Repeat RUQ US on was negative . # Short gut syndrome: The pt is on chronic TPN. Abd exam seems stable. Per PCP pt has been on TPN since and is followed by surgery. It is unclear if the pt still needs TPN, so a trial without TPN had been initiated. However, per nutrition, the patient needs TPN due to poor absorption given her short gut syndrome. TPM was re-initiated and the patient had another PICC line placed for both TPN and her antibiotics. . # Anemia: Hct was 32 on admission, was previously 30 on discharge. The pt has been on epo as outpt started during last hospitalization for ARF, but unclear if pt still needs it. Her Epo has been discontinued this admission. . # h/o ARF: on last admission was felt ATN in setting of hypotension. Cr now 1.5, down from 2.6 on last discharge. . # Avascular necrosis with fluid within the L sacroiliac joint: - repeat MRI here showed persistent fluid in left sacroiliac joint. On vancomycin. To f/u with ID re: duration of vancomycin. . # HTN: The pts hydral and metoprolol were held in the setting of sepsis. Her BP was normotensive without the medications, so she was not discharged on either hydral or metoprolol. . # FEN: replete prn . # PPX: pneumoboots given h/o HIT, no bowel regimen given short gut syndrome, PPI . # Full Code , #Communication: HCP . | DRSG TO DRY Q12HRS. Mediastinal contours are unchanged, with abnormal aortic silhouette related to chronic dissection. PT ARRIVED ON LEVOPHED 0.05MIC/KG/ WITH STABLE B/P. Normal ascending aorta diameter. CVP WHEN TRANSDUCER LEVEL AND PT FLAT . ABD U/S BEING PERFORMED NOW.RENAL: AUTODIURESING, BUT U/O'S HAVE DROPPED OFF. The heart and mediastinum are within normal limits. CARDIAC ECHO DONE. Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is elongated. PT WAS ON CHRONIC TPN. WBC PRESENTLY 12.2PLAN: CONT WITH NS WHEN B/P IS LOW. Mild [1+] TR. LEVOFLOX D/C'ED. D/C foley when able to get up to void. Vanco level is pnd. The mitral valve appearsstructurally normal with trivial mitral regurgitation. LAST LACTATE WAS 1.2. There is nopericardial effusion.Compared with the prior study (images reviewed) of , there is nodiagnostic change. PATIENT/TEST INFORMATION:Indication: Sepsis.Height: (in) 67Weight (lb): 131BSA (m2): 1.69 m2BP (mm Hg): 134/45HR (bpm): 53Status: InpatientDate/Time: at 16:09Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. The new left subclavian central venous catheter terminates in the mid SVC. DID C/O ABD DISCOMFORT BUT HAS RESOLVED WITH THE DEMEROL. WAS GIVEN ATB OF VANCO, ZOSYN AND LEVOQUIN IN THE EW. ABD SOFT WITH +BS. PPP BILAT WITH NO PERIPH EDEMA. RegionalLV systolic function is probably normal (relatively mild basal inferiorhypokinesis). The right PICC remains in unchanged position, with tip at the junction of the SVC and the right atrium. No AS.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Patient needs TPN. The left subclavian IV catheter remains in place. K+ PHOS INFUSING.ID: AFEBRILE, BUT DOES C/O CHILLS, BUT NO RIGORS. Right sacral decubitus ulcer as described, with marginal soft tissue enhancement. TYLENOL WAS GIVEN. The line was forward flushed with none heparinized saline. NARRATIVE NOTE:PT WAS ADM FROM OSH TO WITH T 103.2. ON SEPSIS PROTOCOL ON ADM.CV: B/P HAS RANGED FROM 73/24-144/59. No mass orvegetation on mitral valve.TRICUSPID VALVE: Normal tricuspid valve leaflets. The patient is status post median sternotomy. COMPARISONS: MRCP dated . on Levofloxacin and Vanco. NO ECT NOTED. REPEAT LACTATE SENT. Right ventricular chamber size and free wall motion are normal.The aortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic regurgitation. STARTED ON MEROPENUM. PT HAS HAD CHRONIC TPN VIA PICC LINE, ? Femoral head articular surface is smooth. ON ADM PT C/O CP EKG WAS DONE AND PAIN RESOLVED WITH NO INTERVENTION.RESP: LUNGS HAVE REMAINED CLEAR THROUGHOUT WITH N/C AT 2L. Normalaortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). CREAT 1.4. ATTEMPT AT LEVOPHED WEAN UNSUCCESSFUL SO FAR. As before, there remains small amount of fluid within the left sacroiliac joint, with evidence of edema and enhancement within adjacent iliac and sacral bones. PRESENTLY AT 0.025MIC/KG/. BP 130's. SVO2 74-81. NO RESP DISTRESS. Heart size is unchanged. PLACED ON DROPLET PRECAUTIONS. There has been interval placement of a right lower quadrant ostomy since the prior exam. BENADRYL 25MG IVP WAS GIVEN WITH RELIEF NOTED. OBSERVE PT FOR ANXIETY AND MED FOR RELIEF. The previously identified fluid signal traversing the left sacroiliac notch is not identified on this study. Theestimated pulmonary artery systolic pressure is normal. A 0.018 guidewire was advanced into the needle and positioned in the SVC, under fluoroscopic guidance. WILL NEED A CONSULT WITH THE WOUND NURSE.ID> T-MAX IN EW WAS 103.2. The final fluoroscopic image demonstrating position of the tip of the catheter in the SVC was stored. TECHNIQUE: Coronal T1 and STIR, as well as axial STIR, and axial FAME pre- and post-gadolinium images with subtraction images were obtained through the pelvis. GUAIAC NEG. IN MICU PT WAS 100.3 WITH TYLENOL GIVEN X2. AWAITING CX RESULTS FROM .DECUB DRSG . IS NORMALLY ON TPN. NO C/O SOB. RESP: BS'S REMAIN CLEAR. UO is good via foley and pt with congested productive sounding cough but I have not seen sputum today.Plan: Transfer to floor after orders are written. EACH TIME THE LEVOPHED WAS TURNED OFF B/P QUICKLY DECREASED TO THE 70-80 SYSTOLIC RANGE AND WAS RESTARTED. K+ WAS 3.5 ON ADM, PRESENTLY RECIEVING 40MEQ IV. PLACED ON KINAIR BED.CV: PT EXPERIENCING A BRADY/TACHY RYTHYM. CHEST: AP portable semi-upright view. SVO2 WITHIN NL LIMITS.HEM: CBC SENT. CONT WITH ATB. MONITOR LYTES AND REPLENISH AS NEEDED. COMMENTS: Portable supine AP radiograph of the chest is reviewed, and compared with the previous study of . NO C/O CP. MONITOR TEMPS. IMPRESSION: 1. The extent and distribution has not significantly changed since the prior exam. SITE LOOKS CLEAN, WITH NO DRAINAGE. Continue with QD dressing changes per care recommendations. No pneumothorax. 11:50 AM PICC LINE PLACMENT SCH Clip # Reason: please place PICC Admitting Diagnosis: FEVER ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** MEDICAL CONDITION: 55 year old woman with shrt gut, needs chronic TPN REASON FOR THIS EXAMINATION: please place PICC FINAL REPORT HISTORY: Short-gut syndrome. | 11 | [
{
"category": "Echo",
"chartdate": "2145-02-16 00:00:00.000",
"description": "Report",
"row_id": 79258,
"text": "PATIENT/TEST INFORMATION:\nIndication: Sepsis.\nHeight: (in) 67\nWeight (lb): 131\nBSA (m2): 1.69 m2\nBP (mm Hg): 134/45\nHR (bpm): 53\nStatus: Inpatient\nDate/Time: at 16:09\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve. No AS.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Regional\nLV systolic function is probably normal (relatively mild basal inferior\nhypokinesis). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. No masses or vegetations are seen on\nthe aortic valve. There is no aortic valve stenosis. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. No mass or vegetation is seen on the mitral valve. The\nestimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , there is no\ndiagnostic change. There is no echocardiographic evidence of endocarditis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 900668,
"text": " 6:02 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval central line placement left subclavian\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with complicated PMHx and recent fevers\n\n REASON FOR THIS EXAMINATION:\n please eval central line placement left subclavian\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recent fever, now status post central line placement.\n\n COMPARISON: at 1:51 a.m.\n\n CHEST: AP portable semi-upright view. The new left subclavian central venous\n catheter terminates in the mid SVC. There is no pneumothorax. The right PICC\n remains in unchanged position, with tip at the junction of the SVC and the\n right atrium. Mediastinal contours are unchanged, with abnormal aortic\n silhouette related to chronic dissection. Heart size is unchanged. There is\n no pulmonary edema, consolidation, or pleural effusion.\n\n IMPRESSION: Satisfactory central line position. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 900840,
"text": " 5:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval evaluation\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with complicated PMHx and recent fevers\n\n REASON FOR THIS EXAMINATION:\n interval evaluation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW, PORTABLE\n\n INDICATION: 55-year-old woman with fever.\n\n COMMENTS: Portable supine AP radiograph of the chest is reviewed, and\n compared with the previous study of .\n\n There is new faint opacity in the left lower lobe indicating pneumonia Vs.\n aspiration. The lungs are clear otherwise. The heart and mediastinum are\n within normal limits. The left subclavian IV catheter remains in place. No\n pneumothorax is identified. The patient is status post median sternotomy.\n\n IMPRESSION: Probable left lower lobe pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-19 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 901175,
"text": " 11:50 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: FEVER\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with shrt gut, needs chronic TPN\n REASON FOR THIS EXAMINATION:\n please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Short-gut syndrome. Patient needs TPN.\n\n RADIOLOGISTS: Dr. and Dr. , the Attending Radiologist,\n being present and supervising throughout. Dr. d' reviewed this\n case.\n\n FINDINGS/TECHNIQUE: The patient was placed supine on the angiographic table\n and the left arm was prepped and draped sterilely. Under ultrasound guidance,\n a 21-gauge needle was advanced into the left basilic vein after 1% lidocaine\n was used for local anesthesia. A 0.018 guidewire was advanced into the needle\n and positioned in the SVC, under fluoroscopic guidance. The needle was\n exchanged for a 4.5- French introducer sheath. double-lumen PICC\n line was then advanced over the wire via the introducer and placed with its\n tip in the SVC. The line was secured to the skin with StatLock device and\n sterile dressing. The line was forward flushed with none heparinized saline.\n\n No ultrasound images were stored due to malfunctioning printer. The final\n fluoroscopic image demonstrating position of the tip of the catheter in the\n SVC was stored.\n\n IMPRESSION: Successful placement of PICC line via the left basilic\n vein into the SVC. Please, do not use heparin due to heparin-induced\n thrombocytopenic purpura in this patient. The line is ready for use.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-02-17 00:00:00.000",
"description": "Report",
"row_id": 1262216,
"text": "MICU NPN 1600:\nPt is called out to the floor and awaiting transfer to 11R. wound dressing changed at 1600 as directed in care note. Plan is to hold off restarting TPN for now and encourage PO's until then. New PICC will be inserted when blood cultures are negative. She remains alert and oriented and pleasant and cooperative. She was given pain meds for pain at 1430. BP 130's. HR down to 50's at times and we held her lopressor that was just ordered. Team aware. UO is good via foley and pt with congested productive sounding cough but I have not seen sputum today.\n\nPlan: Transfer to floor after orders are written. D/C foley when able to get up to void. Continue with QD dressing changes per care recommendations. Continue to follow culture results, administer antibiotics as ordered. Vanco level is pnd.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-02-16 00:00:00.000",
"description": "Report",
"row_id": 1262212,
"text": "NARRATIVE NOTE:\n\nPT WAS ADM FROM OSH TO WITH T 103.2. HAS EXTENSIVE PMH, PLEASE SEE ADM NOTE. PT HAS HAD CHRONIC TPN VIA PICC LINE, ? IF LINE SOURCE OF INFECTION. TIP WAS SENT TO LAB FOR CX. PT WAS CULTURED IN EW AS ON THE 4TH OSH CULTURED 2 BOTTLES + FOR GRAM - RODS. WAS GIVEN ATB OF VANCO, ZOSYN AND LEVOQUIN IN THE EW. ON SEPSIS PROTOCOL ON ADM.\n\nCV: B/P HAS RANGED FROM 73/24-144/59. PT ARRIVED ON LEVOPHED 0.05MIC/KG/ WITH STABLE B/P. EACH TIME THE LEVOPHED WAS TURNED OFF B/P QUICKLY DECREASED TO THE 70-80 SYSTOLIC RANGE AND WAS RESTARTED. PRESENTLY AT 0.025MIC/KG/. PT RECIEVED NS BOLUSES OF 500CC X3. CVP WHEN TRANSDUCER LEVEL AND PT FLAT . SVO2 74-81. PPP BILAT WITH NO PERIPH EDEMA. K+ WAS 3.5 ON ADM, PRESENTLY RECIEVING 40MEQ IV. NA+ WAS 132, PRESENTLY 136. PT DRINKS VERY LG AMTS OF BOTTLED WATER. LAST LACTATE WAS 1.2. ON ADM PT C/O CP EKG WAS DONE AND PAIN RESOLVED WITH NO INTERVENTION.\n\nRESP: LUNGS HAVE REMAINED CLEAR THROUGHOUT WITH N/C AT 2L. SAO2 96-100%. NO RESP DISTRESS. RR 15-28.\n\nNEURO: ON ADM PT WAS VERY ANXIOUS. GENERALY UNCOMFORTABLE. RIGORS WERE NOTED AND PT C/O BEING VERY COLD. COVERED WITH BLANKETS AND ROOM TEMP WAS INCREASED. TYLENOL WAS GIVEN. DEMEROL 50MG IVP WAS GIVEN WITH NO RELIEF TO THE RIGORS BUT DID HELP DISCOMFORT. BENADRYL 25MG IVP WAS GIVEN WITH RELIEF NOTED. PT IS A&OX3. PEARL. FOLLOWS SIMPLE COMMANDS. DOES BECOME ANXIOUS EASILY WITH DISCOMFORT. PT WAS VERY TIRED, PRESENTLLY RESTING.\n\nGU/GI: FOLEY CATH PATENT, DRAINING LG AMTS OF CLEAR YELLOW URINE. PT HAS AN ILIOSTOMY WHICH HAS DRAINED LG AMTS OF LIQUID GREEN STOOL. ABD SOFT WITH +BS. DID C/O ABD DISCOMFORT BUT HAS RESOLVED WITH THE DEMEROL. IN THE EW A MRI WAS ORDERED BUT PT REFUSED TO DRINK THE CONTRAST AND IT IS PRESENTLY ON HOLD. PT WAS ON CHRONIC TPN. SWALLOWS PO PILLS WITH NO DIFFICULTY.\n\nSKIN: PT HAS CHRONIC STAGE III DECUB ON COCCYX. SLIGHT YELLOW DRAINAGE NOTED. TEAM QUESTIONS IF THIS IS THE SOURCE OF INFECTION. WILL NEED A CONSULT WITH THE WOUND NURSE.\n\nID> T-MAX IN EW WAS 103.2. IN MICU PT WAS 100.3 WITH TYLENOL GIVEN X2. ON TRIPLE ATB. WBC PRESENTLY 12.2\n\nPLAN: CONT WITH NS WHEN B/P IS LOW. CONT WITH ATB. UPDATE DAUGHTER, HCP ON ANY CHANGES IN PT CONDITION. OBSERVE PT FOR ANXIETY AND MED FOR RELIEF. MONITOR TEMPS. PROVIDE EMOTIONAL SUPPORT. MONITOR LYTES AND REPLENISH AS NEEDED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-02-16 00:00:00.000",
"description": "Report",
"row_id": 1262213,
"text": "RESP: BS'S REMAIN CLEAR. NO C/O SOB. O2 SATS HIGH 90'S. PT. DOES HAVE A COLD. PRODUCTIVE COUGH.\nGI: NPO-CAN EAT, BUT MORE FOR THE PT'S SATISFACTION. PT. IS NORMALLY ON TPN. ILEOSTOMY DRAINING LARGE AMTS OF LIQUID STOOL. GUAIAC NEG. ABD U/S BEING PERFORMED NOW.\nRENAL: AUTODIURESING, BUT U/O'S HAVE DROPPED OFF. CREAT 1.4. DRINKING ALOT OF BOTTLED WATER.\nNEURO: ALERT AND ORIENTATED. APPEARS WEEPY AT TIMES. SHE'S BEEN IN THE HOSPITAL INTERM. FOR THE LAST 8 MONTHS. REQUESTING SEDATION.\nENDOC: LYTES SENT AT 15PM. K+ PHOS INFUSING.\nID: AFEBRILE, BUT DOES C/O CHILLS, BUT NO RIGORS. TEMP CHECKED FREQUENTLY. PLACED ON DROPLET PRECAUTIONS. + BLOOD CX'S FROM SHOWED KLEBSIELLA IN BOTH BOTTLES. STARTED ON MEROPENUM. LEVOFLOX D/C'ED. REPEAT LACTATE SENT. AWAITING CX RESULTS FROM .\nDECUB DRSG . SITE LOOKS CLEAN, WITH NO DRAINAGE. DRSG TO DRY Q12HRS. PLACED ON KINAIR BED.\nCV: PT EXPERIENCING A BRADY/TACHY RYTHYM. NO ECT NOTED. NO C/O CP. CARDIAC ECHO DONE. ATTEMPT AT LEVOPHED WEAN UNSUCCESSFUL SO FAR. DROPS MAP'S INTO 50'S. SVO2 WITHIN NL LIMITS.\nHEM: CBC SENT. \\\nSOCIAL: NO CONTACT WITH FAMILY TODAY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-02-16 00:00:00.000",
"description": "Report",
"row_id": 1262214,
"text": "MICU NPN 1500-1900\nEvents: Levofed weaned to off after 500cc NS IVbolus with BP 110's-120's/50's. PM labs with K+ 3.5, repleted with 40mEq KCl.\n\nCoccyx wound seen by skin care nurse with aquacel and DSD. Wound is healing well with pink granulating tissue. Ostomy appliance changed by skin care nurse as well.\n\nPt tolerating small amounts of food. She has brought her own from home and is eating small amounts.\n\nPlan: Cont to monitor hemodynamics\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-02-17 00:00:00.000",
"description": "Report",
"row_id": 1262215,
"text": "NPN 1900-0700\nNeuro: A&Ox3, c/o pain x 1 to decub., pt states that area is painful from drsg performed by care nurse on , given oxycodone and tylenol for pain with good effect. Slept for approx 6 hrs.after pain meds adm.\n\nResp: Lungs diminished to coarse throughout, RR 15-25, O2 sts 95-99%, no c/o SOB.\n\nCV: HR 49-70 SB-NSR, no ectopy, no c/o CP, BP's 105-127/39-54, off of Levophed since 1600 on , SVO2 78-80's.\n\nID: Tmax 98.6, Meropenum and Piperacillin dc'd, cont. on Levofloxacin and Vanco. Vanco trough to be drawn on at 0300 prior to next Vanco. dose.\n\nGI: BS (+), ileostomy draining lrg amts of golden/greenish liquid stool, x1 stool obtained for C-diff this shift, need another sample sent tomorrow.\n\nGU: Foley intact draining adequate amts of yellow urine with sediment.\n\n: drsg by care nurse last shift. Drsg to q 24hrs see .\n\nSocial: No calls from family this shift.\n\nPlan: Continue to monitor VS, adm abx as ordered, ?diet tolerance today vs. restart of transfer to floor if hemodynamically stable.\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-16 00:00:00.000",
"description": "P US ABD LIMIT, SINGLE ORGAN PORT",
"row_id": 900775,
"text": " 2:24 PM\n US ABD LIMIT, SINGLE ORGAN PORT Clip # \n Reason: please evaluate RUQ for evidence of gallstones, acute cholec\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with persistently elevated LFTs, Fever\n\n REASON FOR THIS EXAMINATION:\n please evaluate RUQ for evidence of gallstones, acute cholecystectomy\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old female with persistently elevated LFTs and fever.\n Evaluate right upper quadrant for evidence of stones.\n\n COMPARISONS: MRCP dated .\n\n LIMITED UPPER QUADRANT ULTRASOUND: The liver is normal in size and\n echogenicity with no focal abnormality. There is no intra or extrahepatic\n biliary ductal dilatation. The gallbladder is not identified consistent with\n history of recent cholecystectomy. There is trace fluid in the gallbladder\n fossa. No biliary calculi are identified.\n\n IMPRESSION: Trace fluid in the gallbladder fossa status post cholecystectomy.\n No evidence of hepatic mass, biliary ductal dilatation or calculi.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-02-18 00:00:00.000",
"description": "B MR HIP W&W/O CONTRAST BILAT",
"row_id": 901078,
"text": " 3:02 PM\n MR HIP W&W/O CONTRAST BILAT; MR CONTRAST GADOLIN Clip # \n Reason: eval for presence of fluid, evidence of osteomyelitis, absce\n Admitting Diagnosis: FEVER\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with complicated PMH, h/o avascular femoral necrosis, fluid\n in SI joint previously, s/p Abx treatment\n REASON FOR THIS EXAMINATION:\n eval for presence of fluid, evidence of osteomyelitis, abscesses\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE PELVIS WITH AND WITHOUT INTRAVENOUS GADOLINIUM\n\n INDICATION: 55-year-old female with complicated past medical history, left\n femoral head avascular necrosis, and fluid within the left sacroiliac joint on\n prior exam. The patient with sacral decubitus ulcer, status post antibiotic\n therapy. Followup examination.\n\n TECHNIQUE: Coronal T1 and STIR, as well as axial STIR, and axial FAME pre-\n and post-gadolinium images with subtraction images were obtained through the\n pelvis. Additional coronal T1 FAME post-gadolinium images through the pelvis\n were obtained. Of note, axial T1-weighted images not obtained due to\n patient's discomfort and inability to remain in the magnet.\n\n FINDINGS: Direct comparison with prior study dated .\n\n As before, there remains small amount of fluid within the left sacroiliac\n joint, with evidence of edema and enhancement within adjacent iliac and sacral\n bones. This has not significantly changed since the prior exam. The\n previously identified fluid signal traversing the left sacroiliac notch is not\n identified on this study. There has also been interval resolution of\n previously seen edema and enhancement deep to the left iliacus muscle and deep\n to the left gluteal muscles.\n\n Signal abnormality within the left femoral head compatible with avascular\n necrosis is again identified. There has been no interval collapse or increase\n in distribution of signal abnormality. There is no hip joint effusion on the\n left. Femoral head articular surface is smooth.\n\n Again seen is a large sacral decubitus ulcer, just to the right of the\n midline, with evidence of marginal soft tissue enhancement. No discrete edema\n or enhancement within the subjacent sacrum or coccyx. No soft tissue or bone\n abscess identified.\n\n Evaluation of the right hip is grossly unremarkable. There is no hip joint\n effusion, or avascular necrosis.\n\n There has been interval placement of a right lower quadrant ostomy since the\n prior exam.\n\n (Over)\n\n 3:02 PM\n MR HIP W&W/O CONTRAST BILAT; MR CONTRAST GADOLIN Clip # \n Reason: eval for presence of fluid, evidence of osteomyelitis, absce\n Admitting Diagnosis: FEVER\n Contrast: MAGNEVIST Amt: 18\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Incidental note is made of diffuse erythropoietic marrow.\n\n IMPRESSION:\n 1. Right sacral decubitus ulcer as described, with marginal soft tissue\n enhancement. No bone or soft tissue abscess.\n\n 2. Persistent fluid within the left sacroiliac joint, and adjacent\n edema/enhancement within the sacrum and iliac bone. The extent and\n distribution has not significantly changed since the prior exam. Persistent\n infection, while unlikely, is not entirely excluded.\n\n\n"
}
] |
3,563 | 117,760 | 50yo found down, hx of EtOH abuse, now obtunded and with large L SDH causing midline shift, obliteration of 4th ventricle, quadrigeminal plate. At the admission and so as entire course in the hospital stay, patient clinical condition for surgical treatment was considered medically futile. Patient was admitted to Neurosurgery service in SICU and continued on maximal medical management including ventilator support, Mannitol, Dilantin (therapeutic dose, until 22:00), head elevation. Dilantin was not given after 22:00 to eliminate any possible effect on the examination. Patient was repeatedly examined over the course, however, never be responsive and his neurological examination got worsen. Initiially, patient had bilateral corneal reflex and gag reflex, but they disappeared at the night of HD#2. Patient did not show any improvement in neurological condition although all general condition was stabilized and all sedative medications were removed from his system. Brain death examination was performed on following hospital protocol confirmed brain death. Apnea test was performed on 10:16-10:26 with no respiratory movement and confirmed elevation of pCO2 (70). ABG ( 10:30A) ART pH7.15/pCO2 70/pO2 387/HCO326/BE-5. Time of death was recorded as 10:26 AM. The case was reported to Medical Examiner's Office and accepted for the case. Contact person at Medical Examiner's Office was Ms. (, Ext.239). | Causes subfalcine shift of 1.1cm to R- MD FINAL REPORT INDICATION: Found down. 6) obliteration of the suprasellar cistern (new compared to ) is suggestive of edema/central herniation OVERREAD: Agree. 6) obliteration of the suprasellar cistern (new compared to ) is suggestive of edema/central herniation OVERREAD: Agree. 2) diffuse subarachnoid hemorrhage. 2) diffuse subarachnoid hemorrhage. 2) diffuse subarachnoid hemorrhage. remains intubated overnoc on A/C. Diffuse subarachnoid hemorrhage. Causes subfalcine shift of 1.1cm to R- MD ADDENDUM: Smaller, 6mm R parietal subdural noted as well- MD WET READ VERSION #1 JJMl WED 4:18 AM 1) bilateral large subdural hematomas layering along both convexities left larger than right. PORTABLE SUPINE CHEST: The endotracheal tube terminates at the thoracic inlet. mixed density of the left subdural hematoma is suggestive of acute (hyperdense) and hyperacute (low density) blood products [given that no subdural was present on . mixed density of the left subdural hematoma is suggestive of acute (hyperdense) and hyperacute (low density) blood products [given that no subdural was present on . mixed density of the left subdural hematoma is suggestive of acute (hyperdense) and hyperacute (low density) blood products [given that no subdural was present on . Pt also sxn'd for mod amts bloody thick secretions.GI/GU: Abd soft and distended + BS no noted flatus. FINDINGS: There are bilateral extraaxial, likely subdural, hematomas, left greater than right. 6) obliteration of the suprasellar cistern (new compared to ) is suggestive of edema/central herniation WET READ VERSION #2 DJD WED 4:31 AM 1) bilateral large subdural hematomas layering along both convexities left larger than right. Hypoxic. There is mixed density of the left subdural hematoma, hyperdensity intermixed with low-density material consistent with acute and hyperacute (noncoagulated) blood products. OGT CLAMPED.GU: FOLEY DRAINING ADEQ CLEAR U/O. if herniating. 3:19 AM CTA CHEST W&W/O C &RECONS Clip # Reason: HYPOXIA, INTUBATION - ? COMPARISON: CT C-spine dated . There is an adjacent hematoma, parencymal versus subdural in the inferior right posterior fossa. There is obliteration of the suprasellar cistern suggestive of downward transtentorial herniation. Resp Care,Pt. There is a mixed density of the left subdural hematoma, hyperdense material as well as low- density material consistent with acute and hyperacute (noncoagulated) blood products. Obliteration of the suprasellar cistern consistent with edema and suggestive of downward transtentorial herniation. ADDENDUM TO NOTE:RESP: REMAINS ON VENT, PLS SEE CAREVUE FOR DETAILS.GI: ABD SOFT, +BS, NPO. FINAL REPORT INDICATION: Found down. Endotracheal and orogastric tubes are in place. COMPARISON: Radiograph dated . Mild interlobular septal thickening at the apices consistent with mild interstitial edema. Bilateral lower lobe atelectasis/consolidation, right worse than left. Nursing Progress NotePlease see carvue for specifics:Neuro: Pt found down by EMS obtunded ? to temp.Resp: Remains intubated on CMV. REASON FOR THIS EXAMINATION: r/o pe No contraindications for IV contrast WET READ: DJD WED 4:35 AM 1) bilateral large subdural hematomas layering along both convexities left larger than right. Pt arrived to unit intubated with stable hemodynamics. There is diffuse subarachnoid hemorrhage along both cerebral convexities. (Over) 3:19 AM CT C-SPINE W/O CONTRAST Clip # Reason: found down, requiring intubation - assess neck for fx FINAL REPORT (Cont) 3. Pt now febrile to 104.6 tylenol given and cooling blanket is on. 4) non-displaced right occipetal bone fracture with extension to the right occipetal condyle and hypoglossal canal 5) hemorrhage in the sphenoid sinus. 4) non-displaced right occipetal bone fracture with extension to the right occipetal condyle and hypoglossal canal 5) hemorrhage in the sphenoid sinus. 4) non-displaced right occipetal bone fracture with extension to the right occipetal condyle and hypoglossal canal 5) hemorrhage in the sphenoid sinus. Poor prognosis per NSurg. 3) possible hyperdensity is seen in the posterior fossa on the right inferiorly that could represent volume averaging or ?blood products. 3) possible hyperdensity is seen in the posterior fossa on the right inferiorly that could represent volume averaging or ?blood products. 3) possible hyperdensity is seen in the posterior fossa on the right inferiorly that could represent volume averaging or ?blood products. ICU Attending MD wrote order for CPR not indicated.Plan: cont supportive care. Brought to and intubated. foley is patent and drng adequate amts of urine.Endo: RISSID: ? pt is DNR. Respiratory Therapy50 Y.O M found down, unresponsive transfered by EMS. Pt given lopressor X2 for HR to 130's. There is subfalcine herniation and left to right midline shift of the septum pellucidum measuring 14 mm. + gag/cough and + Corneals. Found down. There is consolidation in both lower lobes posteriorly, right worse than left. TECHNIQUE: MDCT acquired images of the head were obtained without IV contrast. PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.TMAX 104.1, COOLING BLANKET ON AND TYLENOL 650MG PR GIVEN W/ GOOD EFFECT, TEMP DOWN TO 100.0.NEURO: PT REMAINS UNRESPONSIVE W/ ABNORMAL FLEXION OF LE'S TO NOXIOUS STIMULI NOTED OCCASIONALLY, NO RESPONSE TO PAIN W/ BIL UE'S. | 12 | [
{
"category": "Nursing/other",
"chartdate": "2118-12-15 00:00:00.000",
"description": "Report",
"row_id": 1308230,
"text": "PLEASE REFER TO CAREVUE FOR COMPLETE ASSESSMENT AND SPECIFICS.\n\nTMAX 104.1, COOLING BLANKET ON AND TYLENOL 650MG PR GIVEN W/ GOOD EFFECT, TEMP DOWN TO 100.0.\nNEURO: PT REMAINS UNRESPONSIVE W/ ABNORMAL FLEXION OF LE'S TO NOXIOUS STIMULI NOTED OCCASIONALLY, NO RESPONSE TO PAIN W/ BIL UE'S. NO GAG REFLEX, IMPAIRED COUGH, +CORNEAL, PUPILS REMAIN FIXED AND DILATED.\nCV: STABLE VS, SBP <160, HYDRALAZINE 10MG IV GIVEN Q6HRS W/ GOOD EFFECT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-12-15 00:00:00.000",
"description": "Report",
"row_id": 1308231,
"text": "ADDENDUM TO NOTE:\nRESP: REMAINS ON VENT, PLS SEE CAREVUE FOR DETAILS.\nGI: ABD SOFT, +BS, NPO. OGT CLAMPED.\nGU: FOLEY DRAINING ADEQ CLEAR U/O. AT 3:00AM, PT HAD 1300CC CLEAR YELLOW URINE FOR 1 HR.\nPLAN: MONITOR VS, LABS, NEURO STATUS. ATTEMPT TO LOCATE FAMILY FOR CODE STATUS. CONT CURRENT MGMNT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-12-15 00:00:00.000",
"description": "Report",
"row_id": 1308232,
"text": "Respiratory therapy\nPt remains orally intubated no vent changes overnight. Sx for moderate amounts dark tan to rusty thick secretions. RSBI 200 Plan: wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-12-15 00:00:00.000",
"description": "Report",
"row_id": 1308233,
"text": "STATUS\nD: FEBRILE..NEURO UNCHANGED..PUPILS FIXED DILATED..MOVES LOWER EXTREM'S TO STIMULI NO MOVEMENT OF UPPER EXTREM'S..COUGH REFLEX BUT NO GAG..NO CORNEAL REFLEXES\nA: NO VENT CHANGES..SUCTIONED FOR MOD AMT THICK TAN..SAT'S >97%.. COOLING BLANKET/TYLENOL/ICE PACKS FOR TEMP WITH SLOW DROP..GOOD HUO NO STOOL..STILL UNABLE TO FIND FAMILY MEMBERS PER SOCIAL WORKER..PT REMAINS FULL CODE\nR: UNCHANGED\nP: CONTINUE WITH COMFORT MEASURES..FULL CODE..LABS DC'D..DIFFICULT DRAW\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-12-16 00:00:00.000",
"description": "Report",
"row_id": 1308234,
"text": "Resp Care,\nPt. remains intubated overnoc on A/C. No vent changes this shift. Plan apnea test this am. See carevue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-12-16 00:00:00.000",
"description": "Report",
"row_id": 1308235,
"text": "Please See Carevue for Specifics.\n\nNeuro: Unresponsive, Pupils are fixed (6-7mm) and are non-reactive. -gag, -cough, -corneal reflexes. Does not respond to deep nail bed pressure. SBP decreased from 150's to 60's at and ? if herniating. ST at beginning of shift and slowly became NSR 60-70's. Febrile at start of shift and slowly became hypothermic and requiring bair hugger. Urine ouput decreased throughout shift with drop in SBP. SICU team aware and no intervention.\n\nPOC: Apena test this morning, continue brain death testing, continue to try and locate family, monitor hemodynamics. Continue to keep pt comfortable. pt is DNR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-12-14 00:00:00.000",
"description": "Report",
"row_id": 1308228,
"text": "Respiratory Therapy\n50 Y.O M found down, unresponsive transfered by EMS. Positive for ETOH and Benzo.Int in ED W #8 OETT secured @ 22lip.(+) color change on EasyCap. BS coarse rhonchi bilaterally Sx for mod amt thin bright red X1. Transport to CT uneventful. CT (+) for SAH W shift. Please see radiology reports and Carevue for specifics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-12-14 00:00:00.000",
"description": "Report",
"row_id": 1308229,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Pt found down by EMS obtunded ? Length. Brought to and intubated. CT revealed large bilat Subdural hematomas with diffuse SAH with shift. Poor prognosis per NSurg. NSurg has deemed surgery medically futile. Pt is homeless with no known next of . Pt arrived to unit intubated with stable hemodynamics. Pupils fully dilated and NR. + gag/cough and + Corneals. NEOB notified. pt with no response to pain in bilat UE. Pt did respond to deep pain with abnormal flexion in bilat LE. Pt afebrile most of day until this pm when pt spiked to 103.4 and is currently 104.6. MD is aware\nCV: Pt afebrile most of day as previously indicated. Pt now febrile to 104.6 tylenol given and cooling blanket is on. Pt currently hem stable. Pt did arrive with a SBP in 110's now getting HTN 160 hydralazine X1 with effect. Pt given lopressor X2 for HR to 130's. ? to temp.\nResp: Remains intubated on CMV. Current settings .60% Fi02 TV 550X26 pt observed to be overbreathing vent at one time with increased TV to 700's no intervention made and pt settled on his own. Pt also sxn'd for mod amts bloody thick secretions.\nGI/GU: Abd soft and distended + BS no noted flatus. Pt with OGT clamped. foley is patent and drng adequate amts of urine.\nEndo: RISS\nID: ? aspiration pneumonia.\nSocial: Mult attempts made by SS to locate a family member. SS with mult shelters frequented by pt. ( See social services not for full details) All info followed up but to no avail unable to find any next of . Legal also contact for guide as what to do for pt since there has been no NOK notified. ICU Attending MD wrote order for CPR not indicated.\nPlan: cont supportive care.\n"
},
{
"category": "Radiology",
"chartdate": "2118-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 937914,
"text": " 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with intubatino.\n REASON FOR THIS EXAMINATION:\n eval tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubation.\n\n COMPARISON: Radiograph dated .\n\n PORTABLE SUPINE CHEST: The endotracheal tube terminates at the thoracic\n inlet. The cardiac contour is more prominent compared to the previous exam,\n however this may be due to technique. The lungs are grossly clear. There is\n no evidence of pneumothorax or pleural effusion.\n\n IMPRESSION: Endotracheal tube in satisfactory position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-12-14 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 937916,
"text": " 3:19 AM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: HYPOXIA, INTUBATION - ? PE\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man found down ,+ ETOH requiring intubation\n REASON FOR THIS EXAMINATION:\n assess for ic injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JJMl WED 4:36 AM\n no pe\n bilateral lower lobe opacities right worse than left. given history, consider\n aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found down. Intoxicated. Hypoxic.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT acquired images of the chest were obtained before and after\n the administration of IV contrast for CT angiogram technique. Multiplanar\n reformatted images were also obtained.\n\n CTA OF THE CHEST: There is no evidence of pulmonary embolism. The aorta and\n great vessels appear intact. There is no pericardial effusion. There is no\n pneumothorax. There is consolidation in both lower lobes posteriorly, right\n worse than left. There is no pleural effusion. There are no pathologically\n enlarged axillary, mediastinal, or hilar lymph nodes. Limited images of the\n upper abdomen are unremarkable. There is mild interlobular septal thickening\n at the apices.\n\n Bone windows reveal no suspicious lytic or sclerotic lesions.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism.\n 2. Bilateral lower lobe atelectasis/consolidation, right worse than left.\n Consideration may be given to aspiration given the patient's history.\n 3. Mild interlobular septal thickening at the apices consistent with mild\n interstitial edema.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-12-14 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 937917,
"text": " 3:19 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: found down, requiring intubation - assess neck for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with neck pain, ? fall, EtOH intoxicated.\n REASON FOR THIS EXAMINATION:\n found down, requiring intubation - assess neck for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD WED 4:32 AM\n non-displaced fracture of the occipital bone on the right with involvement of\n the inner and outer tables and extension to the right occipetal condyle and\n right hypoglosal canal.\n\n no cervical spine fracture identified.\n\n\n\n OVERREAD:\n Agree\n\n MD\n WET READ VERSION #1 JJMl WED 4:24 AM\n non-displaced fracture of the occipital bone on the right with involvement of\n the inner and outer tables and extension to the right occipetal condyle and\n right hypoglosal canal.\n\n no cervical spine fracture identified.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Alcohol intoxication. Found down.\n\n COMPARISON: CT C-spine dated .\n\n TECHNIQUE: MDCT acquired images of the cervical spine were obtained with\n coronal and sagittal reformatted images.\n\n CT C-SPINE: There is a nondisplaced right occipital bone fracture that\n extends to the right occipital condyle and the hypoglossal canal on the right.\n The alignment of the cervical spine is normal. There are multiple anterior\n osteophytes again demonstrated consistent with DISH. There is disc space\n narrowing at C5-C6 with bilateral bony neuroforaminal encroachment. There is\n no loss of vertebral body height. There is no facet joint dislocation or\n subluxation. There is interlobular septal thickening demonstrated at the right\n and left lung apex. Endotracheal and orogastric tubes are in place.\n\n IMPRESSION:\n 1. Nondisplaced right occipital bone fracture involving the inner and outer\n tables with extension to the right occipital condyle (Type III OCF) and\n hypoglossal canal.\n 2. No cervical spine fracture identified.\n (Over)\n\n 3:19 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: found down, requiring intubation - assess neck for fx\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Interlobular septal thickening demonstrated at the lung apices may suggest\n interstitial the edema.\n\n Findings conveyed to the emergency board dashboard at 4:23 a.m. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-12-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 937919,
"text": " 3:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o pe\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with hemoptysis.\n REASON FOR THIS EXAMINATION:\n r/o pe\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD WED 4:35 AM\n 1) bilateral large subdural hematomas layering along both convexities left\n larger than right. mixed density of the left subdural hematoma is suggestive\n of acute (hyperdense) and hyperacute (low density) blood products [given that\n no subdural was present on .\n\n 2) diffuse subarachnoid hemorrhage.\n\n 3) possible hyperdensity is seen in the posterior fossa on the right\n inferiorly that could represent volume averaging or ?blood products.\n\n 4) non-displaced right occipetal bone fracture with extension to the right\n occipetal condyle and hypoglossal canal\n\n 5) hemorrhage in the sphenoid sinus.\n\n 6) obliteration of the suprasellar cistern (new compared to ) is\n suggestive of edema/central herniation\n\n OVERREAD: Agree. Subdural measurements: 1.2cm thickness. Causes subfalcine\n shift of 1.1cm to R- MD\n\n ADDENDUM: Smaller, 6mm R parietal subdural noted as well- MD\n WET READ VERSION #1 JJMl WED 4:18 AM\n 1) bilateral large subdural hematomas layering along both convexities left\n larger than right. mixed density of the left subdural hematoma is suggestive\n of acute (hyperdense) and hyperacute (low density) blood products [given that\n no subdural was present on .\n\n 2) diffuse subarachnoid hemorrhage.\n\n 3) possible hyperdensity is seen in the posterior fossa on the right\n inferiorly that could represent volume averaging or ?blood products.\n\n 4) non-displaced right occipetal bone fracture with extension to the right\n occipetal condyle and hypoglossal canal\n\n 5) hemorrhage in the sphenoid sinus.\n\n 6) obliteration of the suprasellar cistern (new compared to ) is\n suggestive of edema/central herniation\n\n WET READ VERSION #2 DJD WED 4:31 AM\n 1) bilateral large subdural hematomas layering along both convexities left\n larger than right. mixed density of the left subdural hematoma is suggestive\n of acute (hyperdense) and hyperacute (low density) blood products [given that\n no subdural was present on .\n\n 2) diffuse subarachnoid hemorrhage.\n\n 3) possible hyperdensity is seen in the posterior fossa on the right\n inferiorly that could represent volume averaging or ?blood products.\n\n 4) non-displaced right occipetal bone fracture with extension to the right\n occipetal condyle and hypoglossal canal\n\n 5) hemorrhage in the sphenoid sinus.\n\n 6) obliteration of the suprasellar cistern (new compared to ) is\n suggestive of edema/central herniation\n\n OVERREAD: Agree. Subdural measurements: 1.2cm thickness. Causes subfalcine\n shift of 1.1cm to R- MD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found down. Alcohol intoxicated. Neck pain.\n (Over)\n\n 3:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o pe\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n COMPARISON: CT head dated .\n\n TECHNIQUE: MDCT acquired images of the head were obtained without IV\n contrast.\n\n FINDINGS: There are bilateral extraaxial, likely subdural, hematomas, left\n greater than right. The maximal diameter of the left subdural hematoma\n measures approximately 20 mm and on the right measures approximately 9 mm\n superiorly. There is a mixed density of the left subdural hematoma, hyperdense\n material as well as low- density material consistent with acute and hyperacute\n (noncoagulated) blood products. There is diffuse subarachnoid hemorrhage along\n both cerebral convexities. There is obliteration of the suprasellar cistern\n suggestive of downward transtentorial herniation. There is subfalcine\n herniation and left to right midline shift of the septum pellucidum measuring\n 14 mm. Globally, the matter-white matter differentiation is poor due\n to cerebral edema.\n\n Bone windows reveal a nondisplaced right occipital bone fracture that extends\n anteriorly to the occipital condyle on the right and involves the right\n hypoglossal canal. There is an adjacent hematoma, parencymal versus\n subdural in the inferior right posterior fossa. Hemorrhage is seen within the\n sphenoid sinus on the right with density extending towards the nasal cavity.\n\n IMPRESSION:\n 1. Bilateral subdural hematomas, left greater than right with significant\n mass effect producing subfalcine herniation. There is mixed density of the\n left subdural hematoma, hyperdensity intermixed with low-density material\n consistent with acute and hyperacute (noncoagulated) blood products.\n 2. Diffuse subarachnoid hemorrhage.\n 3. Obliteration of the suprasellar cistern consistent with edema and\n suggestive of downward transtentorial herniation.\n 4. Hyperdensity is also seen in the posterior fossa on the right at its\n inferior most aspect, likely fracture-associated hematoma.\n 5. Nondisplaced right occipital bone fracture with extension to the right\n occipital condyle and hypoglossal canal.\n 6. Hemorrhage within the sphenoid sinus on the right.\n\n The above was discussed with Dr. immediately after the completion\n of the study, and also flagged for urgent attention to the emergency board\n dashboard at 4:15 a.m. on .\n\n"
}
] |
71,599 | 192,984 | #Sepsis: Ms was hypotensive and hypoxic on admission and was intubated and required pressors. Lactate was 9.1. She was treated empirically for hospital-acquired pneumonia with cefepime and vancomycin; this was narrowed to cefepime after sputum cultures returned positive for pseudomonas aeruginosa. UA was positive and culture also grew pseudomonas. A 14-day course of cefepime was planned. For some concern of c. diff colitis she was initially treated with PO vancomycin, but this was discontinued after toxin assays returned negative. Other sources of infection considered included her various decubitus ulcers, her burn-related ulcer, and her necrotic great toe. Pressors were weaned after 48 hours; her BP remained stable throughout the remainder of her hospitalization. Her ventilator settings were gradually weaned and she was extubated on HD#7, which she tolerated. She was discharged with the plan to continue her IV antibiotics via PICC for a 14-day course. #Left upper extremity DVT: Ms. was noted to have an edematous left arm during hospitalization in the setting of a left internal jugular catheter. Ultrasound demonstrated a cephalic vein DVT. Heparin was begun and changed to lovanox on HD#7, but it was then decided that the risks of anticoagulation exceed the benefits, and this was discontinued. #Nutrition: Ms. gastric tube was clogged after her son administered a tube feeding. The tube then fell out when it was flushed. It was then replaced by a gastrojejunal tube, selected to decrease aspiration risk, which was sutured into place. #: Ms. originally had a creatinine of 1.2 on admission which was attributed to prerenal factors. Creatinine decreased to 0.4 with blood pressure support and fluids. | Left IJ catheter tip is in the mid SVC. There is a left-sided internal jugular venous central catheter which terminates in the mid SVC. Uncomplicated ultrasound and fluoroscopically guided a single lumen PICC line placement via the right brachial venous approach. SEMI-UPRIGHT PORTABLE VIEW OF THE CHEST: The endotracheal tube terminates 1.9 cm above the carina. A 0.035 guidewire was advanced and the Foley catheter removed. A nasogastric tube follows a normal course terminating in the distal stomach. Clinical correlation issuggested. Unchanged small left pleural effusion and subsequent moderate atelectasis of the retrocardiac lung regions. Uncomplicated exchange of pre-existing G-tube for gastrojejunostomy catheter. FINDINGS: Grayscale, color and Doppler images were obtained of the left IJ, subclavian, axillary, brachial, basilic, and cephalic veins. The catheter was secured with 0 silk suture. A sterile dressing was applied. Gastric tube is noted. intubated REASON FOR THIS EXAMINATION: pls assess interval change, tube placement FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST: REASON FOR EXAM: Sepsis, dementia, assess ET tube. Unchanged extent of the pre-existing right basal opacities. Its position was confirmed with contrast injection showing the tip in jejunal loops. FINDINGS: In comparison with the study of , the endotracheal tube is only about 1.5 cm above carina, with the tip pointing towards the right lateral wall. Sinus rhythm. Sinus rhythm. The referring physician . Over the Super Stiff wire gastrojejunostomy catheter was advanced. There are now visible air bronchograms, overlaid by a reticular opacity component. REASON FOR THIS EXAMINATION: pls eval interval change FINAL REPORT CHEST RADIOGRAPH INDICATION: Intubation, evaluation for interval change. The tip is 1.8 cm above the carina, and can be withdrawn 2 cm for standard position. Left basilar airspace opacity could represent aspiration or infection. Noprevious tracing available for comparison. Generalized low voltage.Prolonged QTc interval. Moderate atelectasis at the right lung base. Thrombus is seen within the left cephalic vein. Occlusive thrombus seen within the left cephalic vein. Occlusive thrombus seen within the left cephalic vein. Occlusive thrombus seen within the left cephalic vein. The right upper arm and abdomen were prepared in the usual sterile fashion. Lidocaine gel was put at the pre-existing G-tube site where a Foley catheter was placed. Final internal length of 37.5 cm, with the tip positioned in the SVC. Position of the catheter was confirmed by fluoroscopic spot film of the chest. FINDINGS: As compared to the previous radiograph, the monitoring and support devices are in unchanged position, except for the nasogastric tube that has been removed. Slightly more linear opacity at the right lung base is could represent atelectasis. There is small to moderate left pleural effusion. PROCEDURE: 1. PICC W/O PORT * * FLUORO GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. Unchanged size and appearance of the cardiac silhouette. Borderline A-V conduction delay. Placement of 4 French Vaxcel PASV single-lumen PICC via right brachial venous approach. 1:31 PM UNILAT UP EXT VEINS US LEFT Clip # Reason: dvt? ETT terminates 1.9 cm above the carina. The catheter was secured to the skin, flushed, and a sterile dressing applied. PROCEDURES: 1. There is volume loss in left lower lobe with pleural effusion on the right. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. , F. MED MICU 1:31 PM UNILAT UP EXT VEINS US LEFT Clip # Reason: dvt? Since the previous tracing of further precordial leadT wave changes are present. Unchanged overall lung volumes. There is airspace opacification at the left base most likely aspiration or infection. The wire was exchanged for a 0.035 straight Amplatz wire and the Kumpe catheter (Over) 10:24 AM G-TUBE CHECK/REPLACE Clip # Reason: please exchange, current tube is clogged Admitting Diagnosis: SEPSIS Contrast: OPTIRAY Amt: 20 FINAL REPORT (Cont) removed. With manipulation of the angle of the -tip sheath, and Kumpe catheter, the wire was advanced into the duodenum. | 10 | [
{
"category": "Radiology",
"chartdate": "2123-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1156693,
"text": " 3:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with respiratory failue intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure, with intubation.\n\n FINDINGS: In comparison with the study of , the endotracheal tube is only\n about 1.5 cm above carina, with the tip pointing towards the right lateral\n wall. Areas of opacification persist bilaterally. There is volume loss in\n left lower lobe with pleural effusion on the right. Opacification at the\n right base could reflect atelectatic change, though the possibility of\n supervening pneumonia should certainly be considered in the appropriate\n clinical setting.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1156853,
"text": " 2:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls assess interval change, tube placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 yo F w/ baseline non-verbal dementia x >2 years p/w sepsis and positive U/A.\n intubated\n REASON FOR THIS EXAMINATION:\n pls assess interval change, tube placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n\n REASON FOR EXAM: Sepsis, dementia, assess ET tube.\n\n ET tube is low. The tip is 1.8 cm above the carina, and can be withdrawn 2 cm\n for standard position. There are persistent low lung volumes. Cardiac size\n is normal. Bibasilar opacities, left greater than right, are unchanged from\n the day before, have improved on the right since , and have worsened\n on the left base since . These opacities could be due to multifocal\n pneumonia and worsening atelectasis in the left base. There is small to\n moderate left pleural effusion. Left IJ catheter tip is in the mid SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-19 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 1156779,
"text": " 1:31 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: dvt?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with unilat UE swelling\n REASON FOR THIS EXAMINATION:\n dvt?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LGS TUE 4:54 PM\n 1. Occlusive thrombus seen within the left cephalic vein.\n 2. No thrombus seen within the remainder of the deep veins of the left arm.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 79-year-old female with unilateral upper extremity swelling on\n the left.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler images were obtained of the left IJ,\n subclavian, axillary, brachial, basilic, and cephalic veins. Thrombus is seen\n within the left cephalic vein. This vessel does not compress and no vascular\n flow is seen on color Doppler imaging. Appropriate flow is seen in the\n remainder of the vessels. Edema is seen in the subcutaneous tissues of the\n left upper arm.\n\n IMPRESSION:\n 1. Occlusive thrombus seen within the left cephalic vein.\n 2. No thrombus seen within the remainder of the deep veins of the left arm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-19 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 1156780,
"text": ", F. MED MICU 1:31 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: dvt?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with unilat UE swelling\n REASON FOR THIS EXAMINATION:\n dvt?\n ______________________________________________________________________________\n PFI REPORT\n 1. Occlusive thrombus seen within the left cephalic vein.\n 2. No thrombus seen within the remainder of the deep veins of the left arm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1156501,
"text": " 2:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with intubated. 79 yo F w/ baseline non-verbal dementia x >2\n years p/w sepsis and positive U/A.\n REASON FOR THIS EXAMINATION:\n pls eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Intubation, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position, except for the nasogastric tube that has\n been removed. The pre-existing parenchymal opacities, both on the right and\n on the left, have markedly increased in extent. There are now visible air\n bronchograms, overlaid by a reticular opacity component.\n\n Moderate atelectasis at the right lung base.\n\n The presence of mild to moderate pleural effusions, right more than left,\n cannot be excluded.\n\n The referring physician . was paged for notification at the\n time of reporting on , 8:21 a.m. Subsequently, the findings\n were discussed over the telephone.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1157039,
"text": " 6:12 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, intubation, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS:\n\n As compared to the previous radiograph, the position and course of the central\n monitoring devices is unchanged.\n\n Unchanged size and appearance of the cardiac silhouette. Unchanged extent of\n the pre-existing right basal opacities. Unchanged small left pleural effusion\n and subsequent moderate atelectasis of the retrocardiac lung regions.\n Unchanged overall lung volumes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-21 00:00:00.000",
"description": "CONVERT G TO GJ, ALL INCL.",
"row_id": 1157082,
"text": " 10:24 AM\n G-TUBE CHECK/REPLACE Clip # \n Reason: please exchange, current tube is clogged\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 20\n ********************************* CPT Codes ********************************\n * CONVERT G TO GJ, ALL INCL. PICC W/O PORT *\n * FLUORO GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 yo F w/ baseline non-verbal dementia x >2 years p/w sepsis and positive U/A,\n now with clogged PEG\n REASON FOR THIS EXAMINATION:\n please exchange, current tube is clogged\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n 1. 79-year-old woman with baseline dementia for greater than two years with\n sepsis and positive UA now with clogged G-tube for exchange.\n 2. Need for antibiotics.\n\n PROCEDURES:\n 1. Scout film of the abdomen.\n 2. Placement of 4 French Vaxcel PASV single-lumen PICC via right brachial\n venous approach.\n\n OPERATORS: Dr. (fellow), Dr. and Dr. \n (radiologist) and Dr. (attending interventional\n radiologist) was present and supervising throughout the procedure.\n\n PROCEDURE:\n 1. After the risks, benefits, and alternatives to the procedure were\n explained to the patient's family written informed consent was obtained. The\n patient was brought to the angiography suite and placed supine on the imaging\n table. The right upper arm and abdomen were prepared in the usual sterile\n fashion. Lidocaine gel was put at the pre-existing G-tube site where a Foley\n catheter was placed. A preprocedure timeout and huddle were performed as per\n protocol.\n\n Fluoroscopic image demonstrated the Foley tube to be traversing the stomach\n and entering the esophagus. A 0.035 guidewire was advanced and the Foley\n catheter removed. A 7 French tip sheath was then advanced over the wire\n into the stomach. A 0.35 angled Glidewire was advanced through the sheath\n into the stomach. The sheath was removed over the wires and then be\n introduced over the angled Glidewire only leaving the wire as a safety\n wire. A 5 French Kumpe catheter was placed over the Glidewire.\n\n With manipulation of the angle of the -tip sheath, and Kumpe catheter,\n the wire was advanced into the duodenum. A longer Kumpe catheter was used to\n advance over the wire distal to the ligament of Treitz into the jejunal loops,\n under fluoroscopic guidance and confirmed with contrast injection. The wire\n was exchanged for a 0.035 straight Amplatz wire and the Kumpe catheter\n (Over)\n\n 10:24 AM\n G-TUBE CHECK/REPLACE Clip # \n Reason: please exchange, current tube is clogged\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n removed. Over the Super Stiff wire gastrojejunostomy catheter was\n advanced. Its position was confirmed with contrast injection showing the tip\n in jejunal loops. A locking loop was formed. The catheter was secured with 0\n silk suture. A sterile dressing was applied.\n\n 2. Using sterile technique and local anesthesia a patent right brachial vein\n was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n wire and a single-lumen PICC line measuring 37.5 cm in length was then placed\n through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by fluoroscopic\n spot film of the chest. The peel-away sheath and guidewire were then removed.\n The catheter was secured to the skin, flushed, and a sterile dressing applied.\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION:\n 1. Uncomplicated exchange of pre-existing G-tube for \n gastrojejunostomy catheter.\n 2. Uncomplicated ultrasound and fluoroscopically guided a single lumen PICC\n line placement via the right brachial venous approach. Final internal length\n of 37.5 cm, with the tip positioned in the SVC. Line is ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1156390,
"text": " 10:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with hx intubated\n REASON FOR THIS EXAMINATION:\n eval ETT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old female status post intubation.\n\n COMPARISON: No prior study available for comparison.\n\n SEMI-UPRIGHT PORTABLE VIEW OF THE CHEST: The endotracheal tube terminates 1.9\n cm above the carina. A nasogastric tube follows a normal course terminating\n in the distal stomach. There is a left-sided internal jugular venous central\n catheter which terminates in the mid SVC. Gastric tube is noted.\n\n There is airspace opacification at the left base most likely aspiration or\n infection. Slightly more linear opacity at the right lung base is could\n represent atelectasis. The heart size is normal. There is tortuosity of the\n thoracic aorta with atherosclerotic calcification, but the mediastinal\n silhouette is otherwise unremarkable. No appreciable pleural effusion or\n pneumothorax is noted.\n\n IMPRESSION:\n\n 1. ETT terminates 1.9 cm above the carina.\n\n 2. Left basilar airspace opacity could represent aspiration or infection.\n\n"
},
{
"category": "ECG",
"chartdate": "2123-10-17 00:00:00.000",
"description": "Report",
"row_id": 238786,
"text": "Sinus rhythm. Modest left axis deviation. Generalized low voltage.\nProlonged QTc interval. Findings are non-specific. Clinical correlation is\nsuggested. Since the previous tracing of further precordial lead\nT wave changes are present.\n\n"
},
{
"category": "ECG",
"chartdate": "2123-10-16 00:00:00.000",
"description": "Report",
"row_id": 238787,
"text": "Sinus rhythm. Borderline A-V conduction delay. Generalized low voltages. No\nprevious tracing available for comparison.\n\n"
}
] |
74,716 | 171,434 | 80 year-old speaking gentleman with history of hep B infection, presented with abdominal pain and jaundice consistent with an acute hepatitis, complicated by sepsis requiring pressors and mechanical ventilation. 1. ABDOMINAL PAIN/JAUNDICE- likely from acute hepatitis superimposed upon background of underlying cirrhosis. Imaging was consistent with chronic cirrhosis (etiology unclear) which could be known hep B carrier state and/or hemochromatosis (from Fe/TIBC ratio) or acute exacerbation of underlying liver disease from potential ingestion of herbal medicines while in or other toxic exposures. There was a question of a liver mass (w/ AFP 613) on CT scan which was not noted on ultrasound or MRCP. AFP being over 500 raises strong suspicion for hepatocellular carcinoma. ERCP was performed on hospital day #4 () to evaluate TBILI>20 which revealed no biliary disease. He then developed post-ERCP pancreatitis with some bloating after the procedure. On hospital day #6, his condition acutely worsened. He became tachypneic with increased abdominal distention and loss of bowel sounds. Laboratory studies revealed lactic acidosis. He quickly worsened and became hypotensive. He was transferred to the ICU where he was intubated for respiratory fatigue and placed on pressors. 2. pt developed distributive (hypovolemic) shock as above, which could have been exacerbated by some component of septic shock. He required intubation and blood pressure support while in the ICU. Most likely this was caused by worsening hepatic failure and post-ERCP pancreatitis. Etiology of acute liver injury was unclear and could be related to toxic ingestion/exposure, exacerbation of underlying chronic liver disease or hepatocellular carcinoma, given elevated AFP. However, mass was not clearly visualized on imaging. Diffuse HCC could be a possibility. Patients clinical status continued to deteriorate throughout the night of . He developed anuric renal failure likely in the setting of ATN from severe hypotension with some contribution from contrast-induced nephropathy. CVVH was initiated in an attempt to alleviate renal failure and pt received CVVH on . However, on that day serial ABGs became more and more acidotic and lactate continued to rise. Multiple meetings with pt's family members and interpreter were held throughout the day to clarify patient's goals of care. Due to the pt's poor prognosis in the setting of severe pancreatitis compounded by renal and hepatic failure, decision was reached to make pt DNR. After continued discussion through the night, decision was made to withdraw CVVH. Patient was kept comfortable on maximum sedation and pain control. Patient's electrolytes continued to worsen, lactate rose to 14, potassium increased to 7.6 and pt displayed EKG evidence of hyperkalemia on telemetry, from peaked T waves to sine-waves to ultimately PEA arrest. Patient expired in the presence of family at 0632 on . | CTA: There is slight narrowing at the proximal celiac artery without post-stenotic dilatation, unchnaged. CT PELVIS: Moderate ascites tracks inferiorly into the pelvis. New moderate bilateral pleural effusions with compressive atelectasis. New moderate bilateral pleural effusions with compressive atelectasis. New moderate bilateral pleural effusions with compressive atelectasis. A focus of apparent T2 hypointensity in the distal common bile duct, is only seen on the coronal images, is not confirmed on the axial images, abuts a duodenal diverticulum and is most likely artifactual in nature. Right pleural effusion, trace intrapelvic free fluid. The prostate, seminal vesicles, rectum, and distal sigmoid colon appear within normal limits. The pancreatic duct is prominent but not dilated. Heart size is within normal limits and the aorta is tortuous and calcified. The abdominal aorta shows mild atherosclerotic calcification without aneurysmal dilation. Marrow signal and imaged aorta appear unremarkable. Normal-appearing bowel loops and patent splanchnic vasculature without evidence of mesenteric ischemia. Normal-appearing bowel loops and patent splanchnic vasculature without evidence of mesenteric ischemia. Visualized portion of the heart and pericardium appear unremarkable. CT ABDOMEN WITH IV CONTRAST: Included views of the lung bases demonstrate small right pleural effusion. Subsequent opacification of the pancreatic duct and common duct demonstrates normal caliber ducts. Normal-appearing gallbladder, CBD, pancreas, and pancreatic duct. Moderate degenerative changes with spondylosis and disc space narrowing are redemonstrated in the lower thoracic and upper lumbar spine. Small right pleural effusion. Multiple small retroperitoneal lymph nodes are noted, with the largest node in the left paraaortic region measuring 11 mm (3B:164). A linear collection of contrast material between the common duct and the pancreatic duct is likely within the lumen of the bowel. Stable bilateral renal cysts. Stable bilateral renal cysts. Stable bilateral renal cysts. The rectum, sigmoid colon, and intrapelvic loops of small and large bowel appear normal. Multiple bilateral renal cysts appear unchanged. Concurrent duodenal ulcer rupture not excluded. Distal celiac artery remains patent. New onset small right pleural effusion. FINAL REPORT INDICATION: Jaundice with abnormal LFTs. CT ABDOMEN: Moderate bilateral pleural effusions with compressive atelectasis are new. Perfusion abnormality, No definite hepatic masses are identified. CTA: There is a replaced common hepatic artery arising from the superior mesenteric artery. COMPARISON: ERCP and CT abdomen . Left IJ hemodialysis catheter ends in the mid SVC. Left IJ hemodialysis catheter ends in the mid SVC. Left IJ hemodialysis catheter ends in the mid SVC. pancreatic, ? pancreatic, ? pancreatic, ? INDICATION: Abdominal distension. CT OF THE PELVIS WITH IV CONTRAST: Trace intrapelvic fluid is present(2:70). Inferior lead QRS configuration raises consideration ofpossible prior inferior myocardial infarction, although it is non-diagnosticand may be within normal limits. The portal vein is patent with normal hepatopetal flow. A right internal jugular catheter terminates in the mid SVC and the endotracheal tube is positioned 3.2 cm above the carina. FINDINGS: The liver has a heterogenous echotexture but without evidence of focal hepatic lesions. SINGLE AP UPRIGHT CHEST RADIOGRAPH: Left internal jugular hemodialysis catheter terminates at the level of mid SVC. Contrast media fills the gallbladder, consistent with the recent administration of contrast on the CT of . Trace intrapelvic and intra-abdominal fluid. Multiple right renal cysts. Moderate degenerative changes are seen in the lumbar spine, with anterior bridging osteophytes. R/o pulmonary edema/ effusion. R/o pulmonary edema/ effusion. R/o pulmonary edema/ effusion. Concurrent duodenal ulcer perforation cannot be excluded. Concurrent duodenal ulcer perforation cannot be excluded. The abdominal aorta, celiac trunk, SMA, and are widely patent and normal in caliber. The right lobe of the liver is encompassed by numerous confluent heterogeneously enhancing hypodense lesions, concerning for a primary neoplastic process such as HCC. 2:07 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for other pathology, ? Findings most consistent with pancreatitis, in keeping with recent ERCP. Findings most consistent with pancreatitis, in keeping with recent ERCP. A SINGLE SEMI-UPRIGHT AP CHEST RADIOGRAPH: A right PICC and a left IJ hemodialysis catheter are unchanged in position, terminating in the mid SVC. Sinus tachycardia. COMPARISON: CT abdomen from . Renal cysts. The common hepatic artery originates from the SMA, a variant. The liver demonstrates a nodular contour consistent with cirrhosis. Moderate anasarca is noted centered in the lower abdomen and pelvis. Incidental note of a small duodenal diverticulum is made. IMPRESSION: Nonspecific non-obstructive bowel gas pattern. The gallbladder contains dense contrast, presumably from reflux of contrast from recent ERCP. The cystic duct and intrahepatic biliary ducts are normal in caliber. Modest rightprecordial lead T wave changes. (Over) 2:07 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for other pathology, ? The celiac axis gives off the splenic and left gastric arteries. There is moderate ascites, with extensive fluid and stranding centered around the pancreatic head, most consistent with pancreatitis. Spleen, adrenals, pancreas appear normal. The portal vein, the splenic vein and the superior mesenteric vein are all patent. FINDINGS: A right IJ line is seen with the tip in the SVC and no PTX. COMPARISON: Abdominal CT from . The gallbladder is normal without evidence of stones. Modestright precordial lead ST-T wave changes. FINDINGS: Air-filled loops of large and small bowel are demonstrated but not abnormally dilated. The cardiomediastinal and hilar contours are normal. The cardiomediastinal and hilar contours are normal. Since the previous tracing of sinustachycardia is now present. Heterogenous liver echotexture. cholangiocarcinoma Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) OSSEOUS STRUCTURES: There is no acute fracture or dislocation. | 16 | [
{
"category": "Radiology",
"chartdate": "2113-06-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1134979,
"text": " 9:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: He has tachypnea and SOB. R/o pulmonary edema/ effusion.\n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with post-ERCP pancreatitis, getting aggressive fluids, with\n ileus. He has tachypnea and SOB. R/o pulmonary edema/ effusion.\n REASON FOR THIS EXAMINATION:\n He has tachypnea and SOB. R/o pulmonary edema/ effusion.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 9:44\n\n INDICATION: Shortness of breath and tachypnea.\n\n FINDINGS:\n\n There is a poor definition with some distention of the pulmonary vasculature\n and a crowded appearance in the central location consistent with an element of\n volume overload. The CP angles are still somewhat sharply marginated. Heart\n size is within normal limits and the aorta is tortuous and calcified. This\n study is limited by virtue of a shallow level of inspiration.\n\n IMPRESSION: Shallow inspiration but still suspect volume overload.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-18 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1134980,
"text": " 9:26 AM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: Confirm NGT placement\n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with post-ERCP pancreatitis, getting aggressive fluids, with\n ileus, increasing abdominal girth. NGT placed.\n REASON FOR THIS EXAMINATION:\n Confirm NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN ON \n\n INDICATION: Increasing abdominal girth.\n\n COMPARISON: at 00:11.\n\n FINDINGS:\n\n Nonspecific non-obstructive bowel gas pattern is observed with no evidence of\n progressive distention of bowel loops compared to prior. An NG tube tip is\n seen overlying the expected location of the gastric antrum. Contrast media\n seen in the gallbladder and the urinary bladder. There is no evidence of\n pneumatosis or free air although a single supine view limits assessment for\n the latter.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-13 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1134270,
"text": " 2:07 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for other pathology, ? pancreatic, ? cholangiocarcinoma\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with whole body jaundice and abnormal LFTs. RUQ u/s neg for\n liver and GB pathology\n REASON FOR THIS EXAMINATION:\n eval for other pathology, ? pancreatic, ? cholangiocarcinoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc TUE 5:20 PM\n Large hypodense, heterogeneously-enhancing mass occupying the entire right\n lobe of the liver is concerning for primary neoplasm such as HCC. Biopsy is\n recommended for further evaluation. Neighboring enlarged portocaval and\n portohepatic nodes are concerning for local spread.\n Small right pleural effusion.\n Trace intrapelvic and intra-abdominal fluid.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Jaundice with abnormal LFTs.\n\n COMPARISON: Ultrasound available from .\n\n TECHNIQUE: MDCT-acquired axial images of the abdomen and pelvis were obtained\n with the use of IV contrast. Coronal and sagittal reformats were performed.\n\n CT ABDOMEN WITH IV CONTRAST: Included views of the lung bases demonstrate\n small right pleural effusion. No nodules or masses are detected. Heart size\n is top normal. There is no pericardial effusion.\n\n The right lobe of the liver is encompassed by numerous confluent\n heterogeneously enhancing hypodense lesions, concerning for a primary\n neoplastic process such as HCC. No thrombotic extension into the portal\n venous system is appreciated. Enlarged portacaval, porta hepatic, and\n para-aortic retroperitoneal lymph nodes, measuring up to 14 mm along the short\n axis, is concerning for local nodal spread (2:15, 23, 19). The gallbladder,\n CBD, and pancreas are unremarkable. There is no intrahepatic biliary or\n pancreatic ductal dilatation.\n\n The spleen, adrenal glands, stomach, and intra-abdominal loops of small and\n large bowel appear unremarkable. The kidneys enhance symmetrically. Multiple\n simple renal cysts are seen bilaterally, the largest located at the mid pole\n of the right kidney and better appreciated on the corresponding ultrasound\n examination from . The abdominal aorta, celiac trunk, SMA, and\n are widely patent and normal in caliber.\n\n CT OF THE PELVIS WITH IV CONTRAST:\n Trace intrapelvic fluid is present(2:70). The rectum, sigmoid colon, and\n intrapelvic loops of small and large bowel appear normal. The appendix is\n unremarkable. There is no intrapelvic or inguinal lymphadenopathy is seen.\n The bladder, distal ureters, prostate, and seminal vesicles are normal.\n (Over)\n\n 2:07 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for other pathology, ? pancreatic, ? cholangiocarcinoma\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n OSSEOUS STRUCTURES: There is no acute fracture or dislocation. Moderate\n degenerative changes are present throughout the spine, most severe at L1-L2,\n with an anterior bridging osteophyte and mild loss of intervertebral disc\n height. No concerning sclerotic or lytic lesions are detected.\n\n IMPRESSION:\n 1. Large hypodense heterogeneously enhancing infiltrative lesion occupying\n the entire right lobe of the liver is concerning for primary neoplastic\n process such as HCC. A biopsy is warranted for further evaluation. Enlarged\n enhancing portacaval and porta hepatic nodes are concerning for local spread.\n 2. Normal-appearing gallbladder, CBD, pancreas, and pancreatic duct.\n 3. No CT evidence of tumor thrombosis.\n 4. Right pleural effusion, trace intrapelvic free fluid.\n 5. Multiple bilateral renal cysts.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-13 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1134263,
"text": " 1:05 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: JAUNDICE, EVAL FOR CBD OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with new jaundice\n REASON FOR THIS EXAMINATION:\n eval for cbd obstruction\n ______________________________________________________________________________\n WET READ: JBRe TUE 1:38 PM\n No liver or gallbladder pathology. No evidence of CBD stone. No intra-, or\n extrahepatic biliary duct dilatation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with new jaundice. Please evaluate for CBD\n obstruction.\n\n TECHNIQUE: Doppler ultrasound images of the liver and gallbladder were\n obtained.\n\n COMPARISON: ERCP from .\n\n FINDINGS:\n The liver has a heterogenous echotexture but without evidence of focal hepatic\n lesions. There is no intra- or extra-hepatic biliary duct dilatation with the\n common bile duct measuring 5 mm. The portal vein is patent with normal\n hepatopetal flow. The gallbladder is normal without evidence of stones.\n There is no evidence of distal common bile duct stones. The pancreas is only\n partially visualized and evaluation is limited, but no large masses are seen.\n Multiple right renal cysts are noted, the largest measuring 2 x 1.1 cm at the\n upper pole with a septation or adjacent small cyst.\n\n IMPRESSION:\n 1. No evidence of cholecysto-, or choledocholithiasis. No evidence of acute\n gallbladder pathology or biliary dilatation.\n 2. Heterogenous liver echotexture.\n 3. Multiple right renal cysts.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-16 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 1134702,
"text": " 10:15 AM\n CT ABD W&W/O C Clip # \n Reason: Please perform triple phase CT scan of liver\n Admitting Diagnosis: JAUNDICE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with jaundice, elevated transaminases, and likely cirrhosis, ?\n HCC\n REASON FOR THIS EXAMINATION:\n Please perform triple phase CT scan of liver\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with jaundice and elevated transaminases and\n likely cirrhosis.\n\n COMPARISON: CT of the abdomen and pelvis and an MRCP .\n\n TECHNIQUE: MDCT images were acquired through the abdomen using the triphasic\n liver protocol. Sagittal and coronal reformats were generated and reviewed.\n\n FINDINGS: No suspicious pulmonary nodules are seen in the visualized lung\n bases. Linear atelectasis is seen in the right lower lobe. A small right\n pleural effusion has minimally improved since the prior study. Visualized\n portion of the heart and pericardium appear unremarkable.\n\n The liver demonstrates a nodular contour consistent with cirrhosis. The liver\n shows differential enhancement pattern with hypoenhancement of the right lobe\n and relative of the entire left lobe. No definite hepatic\n mass lesions are identified. The portal vein, the hepatic vein and hepatic\n arteries are all patent. This differential hypo-enhancement of the right\n lobe, likely represents a vascular phenomenon or secondary to hepatitis. There\n is no intrahepatic or extrahepatic biliary dilatation. There is mild\n gallbladder wall edema, likely secondary to the liver pathology. No\n gallstones are seen. Multiple lymph nodes are seen in the portacaval,\n aortocaval regions and along the celiac axis, with the largest lymph node in\n the portocaval region measuring up to 12 mm (6:16). These are unchanged since\n the prior study. Both adrenal glands are normal in appearance. Both kidneys\n show multiple hypoenhancing lesions, consistent simple cysts. The spleen is\n normal measuring 10.4 cm. The pancreas is unremarkable.\n\n The stomach and visualized portion of the small and large bowel appears\n unremarkable. Incidental note of a small duodenal diverticulum is made. The\n abdominal aorta shows mild atherosclerotic calcification without aneurysmal\n dilation. Multiple small retroperitoneal lymph nodes are noted, with the\n largest node in the left paraaortic region measuring 11 mm (3B:164).\n\n CTA: There is a replaced common hepatic artery arising from the superior\n mesenteric artery. The celiac axis gives off the splenic and left gastric\n arteries. The portal vein, the splenic vein and the superior mesenteric vein\n are all patent.\n\n (Over)\n\n 10:15 AM\n CT ABD W&W/O C Clip # \n Reason: Please perform triple phase CT scan of liver\n Admitting Diagnosis: JAUNDICE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n OSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious lytic or sclerotic bone\n lesion is detected. Degenerative changes are seen in the lumbar spine.\n Subcutaneous foci of gas noted in the anterior abdominal wall above the\n umbilicus (401B:42), could relate to a site of injection. Recommended\n clinical correlation.\n\n Moderate degenerative changes are seen in the lumbar spine, with anterior\n bridging osteophytes. No concerning lytic or sclerotic bone lesion is\n identified.\n\n IMPRESSION:\n 1. Nodular contour of the liver likely represents cirrhosis. Perfusion\n abnormality, No definite hepatic masses are identified. Enlarged lymph nodes\n in the porta hepatis and along the celiac axis could be secondary to cirrhosis\n and inflammation.\n\n 2. Multiple renal cortical cysts.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-14 00:00:00.000",
"description": "MRCP (MR ABD W&W/OC)",
"row_id": 1134411,
"text": " 1:15 PM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: please evalaute for obstruction\n Admitting Diagnosis: JAUNDICE\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with liver tumor and worsening transaminitis and jaundice\n REASON FOR THIS EXAMINATION:\n please evalaute for obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Transaminitis and jaundice. Clinical concern for liver\n tumor on prior CT.\n\n COMPARISON: Abdominal CT from .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\n Tesla magnet including dynamic 3D imaging obtained prior to, during, and after\n uneventful intravenous administration of 0.5 mmol/kg of gadolinium-DTPA.\n Multiplanar 2D and 3D reformations and subtraction images were generated on an\n independent workstation.\n\n FINDINGS: The liver demonstrates a nodular contour with heterogeneous\n parenchyma intensity on T1, T2. Patchy areas of enhancement are most\n compatible with acute inflammation. There is no space occupying mass in the\n liver. There is no intrahepatic or extrahepatic biliary ductal dilatation.\n A focus of apparent T2 hypointensity in the distal common bile duct, is only\n seen on the coronal images, is not confirmed on the axial images, abuts a\n duodenal diverticulum and is most likely artifactual in nature. The\n gallbladder contains gallstones. Gallbladder wall is thickened and edematous,\n most likely secondary to underlying liver disease. Spleen, adrenals, pancreas\n appear normal. There is no pancreatic ductal dilatation. Both kidneys are in\n normal anatomic location and demonstrate symmetric enhancement. Multiple\n bilateral renal cysts, one of which contains a thin septation measuring 2.4 cm\n located in the interpolar region of the right kidney are noted. Marrow signal\n and imaged aorta appear unremarkable.\n\n Multiplanar 2D and 3D reformations provided multiple perspectives for the\n dynamic series and were essential in evaluating the bile duct.\n\n IMPRESSION:\n 1. Findings compatible with liver cirrhosis and acute hepatic inflammation.\n 2. No mass in the liver\n 3. Gallstones and gallbladder wall thickening which is most likely secondary\n to underlying liver disease.\n 4. Renal cysts.\n (Over)\n\n 1:15 PM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: please evalaute for obstruction\n Admitting Diagnosis: JAUNDICE\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-16 00:00:00.000",
"description": "ERCP BILIARY&PANCREAS BY GI UNIT",
"row_id": 1135083,
"text": " 8:51 AM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images from .\n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with progressive painless jaundice, elevated LFTs, question\n ductal obstruction.\n REASON FOR THIS EXAMINATION:\n Please review ERCP images from .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with progressive painless jaundice and elevated\n LFTs.\n\n COMPARISON: ERCP and CT abdomen .\n\n ERCP: 18 spot fluoroscopic images were obtained without a radiologist\n present. The scout image demonstrates contrast material within the collecting\n system of the right kidney. Subsequent opacification of the pancreatic duct\n and common duct demonstrates normal caliber ducts. A migratory, ovoid filling\n defect in the common duct likely represents air. A linear collection of\n contrast material between the common duct and the pancreatic duct is likely\n within the lumen of the bowel. The cystic duct and intrahepatic biliary ducts\n are normal in caliber. No extrinsic compression, stricture or filling defect\n is seen.\n\n IMPRESSIONS: No evidence of stricture, fixed filling defects or ductal\n dilatation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-19 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1135111,
"text": " 10:28 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: access for left IJ HD cath line placement\n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with shock, liver, renal failure. New left IJ HD cath. existing\n right IJ CVL\n REASON FOR THIS EXAMINATION:\n access for left IJ HD cath line placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KKgc MON 1:08 PM\n 1. Left IJ hemodialysis catheter ends in the mid SVC. No post-procedural\n complications identified.\n 2. New retrocardiac left lung base opacity, could represent atelectasis or\n pneumonia in the appropriate clinical setting.\n\n The findings were discussed with Dr. at 45 a.m. on .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New left IJ hemodialysis catheter placement in this patient with\n shock and renal failure.\n\n COMPARISON: Chest radiograph .\n\n SINGLE AP UPRIGHT CHEST RADIOGRAPH: Left internal jugular hemodialysis\n catheter terminates at the level of mid SVC. No post-procedural\n complications, especially no pneumothorax or mediastinal widening are seen. A\n right internal jugular catheter terminates in the mid SVC and the endotracheal\n tube is positioned 3.2 cm above the carina. The lung volumes are low. The\n cardiomediastinal and hilar contours are normal. New retrocardiac left lung\n base opacity, represents atelectasis or pneumonia in the appropriate clinical\n setting. No significant pleural effusions or pneumothorax is identified. A\n nasogastric tube ends in the distal stomach with side holes below the\n gastroesophageal junction.\n\n IMPRESSION:\n 1. Left IJ hemodialysis catheter ends in the mid SVC. No post-procedural\n complications identified.\n 2. New retrocardiac left lung base opacity, represents atelectasis or\n pneumonia in the appropriate clinical setting.\n\n The findings were discussed with Dr. at 10.45 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-19 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1135112,
"text": ", MED 10:28 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: access for left IJ HD cath line placement\n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with shock, liver, renal failure. New left IJ HD cath. existing\n right IJ CVL\n REASON FOR THIS EXAMINATION:\n access for left IJ HD cath line placement\n ______________________________________________________________________________\n PFI REPORT\n 1. Left IJ hemodialysis catheter ends in the mid SVC. No post-procedural\n complications identified.\n 2. New retrocardiac left lung base opacity, could represent atelectasis or\n pneumonia in the appropriate clinical setting.\n\n The findings were discussed with Dr. at 45 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-18 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1134942,
"text": " 12:10 AM\n PORTABLE ABDOMEN Clip # \n Reason: constipation vs. ileus\n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with abd distention\n REASON FOR THIS EXAMINATION:\n constipation vs. ileus\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN ON AT 00:11.\n\n INDICATION: Abdominal distension.\n\n FINDINGS:\n\n Air-filled loops of large and small bowel are demonstrated but not abnormally\n dilated. There is no evidence of free air or pneumatosis. Contrast media\n fills the gallbladder, consistent with the recent administration of contrast\n on the CT of .\n\n IMPRESSION:\n\n Nonspecific non-obstructive bowel gas pattern.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-19 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 1135159,
"text": " 1:34 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: Please evaluate for mesenteric ischemia or other causes of a\n Admitting Diagnosis: JAUNDICE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with abdominal distension and acute liver and kidney injury\n REASON FOR THIS EXAMINATION:\n Please evaluate for mesenteric ischemia or other causes of abdominal distension\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YGd MON 5:36 PM\n 1. Findings most consistent with pancreatitis, in keeping with recent ERCP.\n Subtle area of hypoattenuation along the body is suggestive of early necrosis.\n There is no pseudoaneurysm or abscess formation. Likely reactive inflammatory\n changes in the duodenum and stomach. Concurrent duodenal ulcer perforation\n cannot be excluded.\n 2. New moderate bilateral pleural effusions with compressive atelectasis.\n 3. Stable bilateral renal cysts.\n 4. Normal-appearing bowel loops and patent splanchnic vasculature without\n evidence of mesenteric ischemia.\n 5. Moderate anasarca, new since .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with abdominal distention and acute liver and\n kidney injury. Study to evaluate for mesenteric ischemia or other acute\n causes of abdominal distention.\n\n COMPARISON: CT abdomen from .\n\n TECHNIQUE: MDCT of the abdomen was performed prior to and following\n administration of intravenous contrast. Arterial and venous phase imaging\n were performed as per mesenteric CTA protocol. Maximum intensity projection\n and multiplanar reformations were generated.\n\n CT ABDOMEN: Moderate bilateral pleural effusions with compressive atelectasis\n are new. The heart is normal in size. There is no pericardial effusion.\n\n There is moderate ascites, with extensive fluid and stranding centered around\n the pancreatic head, most consistent with pancreatitis. Also noted is\n significant inflammatory thickening along the anterior pararenal and\n lateroconal fascia. Pockets of fluid are seen within the mesentery, and\n abutting the greater curvature of the stomach. A small area of relative\n along the pancreatic body is new, raising question of early\n necrosis. The tail of the pancreas also demonstrates subtle decrease in\n enhancement. The pancreatic duct is prominent but not dilated. A 2.4 cm\n duodenal diverticulum is present. Secondary inflammatory thickening is noted\n in the stomach and duodenum. There is no arterial pseudoaneurysm or venous\n thrombosis. There is no evidence of abscess formation.\n\n The liver, spleen, and adrenal glands appear unremarkable. The gallbladder\n contains dense contrast, presumably from reflux of contrast from recent ERCP.\n (Over)\n\n 1:34 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: Please evaluate for mesenteric ischemia or other causes of a\n Admitting Diagnosis: JAUNDICE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is enhancing periportal and retroperitoneal lymphadenopathy with the\n largest node measuring 1.2 cm in the porta hepatis (6:34). The kidneys\n enhance symmetrically without evidence of hydronephrosis. Multiple bilateral\n renal cysts appear unchanged. Contrast opacified small bowel loops are normal\n in caliber. Although there is no distal progression of oral contrast into the\n colon, the colonic walls remain thin. There is no dilated colon. There is no\n pneumatosis. There is no free air.\n\n CT PELVIS: Moderate ascites tracks inferiorly into the pelvis. The bladder\n is collapsed with a Foley catheter in place. The prostate, seminal vesicles,\n rectum, and distal sigmoid colon appear within normal limits. There is no\n inguinal or pelvic lymphadenopathy by CT size criteria. Moderate anasarca is\n noted centered in the lower abdomen and pelvis.\n\n CTA: There is slight narrowing at the proximal celiac artery without\n post-stenotic dilatation, unchnaged. Distal celiac artery remains patent.\n The splenic artery is diffusely attenuated but patent. The common hepatic\n artery originates from the SMA, a variant. The SMA and SMV are patent without\n evidence of thrombosis.\n\n Moderate degenerative changes with spondylosis and disc space narrowing are\n redemonstrated in the lower thoracic and upper lumbar spine. There is no\n concerning focal lytic or blastic lesions.\n\n IMPRESSION:\n 1. Findings most consistent with post-ERCP pancreatitis, with possible early\n necrosis along the pancreatic body, and reactive inflammation in duodenum and\n stomach. No abscess formation. No arterial pseudoaneurysm or venous\n thrombosis. Concurrent duodenal ulcer rupture not excluded.\n 2. New moderate bilateral pleural effusions with compressive atelectasis.\n 3. Stable bilateral renal cysts.\n 4. No evidence of mesenteric ischemia.\n 5. Moderate anasarca, new since .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-19 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 1135160,
"text": ", MED 1:34 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: Please evaluate for mesenteric ischemia or other causes of a\n Admitting Diagnosis: JAUNDICE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with abdominal distension and acute liver and kidney injury\n REASON FOR THIS EXAMINATION:\n Please evaluate for mesenteric ischemia or other causes of abdominal distension\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Findings most consistent with pancreatitis, in keeping with recent ERCP.\n Subtle area of hypoattenuation along the body is suggestive of early necrosis.\n There is no pseudoaneurysm or abscess formation. Likely reactive inflammatory\n changes in the duodenum and stomach. Concurrent duodenal ulcer perforation\n cannot be excluded.\n 2. New moderate bilateral pleural effusions with compressive atelectasis.\n 3. Stable bilateral renal cysts.\n 4. Normal-appearing bowel loops and patent splanchnic vasculature without\n evidence of mesenteric ischemia.\n 5. Moderate anasarca, new since .\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1134999,
"text": " 1:23 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Placement of CVL\n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with pancreatitis and shock\n REASON FOR THIS EXAMINATION:\n Placement of CVL\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON \n\n INDICATION: CVL placement.\n\n FINDINGS:\n\n A right IJ line is seen with the tip in the SVC and no PTX. There is a poor\n definition to and distention of the pulmonary vasculature consistent with\n volume overload. NGT is visualized extending below the left hemidiaphragm and\n an ETT is seen with the tip 4.7 cm above the carina.\n\n IMPRESSION: Appropriately located right CVL and features of volume overload.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1135238,
"text": " 9:11 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for interval change\n Admitting Diagnosis: JAUNDICE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with worsening hypoxia\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with worsening hypoxia, to assess interval\n change.\n\n COMPARISON: Chest radiograph .\n\n A SINGLE SEMI-UPRIGHT AP CHEST RADIOGRAPH: A right PICC and a left IJ\n hemodialysis catheter are unchanged in position, terminating in the mid SVC.\n Endotracheal tube ends 2.6 cm above the carina. Homogeneous opacity in the\n retrocardiac left lung base is unchanged since prior study and likely\n represents atelectasis or pneumonia in the appropriate clinical setting. The\n nasogastric tube ends within the stomach with side holes below the\n gastroesophageal junction. Small right pleural effusion is new since the\n prior study. Effusion if any on the left, is small. No pneumothorax is\n detected. The cardiomediastinal and hilar contours are normal. The pulmonary\n vasculature is not engorged.\n\n IMPRESSION:\n 1. No significant interval change in the retrocardiac left lung base opacity,\n likely atelectasis or pneumonia.\n 2. New onset small right pleural effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2113-06-18 00:00:00.000",
"description": "Report",
"row_id": 153678,
"text": "Sinus tachycardia. Indeterminate axis. Prolonged QTc interval. Modest\nright precordial lead ST-T wave changes. Findings are non-specific. Clinical\ncorrelation is suggested. Since the previous tracing of sinus\ntachycardia is now present. Otherwise, probably no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2113-06-17 00:00:00.000",
"description": "Report",
"row_id": 153905,
"text": "Sinus rhythm. Inferior lead QRS configuration raises consideration of\npossible prior inferior myocardial infarction, although it is non-diagnostic\nand may be within normal limits. Prolonged QTc interval. Modest right\nprecordial lead T wave changes. Findings are non-specific. Clinical\ncorrelation is suggested. No previous tracing available for comparison.\nTRACING #1\n\n"
}
] |
27,209 | 172,761 | 57 yo M with PMH of non-ischemic cardiomyopathy EF 20-30%, VT s/p ICD placement and now presents with VT and ICD firing. . # Rhythm: ICD fired several times and rhythm strips document VT. He was noted to have hypokalemia which could have potentiated his VT. He was admitted on a lidocaine drip, which controlled his V-tach. Lidocaine drip was tapered off as his antiarrhytmics were increased. Sotalol was increased to 80 TID, and Metoprolol 25mg started. However, as his blood pressure was occaisonally low, Metoprolol was decreased to 12.5mg . It was also noted that Sotalol increased his QTc substantially, and Sotalol was then discontinued. Mexiletine was started at 200mg TID. His electrolytes were closely monitored with goal of Mag >2.5 and K >4.5. He had no further episodes of V-tach or NSVT. He was monitored throught his hospital stay in the CCU on telemetry. . # Acute on chronic systolic heart failure: Non-ischemic cardiomyopathy with EF 20-30%. On admission he was slightly volume overloaded with bibasilar crackles on exam. As these crackles persisted, he was started on lasix 40 daily x3 days. He never had dyspnea or hypoxia. He diuresed well and lasix was decreased. On admission, he did was not taking any diuretic at home. He was discharged on lasix 10mg daily. He will need a Chem 10 in one week to evaluate electrolytes and creatinine. To avoid V-tach, magnesium should be avoid 2.5 and potassium above 4.5. A repeat echo showed no changes, no pericardial effusion, no decrease in EF. . # Mechanical aortic valve- INR was maintained from on coumadin . # Hypotension: The patient had occaisonal episodes of hypotension to SBP 77. These episodes were transient and usually resolved within 15-20min. He remained assymptomatic, mentating well, perfusing well. As the patient was doing well, no major changes were made. Metoprol was decreased from intially dose of 25mg to 12.5mg , and lasix was decreased from 40mg daily to 10mg daily. At discharge, his blood pressure was 110/60 and he was feeling well. A preliminary read of the echo showed no changes, no pericardial effusion, no decrease in EF. | Trivial mitral regurgitation is seen. intrinsic rhythm with 1st degree AVblock with PR 0.22, occ. Normal interatrial septum. "O: Please see careview for VS and additional data.CV: Pt HR 60 A-paced/AV-paced, no ectopy noted, NBP 87-101/53-61 MAPs 61-60. Compared to theprevious tracing of ventricular paced rhythm has been replaced byatrial paced rhythm conducting to native non-paced QRS complexes as described. with mild global free wall hypokinesis. Evaluate for LV, RV function.Height: (in) 66Weight (lb): 130BSA (m2): 1.67 m2BP (mm Hg): 106/64HR (bpm): 60Status: InpatientDate/Time: at 13:00Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. IV Lidocaine, EP consult in am. Total I/O neg. PERLA.GI/GU: Pt abd soft, +BS x4, no stool this shift. Mild global RV free wall hypokinesis.AORTA: Mildly dilated aortic sinus. Left-sided pacer/AICD is noted with the leads in standard position. Lido reconnected and pt without further runs. Diet advanced to reg/cardiac. Pt had 1 R hand PIV. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. Atrial pacing with native ventricular conduction. AVR well seated, normalleaflet/disc motion and transvalvular gradients.MITRAL VALVE: Mildly thickened mitral valve leaflets. Coumadin given today.RESP: O2 sats WNL on RA. Increased short runs NSVT noted--team aware. AM HCT 35.5, INR 2.2 (pt on coumadin d/t mechanical AV) remainder of am labs pending.Resp: Pt LS clear to crackles/diminshed at RLL. The basal to mid inferior and infero-lateral walls appearaneurysmal. The cardiac silhouette is enlarged and unchanged. EKG without ischemia per cardiology.Resp; sats 97-100% on 2L n/c, lungs with bibasilar rales with faint exp. IMPRESSION: Cardiomegaly with mild interstitial edema. Cont to monitor resp status, u/o. Non-paced ventricularexcitation with intraventricular conduction disturbance. Please see carevue for VS and objective data.Neuro: Pt. A-V interval 0.24 seconds.Left ventricular hypertrophy with ST-T wave changes. Right ventricular chambersize is normal. CPK 339/39, Trop. Mildly dilated ascending aorta. Compared to the previoustracing of the rhythm is now just ventricular paced.TRACING #2 AM HCt 35.5, remainder of am labs pending.Resp: Pt LS clear to slightly diminshed at bases, respirations even and regular, RR 17-20, O2 sats 92-95% on room air, no apparent resp distress noted. No ASD by2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness. Deep S waves inlead V2 fulfilling voltage criteria for left ventricular hypertrophy.Non-specific T wave inversions in leads I, aVL and V6. lytes WNL. Moderately dilated LV cavity. Am EKG QTC .49. addenduem to aboveas documented, rhythm paced, AVpaced with occ. There is once again noevidence of left bundle-branch block and no diagnostic interim change.TRACING #1 states that he is A/A/0x3, aware that he is at and in CCU. Prolonged A-V conduction. RR 14-21, breathing appears even and unlabored, O2 sats 94-100% on room air. ccu npn 1900-0700S; speaks Mandarin Chinese, son in for interpretation.O; please see carevue for VS and objective datacvs; hemodynamically stable with HR 58-62 AVpaced, occ. meds as ordered. Pt voiding independently CYU in urinalSKIN/ACCESS: Skin W&D. RR 16-21.GI:GU: NPO at present except for meds, Abdomen soft with active bowel sounds, no stool, voided via urinal just prior to admission.Renal; BUN/CREAT 18/1.0Endo; glucose 130's.ID; afebrile, WBC 5.3Heme; Hct stable at 32.8, INR 2.4 on Coumadin for AVRA: Hemodynamically stable on IV Lidocaine, s/p monomorphic VT, bump in CPKs/trop. No VSD.RIGHT VENTRICLE: Normal RV chamber size. felt secondary to ICD firing rather than ischemiaP: Cont to monitor hemodynamics, rhythm, cont. Bilat grasp equal. Hypotension. Dr. notified, assessed strips in chart. The aortic valve prosthesisappears well seated, with normal leaflet/disc motion and transvalvulargradients. Son, Shun, here for interpretation. No pain noted via grimace scale/vitals. Left bundle-branch block.Compared to the previous tracing there is no significant change. The aortic root ismildly dilated at the sinus level. Left ventricular wall thicknesses are normal. Lido disconnected when pt using urinal--lido briefly disconnected. Declined bowel meds. wheeze. The leftventricular cavity is moderately dilated. Coumadin unless plan for EP procedure. Since then, pt in own intrinsic rhythm, NSR, with rate 50-70, rare A Paced. The ascending aorta is mildly dilated. Sternotomy wires and cardiac valve are again noted. Mag. CCU NPO 0700-1900S: "Thank you. R hand noted to be swollen and pt c/o discomfort--PIV DCd and another placed in R AC.A/P: S/p VT/ICD firing at home of unclear etiology, ?r/t lytes.-closely monitor lytes, K >4, Mg >2-start Mexillitine tomorrow and Lido to 1mg/min-monitor R hand-emotional support, call son if needed to transulate or interpreter. K+ 3.6-3.7 repleted with 40meq po KCL. CCU NPN 0700-1900CV: HR initially 70s A-Paced c occas spikes within QRS. Cont to monitor pt hemodynamics, rhythm, Qtc, follow up with am lytes. arrived on IV Lidocaine at 4mg/min, decreased to 2mg/min upon admission as ordered. FINDINGS: AP view of the chest in upright position. consider cancel diet order in computer as pt does not follow it.QTC was prolonged on rhythm strip this AM, spoke with EP fellow 12 lead done and QT 0.50, they decreased sotolol, and we are to monitor.A: PT s/p V Tach, AICD firing at home, has been doing well here, weaned off lido drip, on mexilitene and decreased dose sotolol.P: follow rhythm, ectopy, QTC, follow lytes, ? No cough noted.Neuro: Pt reportedly A&Ox3 (pt son in during am shift yesterday for translation per report). Overall left ventricular systolic function is moderatelydepressed (LVEF= 30-35 %) with inferior and lateral akinesis ( the apex is notwell seen). No pain noted via grimace/nonverbal/vitals scale. Atrial paced rhythm with intrinsic A-V conduction. Cont to monitor pt hemodynamics-titrate meds as tol/ordered, f/u with remainder of am lab results. Slept well most of night.Skin; right hand swollen s/p peripheral IV, improved with elevation on pillow and warm packs.A; hemodynamically stable, without further shocks from ICD, now on 1mg/min IV Lidocaine, drop in SBP with the addition of even low dose Lopressor with increased SotalolP: Cont to monitor hemdodynamics, Pt's tolerance to med adjustments, may start Mexilitene in am and wean IV Lido. | 16 | [
{
"category": "Radiology",
"chartdate": "2141-04-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1008877,
"text": " 12:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with vtach and aicd firing\n REASON FOR THIS EXAMINATION:\n eval for acute change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Ventricular tachycardia with AICD firing. Rule out acute change.\n\n COMPARISON: .\n\n FINDINGS: AP view of the chest in upright position. Left-sided pacer/AICD is\n noted with the leads in standard position. Small portion of one of the leads\n is excluded from the film. Otherwise, the leads appear intact.\n The cardiac silhouette is enlarged and unchanged. There is no pneumothorax or\n consolidation. There is congestion of the pulmonary vasculature with\n increased interstitial markings consistent with mild interstitial edema. Right\n sided pleural thickening. Sternotomy wires and cardiac valve are again noted.\n\n IMPRESSION: Cardiomegaly with mild interstitial edema.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-04-16 00:00:00.000",
"description": "Report",
"row_id": 1618063,
"text": "CCU NURSING ADMIT NOTE\nPlease see ICU Adm. History/FHP for details of PMHx, reason for admission.\nPt. arrived to CCU at 0230 via stretcher from EW. Pt. sleeping but easily arousable to verbal and tactile stimuli. Please see carevue for VS and objective data.\nNeuro: Pt. speaks Mandarin Chinese only, does not speak or understand English. Son, Shun, here for interpretation. Admits that his father is sleepy but easily arousable and speaking to son. states that he is A/A/0x3, aware that he is at and in CCU. Pt. denies CP at present, admits to chronic right knee pain that is relieved by Pt. tapping on right lower leg with his left foot. Son states that Pt. does not take pain meds at home for this. Pt. following commands, hand grasps equal and strong. MAE, PERL, 2-3mm brisk. Slept well most of night with son present in room.\nCVS; Hemodynamically stable with HR 70's AVpaced, rare intrinsic ventricular beat, occ. PVC without further runs of VT. Pt. arrived on IV Lidocaine at 4mg/min, decreased to 2mg/min upon admission as ordered. K+ 3.6-3.7 repleted with 40meq po KCL. Mag. 2.0. CPK 339/39, Trop. 0.34. CCU team aware. BP ranges 120-150/80's. EKG without ischemia per cardiology.\nResp; sats 97-100% on 2L n/c, lungs with bibasilar rales with faint exp. wheeze. RR 16-21.\nGI:GU: NPO at present except for meds, Abdomen soft with active bowel sounds, no stool, voided via urinal just prior to admission.\nRenal; BUN/CREAT 18/1.0\nEndo; glucose 130's.\nID; afebrile, WBC 5.3\nHeme; Hct stable at 32.8, INR 2.4 on Coumadin for AVR\nA: Hemodynamically stable on IV Lidocaine, s/p monomorphic VT, bump in CPKs/trop. felt secondary to ICD firing rather than ischemia\nP: Cont to monitor hemodynamics, rhythm, cont. IV Lidocaine, EP consult in am. Follow up with am labs. Cont. Coumadin unless plan for EP procedure. Cont. meds as ordered. Comfort and emotional support to Pt. and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-04-16 00:00:00.000",
"description": "Report",
"row_id": 1618064,
"text": "addenduem to above\nas documented, rhythm paced, AVpaced with occ. intrinsic ventricular beats and some ventricular pacing spikes within QRS. Dr. notified, assessed strips in chart. Awaiting EPS evaluation of pacemaker and AICD interogation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-04-18 00:00:00.000",
"description": "Report",
"row_id": 1618069,
"text": "S:Mandarin chinese son and family help with interpretation.\n\nCV:apaced most of day today hr 60 occ. ventricular pacing spike in qrs complex, intrinsic rhythm afib prolonged qt .54 sotalol dc'd mexiletine increased. pt received lasix today with good response bp did drop to 70's for a short time increased to 90's without intervention. k repleated this a.m.\n\nresp:sats 95-100% on room air.lsc.\n\nGU/GI:pt using urinal clear yellow urin, BS +, large bm on commode, tolerating po meds and food, pt did order food tonight son is unable to come back with food tonight.\n\nneuro: son states father is and oriented x3, pt reports he is pain free and comfortable.\n\nA:s/p v tach, aicd firing at home, sotolol dc'd, mexilitene increased hemodynamically stable.\n\n\nP:follow rhythm, qtc, lytes recheck k tonight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-04-19 00:00:00.000",
"description": "Report",
"row_id": 1618070,
"text": "CCU NPN 1900-0700\nS: \"Thank you.\"\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 60's A-paced, NBP 85-107/46-60 MAPs 55-75 (systolic 80's and MAPs 55 when sleeping). Pt given evening metoprolol dose 12.5 mg-pt tol thus far. Bilat pedal pulses palp. AM HCt 35.5, remainder of am labs pending.\n\nResp: Pt LS clear to slightly diminshed at bases, respirations even and regular, RR 17-20, O2 sats 92-95% on room air, no apparent resp distress noted. No cough noted.\n\nNeuro: Pt reportedly A&Ox3 (pt son in during am shift yesterday for translation per report). Pt Mandarin Chinese speaking only, appears to understand some gestures (holds out arm when tourequet visualized, takes deep breaths when stethescope visualized and on back, etc). , pt MAE, turns self in bed, pt gestured to use call light to for RN with assistance out of bed. No pain noted via grimace/nonverbal/vitals scale. Pt slept throughout most of night, bilateral grasp strong.\n\nGI/GU: Pt abd soft, +BS x4, no stool this shift. Pt ate dinner last eve (finished tray not visualized) tolerating pills with water. Pt voiding clear yellow u/o via urinal, -1404 cc's at midnoc.\n\nID: Pt afebrile, WBC 4.8.\n\nSocial: No calls/visitors .\n\nSkin/access: Skin appears intact. 1 PIV.\n\nA/P: 57 y/o male s/p VT/ICD firing at home->pacer interogated, meds adjusted (lidocaine gtt on for approx 36 hours/dc'd-pt switched to PO sotalol and mexilitine, sotalol dc'd d/t prolonged QTC, mexiltine increased) and metoprolol 12.5 mg started with pt hemodynamically stable . Cont to monitor pt hemodynamics-titrate meds as tol/ordered, f/u with remainder of am lab results. Cont to monitor resp status, u/o. Translator as needed, awaiting further POC per CCU Team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-04-16 00:00:00.000",
"description": "Report",
"row_id": 1618065,
"text": "CCU NPN 0700-1900\nCV: HR initially 70s A-Paced c occas spikes within QRS. Lido disconnected when pt using urinal--lido briefly disconnected. Increased short runs NSVT noted--team aware. Lido reconnected and pt without further runs. PCM/ICD interrogated by EP-some changes made. Since then, pt in own intrinsic rhythm, NSR, with rate 50-70, rare A Paced. No plans for EPS at this time. Meds adjested--Sotalol increased to 160mg per EP. 25mg PO Lopressor added. lytes WNL. Coumadin given today.\n\nRESP: O2 sats WNL on RA. LS very dim, faint crackles in bases.\n\nNEURO: Sleeping most of day. Son in to translate this AM. Pt oriented x3 per son. c/o pain. MAE in bed. Self positions in bed.\n\nGI/GU: Taking pills whole with water without difficulty. Diet advanced to reg/cardiac. Son bringing in food. Declined bowel meds. Pt voiding independently CYU in urinal\n\nSKIN/ACCESS: Skin W&D. Pressure areas intact. Pt had 1 R hand PIV. R hand noted to be swollen and pt c/o discomfort--PIV DCd and another placed in R AC.\n\nA/P: S/p VT/ICD firing at home of unclear etiology, ?r/t lytes.\n-closely monitor lytes, K >4, Mg >2\n-start Mexillitine tomorrow and Lido to 1mg/min\n-monitor R hand\n-emotional support, call son if needed to transulate or interpreter.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-04-17 00:00:00.000",
"description": "Report",
"row_id": 1618066,
"text": "ccu npn 1900-0700\nS; speaks Mandarin Chinese, son in for interpretation.\nO; please see carevue for VS and objective data\ncvs; hemodynamically stable with HR 58-62 AVpaced, occ. intrinsic rhythm with 1st degree AVblock with PR 0.22, occ. ventricular pacing spike within QRS. CCU team aware. IV Lidocaine at 2mg/min decreased to 1mg/min at as ordered, rare PVC, only one 4 beat run of NSVT rate<150 at 2300. Increased Sotalol to 160mg at with BP 119-90's/60's, therefore given only 1/2 dose Lopressor 12.5mg at 0000, BP down to 70's/40's while Pt. sleeping. Pt. woken without change in SBP, CCU team notified, given 250cc IV NS bolus with SBP 84-102/50's.\nResp; sats 95-100% on room air, lungs clear with only fine dependent rales only. No SOB.\nGI:GU: Taking po's, no n/v. Abdomem soft with active bowel sounds, no stool. Voiding qs via urinal clear yellow urine. Total I/O neg. at MN.\nPt. eating food brought in by son from home.\nNeuro: Son in to assist with interpretation, states his father is A/A/OX3 and painfree, admits to feeling tired. MAE, following commands and communicating with hand gestures and head nods. Pt. does not speak or understand English, speaks only Mandarin Chinese, tho he did say \"thank you\". Pleasant and cooperative. Slept well most of night.\nSkin; right hand swollen s/p peripheral IV, improved with elevation on pillow and warm packs.\nA; hemodynamically stable, without further shocks from ICD, now on 1mg/min IV Lidocaine, drop in SBP with the addition of even low dose Lopressor with increased Sotalol\nP: Cont to monitor hemdodynamics, Pt's tolerance to med adjustments, may start Mexilitene in am and wean IV Lido. Follow up with am labs. Interpreter in am when rounding with CCU team if son not present. Comfort and emotional support to Pt. and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-04-19 00:00:00.000",
"description": "Report",
"row_id": 1618071,
"text": "CCU NPN\n\n0700-1700\n\nPt has continued to do well on mexilitine, mostly a paced 60-63 occasionally NSR. Pt discharged to home accompanied by daughter in law.at 1730. All discharge instructions, including dietary restrictions and medication administration instructions discussed with daughter in law (pt speaks only mandarin), she verbalized understanding. 2 doses of mexilitine given in the event prescription unable to be filled this evening.\n\nAll belongings sent home with pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-04-17 00:00:00.000",
"description": "Report",
"row_id": 1618067,
"text": "NPN 7 Am -- 7 PM\n\nS: pt states via interpreter that he has no CP, ( some back pain from bed), no dizzyness but reports feeling tired.\n\no: Please see careview for vitals and other objective data.\n\nPt was weaned down, then lidocaine off 3 hours after first mexilitene dose. Rhythm has been stable last 24 hours with 4 beat run yesterday,\notherwise A Paced and occasionally AV paced. Lopressor was added and dc'd today after BP dropped to 80's last night and pt was fiven 250 cc NS at that time. Bp stable all day but did drop to the 80's briefly and team was updated but bp up to 90's without intervention. pt had crackles adn mild CHF by CXR, and 20 mg lasix given. K and mag were aggressively repleated as well. Pt responded to lasix, over 2 liters net negative today after lasix.\n\nInterpreter came by this afternoon, met with pt RN and son in later updated by team. PT will not eat hospital food, no juice only water. Son comes in x per day to bring food from home. consider cancel diet order in computer as pt does not follow it.\n\nQTC was prolonged on rhythm strip this AM, spoke with EP fellow 12 lead done and QT 0.50, they decreased sotolol, and we are to monitor.\n\nA: PT s/p V Tach, AICD firing at home, has been doing well here, weaned off lido drip, on mexilitene and decreased dose sotolol.\n\nP: follow rhythm, ectopy, QTC, follow lytes, ? dc to floor if no further arrythmias, keep pt and family updated on POC as discussed in CCU rounds\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-04-18 00:00:00.000",
"description": "Report",
"row_id": 1618068,
"text": "CCU NPO 0700-1900\nS: \"Thank you.\"\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 60 A-paced/AV-paced, no ectopy noted, NBP 87-101/53-61 MAPs 61-60. Pt cont on PO sotalol 120 mg and mexilitine 150 mg Q8H. Am EKG QTC .49. Bilat pedal pulses palp. AM HCT 35.5, INR 2.2 (pt on coumadin d/t mechanical AV) remainder of am labs pending.\n\nResp: Pt LS clear to crackles/diminshed at RLL. RR 14-21, breathing appears even and unlabored, O2 sats 94-100% on room air. No cough noted.\n\nNeuro: Pt mandarin chinese speaking and understanding only. Reportedly, pt A&Ox3 (difficult to assess d/t language barrier), pt appears to understand in hospital (sticks arm out when saw tournequet, deep breathing with stethescope on chest, etc). No pain noted via grimace scale/vitals. Pt slept throughout most of night. MAE, able to turn self in bed, sits up in bed with assistance. Bilat grasp equal. PERLA.\n\nGI/GU: Pt abd soft, +BS x4, no stool this shift. Pt tol water with pills. Pt voiding via urinal, clear yellow u/o, -2077 cc's at midnoc.\n\nID: Afebrile, AM WBC 5.1.\n\nSocial: No calls/visitors .\n\nSkin/Access: Pt skin intact. 2 PIV's.\n\nA/P: 57 y/o male s/p VT/ICD firing at home, hemodynamically stable off lidocaine gtt on PO sotalol and mexilitine. Cont to monitor pt hemodynamics, rhythm, Qtc, follow up with am lytes. Cont to monitor resp status, u/o, translator as needed. Anticipate pt to be ?called out later today, awaiting further POC per CCU Team.\n"
},
{
"category": "Echo",
"chartdate": "2141-04-19 00:00:00.000",
"description": "Report",
"row_id": 84199,
"text": "PATIENT/TEST INFORMATION:\nIndication: Previous history of CM, ICD, AVR. Hypotension. Evaluate for LV, RV function.\nHeight: (in) 66\nWeight (lb): 130\nBSA (m2): 1.67 m2\nBP (mm Hg): 106/64\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 13:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and extending into the RV. Normal interatrial septum. No ASD by\n2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. No LV\nmass/thrombus. Moderately depressed LVEF. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. Normal\naortic arch diameter.\n\nAORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). AVR well seated, normal\nleaflet/disc motion and transvalvular gradients.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thicknesses are normal. The left\nventricular cavity is moderately dilated. No masses or thrombi are seen in the\nleft ventricle. Overall left ventricular systolic function is moderately\ndepressed (LVEF= 30-35 %) with inferior and lateral akinesis ( the apex is not\nwell seen). The basal to mid inferior and infero-lateral walls appear\naneurysmal. There is no ventricular septal defect. Right ventricular chamber\nsize is normal. with mild global free wall hypokinesis. The aortic root is\nmildly dilated at the sinus level. The ascending aorta is mildly dilated. A\nbileaflet aortic valve prosthesis is present. The aortic valve prosthesis\nappears well seated, with normal leaflet/disc motion and transvalvular\ngradients. The mitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. The pulmonary artery systolic pressure could\nnot be determined. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , no significant\nchange.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2141-04-19 00:00:00.000",
"description": "Report",
"row_id": 208375,
"text": "Atrial paced rhythm. Prolonged A-V conduction. Non-paced ventricular\nexcitation with intraventricular conduction disturbance. Deep S waves in\nlead V2 fulfilling voltage criteria for left ventricular hypertrophy.\nNon-specific T wave inversions in leads I, aVL and V6. Compared to the\nprevious tracing of ventricular paced rhythm has been replaced by\natrial paced rhythm conducting to native non-paced QRS complexes as described.\n\n"
},
{
"category": "ECG",
"chartdate": "2141-04-18 00:00:00.000",
"description": "Report",
"row_id": 208376,
"text": "The rhythm is now ventricular paced with capture. Compared to the previous\ntracing of the rhythm is now just ventricular paced.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2141-04-18 00:00:00.000",
"description": "Report",
"row_id": 208377,
"text": "Atrial paced rhythm with intrinsic A-V conduction. A-V interval 0.24 seconds.\nLeft ventricular hypertrophy with ST-T wave changes. Compared to the previous\ntracing of the Q-T interval remains long. There is once again no\nevidence of left bundle-branch block and no diagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2141-04-17 00:00:00.000",
"description": "Report",
"row_id": 208606,
"text": "Atrial pacing with native ventricular conduction. Left bundle-branch block.\nCompared to the previous tracing there is no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2141-04-15 00:00:00.000",
"description": "Report",
"row_id": 208607,
"text": "Atrially paced and ventricularly sensed rhythm at 75 beats per minute\nwith A-V conduction delay and intraventricular conduction defect of\nthe left bundle-branch block variety. Compared to the previous tracing\nof atrial pacing is new.\n\n"
}
] |
95,555 | 103,704 | The patient is a yo F with CAD s/p CABG in and transfered from for hypotension, renal failure and cancer work-up found to have metastatic cancer likely primary ovarian. Each of the problems addressed during this hospitalization are described in detail below. | was intubated for resp. was intubated for resp. was intubated for resp. was intubated for resp. was intubated for resp. was intubated for resp. was intubated for resp. was intubated for resp. was intubated for resp. was intubated for resp. was intubated for resp. RT A-line dampened. RT A-line dampened. RT A-line dampened. RT A-line dampened. RT A-line dampened. Re-sutured. Resp: extubated on . Resp: extubated on . Resp: extubated on . Resp: extubated on . Resp: extubated on . Action: Vasopressors weaned off. -Cytologies from OSH recent thoracentesis -F/u cytologies from pleural fluid here - gyn/onc recs . Remains pressor dependent on levophed and vasopressin. Remains pressor dependent on levophed and vasopressin. Remains pressor dependent on levophed and vasopressin. Remains pressor dependent on levophed and vasopressin. The patient was re-started on Levophed. Extubate if tolerates -F/u serial ABGs -Re-site Arterial line -Continue Vanc/zosyn . Titrating levophed at this time. Titrating levophed at this time. Renal consult if no improvement in UO and Creat. Renal consult if no improvement in UO and Creat. Cont weaning levophed gtt. Cont weaning levophed gtt. distress HEENT: Normocephalic, atraumatic. yo F with CAD s/p CABG in and transfered from for sepsis and CA w/u. yo F with CAD s/p CABG in and transfered from for sepsis and CA w/u. yo F with CAD s/p CABG in and transfered from for sepsis and CA w/u. yo F with CAD s/p CABG in and transfered from for sepsis and CA w/u. yo F with CAD s/p CABG in and transfered from for sepsis and CA w/u. was intubated for resp. Chief Complaint: transfered from for sepsis and CA w/u HPI: yo F with CAD s/p CABG in and transfered from for sepsis and CA w/u. Chief Complaint: transfered from for sepsis and CA w/u HPI: yo F with CAD s/p CABG in and transfered from for sepsis and CA w/u. # Pleural effusions / Respiratory status: -Monitor resp. was intubated for resp. Respiratory failure, acute (not ARDS/) Assessment: Received Pt. Respiratory failure, acute (not ARDS/) Assessment: Received Pt. Vasopressin. Mild (1+) mitral regurgitation is seen. yo F with CAD s/p CABG in and transfered from for sepsis and CA w/u. Patient is now intubated and s/p thoracentesis. Moderate mitral annularcalcification. Mild (1+) aortic regurgitation is seen. Plan: F/U final CT read. line in right IJ, now removed. -Monitor resp. -Cytologies from OSH recent thoracentesis -F/u cytologies from pleural fluid here . Vasopressin initiated. Interval removal of NGT. Also being empirically treated with vanco/zosyn. Admitted to for likely sepsis. Hypotension (not Shock) Assessment: Remains pressor dependent, changed from vasopressin to levophed to facilitate titrating of pressor. Hypotension (not Shock) Assessment: Remains pressor dependent, changed from vasopressin to levophed to facilitate titrating of pressor. Femoral line placed and levophed started. LUNGS: CTAB, decreased breaths sounds bilaterally. Paradoxic septal motion consistent withconduction abnormality/ventricular pacing.AORTA: Moderately dilated aortic sinus. # Pleural effusions / Respiratory status: -Monitor resp. # Pleural effusions / Respiratory status: -Monitor resp. was intubated for resp. was intubated for resp. was intubated for resp. was intubated for resp. was intubated for resp. Remains pressor dependent on levophed and vasopressin. Hypotension (not Shock) Assessment: Remains pressor dependent, changed from vasopressin to levophed to facilitate titrating of pressor. Extubate if tolerates -F/u serial ABGs -Re-site Arterial line -Continue Vanc/zosyn . Action: Vasopressors weaned off. -Cytologies from OSH recent thoracentesis -F/u cytologies from pleural fluid here - gyn/onc recs . Hypotension (not Shock) Assessment: Remains pressor dependent on levophed and vasopressin. Hypotension (not Shock) Assessment: Remains pressor dependent on levophed and vasopressin. Hypotension (not Shock) Assessment: Remains pressor dependent on levophed and vasopressin. Resp: extubated on . Resp: extubated on . -Cytologies from OSH recent thoracentesis -F/u cytologies from pleural fluid here - gyn/onc cs . # Pleural effusions / Respiratory status: -Monitor resp. Right small pleural effusion with adjacent atelectasis. Right-sided pleural effusion with adjacent atelectasis is noted. A central line is noted within the right common femoral , with small locules of air seen within the right external iliac , reflect sequela of injection. Atheromatous calcification of the aortic knob is noted. The right basilic vein was noted to not compress consistent with occlusive thrombus. There remains a small left-sided pleural effusion and a left retrocardiac opacity. Complete opacification of the left hemithorax may represent pleural effusion- atelectasis. Nasogastric tube is coiled in a moderate hiatus hernia. There is complete opacification of the left hemithorax with no significant shift of the mediastinum, which may represent a combination of pleural effusion and atelectasis. Also noted is a moderate right pleural effusion with associated atelectasis, unchanged since the prior study. SINGLE AP CHEST RADIOGRAPH: Again noted is a left IJ catheter following a normal course but extending across to the midline and slightly coursing upwards, suggesting that the tip might be in the proximal right brachiocephalic . CT OF THE CHEST WITHOUT IV CONTRAST: Coronary artery calcifications are noted. | 86 | [
{
"category": "Physician ",
"chartdate": "2117-10-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 498665,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Extubated, pressors d/c'd, mentating well.\n -However, later in PM, hypotensive to SBP of 70, continues to mentate\n normally\n -Transiently responded to IVF boluses x3, but we did not want to\n continue load the pt. with IVF as she was getting very edematous , and\n there was concern about accumulation of pleural fluid, which would\n likely require re-intubation. The patient was re-started on Levophed.\n -ABG at 10pm: 7.35/39/92/22/-3\n This AM, concern about oozing from a CVL as well as movement of CVL.\n Re-stiched at a closer site to insertion. Switched from Levophed to\n Vasopressin due to concern over\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:08 PM\n Vancomycin - 12:43 AM\n Piperacillin/Tazobactam (Zosyn) - 02:31 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:03 AM\n Heparin Sodium (Prophylaxis) - 12:42 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.3\nC (97.4\n HR: 79 (72 - 85) bpm\n BP: 87/51(63) {67/38(49) - 135/97(113)} mmHg\n RR: 27 (15 - 31) insp/min\n SpO2: 100%\n Heart rhythm: AV Paced\n Total In:\n 5,400 mL\n 588 mL\n PO:\n TF:\n 120 mL\n IVF:\n 5,280 mL\n 588 mL\n Blood products:\n Total out:\n 1,590 mL\n 635 mL\n Urine:\n 1,000 mL\n 285 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,810 mL\n -47 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 82\n PIP: 17 cmH2O\n Plateau: 12 cmH2O\n SpO2: 100%\n ABG: 7.35/39/91./19/-3\n Ve: 8.1 L/min\n PaO2 / FiO2: 230\n Physical Examination\n GENERAL: intubated, opens eyes, nods to voice commands\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: CTAB, significantly improved air movement on L side\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent, but difficulty\n competing sentences Moves all extremities.\n Labs / Radiology\n 431 K/uL\n 10.5 g/dL\n 102 mg/dL\n 1.2 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 40 mg/dL\n 110 mEq/L\n 139 mEq/L\n 34.2 %\n 13.8 K/uL\n [image002.jpg]\n 03:05 AM\n 04:54 AM\n 05:01 AM\n 10:06 AM\n 08:42 PM\n 04:00 AM\n 02:06 PM\n 05:01 PM\n 10:16 PM\n 04:20 AM\n WBC\n 13.0\n 11.0\n 13.8\n Hct\n 31\n 30.8\n 28.1\n 34.2\n Plt\n 381\n 340\n 431\n Cr\n 2.1\n 1.3\n 1.2\n TCO2\n 26\n 25\n 24\n 23\n 23\n 21\n 22\n Glucose\n 136\n 144\n 102\n Other labs: PT / PTT / INR:12.6/32.8/1.1, ALT / AST:14/20, Alk Phos / T\n Bili:67/0.3, Differential-Neuts:85.5 %, Lymph:7.6 %, Mono:5.8 %,\n Eos:1.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.3 g/dL, LDH:192 IU/L,\n Ca++:6.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n yo F w/ CAD s/p CABG (), x-fer from for hypotension,\n renal failure and cancer workup, likely ovarian primary.\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock. There is no pericardial effusion in TTE.. \n stim test demostrated appropriate response. PE is highly unlikely.\n - Vanc and Zosyn, currently day 3. Switch Vanc to daily dosing based\n on improved renal function.\n - hold anti-HTN and lasix\n - continue Levophed and vasopressin as needed for MAP >60, SBP >90.\n Wean as tolerated.\n -Use IVF boluses, as needed to keep MAP > 60\n - f/u cultures from as well as \n .\n # Hypoxic respiratory failure, likely to significant effusions,\n left lung collapse, +/- PNA. Significantly worsening this AM.\n -SBT today. Extubate if tolerates\n -F/u serial ABGs\n -Re-site Arterial line\n -Continue Vanc/zosyn\n .\n #. Oliguric renal failure: Cr 1.3 and improving, likely pre-renal /\n secondary to hypotension. No evidence of obstruction / no\n hydronephrosis on OSH CT.\n - Hold lasix and anti-HTN\n - Monitor UOP and Cr daily\n -Renally dose meds and avoid nephrotoxins\n .\n #. New carcinomatosis on CT / pleural effusions: last CA screening\n (mammogram, pap and colonoscopy 10-20 years ago). Concerning due to\n elevated CEA and CA125.\n -Cytologies from OSH recent thoracentesis\n -F/u cytologies from pleural fluid here\n - gyn/onc recs\n .\n #. hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n FEN: regular diet\n .\n PPX:\n -DVT ppx with heparin SC\n ICU Care\n Nutrition: Hold tube feeds for now\n Glycemic Control:\n Lines:\n Multi Lumen - 12:31 AM\n 22 Gauge - 12:43 AM\n Prophylaxis:\n DVT: Boots / Heparin SC\n Stress ulcer: pantoprazole\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 498115,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:15 AM\n ARTERIAL LINE - START 11:30 PM\n -Intubated yesterday AM for respiratory failure\n -CT torso (w/o IV contrast) showed:\n 1. Large L- pleural effusion, w/ near complete collapse and\n consolidation of L-lungs\n 2. Moderate-to-large R pleural effusion.\n 3. Ascites, with diffuse nodularity of the peritoneum, suspicious for\n peritoneal carcinomatosis.\n 4. Mesenteric lymphadenopathy.\n 5. Ill-defined lesion within the left lower pelvis, in the expected\n location of the uterus and adnexa, with calcifications seen. The origin\n and etiology of this lesion is unclear without intravenous contrast,\n and could reflect a uterine fibroid, or adnexal lesion. This can be\n correlated by ultrasound if clinically indicated.\n 6. Prominence of the cecal and sigmoid colonic walls. Correlate with\n colonoscopy findings.\n -Thoracentesis done (2300 mL off); chest tube placed to water seal\n -Renal recs: etiology of renal failure is pre-renal, can treat with\n fluids; at high risk of transition to ATN; need to determine baseline\n creatinine\n -Obtained outside records from (in chart) -\n thoracentesis cultures negative to date\n -Will need gyn/onc consult\n -Placed left femoral a-line after failed attempts at both radial\n arteries\n -Will need central line (so that right femoral central venous line can\n be d/c'ed)\n -Received multiple fluid boluses for decreased urine output\n -Vigileo showed cardiac index good, improved with fluid bolus of 1L,\n urine output also improved with fluid bolus of 1 liter\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 03:19 AM\n Vancomycin - 08:16 AM\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.23 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 01:20 PM\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 73 (60 - 97) bpm\n BP: 91/52(65) {91/50(65) - 141/73(95)} mmHg\n RR: 28 (11 - 31) insp/min\n SpO2: 95%\n Heart rhythm: AV Paced\n Total In:\n 4,809 mL\n 2,310 mL\n PO:\n 60 mL\n TF:\n IVF:\n 3,849 mL\n 2,250 mL\n Blood products:\n Total out:\n 2,725 mL\n 720 mL\n Urine:\n 425 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,084 mL\n 1,590 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 280 (280 - 280) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 19 cmH2O\n Plateau: 18 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 95%\n ABG: 7.29/50/167/23/-2\n Ve: 7.3 L/min\n PaO2 / FiO2: 418\n Physical Examination\n GENERAL: intubated, sedated\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: CTAB, decreased breaths sounds bilaterally.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent, but difficulty\n competing sentences Moves all extremities.\n Labs / Radiology\n 381 K/uL\n 9.3 g/dL\n 136 mg/dL\n 2.1 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 57 mg/dL\n 103 mEq/L\n 135 mEq/L\n 30.8 %\n 13.0 K/uL\n [image002.jpg]\n 04:06 AM\n 09:04 AM\n 01:45 PM\n 11:13 PM\n 11:23 PM\n 03:05 AM\n 04:54 AM\n 05:01 AM\n WBC\n 13.7\n 13.8\n 13.0\n Hct\n 32.3\n 35.8\n 31\n 30.8\n Plt\n 379\n 399\n 381\n Cr\n 2.5\n 2.3\n 2.1\n TCO2\n 31\n 29\n 27\n 26\n 25\n Glucose\n 122\n 124\n 136\n Other labs: PT / PTT / INR:13.2/35.0/1.1, ALT / AST:14/20, Alk Phos / T\n Bili:67/0.3, Lactic Acid:1.9 mmol/L, LDH:192 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n yo F w/ CAD s/p CABG (), x-fer from for hypotension,\n renal failure and cancer workup, likely ovarian primary.\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock . Pericardial effusion is also unlikely w/o low\n voltage EKG and no JVD, no effusion of CT chest. Infectious sources\n could be GI given carcinomatosis as well as pulmonary given recent dx\n PNA. Although there was no definate infiltrate on CT chest, there was\n significant lung collapse and effusion to make evaluation difficult. UA\n neg.\n - Vanc and Zosyn, will need to dose vanc by level (holding for now\n given renal function)\n - hold anti-HTN and lasix\n - continue Levophed and vasopressin as needed for MAP >60, SBP >90.\n -Minimize IVF boluses, but use as needed to keep MAP > 60\n - f/u cultures from as well as \n - stim test\n .\n # Hypoxic respiratory failure, likely to significant effusions,\n left lung collapse, +/- PNA. Significantly worsening this AM.\n -Intubate, start on mechanical ventilation with AC, tidal volume\n 4ml/kg, FiO2 at 100% (wean as tolerated), PEEP .\n -Sedation with Versed and Fentanyl.\n -CXR to evaluate ETT tube and OGT placement\n -Chest tube to decompress pleural space\n - will need thoracentesis\n -F/u serial ABGs\n -Arterial line\n -CT of chest and a/p today (without IV contrast)\n -Hard copies of scans from OSH, cytologies from OSH\n - Vanc/zosyn\n - increase tidal volume\n - consider decreasing PEEP to 8 from 10\n .\n #. Oliguric renal failure: cr 2.5 this AM, slightly improved, bland\n sediment, minimal UOP - pre-renal vs ATN. Renal failure may be\n secondary to low BP, but may also have a component of a more chronic\n process. No evidence of obstruction / no hydronephrosis on OSH CT.\n - hold lasix and anti-HTN\n - urine lytes\n - f/u CT a/p\n - urine eos\n - renal consult\n - monitor UOP\n .\n #. New carcinomatosis on CT / pleural effusions: last CA screening\n (mammogram, pap and colonoscopy 10-20 years ago). Concerning due to\n elevated CEA and CA125.\n -Cytologies from OSH recent thoracentesis\n -F/u cytologies from pleural fluid here\n - gyn/onc cs\n .\n #. hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n FEN: regular diet\n .\n PPX:\n -DVT ppx with heparin SC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:31 AM. Replace femoral line tomorrow.\n 22 Gauge - 12:43 AM\n Prophylaxis:\n DVT: Boots / Heparin SC\n Stress ulcer: pantoprazole\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498245,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP.\n SHIFT EVENTS:\n -As pt. has R femoral groin line and L femoral ALine, MDs placed new L\n IJTL yesterday . CXR showed line not in place. MDs attempted to\n reposition line last night but were unsuccessful. New Central line to\n be placed today. Also, ALine extremely dampened. MD\ns unable to place\n radial ALine at this time. Another attempt will be made today with\n attending MD.\n -TFeeds started at 10cc/hr at midnight\n Hypotension (not Shock)\n Assessment:\n SBP ranging from 90\ns to 140\ns. ALine dampened as noted above. Using\n non-invasive cuff at this time, as it correlated with A-Line earlier in\n the day. Remains pressor dependent on levophed and vasopressin.\n Action:\n Pt. received a total of 1L NS bolus for low BP and UO. Titrating\n levophed at this time.\n Response:\n Ongoing assessment.\n Plan:\n Continue to titrate pressors at tolerated. MDs to place new radial\n A-Line today.\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498247,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP.\n SHIFT EVENTS:\n -As pt. has R femoral groin line and L femoral ALine, MDs placed new L\n IJTL yesterday . CXR showed line not in place. MDs attempted to\n reposition line last night but were unsuccessful. New Central line to\n be placed today. Also, ALine extremely dampened. MD\ns unable to place\n radial ALine at this time. Another attempt will be made today with\n attending MD.\n -TFeeds started at 10cc/hr at midnight\n Hypotension (not Shock)\n Assessment:\n SBP ranging from 90\ns to 140\ns. ALine dampened as noted above. Using\n non-invasive cuff at this time, as it correlated with A-Line earlier in\n the day. Remains pressor dependent on levophed and vasopressin.\n Action:\n Pt. received a total of 1L NS bolus for low BP and UO. Titrating\n levophed at this time.\n Response:\n Ongoing assessment.\n Plan:\n Continue to titrate pressors at tolerated. MDs to place new radial\n A-Line and central line today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. intubated for increased respiratory distress. Remains\n intubated, AC mode, increased tV to 45Occ w/improvement in ventilation.\n PEEP decreased from 8 to 5 and paO2 remains 120s, rate decreased to 16\n from 28. Breath sounds diminished bibasilar. Left posterior pigtail\n chest tube remains intact, noted rare leak at water seal, -fluctuation,\n -crepitus. Dressing D&I, drained ___cc serosang fluid. Gross anasarca\n persists, noting increase in extremity edema.\n Action:\n Bleed gases monitored closely and vent changes made according to\n results. (see metavision) Pt. turned Q2h. Mouth care Q4h. Sedated on\n fentanyl 50mcg and versed 2mg for pt. comfort.\n Response:\n Blood gases continue to improve. Pt. appears comfortable at this time.\n Plan:\n Cont w/VAP prevention. Cont to wean vent as tolerated. Plan is to wean\n vent in hopes for possible extubation within the next couple of days.\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498248,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP.\n SHIFT EVENTS:\n -As pt. has R femoral groin line and L femoral ALine, MDs placed new L\n IJTL yesterday . CXR showed line not in place. MDs attempted to\n reposition line last night but were unsuccessful. New Central line to\n be placed today. Also, ALine extremely dampened. MD\ns unable to place\n radial ALine at this time. Another attempt will be made today with\n attending MD.\n -TFeeds started at 10cc/hr at midnight\n Hypotension (not Shock)\n Assessment:\n SBP ranging from 90\ns to 140\ns. ALine dampened as noted above. Using\n non-invasive cuff at this time, as it correlated with A-Line earlier in\n the day. Remains pressor dependent on levophed and vasopressin.\n Action:\n Pt. received a total of 1L NS bolus for low BP and UO. Titrating\n levophed at this time.\n Response:\n Ongoing assessment.\n Plan:\n Continue to titrate pressors at tolerated. MDs to place new radial\n A-Line and central line today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. intubated for increased respiratory distress. Remains\n intubated, AC mode, increased tV to 45Occ w/improvement in ventilation.\n PEEP decreased from 8 to 5 and paO2 remains 120s, rate decreased to 16\n from 28. Breath sounds diminished bibasilar. Left posterior pigtail\n chest tube remains intact, noted rare leak at water seal, -fluctuation,\n -crepitus. Dressing D&I, drained ___cc serosang fluid. Gross anasarca\n persists, noting increase in extremity edema.\n Action:\n Bleed gases monitored closely and vent changes made according to\n results. (see metavision) Pt. turned Q2h. Mouth care Q4h. Sedated on\n fentanyl 50mcg and versed 2mg for pt. comfort. Also being empirically\n treated with vanco/zosyn as pt. with history of recent pneumonia.\n Response:\n Blood gases continue to improve. Pt. appears comfortable at this time.\n Plan:\n Cont w/VAP prevention. Cont to wean vent as tolerated. Plan is to wean\n vent in hopes for possible extubation within the next couple of days.\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498864,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP.\n Hypotension (not Shock)\n Assessment:\n Received patient on levophed. Hr in 60-90 AV paced. Sbp 70-130\ns B/L\n arm edema. Difficult to palpate pulses. UOP 30-40cc/hr\n Action:\n Occasional SBP 70-80\ns however patient w/o change in MS. \nhed and titrated to MAP >55-60. continue ABX\n Response:\n Ongoing\n Plan:\n Continue to monitor hemodynamic status, f/u cx data, ID consult if\n needed. Wean off pressor.\n Neuro: alert oriented X1-2, follows commands, garbled speech.\n Resp: extubated on . Weaned to NC 5 L with sats at mid 90\ns. B/L\n LS clear w/crackles at the bases. LT CT to water seal draining\n serosang. Patient denies resp distress when asked.\n GI: abd soft non tender, positive for BS. 1-2X BM this shift. Desphagia\n diet w/nectar thick liquids. Denies nausea, vomiting\n GU: clear yellow urine via foley. 30-40cc/hr\n IV access: LT IJ\n appears to leak around insertion site re-sutured\n yesterday. RT A-line\n dampened.\n Social: patient is a FULL CODE>\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498251,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP.\n SHIFT EVENTS:\n -As pt. has R femoral groin line and L femoral ALine, MDs placed new L\n IJTL yesterday . CXR showed line not in place. MDs attempted to\n reposition line last night but were unsuccessful. New Central line to\n be placed today. Also, ALine extremely dampened. MD\ns unable to place\n radial ALine at this time. Another attempt will be made today with\n attending MD.\n -TFeeds started at 10cc/hr at midnight. (Goal 30cc/hr)\n Hypotension (not Shock)\n Assessment:\n SBP ranging from 90\ns to 140\ns. ALine dampened as noted above. Using\n non-invasive cuff at this time, as it correlated with A-Line earlier in\n the day. Remains pressor dependent on levophed and vasopressin.\n Action:\n Pt. received a total of 1L NS bolus for low BP and UO. Titrating\n levophed at this time.\n Response:\n Ongoing assessment.\n Plan:\n Continue to titrate pressors at tolerated. MDs to place new radial\n A-Line and central line today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. intubated for increased respiratory distress. Remains\n intubated, AC mode, increased tV to 45Occ w/improvement in ventilation.\n PEEP decreased from 8 to 5 and paO2 remains 120s, rate decreased to 16\n from 28. Breath sounds diminished bibasilar. Left posterior pigtail\n chest tube remains intact, noted rare leak at water seal, -fluctuation,\n -crepitus. Dressing D&I, drained ___cc serosang fluid. Gross anasarca\n persists, noting increase in extremity edema.\n Action:\n Bleed gases monitored closely and vent changes made according to\n results. (see metavision) Pt. turned Q2h. Mouth care Q4h. Sedated on\n fentanyl 50mcg and versed 2mg for pt. comfort. Also being empirically\n treated with vanco/zosyn as pt. with history of recent pneumonia.\n Response:\n Blood gases continue to improve. Pt. appears comfortable at this time.\n Plan:\n Cont w/VAP prevention. Cont to wean vent as tolerated. Plan is to wean\n vent in hopes for possible extubation within the next couple of days.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Pt\ns 4 children spoke w/OB/GYN and ICU team re: CT results and ICU\n plan of care yesterday. Awaiting cytology report for definitive\n diagnosis of probable ovarian CA vs lymphoma to direct care. Pt\ns dtr\n (HCP and RN) took RN aside to discuss possibility of comfort\n care.\n Action:\n Family spoke w/surgery and ICU team. Discussing plan of care amongst\n siblings.\n Response:\n Awaiting cytology results for definitive diagnosis.\n Plan:\n F/u w/results, assist patient\ns family to understand diagnosis and\n treatment possibilities.\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498532,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented. Gd O2sats.\n Action:\n Weaned and extubated.\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n On Vassopressin at 1.2 and Levophed at .08. Given 1L NS IVB.\n Action:\n Vasopressors weaned off. R radial art line placed. L femoral art line\n dc\n Response:\n Marginal BP. Given second liter bolus. BP 90-100s systolic. MAPs 58-70.\n Better wave form with new art line.\n Plan:\n Continue to monitor BP.\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498242,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP.\n SHIFT EVENTS:\n -As pt. has R femoral groin line and L femoral ALine, MDs placed new L\n IJTL yesterday . CXR showed line not in place. MDs attempted to\n reposition line last night but were unsuccessful. New Central line to\n be placed today. Also, ALine extremely dampened. MD\ns unable to place\n radial ALine at this time. Another attempt will be made today with\n attending MD.\n -TFeeds started at 10cc/hr at midnight\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498650,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP.\n Hypotension (not Shock)\n Assessment:\n Received patient off pressor since 16 pm on . Hr in 70-90 AV\n paced. B/L arm edema. Difficult to palpate pulses. Lactate 1.7 UOP\n 30-40cc/hr\n Action:\n SBP 70-80\ns however patient w/o change in MS. 1L NS bolus given\n w/transient effect. Levophed restarted and titrated up to MAP >55-60.\n due to line problems switched to vasopressin.( when line placement\n verified will reconsider restarting levophed if still needed) continue\n ABX\n Response:\n Ongoing\n Plan:\n Continue to monitor resp status, f/u cx data, ID consult if needed.\n Wean off pressor.\n Neuro: alert oriented X1-2, follows commands, garbled speech.\n Resp: extubated on . Weaned to NC 6 L with sats at high 90\ns-100.\n B/L LS diminished. LT CT to water seal draining serosang. Patient\n denies resp distress when asked.\n GI: abd soft non tender, positive for BS. No BM this shift. NPO. Denies\n nausea, vomiting\n GU: clear yellow urine via foley. 30-40cc/hr\n IV access: LT IJ- appears to be 9 cm out\n team notified. Re-sutured.\n CXR to verify placement. RT A-line\n dampened.\n Social: patient is a FULL CODE>\n"
},
{
"category": "Rehab Services",
"chartdate": "2117-10-07 00:00:00.000",
"description": "Swallowing Follow Up",
"row_id": 499033,
"text": "TITLE:\nSWALLOWING FOLLOW UP\nS: \"My swallowing is going OK, but I still don't have an\nappetite.\"\nO: Pt was seen at the bedside for a swallowing follow up. She is\ntolerating current diet of nectar thick liquids and pureed solids\nand has improved strength. Pt tolerated thin liquids and moist\nground solids without signs of aspiration. Mastication was\nprolonged with soft solids, requiring several sips of liquid to\nclear the residue.\nA: Ms. can be advanced to thin liquids and moist ground\nsolids. She will continue to require assistance for feeding\nduring meals. Pill scan be attempted whole with water, but it is\nlikely she will tolerate easier with apple sauce. Please page if\nthere are any concerns.\nRECOMMENDATIONS:\n1. Suggest advancing the pt to a PO diet of thin liquids and\nmoist, ground solids.\n2. Pills whole as tolerated, likely with apple sauce.\n3. TID oral care.\n4. Continued assistance for feeding during meals.\n5. Nutrition consult if intake is limited.\n6. Please page if there are any concerns.\n_________________________________\n , MS, CCC-SLP\nPager#\nFace Time: 10:30-10:50\nTotal Time: 40 minutes\n 11:04\n"
},
{
"category": "General",
"chartdate": "2117-10-07 00:00:00.000",
"description": "ICU Event Note",
"row_id": 499141,
"text": "Clinician: Attending\n Met with the patient, her daughter and a granddaughter. Primary nurse\n was also present with the medical student. patient updated on course.\n Discussed what her wishes would be for care in the event she were to\n have an arrhythmia or her heart were to stop as well as in the event of\n respiratory decompensastion. Patient declared that she would not want\n chest compressions/shock in the event of a cardiac arrest. she would\n want to be intubated for respiratory decompensation in the short term\n as long as there were reversible causes responsive to therapeutic\n intervention.\n Total time spent: 30 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498920,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP.\n Hypotension (not Shock)\n Assessment:\n Received patient on levophed. Hr in 60-90 AV paced. Sbp 70-130\ns B/L\n arm edema. Difficult to palpate pulses. UOP 30-40cc/hr\n Action:\n Occasional SBP 70-80\ns however patient w/o change in MS. \nhed and titrated to MAP >55-60. continue ABX\n Response:\n Ongoing\n Plan:\n Continue to monitor hemodynamic status, f/u cx data, ID consult if\n needed. Wean off pressor.\n Neuro: alert oriented X1-2, follows commands, garbled speech.\n Resp: extubated on . Weaned to NC 5 L with sats at mid 90\ns. B/L\n LS clear w/crackles at the bases. LT CT to water seal draining\n serosang. Patient denies resp distress when asked.\n GI: abd soft non tender, positive for BS. 1-2X BM this shift. Dysphasia\n diet w/nectar thick liquids. Denies nausea, vomiting\n GU: clear yellow urine via foley. 30-40cc/hr\n IV access: LT IJ\n appears to leak around insertion site, re-sutured\n yesterday. RT A-line\n dampened.\n Social: patient is a FULL CODE>\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498923,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP.\n Hypotension (not Shock)\n Assessment:\n Received patient on levophed. Hr in 60-90 AV paced. Sbp 70-130\ns B/L\n arm edema. Difficult to palpate pulses. UOP 30-40cc/hr\n Action:\n Occasional SBP 70-80\ns however patient w/o change in MS. \nhed and titrated to MAP >55-60. continue ABX\n Response:\n Ongoing\n Plan:\n Continue to monitor hemodynamic status, f/u cx data, ID consult if\n needed. Wean off pressor.\n Neuro: alert oriented X1-2, follows commands, garbled speech.\n Resp: extubated on . Weaned to NC 5 L with sats at mid 90\ns. B/L\n LS clear w/crackles at the bases. LT CT to water seal draining\n serosang. Patient denies resp distress when asked.\n GI: abd soft non tender, positive for BS. 1-2X BM this shift. Dysphasia\n diet w/nectar thick liquids. Denies nausea, vomiting\n GU: clear yellow urine via foley. 30-40cc/hr\n IV access: LT IJ\n appears to leak around insertion site, re-sutured\n yesterday. RT A-line\n dampened.\n Social: patient is a FULL CODE>\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-08 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 499434,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP, now on levophed for b/p\n support. Extubated .\n Pressors off \n Respiratory failure, acute (not ARDS/)\n Assessment:\n On 4l nc..rr 20\nsats mid to high 90\ns. Non-congested cough.\n Left chest tube still in place. To water seal\n Sanquinous drainage\n Action:\n No change in antibiotics\n Response:\n Remains afebrile\n Plan:\n Continue current course.. ??plan for chest tube\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Heme/Onc and palliative care met with pt and family today\n Action:\n Discussed options for palliative chemo\n Response:\n Pt and family thinking over options..\n Plan:\n Ongoing communication.\n Lines:\n Pt had double lumen PICC line placed in IR this morning. Funcioning\n well.\n u/o fair\nneeds more po intake\n??fluid bolus.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n SEPSIS\n Code status:\n DNR..ok to intubate short term\n Height:\n Admission weight:\n 88.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: COPD\n CV-PMH: CAD, Hypertension, Pacemaker\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:110\n D:70\n Temperature:\n 97\n Arterial BP:\n S:151\n D:81\n Respiratory rate:\n 30 insp/min\n Heart Rate:\n 97 bpm\n Heart rhythm:\n AV Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 2% %\n 24h total in:\n 1,473 mL\n 24h total out:\n 820 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 03:07 AM\n Potassium:\n 3.8 mEq/L\n 03:07 AM\n Chloride:\n 112 mEq/L\n 03:07 AM\n CO2:\n 19 mEq/L\n 03:07 AM\n BUN:\n 26 mg/dL\n 03:07 AM\n Creatinine:\n 0.9 mg/dL\n 03:07 AM\n Glucose:\n 95 mg/dL\n 03:07 AM\n Hematocrit:\n 31.3 %\n 03:07 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4 \n Transferred to: 1174\n Date & time of Transfer: ^th 1745\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-07 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 499058,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Slight appetite this morning\n Back on levo for BP in 80's, mentating\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:08 PM\n Vancomycin - 12:50 AM\n Piperacillin/Tazobactam (Zosyn) - 09:36 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:07 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:52 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.1\nC (96.9\n HR: 75 (63 - 95) bpm\n BP: 125/60(81) {95/41(59) - 144/68(94)} mmHg\n RR: 28 (14 - 29) insp/min\n SpO2: 95%\n Heart rhythm: AV Paced\n Total In:\n 2,127 mL\n 977 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,787 mL\n 977 mL\n Blood products:\n 100 mL\n Total out:\n 1,649 mL\n 690 mL\n Urine:\n 959 mL\n 590 mL\n NG:\n Stool:\n Drains:\n Balance:\n 478 mL\n 287 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///20/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, epistaxis\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.8 g/dL\n 399 K/uL\n 99 mg/dL\n 1.1 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 34 mg/dL\n 114 mEq/L\n 144 mEq/L\n 31.7 %\n 10.2 K/uL\n [image002.jpg]\n 04:54 AM\n 05:01 AM\n 10:06 AM\n 08:42 PM\n 04:00 AM\n 02:06 PM\n 05:01 PM\n 10:16 PM\n 04:20 AM\n 03:51 AM\n WBC\n 13.0\n 11.0\n 13.8\n 10.2\n Hct\n 30.8\n 28.1\n 34.2\n 31.7\n Plt\n 381\n 340\n 431\n 399\n Cr\n 2.1\n 1.3\n 1.2\n 1.1\n TCO2\n 25\n 24\n 23\n 23\n 21\n 22\n Glucose\n 136\n 144\n 102\n 99\n Other labs: PT / PTT / INR:13.1/34.3/1.1, ALT / AST:27/28, Alk Phos / T\n Bili:64/0.4, Differential-Neuts:76.7 %, Lymph:12.0 %, Mono:8.9 %,\n Eos:2.2 %, Lactic Acid:1.7 mmol/L, Albumin:2.6 g/dL, LDH:300 IU/L,\n Ca++:6.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN): Morphine, adequately\n controlled.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Comfortable from a\n respiratory standpoint on nasal cannula, epistaxis this am likely\n secondary to the dryness, change to humidified face mask. Chest tube to\n water seal, no leak. Output has decreased.\n PLEURAL EFFUSION: As above. Cytology negative to date. Consult med\n oncology.\n HYPOTENSION (NOT SHOCK): Despite total body fluid overlaoded, still\n intravascularly depleted. IVF bolus, consider albumin.\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL): medical oncology consult.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Cr slightly\n improved.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:30 PM\n Arterial Line - 03:13 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498591,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP.\n Hypotension (not Shock)\n Assessment:\n Received patient off pressor since 16 pm on . Hr in 70-90 AV\n paced. B/L arm edema. Difficult to palpate pulses. Lactate 1.7 UOP\n 30-40cc/hr\n Action:\n SBP 70-80\ns however patient w/o change in MS. 1L NS bolus given\n w/transient effect. Levophed restarted and titrated up to MAP >55-60.\n continue ABX\n Response:\n Ongoing\n Plan:\n Continue to monitor resp status, f/u cx data, ID consult if needed.\n Wean off pressor.\n Neuro: alert oriented X1-2, follows commands, garbled speech.\n Resp: extubated on . Weaned to NC 6 L with sats at high 90\ns-100.\n B/L LS diminished. LT CT to water seal draining serosang. Patient\n denies resp distress when asked.\n GI: abd soft non tender, positive for BS. No BM this shift. NPO. Denies\n nausea, vomiting\n GU: clear yellow urine via foley. 30-40cc/hr\n IV access: LT IJ- appears to be 9 cm out\n team notified. CXR to verify\n placement. RT A-line\n dampened.\n Social: patient is a FULL CODE>\n"
},
{
"category": "Nutrition",
"chartdate": "2117-10-07 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 499010,
"text": "Subjective\n Patient s/p SLP evaluation- cleared for purees and nectar thick liquids\n Objective\n Pertinent medications: norepinephrine, others noted\n Labs:\n Value\n Date\n Glucose\n 99 mg/dL\n 03:51 AM\n BUN\n 34 mg/dL\n 03:51 AM\n Creatinine\n 1.1 mg/dL\n 03:51 AM\n Sodium\n 144 mEq/L\n 03:51 AM\n Potassium\n 3.6 mEq/L\n 03:51 AM\n Chloride\n 114 mEq/L\n 03:51 AM\n TCO2\n 20 mEq/L\n 03:51 AM\n Albumin\n 2.6 g/dL\n 03:51 AM\n Calcium non-ionized\n 6.8 mg/dL\n 03:51 AM\n Phosphorus\n 2.2 mg/dL\n 03:51 AM\n Magnesium\n 2.3 mg/dL\n 03:51 AM\n Current diet order / nutrition support: Pureed with nectar thick\n liquids\n GI: Abdomen soft/obese with positive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n year old female transferred from outside hospital for workup of\n sepsis. Patient now extubated and off of tube feedings. Was able to\n pass swallow evaluation, but noted plans for re-evaluation today d/t\n limited exam yesterday. Anticipate that patient may not be able to meet\n 100% of nutrition needs. If appropriate, can consider nutrition support\n via tube feedings. Would suggest Isosource 1.5 at 45ml/hr x 24 hours to\n provide 1620kcal and 73g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n c/w diet as ordered, advance texture per swallow evaluation\n today\n Will provide Ensure Pudding with meals\n Encourage PO intake\n Consider nutrition support as above if patient unable to\n take good POs.\n Will follow\n 09:23 AM\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 499139,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP, now on levophed for b/p\n support. Extubated , now on 2L NC breathing w/some effort at\n rate 20-26bpm.\n Hypotension (not Shock)\n Assessment:\n Levophed weaned off today, off since 1300. Albumin 25% administered as\n ordered @ 1730. TLC appears out by 10cm today. Bed linens soaked w/what\n appears to be IVF. IVF infusions stopped, assessed by IV RN for PICC\n and d/t difficulties w/TLC placement and pacemaker will have PICC\n placed by IR tomorrow. ICU team to d/c TLC.\n Action:\n Levophed off, albumin administered again today.\n Response:\n Normotensive.\n Plan:\n Cont to monitor b/p, if hypotensive rx w/fluids and colloids vs\n pressors as central line to be d/c\nd as not functioning properly.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Action:\n .\n Response:\n .\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o supra pubic abd pain and occasional back discomfort. Requested pain\n medication this morning. C/o neck pain from TLC site, medicated w/650mg\n PO Tylenol (elixir mixed w/nectar thick water) w/relief of pain. Small\n hematoma @ TLC site.\n Action:\n Medicated for pain with .5mg morphine IV x2 within\n hour w/relief of\n pain. Subsequent pain relieved w/position changes every 2 hours.\n Response:\n Relief of pain w/1mg morphine IV. Pt requiring q2hour position changes\n for comfort. Patient appreciated back rubs and hair being combed.\n Tylenol relieved neck pain from TLC site.\n Plan:\n Cont to assess for pain, medicate w/1mg morphine for pain or\n greater and reposition at least q2hours w/back rubs for comfort and\n continual assessment of stage 1 pressure ulcer @ coccyx.\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 498428,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Tidal volume was increased after the patient\ns left lung re-expanded\n - The patient received several IVF boluses, continued on levophed/\n vasopressin\n - Tube feeds were started\n - Family meeting was held along with Ob/Gyn doctors to discuss\n \n - New IJ CVL was placed, but was found to be in azygous v., was pulled\n back, but is still not in proper position. The patient continues to\n have femoral CVL for now.\n This AM, the pt. opens eyes, nods to voice command. Denies having\n pain.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Piperacillin - 10:55 PM\n Vancomycin - 01:34 AM\n Infusions:\n Vasopressin - 1.2 units/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:55 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.2\n HR: 76 (60 - 76) bpm\n BP: 94/50(64) {52/35(42) - 148/82(96)} mmHg\n RR: 16 (11 - 29) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n CVP: 8 (6 - 8)mmHg\n Total In:\n 6,160 mL\n 1,518 mL\n PO:\n TF:\n 5 mL\n 71 mL\n IVF:\n 6,095 mL\n 1,448 mL\n Blood products:\n Total out:\n 1,720 mL\n 790 mL\n Urine:\n 1,250 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,440 mL\n 728 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (280 - 450) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 17 cmH2O\n Plateau: 15 cmH2O\n Compliance: 45 cmH2O/mL\n SpO2: 99%\n ABG: 7.41/35/130/22/-1\n Ve: 6.6 L/min\n PaO2 / FiO2: 325\n Physical Examination\n GENERAL: intubated, opens eyes, nods to voice commands\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: CTAB, significantly improved air movement on L side\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent, but difficulty\n competing sentences Moves all extremities.\n Labs / Radiology\n 340 K/uL\n 8.9 g/dL\n 144 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 42 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.1 %\n 11.0 K/uL\n [image002.jpg] ABG: 7.41/35/130/23/-1\n 09:04 AM\n 01:45 PM\n 11:13 PM\n 11:23 PM\n 03:05 AM\n 04:54 AM\n 05:01 AM\n 10:06 AM\n 08:42 PM\n 04:00 AM\n WBC\n 13.8\n 13.0\n 11.0\n Hct\n 35.8\n 31\n 30.8\n 28.1\n Plt\n 399\n 381\n 340\n Cr\n 2.3\n 2.1\n 1.3\n TCO2\n 31\n 29\n 27\n 26\n 25\n 24\n 23\n Glucose\n 124\n 136\n 144\n Other labs: PT / PTT / INR:13.3/35.5/1.1, ALT / AST:14/20, Alk Phos / T\n Bili:67/0.3, Differential-Neuts:85.5 %, Lymph:7.6 %, Mono:5.8 %,\n Eos:1.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.3 g/dL, LDH:192 IU/L,\n Ca++:6.7 mg/dL, Mg++:1.7 mg/dL, PO4:2.7 mg/dL\n Pleural fluid: Gram Stain PMN 1+, no microorganisms, Cx pending.\n Urine, Blood Cx pending\n Assessment and Plan\n yo F w/ CAD s/p CABG (), x-fer from for hypotension,\n renal failure and cancer workup, likely ovarian primary.\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock. There is no pericardial effusion in TTE.. \n stim test demostrated appropriate response. PE is highly unlikely.\n - Vanc and Zosyn, currently day 3. Switch Vanc to daily dosing based\n on improved renal function.\n - hold anti-HTN and lasix\n - continue Levophed and vasopressin as needed for MAP >60, SBP >90.\n Wean as tolerated.\n -Use IVF boluses, as needed to keep MAP > 60\n - f/u cultures from as well as \n .\n # Hypoxic respiratory failure, likely to significant effusions,\n left lung collapse, +/- PNA. Significantly worsening this AM.\n -Intubate, start on mechanical ventilation with AC, tidal volume\n 4ml/kg, FiO2 at 100% (wean as tolerated), PEEP .\n -Sedation with Versed and Fentanyl.\n -CXR to evaluate ETT tube and OGT placement\n -Chest tube to decompress pleural space\n - will need thoracentesis\n -F/u serial ABGs\n -Arterial line\n -CT of chest and a/p today (without IV contrast)\n -Hard copies of scans from OSH, cytologies from OSH\n - Vanc/zosyn\n - increase tidal volume\n - consider decreasing PEEP to 8 from 10\n .\n #. Oliguric renal failure: cr 2.5 this AM, slightly improved, bland\n sediment, minimal UOP - pre-renal vs ATN. Renal failure may be\n secondary to low BP, but may also have a component of a more chronic\n process. No evidence of obstruction / no hydronephrosis on OSH CT.\n - hold lasix and anti-HTN\n - urine lytes\n - f/u CT a/p\n - urine eos\n - renal consult\n - monitor UOP\n .\n #. New carcinomatosis on CT / pleural effusions: last CA screening\n (mammogram, pap and colonoscopy 10-20 years ago). Concerning due to\n elevated CEA and CA125.\n -Cytologies from OSH recent thoracentesis\n -F/u cytologies from pleural fluid here\n - gyn/onc cs\n .\n #. hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n FEN: regular diet\n .\n PPX:\n -DVT ppx with heparin SC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:31 AM\n 22 Gauge - 12:43 AM\n Prophylaxis:\n DVT: Boots / Heparin SC\n Stress ulcer: pantoprazole\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498026,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD.\n At pt was noted to be in ARF w/ Cr of 2.5. She was\n also noted to have leukocytosis. CT abdomen was performed and notable\n for ascites and diffuse nodular changes in peritoneal cavity and on\n omentum suggesting carcinomatosis. The stomach is herniated into chest\n cavity. CT of lungs was significant for collapsed left lung with left\n chest cavity filled with fluid.\n She was also noted to be hypotensive to 80/50 after CT scan and was\n bolused with fluids & given Vanco and Zosyn for presumed sepsis and\n transferred to for further care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on AC 60% x 280 x 28 w/ PEEP 10. O2 sats 93-98%\n (poor pleth noted @ times) Pt appears comfortably sedated on Fentanyl\n 50mg/hr & Versed 1mg/hr. Synchronous w/ current ventilator settings. Pt\n showing left lung whiteout consistent w/ large pleural effusion. CT\n (pigtail) placed by IP yesterday afternoon (initial output on insertion\n ~ 2300cc) CT currently draining serous fluid to gravity (IP aware &\n would not like suction/H2O seal @ this time) LS clear, diminished @\n bases. Impaired cough/gag.\n Action:\n Vent setting decreased to FiO2 40%. AM ABG 7.29/50/167. SaO2 99%.\n Suctioned pt intermittently throughout the night for scant, white/thick\n secretions. Aline placed @ bedside last evening. Sedation increased to\n Fentanyl 75mcg/hr & Versed 2mg/hr during Aline placement. Fluid\n challenge this AM.\n Response:\n Pt remains on Fent @ 75 & Versed 2mg increased anxiety. CT draining\n appropriately. Lactic Acid 1.9. UOP ranging 10-50cc/hr. Awaiting AM\n labs results.\n Plan:\n Tolerating IVF @ this time. Wean ventilator settings as tolerated. VAP\n bundle. Suction PRN.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n #16 Foley Catheter in place draining clear, yellow urine. UOP\n 10-50cc/hr. PM BUN/Cr 59/2.3\n Action:\n Fluid challenge this AM. UOP slowly increasing. AM BUN/Cr 57/2.1\n Response:\n BUN/Cr trending down. UOP increasing w/ fluid intake.\n Plan:\n Wean pressors as tolerated. IVFB if pt tolerates. Trend lab values.\n Renally dose meds if needed. If renal fx worsens, consider Renal cx.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed 0.22mcg/kg/min & Vasopressin 2.4 units/hr. At\n change of shift SBP 50-60\ns w/ MAPs in 40\ns (via NIBP) Pt appearing in\n NAD and able to open eyes and follow commands. UOP poor as noted above.\n WBC 13.8 last evening. Lactic acid 1.9\n Action:\n Levophed increased to 0.3mcg/kg/min. NS 250 fluid boluses given X 4 w/\n 1L fluid (challenge) bolus this AM. Levophed gtt ranging from 0.2\n 0.3mcg/kg/min. Left femoral Aline placed by Dr. . Difficulty\n placing radial Aline. Vigileo monitor initiated @ 0200. IV abx\n administered as ordered. (pt did travel day shift for CT\n chest/abd/pelvis)\n Response:\n WBC this AM 13. SBP ranging 80-130\ns (pt sensitive to Levophed\n decrease)\n Plan:\n MAP goal > 60, SBP 90. Fluid challenge as noted. Wean pressors as\n tolerated. Cont to trend lab values & culture data for source of\n probable sepsis (most likely CA related) IV abx.\n R Femoral TLC\n L Femoral ALine\n Full Code\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497892,
"text": " yo F with CAD s/p CABG in and transfered from for\n sepsis and CA w/u. The patient reports that she was treated for PNA\n with abx and then thoracentesis two weeks ago. Pt rpts difficulty\n urinating and recent visit to renal MD. PCP recommended going to \n .\n At , pt was noted to be in ARF with Cr of 2.5. She was\n also noted to have leukocytosis. CT abdomen was performed and was\n notable for ascites and diffuse nodular changes in periotoneal cavity\n and on omentum suggesting carcinomatosis. The stomach is herniated\n into chest cavity. Left kideny had 1.5 mm lower pole and 5.5 exophytic\n cyst as well as 1mm nonobtracting calculus. Right kidney had no\n evidence of obstruction. CT of lungs was significant for collapsed\n left lung with left chest cavity filled with fluid, significant\n compression and collapse of the right lower lobe with large right\n pleural effusion.\n She was also noted to be hypotensive to SBP of 80/50 after CT scan and\n was bolused with fluids. started on Vanc and Zosyn for presumed sepsis\n and transferred to for further care.\n .\n In the ED initial vitals were HR 67 BP 79/60 RR 23 and O2 sat: 97% on\n 3L NC. Femoral line placed and levophed started. Admitted to for\n likely sepsis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received Pt. on 6L /min simple face mask. O2 sat mid 90\ns. RR high\n 20\ns. Pt. breathing labored with noted use of accessory muscles. O2\n sat started to decline to 80\ns and did not improve with increased O2\n supplement. ABG 7.23/70/69/31. CXR shows L lung white out with very\n diminished breath sounds on L.\n Action:\n Pt. intubated at 0915. On CMV 280 x28 PEEP 10 and FiO2 60%. IP\n consulted. CT of chest done. Lightly sedated with Fentanyl 50mcg/hr\n and midazolam at 1mg/hr.\n Response:\n Pt. tolerating current vent settings. IP to place CT.\n Plan:\n Wean vent settings as Pt. tolerates.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt. with C/O difficulty urinating prior to admission. On admission BUN\n and creatnine elevated.\n Action:\n FB 500cc x1 for hydration. Renal team consulted.\n Response:\n Cont. to make small amount of urine ~10cc/hr.\n Plan:\n Follow renal recs. Monitor labs. Renally dose meds.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Pt. with fluid in abdominal cavity per CT scan from OSH. Pt. denies\n pain.\n Action:\n CT torso repeated here.\n Response:\n Uterine mass present concerning for CA. GYN team consulted.\n Plan:\n F/U final CT read. GYN recs.\n Hypotension (not Shock)\n Assessment:\n Received Pt. on Levophed 0.08mcg/kg/min. BP 90\ns-100\ns systolic.\n Shortly after intubation Pt. began to dropp BP to 50\ns-60\n Action:\n Received 500cc FB and Levophed maxed at 0.3mcg/kg/min with BP only\n improving to 80\ns systolic. Vasopressin initiated.\n Response:\n Able to wean down Levophed to 0.25mcg/kg/min. Cont. Vasopressin. Pt.\n afebrile.\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497816,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n This morning, the patient\ns breathing is significantly more labored,\n she is more dyspneic. Still mentating well, but has difficulty\n completing sentences.\n There is radiographic worsening infiltrates in right upper and middle\n lobes.\n The patient is desatting into 80s on 50% humidified face mask.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 03:19 AM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 67 (61 - 76) bpm\n BP: 91/51(61) {65/38(52) - 102/78(84)} mmHg\n RR: 20 (17 - 27) insp/min\n SpO2: 95%\n Heart rhythm: AV Paced\n Total In:\n 1,230 mL\n PO:\n TF:\n IVF:\n 1,230 mL\n Blood products:\n Total out:\n 0 mL\n 75 mL\n Urine:\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,155 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n SpO2: 95%\n ABG: ///32/\n Physical Examination\n GENERAL: Pleasant, elderly F, slightly tachypneic, in worsening resp.\n distress\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: CTAB, decreased breaths sounds bilaterally.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent, but difficulty\n competing sentences Moves all extremities.\n Labs / Radiology\n 379 K/uL\n 9.7 g/dL\n 122 mg/dL\n 2.5 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 62 mg/dL\n 100 mEq/L\n 140 mEq/L\n 32.3 %\n 13.7 K/uL\n [image002.jpg]\n 04:06 AM\n WBC\n 13.7\n Hct\n 32.3\n Plt\n 379\n Cr\n 2.5\n Glucose\n 122\n Other labs: PT / PTT / INR:13.0/32.8/1.1, Ca++:8.7 mg/dL, Mg++:2.2\n mg/dL, PO4:6.1 mg/dL\n CEA 4.1, CA125 2477\n Assessment and Plan\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock . Pericardial effusion is also unlikely w/o low\n voltage EKG and no JVD, no effusion of CT chest. Infectious sources\n could be GI given carcinomatosis as well as pulmonary given recent dx\n PNA. Although there was no definate infiltrate on CT chest, there was\n significant lung collapse and effusion to make evaluation difficult. UA\n neg.\n - Vanc and Zosyn, will need to dose vanc by level\n - hold anti-HTN and lasix\n - continue Levophed as needed for MAP >60, SBP >90. Add additional\n pressors if needed to keep MAP > 60.\n -Minimize IVF boluses, but use as needed to keep MAP > 60\n - f/u cultures from as well as \n .\n # Hypoxic respiratory failure, likely to significant effusions,\n left lung collapse, +/- PNA. Significantly worsening this AM.\n -Intubate, start on mechanical ventilation with AC, tidal volume\n 4ml/kg, FiO2 at 100% (wean as tolerated), PEEP .\n -Sedation with Versed and Fentanyl.\n -CXR to evaluate ETT tube and OGT placement\n -Chest tube to decompress pleural space\n - will need thoracentesis\n -F/u serial ABGs\n -Arterial line\n -CT of chest and a/p today (without IV contrast)\n -Hard copies of scans from OSH, cytologies from OSH\n - Vanc/zosyn\n .\n #. Oliguric renal failure: cr 2.5 this AM, slightly improved, bland\n sediment, minimal UOP - pre-renal vs ATN. Renal failure may be\n secondary to low BP, but may also have a component of a more chronic\n process. No evidence of obstruction / no hydronephrosis on OSH CT.\n - hold lasix and anti-HTN\n - urine lytes\n - f/u CT a/p\n - urine eos\n - renal consult\n - monitor UOP\n .\n #. New carcinomatosis on CT / pleural effusions: last CA screening\n (mammogram, pap and colonoscopy 10-20 years ago). Concerning due to\n elevated CEA and CA125.\n -Cytologies from OSH recent thoracentesis\n -F/u cytologies from pleural fluid here\n .\n #. hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n FEN: regular diet\n .\n PPX:\n -DVT ppx with heparin SC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:31 AM. Replace femoral line tomorrow.\n 22 Gauge - 12:43 AM\n Prophylaxis:\n DVT: Boots / Heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-03 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 497820,
"text": "Chief Complaint: transfered from for sepsis and CA w/u\n HPI:\n yo F with CAD s/p CABG in and transfered from for\n sepsis and CA w/u. The patient reports that she was treated for PNA\n with abx and then thoracentesis two weeks ago. Since then, the patient\n does note that she has had problems with dysuria for the past several\n weeks and recently saw a \"kidney doctor\" for it, but details of that\n are not clear. She states that she was prescribed several pills by her\n kidney doctor, but this morning the \"white pill\" did not help. She\n noted one day prior to admission that she had been unable to urinate\n with suprapubic pain. She called her PCP who recommended that she go to\n .\n .\n While there, the patient was noted to be in ARF with Cr of 2.5. She\n was also noted to have leukocytosis with WBC of 11.9 and 82% PMNs. She\n was given 2mg of Hydromorhone and Zofran. CT abdomen was performed and\n was notable for ascites and diffuse nodular changes in periotoneal\n cavity and on omentum suggesting carcinomatosis. The stomach is\n herniated into chest cavity. Left kideny had 1.5 mm lower pole and 5.5\n exophytic cyst as well as 1mm nonobtracting calculus. Right kidney had\n no evidence of obstruction. CT of lungs was significant for collapsed\n left lung with left chest cavity filled with fluid, significant\n compression and collapse of the right lower lobe with large right\n pleural effusion. She was also noted to be hypotensive to SBP of 80/50\n after CT scan and was bolused with fluids. The patient was started on\n Vanc and Zosyn for presumed sepsis and transferred to for further\n care.\n .\n The patient reports that she currently feels well, s/o lightheadness,\n dizziness, CP, no abd -resolved. She endorsed mild SOB with slight\n sputum production as of today. No fever, no chills.\n .\n In the emergency department, initial vitals were HR 67 BP 79/60 RR 23\n and O2 sat: 97% on 3L NC. 15 minutes later BP decreased further to SBP\n of 68 and Levophed was initiated. The patient was mentating and\n responding appropriately, appeared comfortable. The patient also\n received a right femoral line. Troponins 0.04 x 1. The patient was\n admitted to for likely sepsis. On transfer, vitals were T98.0 HR\n 72 BP 101/68 RR 30 93% 3L.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.12 mcg/Kg/min\n Other ICU medications:\n Other medications:\n MEDICATIONS:\n Aspirin 81mg daily\n Atorvastatin 10mg daily\n Metoprolol tartate 25mg \n Lasix 40mg daily\n Tylenol\n Colase\n Milk of magnesia\n Past medical history:\n Family history:\n Social History:\n Hypertension\n Hyperlipidemia\n CAD s/p CABG\n PCM placement\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Quit smoking at the age of 30. Denies EtOH history. Lives\n alone in . 8 children.\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea\n Gastrointestinal: Abdominal pain\n Flowsheet Data as of 03:21 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 61 (61 - 76) bpm\n BP: 88/40(52) {65/40(52) - 88/52(60)} mmHg\n RR: 19 (19 - 27) insp/min\n SpO2: 93%\n Heart rhythm: AV Paced\n Total In:\n 1,061 mL\n PO:\n TF:\n IVF:\n 1,061 mL\n Blood products:\n Total out:\n 0 mL\n 40 mL\n Urine:\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,021 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n GENERAL: Pleasant, elderly F, slightly tachypneic, but in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: CTAB, decreased breaths sounds bilaterally, RLL worse than LLL.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent. Moves all\n extremities.\n Labs / Radiology\n 444\n 2.9\n 63\n 32\n 95\n 4.4\n 141\n 34\n 14\n [image002.jpg]\n Other labs: PT / PTT / INR:1.1, CK / CKMB / Troponin-T:// trop 0.04,\n ALT / AST:34/45, Differential-Neuts:88, Band:0, Lactic Acid:3.5\n Imaging: CT torso: CT abdomen was performed and was notable for\n ascites and diffuse nodular changes in periotoneal cavity and on\n omentum suggesting carcinomatosis. The stomach is herniated into chest\n cavity. Left kideny had 1.5 mm lower pole and 5.5 exophytic cyst as\n well as 1mm nonobtracting calculus. Right kidney had no evidence of\n obstruction. CT of lungs was significant for collapsed left lung with\n left chest cavity filled with fluid, significant compression and\n collapse of the right lower lobe with large right pleural effusion.\n Microbiology: UA: neg\n ECG: a-v paced\n Assessment and Plan90 yo F with CAD s/p CABG in and PCM transfered\n from for hypotension, renal failure and CA w/u.\n .\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock - unlikely cardiac w/o CP or elevated CK.\n Pericardial effusion is also unlikely w/o low voltage EKG and no JVD,\n no effusion of CT chest. Infectious sources could be GI given\n carcinomatosis as well as pulmonary given recent dx PNA. Although there\n was no definate infiltrate on CT chest, there was significant lung\n collapse and effusion to make evaluation difficult. UA neg. It is also\n possible that the patient had an adverse rxn dilauded or Ct contrast as\n she was normotensive on arrival to . Given ongoing pressor\n requirement, will tx empirically with vanc and zosyn.\n - Vanc and Zosyn, will need to dose vanc by level\n - hold anti-HTN and lasix\n - wean levophed\n - keep MAP >60, SBP >90\n - f/u cultures from \n .\n # Hypoxia: 91-93% on 4: NC, likely to significant effusions +/- PNA\n - will need thoracentesis\n - Vanc/zosyn\n .\n #. Oliguric renal failure: cr 2.9, bland sediment, minimal UOP -\n pre-renal vs ATN. Renal failure may be low BP, but I am concerned\n that she had renal failure even before becoming hypotensive - at least\n presumably she was not hypotensive on her first visit to nephrology. It\n is possble that she has AIN from abx for initial PNA. no hydronephrosis\n on OSH CT.\n - hold lasix and anti-HTN\n - urine lytes\n - fluids\n - urine eos\n - renal consult in am if cr not improving with fluids and pressors\n - monitor UOP\n .\n #. New carcinomatosis on CT: last CA screening (mammogram, pap and\n colonoscopy 10-20 years ago)\n - colonoscopy when stable\n - transvaginal U/s when stable\n - CEA and CA 125\n .\n # Effusions: given carcinomatosis, they are likely to be malignant vs\n paraneumonic\n - will need diagnostic and therapeutic thoracentesis\n .\n #. hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n FEN: regular diet\n .\n PPX:\n -DVT ppx with heparin\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:31 AM\n 22 Gauge - 12:43 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM:\n I have seen and examined Mrs and concur with Dr \n assessment.\n She has had worsening respiratory distress after fluid rescucitation\n and will need intubation.\n She has a large left sided pleural effusion with shift of mediastinum\n to the right and will need a chest tube placed for complete drainage.\n Her Abd CT scans at OSH are concerning for peritoneal carcinomatosis\n and her CA 125 is greater than 2400.\n There are new concerns for hypotension and sepsis ( urinary, pulmonary\n sources, adrenal insufficiency ) but no features of pericardial\n effusion causing tamponade.\n We will need to repeat imaging ( chest, abd, Pelvis) after pleural\n drainage completed and obtain results of pleural fluid cytology from\n .\n I suspect oncology and renal colleagues will help with additional\n insight on account of her renal failure and likely metastatic ? ovarian\n carcinoma. Family members have been updated regarding these concerns.\n ,M.D.\n Pulmonary and Critical Care Medicine.\n . , .\n ------ Protected Section Addendum Entered By: , MD\n on: 01:22 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497899,
"text": " yo F with CAD s/p CABG in and transfered from for\n sepsis and CA w/u. The patient reports that she was treated for PNA\n with abx and then thoracentesis two weeks ago. Pt rpts difficulty\n urinating and recent visit to renal MD. PCP recommended going to \n .\n At , pt was noted to be in ARF with Cr of 2.5. She was\n also noted to have leukocytosis. CT abdomen was performed and was\n notable for ascites and diffuse nodular changes in periotoneal cavity\n and on omentum suggesting carcinomatosis. The stomach is herniated\n into chest cavity. Left kideny had 1.5 mm lower pole and 5.5 exophytic\n cyst as well as 1mm nonobtracting calculus. Right kidney had no\n evidence of obstruction. CT of lungs was significant for collapsed\n left lung with left chest cavity filled with fluid, significant\n compression and collapse of the right lower lobe with large right\n pleural effusion.\n She was also noted to be hypotensive to SBP of 80/50 after CT scan and\n was bolused with fluids. started on Vanc and Zosyn for presumed sepsis\n and transferred to for further care.\n .\n In the ED initial vitals were HR 67 BP 79/60 RR 23 and O2 sat: 97% on\n 3L NC. Femoral line placed and levophed started. Admitted to for\n likely sepsis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received Pt. on 6L /min simple face mask. O2 sat mid 90\ns. RR high\n 20\ns. Pt. breathing labored with noted use of accessory muscles. O2\n sat started to decline to 80\ns and did not improve with increased O2\n supplement. ABG 7.23/70/69/31. CXR shows L lung white out with very\n diminished breath sounds on L.\n Action:\n Pt. intubated at 0915. On CMV 280 x28 PEEP 10 and FiO2 60%. IP\n consulted. CT of chest done. Lightly sedated with Fentanyl 50mcg/hr\n and midazolam at 1mg/hr.\n Response:\n Pt. tolerating current vent settings. IP to place CT.\n Plan:\n Wean vent settings as Pt. tolerates.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt. with C/O difficulty urinating prior to admission. On admission BUN\n and creatnine elevated.\n Action:\n FB 500cc x1 for hydration. Renal team consulted.\n Response:\n Cont. to make small amount of urine ~10cc/hr. BUN and creatnine\n trending down.\n Plan:\n Follow renal recs. Monitor labs. Renally dose meds.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Pt. with fluid in abdominal cavity per CT scan from OSH. Pt. denies\n pain.\n Action:\n CT torso repeated here.\n Response:\n Uterine mass present concerning for CA. GYN team consulted.\n Plan:\n F/U final CT read. GYN recs.\n Hypotension (not Shock)\n Assessment:\n Received Pt. on Levophed 0.08mcg/kg/min. BP 90\ns-100\ns systolic.\n Shortly after intubation Pt. began to dropp BP to 50\ns-60\ns. WBC up to\n 14 on admission.\n Action:\n Received 500cc FB and Levophed maxed at 0.3mcg/kg/min with BP only\n improving to 80\ns systolic. Vasopressin initiated. Started on Zosyn\n and Vanco x1 dose given today.\n Response:\n Able to wean down Levophed to 0.25mcg/kg/min. Cont. Vasopressin. Pt.\n afebrile.\n Plan:\n Cont. abx. As ordered. Wean pressors as Pt. tolerates.\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498013,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD.\n At pt was noted to be in ARF w/ Cr of 2.5. She was\n also noted to have leukocytosis. CT abdomen was performed and notable\n for ascites and diffuse nodular changes in peritoneal cavity and on\n omentum suggesting carcinomatosis. The stomach is herniated into chest\n cavity. CT of lungs was significant for collapsed left lung with left\n chest cavity filled with fluid.\n She was also noted to be hypotensive to 80/50 after CT scan and was\n bolused with fluids & given Vanco and Zosyn for presumed sepsis and\n transferred to for further care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on AC 60% x 280 x 28 w/ PEEP 10. O2 sats 93-98%\n (poor pleth noted @ times) Pt appears comfortably sedated on Fentanyl\n 50mg/hr & Versed 1mg/hr. Synchronous w/ current ventilator settings. Pt\n showing left lung whiteout consistent w/ large pleural effusion. CT\n placed by IP yesterday afternoon (initial output on insertion ~ 2300cc)\n CT currently draining serous fluid to gravity (IP aware & would not\n like suction/H2O seal @ this time) LS clear, diminished @ bases.\n Impaired cough/gag.\n Action:\n Vent setting decreased to FiO2 40%. AM ABG 7.29/50/167. SaO2 99%.\n Suctioned pt intermittently throughout the night for scant, white/thick\n secretions. Aline placed @ bedside last evening. Sedation increased to\n Fentanyl 75mcg/hr & Versed 2mg/hr during Aline placement. Fluid\n challenge this AM.\n Response:\n Pt remains on Fent @ 75 & Versed 2mg increased anxiety. CT draining\n appropriately. Lactic Acid 1.9. UOP ranging 10-50cc/hr. Awaiting AM\n labs results.\n Plan:\n Tolerating IVF @ this time. Wean ventilator settings as tolerated. VAP\n bundle. Suction PRN.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n #16 Foley Catheter in place draining clear, yellow urine. UOP\n 10-50cc/hr. PM BUN/Cr 59/2.3\n Action:\n Fluid challenge this AM. UOP slowly increasing. AM BUN/Cr 57/2.1\n Response:\n BUN/Cr trending down. UOP increasing w/ fluid intake.\n Plan:\n Wean pressors as tolerated. IVFB if pt tolerates. Trend lab values.\n Renally dose meds if needed. If renal fx worsens, consider Renal cx.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed 0.22mcg/kg/min & Vasopressin 2.4 units/hr. At\n change of shift SBP 50-60\ns w/ MAPs in 40\ns (via NIBP) Pt appearing in\n NAD and able to open eyes and follow commands. UOP poor as noted above.\n WBC 13.8 last evening. Lactic acid 1.9\n Action:\n Levophed increased to 0.3mcg/kg/min. NS 250 fluid boluses given X 4 w/\n 1L fluid (challenge) bolus this AM. Levophed gtt ranging from 0.2\n 0.3mcg/kg/min. Left femoral Aline placed by Dr. . Difficulty\n placing radial Aline. Vigileo monitor initiated @ 0200. IV abx\n administered as ordered. (pt did travel day shift for CT\n chest/abd/pelvis)\n Response:\n WBC this AM 13. SBP ranging 80-130\ns (pt sensitive to Levophed\n decrease)\n Plan:\n MAP goal > 60, SBP 90. Fluid challenge as noted. Wean pressors as\n tolerated. Cont to trend lab values & culture data for source of\n probable sepsis (most likely CA related) IV abx.\n R Femoral TLC\n L Femoral ALine\n Vigileo\n Full Code\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497757,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MICU RESIDENT HISTORY AND PHYSICAL\n .\n CHIEF COMPLAINT: transfered from for sepsis and CA w/u\n .\n HISTORY OF PRESENT ILLNESS: yo F with CAD s/p CABG in and \n transfered from for sepsis and CA w/u. The patient reports that\n she was treated for PNA with abx and then thoracentesis two weeks ago.\n Since then, the patient does note that she has had problems with\n dysuria for the past several weeks and recently saw a \"kidney doctor\"\n for it, but details of that are not clear. She states that she was\n prescribed several pills by her kidney doctor, but this morning the\n \"white pill\" did not help. She noted one day prior to admission that\n she had been unable to urinate with suprapubic pain. She called her PCP\n who recommended that she go to .\n .\n While there, the patient was noted to be in ARF with Cr of 2.5. She\n was also noted to have leukocytosis with WBC of 11.9 and 82% PMNs. She\n was given 2mg of Hydromorhone and Zofran. CT abdomen was performed and\n was notable for ascites and diffuse nodular changes in periotoneal\n cavity and on omentum suggesting carcinomatosis. The stomach is\n herniated into chest cavity. Left kideny had 1.5 mm lower pole and 5.5\n exophytic cyst as well as 1mm nonobtracting calculus. Right kidney had\n no evidence of obstruction. CT of lungs was significant for collapsed\n left lung with left chest cavity filled with fluid, significant\n compression and collapse of the right lower lobe with large right\n pleural effusion. She was also noted to be hypotensive to SBP of 80/50\n after CT scan and was bolused with fluids. The patient was started on\n Vanc and Zosyn for presumed sepsis and transferred to for further\n care.\n .\n The patient reports that she currently feels well, s/o lightheadness,\n dizziness, CP, no abd -resolved. She endorsed mild SOB with slight\n sputum production as of today. No fever, no chills.\n .\n In the emergency department, initial vitals were HR 67 BP 79/60 RR 23\n and O2 sat: 97% on 3L NC. 15 minutes later BP decreased further to SBP\n of 68 and Levophed was initiated. The patient was mentating and\n responding appropriately, appeared comfortable. The patient also\n received a right femoral line. Troponins 0.04 x 1. The patient was\n admitted to for likely sepsis. On transfer, vitals were T98.0 HR\n 72 BP 101/68 RR 30 93% 3L.\n .\n PAST MEDICAL HISTORY:\n Hypertension\n Hyperlipidemia\n CAD s/p CABG\n PCM placement\n .\n MEDICATIONS:\n Aspirin 81mg daily\n Atorvastatin 10mg daily\n Metoprolol tartate 25mg \n Lasix 40mg daily\n Tylenol\n Colase\n Milk of magnesia\n .\n ALLERGIES: NKDA\n .\n .\n SOCIAL HISTORY:\n Quit smoking at the age of 30. Denies EtOH history. Lives alone in\n . 8 children.\n .\n FAMILY HISTORY: NC\n .\n .\n VITAL SIGNS:\n .\n PHYSICAL EXAM\n GENERAL: Pleasant, elderly F, slightly tachypneic, but in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: CTAB, decreased breaths sounds bilaterally, RLL worse than LLL.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent. Moves all\n extremities.\n .\n LABS: (see below)\n UA- neg\n .\n STUDIES:\n - CT torso: CT abdomen was performed and was notable for ascites and\n diffuse nodular changes in periotoneal cavity and on omentum suggesting\n carcinomatosis. The stomach is herniated into chest cavity. Left\n kideny had 1.5 mm lower pole and 5.5 exophytic cyst as well as 1mm\n nonobtracting calculus. Right kidney had no evidence of obstruction.\n CT of lungs was significant for collapsed left lung with left chest\n cavity filled with fluid, significant compression and collapse of the\n right lower lobe with large right pleural effusion.\n EKG: A-V Paced rhythm, no acute ST changes\n .\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 03:19 AM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 67 (61 - 76) bpm\n BP: 91/51(61) {65/38(52) - 102/78(84)} mmHg\n RR: 20 (17 - 27) insp/min\n SpO2: 95%\n Heart rhythm: AV Paced\n Total In:\n 1,230 mL\n PO:\n TF:\n IVF:\n 1,230 mL\n Blood products:\n Total out:\n 0 mL\n 75 mL\n Urine:\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,155 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n SpO2: 95%\n ABG: ///32/\n Physical Examination\n GENERAL: Pleasant, elderly F, slightly tachypneic, but in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: CTAB, decreased breaths sounds bilaterally, RLL worse than LLL.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent. Moves all\n extremities.\n Labs / Radiology\n 379 K/uL\n 9.7 g/dL\n 122 mg/dL\n 2.5 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 62 mg/dL\n 100 mEq/L\n 140 mEq/L\n 32.3 %\n 13.7 K/uL\n [image002.jpg]\n 04:06 AM\n WBC\n 13.7\n Hct\n 32.3\n Plt\n 379\n Cr\n 2.5\n Glucose\n 122\n Other labs: PT / PTT / INR:13.0/32.8/1.1, Ca++:8.7 mg/dL, Mg++:2.2\n mg/dL, PO4:6.1 mg/dL\n Assessment and Plan\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock - unlikely cardiac w/o CP or elevated CK.\n Pericardial effusion is also unlikely w/o low voltage EKG and no JVD,\n no effusion of CT chest. Infectious sources could be GI given\n carcinomatosis as well as pulmonary given recent dx PNA. Although there\n was no definate infiltrate on CT chest, there was significant lung\n collapse and effusion to make evaluation difficult. UA neg. It is also\n possible that the patient had an adverse rxn dilauded or Ct contrast as\n she was normotensive on arrival to . Given ongoing pressor\n requirement, will tx empirically with vanc and zosyn.\n - Vanc and Zosyn, will need to dose vanc by level\n - hold anti-HTN and lasix\n - wean levophed\n - keep MAP >60, SBP >90\n - f/u cultures from \n .\n # Hypoxia: 91-93% on 4: NC, likely to significant effusions +/- PNA\n - will need thoracentesis\n - Vanc/zosyn\n .\n #. Oliguric renal failure: cr 2.9, bland sediment, minimal UOP -\n pre-renal vs ATN. Renal failure may be low BP, but I am concerned\n that she had renal failure even before becoming hypotensive - at least\n presumably she was not hypotensive on her first visit to nephrology. It\n is possble that she has AIN from abx for initial PNA. no hydronephrosis\n on OSH CT.\n - hold lasix and anti-HTN\n - urine lytes\n - fluids\n - urine eos\n - renal consult in am if cr not improving with fluids and pressors\n - monitor UOP\n .\n #. New carcinomatosis on CT: last CA screening (mammogram, pap and\n colonoscopy 10-20 years ago)\n - colonoscopy when stable\n - transvaginal U/s when stable\n - CEA and CA 125\n .\n # Effusions: given carcinomatosis, they are likely to be malignant vs\n paraneumonic\n - will need diagnostic and therapeutic thoracentesis\n .\n #. hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n FEN: regular diet\n .\n PPX:\n -DVT ppx with heparin\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:31 AM\n 22 Gauge - 12:43 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498011,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD.\n At pt was noted to be in ARF w/ Cr of 2.5. She was\n also noted to have leukocytosis. CT abdomen was performed and notable\n for ascites and diffuse nodular changes in peritoneal cavity and on\n omentum suggesting carcinomatosis. The stomach is herniated into chest\n cavity. CT of lungs was significant for collapsed left lung with left\n chest cavity filled with fluid.\n She was also noted to be hypotensive to 80/50 after CT scan and was\n bolused with fluids & given Vanco and Zosyn for presumed sepsis and\n transferred to for further care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on AC 60% x 280 x 28 w/ PEEP 10. O2 sats 93-98%\n (poor pleth noted @ times) Pt appears comfortably sedated on Fentanyl\n 50mg/hr & Versed 1mg/hr. Synchronous w/ current ventilator settings. Pt\n showing left lung whiteout consistent w/ large pleural effusion. CT\n placed by IP yesterday afternoon (initial output on insertion ~ 2300cc)\n CT currently draining serous fluid to gravity (IP aware & would not\n like suction/H2O seal @ this time) LS clear, diminished @ bases.\n Impaired cough/gag.\n Action:\n Vent setting decreased to FiO2 40%. AM ABG 7.29/50/167. SaO2 99%.\n Suctioned pt intermittently throughout the night for scant, white/thick\n secretions. Aline placed @ bedside last evening. Sedation increased to\n Fentanyl 75mcg/hr & Versed 2mg/hr during Aline placement. Fluid\n challenge this AM.\n Response:\n Pt remains on Fent @ 75 & Versed 2mg increased anxiety. CT draining\n appropriately. Lactic Acid 1.9. UOP ranging 10-50cc/hr. Awaiting AM\n labs results.\n Plan:\n Tolerating IVF @ this time. Wean ventilator settings as tolerated. VAP\n bundle. Suction PRN.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n #16 Foley Catheter in place draining clear, yellow urine. UOP\n 10-50cc/hr. PM BUN/Cr 59/2.3\n Action:\n Fluid challenge this AM. UOP slowly increasing. AM BUN/Cr\n Response:\n BUN/Cr trending down. UOP increasing w/ fluid intake.\n Plan:\n Wean pressors as tolerated. IVFB if pt tolerates. Trend lab values.\n Renally dose meds if needed. If renal fx worsens, consider Renal cx.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed 0.22mcg/kg/min & Vasopressin 2.4 units/hr. At\n change of shift SBP 50-60\ns w/ MAPs in 40\ns (via NIBP) Pt appearing in\n NAD and able to open eyes and follow commands. UOP poor as noted above.\n WBC 13.8 last evening. Lactic acid 1.9\n Action:\n Levophed increased to 0.3mcg/kg/min. NS 250 fluid boluses given X 4 w/\n 1L fluid (challenge) bolus this AM. Levophed gtt ranging from 0.2\n 0.3mcg/kg/min. Left femoral Aline placed by Dr. . Difficulty\n placing radial Aline. Vigileo monitor initiated @ 0200. IV abx\n administered as ordered. (pt did travel day shift for CT\n chest/abd/pelvis)\n Response:\n WBC this AM 13. SBP ranging 80-130\ns (pt sensitive to Levophed\n decrease)\n Plan:\n MAP goal > 60, SBP 90. Fluid challenge as noted. Wean pressors as\n tolerated. Cont to trend lab values & culture data for source of\n probable sepsis (most likely CA related) IV abx.\n R Femoral TLC\n L Femoral ALine\n Vigileo\n Full Code\n"
},
{
"category": "General",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Generic Note",
"row_id": 497989,
"text": "TITLE:\n Called to evaluate patient because of persistent hypotension on two\n vasopressors as well as decreased urine output. Patient is intubated\n and sedated with severe hypotension presumed secondary to sepsis. She\n is not currently receiving intravenous fluids, has minimal urine\n output, is on levophed and vasopression, and has excellent oxygenation\n on minimal Fio2. Given this scenario, the best course of action is to\n provide a more aggressive fluid resuscitation to see if can improve her\n perfusion. Thus, will provide bolus and monitor the response of urine,\n blood pressure, and trend of cardiac output (vigileo placed but given\n the atrial fib, this is not accurate). Overall prognosis given the\n underlying cancer is likely quite poor and overall goals of care may\n need to be addressed but for now will aggressive resuscitate patient.\n A:\n Shock\n presumably septic with poor perfusion\n Plan:\n Fluid bolus and assess response to perfusion paramters\n Will monitor closely and reassess after bolus\n Patient is critically ill (35 minutes)\n"
},
{
"category": "Respiratory ",
"chartdate": "2117-10-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 497933,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-03 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 497677,
"text": "Chief Complaint: transfered from for sepsis and CA w/u\n HPI:\n yo F with CAD s/p CABG in and transfered from for\n sepsis and CA w/u. The patient reports that she was treated for PNA\n with abx and then thoracentesis two weeks ago. Since then, the patient\n does note that she has had problems with dysuria for the past several\n weeks and recently saw a \"kidney doctor\" for it, but details of that\n are not clear. She states that she was prescribed several pills by her\n kidney doctor, but this morning the \"white pill\" did not help. She\n noted one day prior to admission that she had been unable to urinate\n with suprapubic pain. She called her PCP who recommended that she go to\n .\n .\n While there, the patient was noted to be in ARF with Cr of 2.5. She\n was also noted to have leukocytosis with WBC of 11.9 and 82% PMNs. She\n was given 2mg of Hydromorhone and Zofran. CT abdomen was performed and\n was notable for ascites and diffuse nodular changes in periotoneal\n cavity and on omentum suggesting carcinomatosis. The stomach is\n herniated into chest cavity. Left kideny had 1.5 mm lower pole and 5.5\n exophytic cyst as well as 1mm nonobtracting calculus. Right kidney had\n no evidence of obstruction. CT of lungs was significant for collapsed\n left lung with left chest cavity filled with fluid, significant\n compression and collapse of the right lower lobe with large right\n pleural effusion. She was also noted to be hypotensive to SBP of 80/50\n after CT scan and was bolused with fluids. The patient was started on\n Vanc and Zosyn for presumed sepsis and transferred to for further\n care.\n .\n The patient reports that she currently feels well, s/o lightheadness,\n dizziness, CP, no abd -resolved. She endorsed mild SOB with slight\n sputum production as of today. No fever, no chills.\n .\n In the emergency department, initial vitals were HR 67 BP 79/60 RR 23\n and O2 sat: 97% on 3L NC. 15 minutes later BP decreased further to SBP\n of 68 and Levophed was initiated. The patient was mentating and\n responding appropriately, appeared comfortable. The patient also\n received a right femoral line. Troponins 0.04 x 1. The patient was\n admitted to for likely sepsis. On transfer, vitals were T98.0 HR\n 72 BP 101/68 RR 30 93% 3L.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.12 mcg/Kg/min\n Other ICU medications:\n Other medications:\n MEDICATIONS:\n Aspirin 81mg daily\n Atorvastatin 10mg daily\n Metoprolol tartate 25mg \n Lasix 40mg daily\n Tylenol\n Colase\n Milk of magnesia\n Past medical history:\n Family history:\n Social History:\n Hypertension\n Hyperlipidemia\n CAD s/p CABG\n PCM placement\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Quit smoking at the age of 30. Denies EtOH history. Lives\n alone in . 8 children.\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea\n Gastrointestinal: Abdominal pain\n Flowsheet Data as of 03:21 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 61 (61 - 76) bpm\n BP: 88/40(52) {65/40(52) - 88/52(60)} mmHg\n RR: 19 (19 - 27) insp/min\n SpO2: 93%\n Heart rhythm: AV Paced\n Total In:\n 1,061 mL\n PO:\n TF:\n IVF:\n 1,061 mL\n Blood products:\n Total out:\n 0 mL\n 40 mL\n Urine:\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,021 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n Physical Examination\n GENERAL: Pleasant, elderly F, slightly tachypneic, but in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: CTAB, decreased breaths sounds bilaterally, RLL worse than LLL.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent. Moves all\n extremities.\n Labs / Radiology\n 444\n 2.9\n 63\n 32\n 95\n 4.4\n 141\n 34\n 14\n [image002.jpg]\n Other labs: PT / PTT / INR:1.1, CK / CKMB / Troponin-T:// trop 0.04,\n ALT / AST:34/45, Differential-Neuts:88, Band:0, Lactic Acid:3.5\n Imaging: CT torso: CT abdomen was performed and was notable for\n ascites and diffuse nodular changes in periotoneal cavity and on\n omentum suggesting carcinomatosis. The stomach is herniated into chest\n cavity. Left kideny had 1.5 mm lower pole and 5.5 exophytic cyst as\n well as 1mm nonobtracting calculus. Right kidney had no evidence of\n obstruction. CT of lungs was significant for collapsed left lung with\n left chest cavity filled with fluid, significant compression and\n collapse of the right lower lobe with large right pleural effusion.\n Microbiology: UA: neg\n ECG: a-v paced\n Assessment and Plan90 yo F with CAD s/p CABG in and PCM transfered\n from for hypotension, renal failure and CA w/u.\n .\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock - unlikely cardiac w/o CP or elevated CK.\n Pericardial effusion is also unlikely w/o low voltage EKG and no JVD,\n no effusion of CT chest. Infectious sources could be GI given\n carcinomatosis as well as pulmonary given recent dx PNA. Although there\n was no definate infiltrate on CT chest, there was significant lung\n collapse and effusion to make evaluation difficult. UA neg. It is also\n possible that the patient had an adverse rxn dilauded or Ct contrast as\n she was normotensive on arrival to . Given ongoing pressor\n requirement, will tx empirically with vanc and zosyn.\n - Vanc and Zosyn, will need to dose vanc by level\n - hold anti-HTN and lasix\n - wean levophed\n - keep MAP >60, SBP >90\n - f/u cultures from \n .\n # Hypoxia: 91-93% on 4: NC, likely to significant effusions +/- PNA\n - will need thoracentesis\n - Vanc/zosyn\n .\n #. Oliguric renal failure: cr 2.9, bland sediment, minimal UOP -\n pre-renal vs ATN. Renal failure may be low BP, but I am concerned\n that she had renal failure even before becoming hypotensive - at least\n presumably she was not hypotensive on her first visit to nephrology. It\n is possble that she has AIN from abx for initial PNA. no hydronephrosis\n on OSH CT.\n - hold lasix and anti-HTN\n - urine lytes\n - fluids\n - urine eos\n - renal consult in am if cr not improving with fluids and pressors\n - monitor UOP\n .\n #. New carcinomatosis on CT: last CA screening (mammogram, pap and\n colonoscopy 10-20 years ago)\n - colonoscopy when stable\n - transvaginal U/s when stable\n - CEA and CA 125\n .\n # Effusions: given carcinomatosis, they are likely to be malignant vs\n paraneumonic\n - will need diagnostic and therapeutic thoracentesis\n .\n #. hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n FEN: regular diet\n .\n PPX:\n -DVT ppx with heparin\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:31 AM\n 22 Gauge - 12:43 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497679,
"text": "Neuro: alert and orientedx3, not a good historian on medical history.\n Afebrile, c/o abdominal pain in ED was given Maalox w/ good effect.\n Resp: LS diminished, O2 sat 90s on 4L NC. c/o SOB w/ exertion.\n CV: arrived on levophed gtt, 0.12mcg, BP 80s-90s. HR 60s and AV paced.\n 1L NS bolus given w/ moderate effect.\n GI/GU: foley placed and draining small amount of yellow urine, minimal\n increase with blous. +BS, no stool this shift.\n Access: R femoral TL\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497683,
"text": " yo F with CAD s/p CABG in and transfered from for\n sepsis and CA w/u. The patient reports that she was treated for PNA\n with abx and then thoracentesis two weeks ago. Pt rpts difficulty\n urinating and recent visit to renal MD. PCP recommended going to \n .\n At , pt was noted to be in ARF with Cr of 2.5. She was\n also noted to have leukocytosis. CT abdomen was performed and was\n notable for ascites and diffuse nodular changes in periotoneal cavity\n and on omentum suggesting carcinomatosis. The stomach is herniated\n into chest cavity. Left kideny had 1.5 mm lower pole and 5.5 exophytic\n cyst as well as 1mm nonobtracting calculus. Right kidney had no\n evidence of obstruction. CT of lungs was significant for collapsed\n left lung with left chest cavity filled with fluid, significant\n compression and collapse of the right lower lobe with large right\n pleural effusion.\n She was also noted to be hypotensive to SBP of 80/50 after CT scan and\n was bolused with fluids. started on Vanc and Zosyn for presumed sepsis\n and transferred to for further care.\n .\n In the ED initial vitals were HR 67 BP 79/60 RR 23 and O2 sat: 97% on\n 3L NC. Femoral line placed and levophed started. Admitted to for\n likely sepsis.\n Neuro: alert and orientedx3, not a good historian on medical history.\n Afebrile, c/o abdominal pain in ED was given Maalox w/ good effect.\n Resp: LS diminished, O2 sat 90s on 4L NC. c/o SOB w/ exertion. O2 sat\n dropped to 80s while sleeping and changed to FM @6L, O2 sat 95%.\n CV: arrived on levophed gtt, 0.12mcg, BP 80s-90s. HR 60s and AV paced.\n 1L NS bolus given w/ moderate effect.\n GI/GU: foley placed and draining small amount of yellow urine, minimal\n increase with blous. +BS, no stool this shift. Renal consult if no\n improvement in UO and Creat.\n Access: R femoral TL\n Plan: colonoscopy and transvaginal US when stable to evaluate\n carcinomatosis. Repeat CT scans, films did not come w/ pt form OSH.\n Probable thoracentesis. Cont weaning levophed gtt.\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497730,
"text": " yo F with CAD s/p CABG in and transfered from for\n sepsis and CA w/u. The patient reports that she was treated for PNA\n with abx and then thoracentesis two weeks ago. Pt rpts difficulty\n urinating and recent visit to renal MD. PCP recommended going to \n .\n At , pt was noted to be in ARF with Cr of 2.5. She was\n also noted to have leukocytosis. CT abdomen was performed and was\n notable for ascites and diffuse nodular changes in periotoneal cavity\n and on omentum suggesting carcinomatosis. The stomach is herniated\n into chest cavity. Left kideny had 1.5 mm lower pole and 5.5 exophytic\n cyst as well as 1mm nonobtracting calculus. Right kidney had no\n evidence of obstruction. CT of lungs was significant for collapsed\n left lung with left chest cavity filled with fluid, significant\n compression and collapse of the right lower lobe with large right\n pleural effusion.\n She was also noted to be hypotensive to SBP of 80/50 after CT scan and\n was bolused with fluids. started on Vanc and Zosyn for presumed sepsis\n and transferred to for further care.\n .\n In the ED initial vitals were HR 67 BP 79/60 RR 23 and O2 sat: 97% on\n 3L NC. Femoral line placed and levophed started. Admitted to for\n likely sepsis.\n Neuro: alert and orientedx3, not a good historian on medical history.\n Afebrile, c/o abdominal pain in ED was given Maalox w/ good effect.\n Resp: LS diminished, O2 sat 90s on 4L NC. c/o SOB w/ exertion. O2 sat\n dropped to 80s while sleeping and changed to FM @6L, O2 sat 95%.\n CV: arrived on levophed gtt, 0.12mcg weaned to 0.08mcg, BP 80s-90s. HR\n 60s and AV paced. 1L NS bolus given w/ moderate effect.\n GI/GU: foley placed and draining small amount of yellow urine, minimal\n increase with blous. +BS, no stool this shift. Renal consult if no\n improvement in UO and Creat. AM Crt 2.5/BUN 62.\n Access: R femoral TL\n Plan: colonoscopy and transvaginal US when stable to evaluate\n carcinomatosis. Repeat CT scans, films did not come w/ pt from OSH.\n Probable thoracentesis. Cont weaning levophed gtt.\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497663,
"text": "Neuro: alert and orientedx3, not a good historian on medical history.\n Afebrile, c/o abdominal pain in ED was given Maalox w/ good effect.\n Resp: LS diminished, O2 sat 90s on 4L NC. c/o SOB w/ exertion.\n CV: arrived on levophed gtt, 0.12mcg, BP 80s-90s. HR 60s and AV paced.\n 1L NS bolus given w/ moderate effect.\n GI/GU: foley placed and draining small amount of yellow urine, minimal\n increase with blous. +BS, no stool this shift.\n Access: R EJ and L PIV placed in OSH, R groin TL.\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497909,
"text": " yo F with CAD s/p CABG in and transfered from for\n sepsis and CA w/u. The patient reports that she was treated for PNA\n with abx and then thoracentesis two weeks ago. Pt rpts difficulty\n urinating and recent visit to renal MD. PCP recommended going to \n .\n At , pt was noted to be in ARF with Cr of 2.5. She was\n also noted to have leukocytosis. CT abdomen was performed and was\n notable for ascites and diffuse nodular changes in periotoneal cavity\n and on omentum suggesting carcinomatosis. The stomach is herniated\n into chest cavity. Left kideny had 1.5 mm lower pole and 5.5 exophytic\n cyst as well as 1mm nonobtracting calculus. Right kidney had no\n evidence of obstruction. CT of lungs was significant for collapsed\n left lung with left chest cavity filled with fluid, significant\n compression and collapse of the right lower lobe with large right\n pleural effusion.\n She was also noted to be hypotensive to SBP of 80/50 after CT scan and\n was bolused with fluids. started on Vanc and Zosyn for presumed sepsis\n and transferred to for further care.\n .\n In the ED initial vitals were HR 67 BP 79/60 RR 23 and O2 sat: 97% on\n 3L NC. Femoral line placed and levophed started. Admitted to for\n likely sepsis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received Pt. on 6L /min simple face mask. O2 sat mid 90\ns. RR high\n 20\ns. Pt. breathing labored with noted use of accessory muscles. O2\n sat started to decline to 80\ns and did not improve with increased O2\n supplement. ABG 7.23/70/69/31. CXR shows L lung white out with very\n diminished breath sounds on L.\n Action:\n Pt. intubated at 0915. On CMV 280 x28 PEEP 10 and FiO2 60%. IP\n consulted. CT of chest done. Lightly sedated with Fentanyl 50mcg/hr\n and midazolam at 1mg/hr.\n Response:\n Pt. tolerating current vent settings. IP to place CT.\n Plan:\n Wean vent settings as Pt. tolerates.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt. with C/O difficulty urinating prior to admission. On admission BUN\n and creatnine elevated.\n Action:\n FB 500cc x1 for hydration. Renal team consulted.\n Response:\n Cont. to make small amount of urine ~10-20 cc/hr. BUN and creatnine\n trending down.\n Plan:\n Follow renal recs. Monitor labs. Renally dose meds.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Pt. with fluid in abdominal cavity per CT scan from OSH. Pt. denies\n pain.\n Action:\n CT torso repeated here.\n Response:\n Uterine mass present concerning for CA. GYN team consulted.\n Plan:\n F/U final CT read. GYN recs.\n Hypotension (not Shock)\n Assessment:\n Received Pt. on Levophed 0.08mcg/kg/min. BP 90\ns-100\ns systolic.\n Shortly after intubation Pt. began to dropp BP to 50\ns-60\ns. WBC up to\n 14 on admission.\n Action:\n Received 500cc FB and Levophed maxed at 0.3mcg/kg/min with BP only\n improving to 80\ns systolic. Vasopressin initiated. Started on Zosyn\n and Vanco x1 dose given today.\n Response:\n Able to wean down Levophed to 0.22mcg/kg/min. Cont. Vasopressin. Pt.\n afebrile.\n Plan:\n Cont. abx. As ordered. Wean pressors as Pt. tolerates.\n"
},
{
"category": "Nutrition",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 498077,
"text": "Subjective\n Patient intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 163 (estimated) cm\n 88.2 kg\n 33\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 55 kg\n 160%\n 63 kg\n Unable to ascertain\n Diagnosis: sepsis\n PMHx: HTN, hyperlipidemia, CAD s/p CABG (), PCM placement\n Food allergies and intolerances: none noted\n Pertinent medications: pantoprazole, fentanyl, versed, norepinephrine,\n vasopressin\n Labs:\n Value\n Date\n Glucose\n 136 mg/dL\n 04:54 AM\n BUN\n 57 mg/dL\n 04:54 AM\n Creatinine\n 2.1 mg/dL\n 04:54 AM\n Sodium\n 135 mEq/L\n 04:54 AM\n Potassium\n 4.0 mEq/L\n 04:54 AM\n Chloride\n 103 mEq/L\n 04:54 AM\n TCO2\n 23 mEq/L\n 04:54 AM\n PO2 (arterial)\n 167 mm Hg\n 05:01 AM\n PCO2 (arterial)\n 50 mm Hg\n 05:01 AM\n pH (arterial)\n 7.29 units\n 05:01 AM\n pH (venous)\n 7.25 units\n 08:29 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 05:01 AM\n Calcium non-ionized\n 7.5 mg/dL\n 04:54 AM\n Phosphorus\n 4.2 mg/dL\n 04:54 AM\n Magnesium\n 1.9 mg/dL\n 04:54 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen soft with positive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1300-1600 (BEE x or / 20-25 cal/kg)\n Protein: 60-75 (1-1.2 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Specifics:\n year old female transferred from outside hospital for workup of\n sepsis, ARF and cancer. Patient is now intubated and s/p thoracentesis.\n Consult received for tube feeding recommendations. Once patient stable,\n recommend Novosource Renal with 15g beneprotein at 30ml/hr x 24 hours\n to provide 1494kcal and 68g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n Start Novosource Renal with 15g beneprotein at 10ml/hr,\n advance by 10ml q6H to goal rate of 30ml/hr x 24 hours\n Monitor residuals q4H and hold tube feeding if greater than\n 200ml\n Will follow and make adjustments PRN\n 09:29 AM\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 498061,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:15 AM\n ARTERIAL LINE - START 11:30 PM\n -Intubated yesterday AM for respiratory failure\n -CT torso (w/o IV contrast) showed:\n 1. Large L- pleural effusion, w/ near complete collapse and\n consolidation of L-lungs\n 2. Moderate-to-large R pleural effusion.\n 3. Ascites, with diffuse nodularity of the peritoneum, suspicious for\n peritoneal carcinomatosis.\n 4. Mesenteric lymphadenopathy.\n 5. Ill-defined lesion within the left lower pelvis, in the expected\n location of the uterus and adnexa, with calcifications seen. The origin\n and etiology of this lesion is unclear without intravenous contrast,\n and could reflect a uterine fibroid, or adnexal lesion. This can be\n correlated by ultrasound if clinically indicated.\n 6. Prominence of the cecal and sigmoid colonic walls. Correlate with\n colonoscopy findings.\n -Thoracentesis done (2300 mL off); chest tube placed to water seal\n -Renal recs: etiology of renal failure is pre-renal, can treat with\n fluids; at high risk of transition to ATN; need to determine baseline\n creatinine\n -Obtained outside records from (in chart) -\n thoracentesis cultures negative to date\n -Will need gyn/onc consult\n -Placed left femoral a-line after failed attempts at both radial\n arteries\n -Will need central line (so that right femoral central venous line can\n be d/c'ed)\n -Received multiple fluid boluses for decreased urine output\n -Vigileo showed cardiac index good, improved with fluid bolus of 1L,\n urine output also improved with fluid bolus of 1 liter\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 03:19 AM\n Vancomycin - 08:16 AM\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.23 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 01:20 PM\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 73 (60 - 97) bpm\n BP: 91/52(65) {91/50(65) - 141/73(95)} mmHg\n RR: 28 (11 - 31) insp/min\n SpO2: 95%\n Heart rhythm: AV Paced\n Total In:\n 4,809 mL\n 2,310 mL\n PO:\n 60 mL\n TF:\n IVF:\n 3,849 mL\n 2,250 mL\n Blood products:\n Total out:\n 2,725 mL\n 720 mL\n Urine:\n 425 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,084 mL\n 1,590 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 280 (280 - 280) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 19 cmH2O\n Plateau: 18 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 95%\n ABG: 7.29/50/167/23/-2\n Ve: 7.3 L/min\n PaO2 / FiO2: 418\n Physical Examination\n GENERAL: intubated, sedated\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: CTAB, decreased breaths sounds bilaterally.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent, but difficulty\n competing sentences Moves all extremities.\n Labs / Radiology\n 381 K/uL\n 9.3 g/dL\n 136 mg/dL\n 2.1 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 57 mg/dL\n 103 mEq/L\n 135 mEq/L\n 30.8 %\n 13.0 K/uL\n [image002.jpg]\n 04:06 AM\n 09:04 AM\n 01:45 PM\n 11:13 PM\n 11:23 PM\n 03:05 AM\n 04:54 AM\n 05:01 AM\n WBC\n 13.7\n 13.8\n 13.0\n Hct\n 32.3\n 35.8\n 31\n 30.8\n Plt\n 379\n 399\n 381\n Cr\n 2.5\n 2.3\n 2.1\n TCO2\n 31\n 29\n 27\n 26\n 25\n Glucose\n 122\n 124\n 136\n Other labs: PT / PTT / INR:13.2/35.0/1.1, ALT / AST:14/20, Alk Phos / T\n Bili:67/0.3, Lactic Acid:1.9 mmol/L, LDH:192 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock . Pericardial effusion is also unlikely w/o low\n voltage EKG and no JVD, no effusion of CT chest. Infectious sources\n could be GI given carcinomatosis as well as pulmonary given recent dx\n PNA. Although there was no definate infiltrate on CT chest, there was\n significant lung collapse and effusion to make evaluation difficult. UA\n neg.\n - Vanc and Zosyn, will need to dose vanc by level\n - hold anti-HTN and lasix\n - continue Levophed as needed for MAP >60, SBP >90. Add additional\n pressors if needed to keep MAP > 60.\n -Minimize IVF boluses, but use as needed to keep MAP > 60\n - f/u cultures from as well as \n .\n # Hypoxic respiratory failure, likely to significant effusions,\n left lung collapse, +/- PNA. Significantly worsening this AM.\n -Intubate, start on mechanical ventilation with AC, tidal volume\n 4ml/kg, FiO2 at 100% (wean as tolerated), PEEP .\n -Sedation with Versed and Fentanyl.\n -CXR to evaluate ETT tube and OGT placement\n -Chest tube to decompress pleural space\n - will need thoracentesis\n -F/u serial ABGs\n -Arterial line\n -CT of chest and a/p today (without IV contrast)\n -Hard copies of scans from OSH, cytologies from OSH\n - Vanc/zosyn\n .\n #. Oliguric renal failure: cr 2.5 this AM, slightly improved, bland\n sediment, minimal UOP - pre-renal vs ATN. Renal failure may be\n secondary to low BP, but may also have a component of a more chronic\n process. No evidence of obstruction / no hydronephrosis on OSH CT.\n - hold lasix and anti-HTN\n - urine lytes\n - f/u CT a/p\n - urine eos\n - renal consult\n - monitor UOP\n .\n #. New carcinomatosis on CT / pleural effusions: last CA screening\n (mammogram, pap and colonoscopy 10-20 years ago). Concerning due to\n elevated CEA and CA125.\n -Cytologies from OSH recent thoracentesis\n -F/u cytologies from pleural fluid here\n .\n #. hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n FEN: regular diet\n .\n PPX:\n -DVT ppx with heparin SC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:31 AM. Replace femoral line tomorrow.\n 22 Gauge - 12:43 AM\n Prophylaxis:\n DVT: Boots / Heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 498074,
"text": "Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 y.o. woman with massive left pleural effusion and likely malignant\n ascites now intubated.\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:15 AM' omtibated after\n rounds yesterday given increasing respiratory distress; work of\n breathing increased, appeared to be tiring\n ARTERIAL LINE - START 11:30 PM - right femoral a-line\n placed\n CT chest shows left greater than right pleural effusion\n Thorocentesis 2300 cc, chest tube placed by surgical service; CT to\n water seal.\n Had been able to decrease pressors slightly overnight as she was\n responsive to IVF challenges. This am she had documented BP 80/50, MAP\n 50 - increased levo\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 03:19 AM\n Vancomycin - 08:16 AM\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Fentanyl (Concentrate) - 75 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.23 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 01:20 PM\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Nutritional Support: NPO\n Respiratory: Intubated\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.8\nC (98.3\n HR: 76 (60 - 97) bpm\n BP: 103/55(71) {91/50(65) - 141/73(95)} mmHg\n RR: 27 (11 - 31) insp/min\n SpO2: 94%\n Heart rhythm: AV Paced\n Total In:\n 4,809 mL\n 2,353 mL\n PO:\n 60 mL\n TF:\n IVF:\n 3,849 mL\n 2,293 mL\n Blood products:\n Total out:\n 2,725 mL\n 720 mL\n Urine:\n 425 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,084 mL\n 1,633 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 280 (280 - 280) mL\n RR (Set): 28\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 19 cmH2O\n Plateau: 18 cmH2O\n Compliance: 35 cmH2O/mL\n SpO2: 94%\n ABG: 7.29/50/167/23/-2\n Ve: 7.3 L/min\n PaO2 / FiO2: 418\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bilateral bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Purposeful, Sedated, Tone: Not assessed\n Labs / Radiology\n 9.3 g/dL\n 381 K/uL\n 136 mg/dL\n 2.1 mg/dL\n 23 mEq/L\n 4.0 mEq/L\n 57 mg/dL\n 103 mEq/L\n 135 mEq/L\n 30.8 %\n 13.0 K/uL\n [image002.jpg]\n 04:06 AM\n 09:04 AM\n 01:45 PM\n 11:13 PM\n 11:23 PM\n 03:05 AM\n 04:54 AM\n 05:01 AM\n WBC\n 13.7\n 13.8\n 13.0\n Hct\n 32.3\n 35.8\n 31\n 30.8\n Plt\n 379\n 399\n 381\n Cr\n 2.5\n 2.3\n 2.1\n TCO2\n 31\n 29\n 27\n 26\n 25\n Glucose\n 122\n 124\n 136\n Other labs: PT / PTT / INR:13.2/35.0/1.1, ALT / AST:14/20, Alk Phos / T\n Bili:67/0.3, Lactic Acid:1.9 mmol/L, LDH:192 IU/L, Ca++:7.5 mg/dL,\n Mg++:1.9 mg/dL, PO4:4.2 mg/dL\n Fluid analysis / Other labs: Pleural Fluid: Pro - 4.6 LDH-114\n PH-7.32\n >20,000 RBC, 500 WBC, 7 PMNs/60 lymphs/50 monos\n Imaging: CXR: ETT in good position ~4cm above the carina, bilateral\n effusions, chest tube in place on left, no PTX\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Secondary to pleural\n effusions now s/p large volume thorocentesis and chest tube placement\n on the left, now at water seal. Relatively hypoventilated (pCO2 50),\n oxygenating well. Decrease PEEP to 8, plan to increase tidal volumes\n 6-8 mg/kg. Also being empirically treated with vanco/zosyn. Minimal\n secretions per the ETT. Also stim testing. WBC slightly\n decreased.\n PLERUAL EFFUSIONS: Pleural fluid chemistries consistent with\n exudate. Culutre and cytology pending.\n HYPOTENSION (NOT SHOCK): Continues on levo/vasopressin. Responsive\n to IVF boluses overnight. Hypotensive this am prompting increase in\n levo. Plan for continued volume resusitation. No new culture data.\n Continues broad spectrum antibiotics as above. Follow up on outside\n hospital cultures as well. Has two groin lines in place, plan to\n resite a-line and central line today. Check echo today.\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL): Workup as per housestaff note. Consult\n gynecological oncology.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Cr improving, some\n increase in urine output with IVF challenges albeit continues\n oliguric. Doing meds accordingly.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 12:31 AM\n Arterial Line - 11:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :\n Total time spent: 65 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 498040,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments/Plan\n Pt remains intubated, fully vent supported. No changes made\n overnight. See flowsheet for further pt data.\n 06:41\n"
},
{
"category": "Echo",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Report",
"row_id": 71660,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion. Right ventricular function.\nHeight: (in) 62\nWeight (lb): 150\nBSA (m2): 1.69 m2\nBP (mm Hg): 128/59\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 11:51\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: RV not well seen. Paradoxic septal motion consistent with\nconduction abnormality/ventricular pacing.\n\nAORTA: Moderately dilated aortic sinus. Moderately dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. No MS. Mild (1+) MR. [Due to acoustic shadowing, the severity\nof MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Moderate to\nsevere [3+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS. Significant PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor suprasternal views.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and global systolic function (LVEF>55%).\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. There is no ventricular septal defect. The aortic root is\nmoderately dilated at the sinus level. The ascending aorta is moderately\ndilated. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\n[Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The tricuspid valve leaflets are mildly\nthickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. Significant pulmonic\nregurgitation is seen. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2117-10-02 00:00:00.000",
"description": "Report",
"row_id": 177569,
"text": "Sinus rhythm. Ventricular paced rhythm. No previous tracing available for\ncomparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106692,
"text": " 10:02 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate ET tube and OG tube placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with respiratory failure, just intubated.\n REASON FOR THIS EXAMINATION:\n evaluate ET tube and OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: , 5:34 a.m.\n\n FINDINGS: In the interval, the patient has been intubated. The tip of the\n endotracheal tube projects 3 cm above the carina. A nasogastric tube has been\n inserted. The tip of the tube is not visible on the radiograph; however,\n coiling of the tube is evidence of a previously not visible hiatal hernia.\n There is a central area of the left lung that is now ventilated.\n Nevertheless, a substantial decrease of the extensive left pleural effusion\n cannot be confirmed. Unchanged aspect of the right lung with small right\n pleural effusion and right pectoral pacemaker in situ. No interval occurrence\n of right-sided parenchymal opacities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106661,
"text": " 4:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change and resolution of ?malplaced line\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with ? line in right IJ, now removed.\n REASON FOR THIS EXAMINATION:\n interval change and resolution of ?malplaced line\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is unchanged\n complete opacification of the left hemithorax with shift of the mediastinum\n towards the right, suggesting left-sided pleural effusion. Small-to-moderate\n right-sided pleural effusion with basal parenchymal opacity suggesting\n atelectasis that are unchanged as compared to the previous examination. The\n previously placed right-sided central venous access line over the right\n subclavian vein has been removed. There is no evidence of complications,\n notably no evidence of right-sided pneumothorax. Unchanged appearance of the\n right pectoral pacemaker.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1107076,
"text": " 5:27 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with readjusted central line\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n WET READ: SBNa TUE 6:40 PM\n Left IJ is slightly retracted and tip remains in left brachiocephalic.\n Interval removal of NGT. Otherwise no change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n FINDINGS: In comparison with the earlier study of this date, the left IJ\n catheter has been slightly retracted with the tip in the left brachiocephalic\n vein. Nasogastric tube has been removed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1107120,
"text": " 4:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for IJ CVL placement, interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with bilateral pleural effusions, likely peritoneal\n carcinomatosis\n REASON FOR THIS EXAMINATION:\n Please evaluate for IJ CVL placement, interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: For central line placement.\n\n FINDINGS: In comparison with the study of , the left IJ catheter has\n been pulled back somewhat further. It now lies close to the junction of the\n left jugular vein and subclavian vein, probably in the proximal\n brachiocephalic vein.\n\n IMPRESSION: Little overall change in the appearance of the heart and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1107129,
"text": " 6:49 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: line placment\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with resuturing of central line.\n REASON FOR THIS EXAMINATION:\n line placment\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Comparison is made with prior study is from 2 hours earlier.\n\n Left IJ catheter tip is in the left brachiocephalic vein not really changed\n from prior study.\n\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 499385,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n The patient is maintaining BPs off pressors.\n CVL was leaking and was d/c\nd at 2300. She will get a new PICC in AM.\n Dr met w/ patient and family re: code status. She is now DNR\n but can be intubated for short periods of time\n Got a small dose of Ativan for sleep this AM.\n This AM, pt. reports breathing better. States her pain is under\n control.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:08 PM\n Vancomycin - 12:34 AM\n Piperacillin/Tazobactam (Zosyn) - 02:14 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:33 AM\n Morphine Sulfate - 03:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.8\nC (96.5\n HR: 93 (67 - 93) bpm\n BP: 102/71(79) {95/43(53) - 117/75(80)} mmHg\n RR: 17 (17 - 31) insp/min\n SpO2: 95%\n Heart rhythm: AV Paced\n Total In:\n 2,848 mL\n 720 mL\n PO:\n 960 mL\n TF:\n IVF:\n 1,788 mL\n 720 mL\n Blood products:\n 100 mL\n Total out:\n 1,440 mL\n 700 mL\n Urine:\n 1,140 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,408 mL\n 20 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95% on 3L NC\n ABG: ///19/\n Physical Examination\n GENERAL: Alert, responsive, NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: Crackles b/l, decreased breath sounds\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent, but difficulty\n competing sentences Moves all extremities.\n Labs / Radiology\n 391 K/uL\n 9.7 g/dL\n 95 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 26 mg/dL\n 112 mEq/L\n 144 mEq/L\n 31.3 %\n 9.1 K/uL\n [image002.jpg]\n 05:01 AM\n 10:06 AM\n 08:42 PM\n 04:00 AM\n 02:06 PM\n 05:01 PM\n 10:16 PM\n 04:20 AM\n 03:51 AM\n 03:07 AM\n WBC\n 11.0\n 13.8\n 10.2\n 9.1\n Hct\n 28.1\n 34.2\n 31.7\n 31.3\n Plt\n 91\n Cr\n 1.3\n 1.2\n 1.1\n 0.9\n TCO2\n 25\n 24\n 23\n 23\n 21\n 22\n Glucose\n 144\n 102\n 99\n 95\n Other labs: PT / PTT / INR:13.6/38.5/1.2, ALT / AST:24/27, Alk Phos / T\n Bili:61/0.5, Differential-Neuts:78.3 %, Lymph:11.4 %, Mono:7.6 %,\n Eos:2.4 %, Lactic Acid:1.7 mmol/L, Albumin:2.6 g/dL, LDH:300 IU/L,\n Ca++:6.9 mg/dL, Mg++:2.3 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n yo F w/ CAD s/p CABG (), x-fer from for hypotension,\n renal failure and cancer workup, likely ovarian primary.\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock. There is no pericardial effusion in TTE. stim\n test demostrated appropriate response. PE is highly unlikely.\n Increasing leukocytosis today and persistent hypotension, although no\n fevers, decent UOP.\n - Vanc and Zosyn, currently day 6 of a 7 day course.\n - f/u cultures from as well as (blood, sputum, urine)\n - hold anti-HTN and lasix\n - IVF boluses, as needed to keep MAP > 60.\n .\n # Pleural effusions / Respiratory status: Continues to drain large\n amt. of fluid through chest tube. Chest tube to stay in place for now.\n -Monitor resp. status closely today. Repeat CXR if increasing work of\n breathing, tachypnea.\n -Continue Vanc/zosyn\n -Minimize IVF as they may lead to reaccumulation of fluid\n .\n #. Oliguric renal failure: Cr 0.9 and improving, likely pre-renal /\n secondary to hypotension. No evidence of obstruction / no\n hydronephrosis on OSH CT.\n - Hold lasix and anti-HTN\n - Monitor UOP and Cr daily\n -Renally dose meds and avoid nephrotoxins\n .\n #. New carcinomatosis on CT / pleural effusions: last CA screening\n (mammogram, pap and colonoscopy 10-20 years ago). Concerning due to\n elevated CEA and CA125.\n -Cytologies from OSH recent thoracentesis\n -F/u cytologies from pleural fluid here\n -Tylenol and Morphine PRN for pain\n -Med/Onc consult\n .\n # hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n PPX:\n -DVT ppx with heparin SC and Boots\n ICU Care\nNutrition: thin liquids and moist, ground solids\n Glycemic Control:\n Lines:\n PIV\n Arterial Line\n Prophylaxis:\n DVT: Boots / Heparin SC\n Stress ulcer: None\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR, but may intubate for short periods of time\n Disposition: Call out today\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497880,
"text": " yo F with CAD s/p CABG in and transfered from for\n sepsis and CA w/u. The patient reports that she was treated for PNA\n with abx and then thoracentesis two weeks ago. Pt rpts difficulty\n urinating and recent visit to renal MD. PCP recommended going to \n .\n At , pt was noted to be in ARF with Cr of 2.5. She was\n also noted to have leukocytosis. CT abdomen was performed and was\n notable for ascites and diffuse nodular changes in periotoneal cavity\n and on omentum suggesting carcinomatosis. The stomach is herniated\n into chest cavity. Left kideny had 1.5 mm lower pole and 5.5 exophytic\n cyst as well as 1mm nonobtracting calculus. Right kidney had no\n evidence of obstruction. CT of lungs was significant for collapsed\n left lung with left chest cavity filled with fluid, significant\n compression and collapse of the right lower lobe with large right\n pleural effusion.\n She was also noted to be hypotensive to SBP of 80/50 after CT scan and\n was bolused with fluids. started on Vanc and Zosyn for presumed sepsis\n and transferred to for further care.\n .\n In the ED initial vitals were HR 67 BP 79/60 RR 23 and O2 sat: 97% on\n 3L NC. Femoral line placed and levophed started. Admitted to for\n likely sepsis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received Pt. on 6L /min simple face mask. O2 sat mid 90\ns. RR high\n 20\ns. Pt. breathing labored with noted use of accessory muscles. O2\n sat started to decline to 80\ns and did not improve with increased O2\n supplement. ABG 7.23/70/69/31. CXR shows L lung white out with very\n diminished breath sounds on L.\n Action:\n Pt. intubated at 0915. On CMV 280 x28 PEEP 10 and FiO2 60%. IP\n consulted. CT of chest done.\n Response:\n Pt. tolerating current vent settings. IP to place CT.\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497948,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD.\n At pt was noted to be in ARF w/ Cr of 2.5. She was\n also noted to have leukocytosis. CT abdomen was performed and notable\n for ascites and diffuse nodular changes in peritoneal cavity and on\n omentum suggesting carcinomatosis. The stomach is herniated into chest\n cavity. CT of lungs was significant for collapsed left lung with left\n chest cavity filled with fluid.\n She was also noted to be hypotensive to 80/50 after CT scan and was\n bolused with fluids & given Vanco and Zosyn for presumed sepsis and\n transferred to for further care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received Pt. on 6L /min simple face mask. O2 sat mid 90\ns. RR high\n 20\ns. Pt. breathing labored with noted use of accessory muscles. O2\n sat started to decline to 80\ns and did not improve with increased O2\n supplement. ABG 7.23/70/69/31. CXR shows L lung white out with very\n diminished breath sounds on L.\n Action:\n Pt. intubated at 0915. On CMV 280 x28 PEEP 10 and FiO2 60%. IP\n consulted. CT of chest done. Lightly sedated with Fentanyl 50mcg/hr\n and midazolam at 1mg/hr.\n Response:\n Pt. tolerating current vent settings. IP to place CT.\n Plan:\n Wean vent settings as Pt. tolerates.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt. with C/O difficulty urinating prior to admission. On admission BUN\n and creatnine elevated.\n Action:\n FB 500cc x1 for hydration. Renal team consulted.\n Response:\n Cont. to make small amount of urine ~10-20 cc/hr. BUN and creatnine\n trending down.\n Plan:\n Follow renal recs. Monitor labs. Renally dose meds.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Pt. with fluid in abdominal cavity per CT scan from OSH. Pt. denies\n pain.\n Action:\n CT torso repeated here.\n Response:\n Uterine mass present concerning for CA. GYN team consulted.\n Plan:\n F/U final CT read. GYN recs.\n Hypotension (not Shock)\n Assessment:\n Received Pt. on Levophed 0.08mcg/kg/min. BP 90\ns-100\ns systolic.\n Shortly after intubation Pt. began to dropp BP to 50\ns-60\ns. WBC up to\n 14 on admission.\n Action:\n Received 500cc FB and Levophed maxed at 0.3mcg/kg/min with BP only\n improving to 80\ns systolic. Vasopressin initiated. Started on Zosyn\n and Vanco x1 dose given today.\n Response:\n Able to wean down Levophed to 0.22mcg/kg/min. Cont. Vasopressin. Pt.\n afebrile.\n Plan:\n Cont. abx. As ordered. Wean pressors as Pt. tolerates.\n R Femoral TLC\n L Femoral ALine\n Full Code\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-05 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 498423,
"text": "Chief Complaint: Respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85 y.o. woman with massive left pleural effusion and likely malignant\n ascites now intubated.\n 24 Hour Events:\n MULTI LUMEN - START 06:30 PM; in azogus vein\n Echo: LVH, LVEF>55%, can't exclude focal WMA, mildly dilated aortic\n root, 1+ AR/MR; no effusion\n Sedation off since 6 am, appears comfortable, eyes open\n Continues on two pressors\n Opens eyes to touch\n Minimal respiratory secretions\n Patient unable to provide history: ventilated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Vancomycin - 01:34 AM\n Piperacillin - 08:02 AM\n Infusions:\n Vasopressin - 1.2 units/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:03 AM\n Heparin Sodium (Prophylaxis) - 08:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:14 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.2\n HR: 77 (60 - 78) bpm\n BP: 81/46(58) {52/35(42) - 142/82(96)} mmHg\n RR: 16 (15 - 28) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\n Total In:\n 6,160 mL\n 1,779 mL\n PO:\n TF:\n 5 mL\n 118 mL\n IVF:\n 6,095 mL\n 1,660 mL\n Blood products:\n Total out:\n 1,720 mL\n 885 mL\n Urine:\n 1,250 mL\n 595 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,440 mL\n 894 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (350 - 450) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 17 cmH2O\n Plateau: 12 cmH2O\n Compliance: 64.3 cmH2O/mL\n SpO2: 97%\n ABG: 7.41/35/130/22/-1\n Ve: 8.1 L/min\n PaO2 / FiO2: 325\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Crackles : dependently,\n Diminished: bases)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.9 g/dL\n 340 K/uL\n 144 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 42 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.1 %\n 11.0 K/uL\n [image002.jpg]\n 09:04 AM\n 01:45 PM\n 11:13 PM\n 11:23 PM\n 03:05 AM\n 04:54 AM\n 05:01 AM\n 10:06 AM\n 08:42 PM\n 04:00 AM\n WBC\n 13.8\n 13.0\n 11.0\n Hct\n 35.8\n 31\n 30.8\n 28.1\n Plt\n 399\n 381\n 340\n Cr\n 2.3\n 2.1\n 1.3\n TCO2\n 31\n 29\n 27\n 26\n 25\n 24\n 23\n Glucose\n 124\n 136\n 144\n Other labs: PT / PTT / INR:13.3/35.5/1.1, ALT / AST:14/20, Alk Phos / T\n Bili:67/0.3, Differential-Neuts:85.5 %, Lymph:7.6 %, Mono:5.8 %,\n Eos:1.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.3 g/dL, LDH:192 IU/L,\n Ca++:6.7 mg/dL, Mg++:1.7 mg/dL, PO4:2.7 mg/dL\n Imaging: CXR: left central line in BC vein\n Microbiology: Pleural fluid: NGTD\n Blood Cx: NGTD\n UCx: NGTD\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Improved with drainage of\n large left sided pleural effusion. Awake this morning, check RISB,\n pressure support wean as tolerated. Hold tube feeds given the\n possibility she may tolerate wean and head towards extubation.\n HYPOTENSION (NOT SHOCK): Most likely sepsis. Continues on two\n pressors. More fluid challenges today. stimulation test does not\n suggest adrenal insufficiency. Continues zosyn, dosing vanco in\n setting of renal failure. No new culture data.\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Secondary to\n hypovolemia/hypotension. Cr improving.\n ANEMIA: Hct slightly decreased. be dilutional given positive\n fluid balance in past 24 hours.\n LINES: Change left central line over a wire to see if we can postion\n appropriately. Discontinue groin a-line, place radial a-line given\n likely need for\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 11:33 PM 10 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 11:30 PM\n Multi Lumen - 06:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498743,
"text": "Hypotension (not Shock)\n Assessment:\n Remains pressor dependent, changed from vasopressin to levophed to\n facilitate titrating of pressor. Currently on .13mcg/kg/min maintaining\n MAP > 65.\n Action:\n Vasopressin changed to levophed.\n Response:\n Remains pressor dependent. A-line remains dampened.\n Plan:\n Cont to titrate pressors as able.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Pt aware of potential diagnosis of CA, continue to await definitive\n cytology (2 pleurovacs sent for cytology today).\n Action:\n Social work consulted to assist w/emotional support for patient and\n family.\n Response:\n Plan:\n Emotional support for patient and family. Social work following\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498745,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP, now on levophed for b/p\n support. Extubated , now on 5L NC breathing w/some effort at\n rate 20-26bpm.\n Hypotension (not Shock)\n Assessment:\n Remains pressor dependent, changed from vasopressin to levophed to\n facilitate titrating of pressor. Currently on .13mcg/kg/min maintaining\n MAP > 65.\n Action:\n Vasopressin changed to levophed.\n Response:\n Remains pressor dependent. A-line remains dampened.\n Plan:\n Cont to titrate pressors as able.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Pt aware of potential diagnosis of CA, continue to await definitive\n cytology (2 pleurovacs sent for cytology today).\n Action:\n Social work consulted to assist w/emotional support for patient and\n family.\n Response:\n Plan:\n Emotional support for patient and family. Social work following\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o supra pubic abd pain and occasional back discomfort. Requested pain\n medication this morning.\n Action:\n Medicated for pain with .5mg morphine IV x2 within\n hour w/relief of\n pain. Subsequent pain relieved w/position changes every 2 hours.\n Response:\n Relief of pain w/1mg morphine IV. Pt requiring q2hour position changes\n for comfort. Patient appreciated back rubs and hair being combed.\n Plan:\n Cont to assess for pain, medicate w/1mg morphine for pain or\n greater and\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 499115,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Vanc level was 17.1. The patient received 1g of Vanco at 1:00.\n The patient remains on a small dose of Levophed. This AM, she\n complains of not being able to sleep, but otherwise states she feels a\n little better. Pain is under control. No abdominal pain at this\n point.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:08 PM\n Vancomycin - 12:50 AM\n Piperacillin/Tazobactam (Zosyn) - 02:31 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:06 AM\n Morphine Sulfate - 12:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36\nC (96.8\n HR: 75 (63 - 95) bpm\n BP: 105/46(63) {74/38(50) - 144/68(94)} mmHg\n RR: 24 (14 - 29) insp/min\n SpO2: 98%\n Heart rhythm: AV Paced\n Total In:\n 2,127 mL\n 772 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,787 mL\n 772 mL\n Blood products:\n 100 mL\n Total out:\n 1,649 mL\n 570 mL\n Urine:\n 959 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 478 mL\n 202 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///20/\n Physical Examination\n GENERAL: Alert, responsive, NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: Crackles b/l, decreased breath sounds\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent, but difficulty\n competing sentences Moves all extremities.\n Labs / Radiology\n 399 K/uL\n 9.8 g/dL\n 99 mg/dL\n 1.1 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 34 mg/dL\n 114 mEq/L\n 144 mEq/L\n 31.7 %\n 10.2 K/uL\n [image002.jpg]\n 04:54 AM\n 05:01 AM\n 10:06 AM\n 08:42 PM\n 04:00 AM\n 02:06 PM\n 05:01 PM\n 10:16 PM\n 04:20 AM\n 03:51 AM\n WBC\n 13.0\n 11.0\n 13.8\n 10.2\n Hct\n 30.8\n 28.1\n 34.2\n 31.7\n Plt\n 381\n 340\n 431\n 399\n Cr\n 2.1\n 1.3\n 1.2\n 1.1\n TCO2\n 25\n 24\n 23\n 23\n 21\n 22\n Glucose\n 136\n 144\n 102\n 99\n Other labs: PT / PTT / INR:13.1/34.3/1.1, ALT / AST:27/28, Alk Phos / T\n Bili:64/0.4, Differential-Neuts:76.7 %, Lymph:12.0 %, Mono:8.9 %,\n Eos:2.2 %, Lactic Acid:1.7 mmol/L, Albumin:2.6 g/dL, LDH:300 IU/L,\n Ca++:6.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n yo F w/ CAD s/p CABG (), x-fer from for hypotension,\n renal failure and cancer workup, likely ovarian primary.\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock. There is no pericardial effusion in TTE. stim\n test demostrated appropriate response. PE is highly unlikely.\n Increasing leukocytosis today and persistent hypotension, although no\n fevers, decent UOP.\n - Vanc and Zosyn, currently day 5.\n - Obtain Vanc trough\n - f/u cultures from as well as (blood, sputum, urine)\n - hold anti-HTN and lasix\n - continue Levophed as needed for MAP >60, SBP >90. Wean as\n tolerated.\n - Minimal IVF boluses, as needed to keep MAP > 60.\n .\n # Pleural effusions / Respiratory status:\n -Monitor resp. status closely today. Repeat CXR if increasing work of\n breathing, tachypnea.\n -Continue Vanc/zosyn\n -Minimize IVF as they may lead to reaccumulation of fluid\n .\n #. Oliguric renal failure: Cr 1.1 and improving, likely pre-renal /\n secondary to hypotension. No evidence of obstruction / no\n hydronephrosis on OSH CT.\n - Hold lasix and anti-HTN\n - Monitor UOP and Cr daily\n -Renally dose meds and avoid nephrotoxins\n .\n #. New carcinomatosis on CT / pleural effusions: last CA screening\n (mammogram, pap and colonoscopy 10-20 years ago). Concerning due to\n elevated CEA and CA125.\n -Cytologies from OSH recent thoracentesis\n -F/u cytologies from pleural fluid here\n -Discussion with family and patient today\n -Morphine PRN for pain\n -Gyn/onc recs\n .\n #. hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n PPX:\n -DVT ppx with heparin SC and Boots\n ICU Care\nNutrition: thin liquids and moist, ground solids\n Glycemic Control:\n Lines:\n Multi Lumen - 12:31 AM\n Arterial Line\n Prophylaxis:\n DVT: Boots / Heparin SC\n Stress ulcer: None\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498822,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP, now on levophed for b/p\n support. Extubated , now on 5L NC breathing w/some effort at\n rate 20-26bpm.\n Hypotension (not Shock)\n Assessment:\n Remains pressor dependent, changed from vasopressin to levophed to\n facilitate titrating of pressor. Currently on .1mcg/kg/min maintaining\n MAP > 65.\n Action:\n Vasopressin changed to levophed. Attempted to obtain CVP however\n waveform dampened and unable to draw from any port on TLC despite good\n placement on CXR. Albumin 25% as ordered, appeared to increase\n pleuravac drainage. Unable to wean off pressor.\n Response:\n Remains pressor dependent. A-line remains dampened.\n Plan:\n Cont to titrate pressors as able.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Pt aware of potential diagnosis of CA, continue to await definitive\n cytology (2 pleurovacs sent for cytology today).\n Action:\n Social work consulted to assist w/emotional support for patient and\n family.\n Response:\n Pt receptive to talking about potential diagnosis and wanted to know\n which family members are aware.\n Plan:\n Emotional support for patient and family. Social work following.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o supra pubic abd pain and occasional back discomfort. Requested pain\n medication this morning. C/o neck pain from TLC site, medicated w/650mg\n PO Tylenol (elixir mixed w/nectar thick water) w/relief of pain. Small\n hematoma @ TLC site.\n Action:\n Medicated for pain with .5mg morphine IV x2 within\n hour w/relief of\n pain. Subsequent pain relieved w/position changes every 2 hours.\n Response:\n Relief of pain w/1mg morphine IV. Pt requiring q2hour position changes\n for comfort. Patient appreciated back rubs and hair being combed.\n Tylenol relieved neck pain from TLC site.\n Plan:\n Cont to assess for pain, medicate w/1mg morphine for pain or\n greater and reposition at least q2hours w/back rubs for comfort and\n continual assessment of stage 1 pressure ulcer @ coccyx.\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498212,
"text": "Hypotension (not Shock)\n Assessment:\n Remains pressor dependent on levophed and vasopressin. Rec\nd total of\n 3L IVF boluses for b/p and would respond well initially & able to\n lower levophed dose and then appear to equilibrate and require\n increased dose of levophed. Quad lumen catheter placed this evening in\n left IJ, required total of 2mg versed and 50mcg fentanyl for patient\n comfort.\n Action:\n 3L IVF boluses. Titrating levophed accordingly.\n Response:\n Appears fluid responsive.\n Plan:\n f/u w/CXR for line placement, once confirmed obtain CVP and venous ABG\n via new quad lumen and d/c femoral. ICU team plan is to change a-line\n from femoral to radial this evening.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Pt\ns 4 children spoke w/OB/GYN and ICU team re: CT results and ICU\n plan of care. Await cytology report for definitive diagnosis of\n ?ovarian CA vs lymphoma to direct care. Pt\ns dtr (HCP and RN)\n took me aside to discuss possibility of comfort care.\n Action:\n Family spoke w/surgery and ICU team\n Response:\n Await cytology results for definitive diagnosis.\n Plan:\n F/u w/results, assist patient\ns family to understand diagnosis and\n treatment possibilities.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, AC mode, increased tV to 35Occ w/improvement in\n ventilation. PEEP decreased from 10 to 8 and paO2 remains 120s, no\n further decrease in PEEP given anticipated large volume fluid\n resusutation. LS: diminished bibasilar. Left posterior pigtail chest\n tube remains intact, noted rare leak at water seal, -fluctuation,\n -crepitus. Dressing D&I, drained 320cc serosang fluid. Gross anasarca\n persists, noting increase in extremity edema (dependent) with fluid\n boli.\n Action:\n Vent changes to improve ventilation\n Response:\n Ventilation improved w/increase in TV\n Plan:\n Cont w/VAP prevention. Cont to assess tolerance to ventilator.\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498213,
"text": "Hypotension (not Shock)\n Assessment:\n Remains pressor dependent on levophed and vasopressin. Rec\nd total of\n 3L IVF boluses for b/p and would respond well initially & able to\n lower levophed dose and then appear to equilibrate and require\n increased dose of levophed. Quad lumen catheter placed this evening in\n left IJ, required total of 2mg versed and 50mcg fentanyl for patient\n comfort.\n Action:\n 3L IVF boluses. Titrating levophed accordingly.\n Response:\n Appears fluid responsive.\n Plan:\n f/u w/CXR for line placement, once confirmed obtain CVP and venous ABG\n via new quad lumen and d/c femoral. ICU team plan is to change a-line\n from femoral to radial this evening.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Pt\ns 4 children spoke w/OB/GYN and ICU team re: CT results and ICU\n plan of care. Await cytology report for definitive diagnosis of\n ?ovarian CA vs lymphoma to direct care. Pt\ns dtr (HCP and RN)\n took me aside to discuss possibility of comfort care.\n Action:\n Family spoke w/surgery and ICU team\n Response:\n Await cytology results for definitive diagnosis.\n Plan:\n F/u w/results, assist patient\ns family to understand diagnosis and\n treatment possibilities.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, AC mode, increased tV to 35Occ w/improvement in\n ventilation. PEEP decreased from 10 to 8 and paO2 remains 120s, no\n further decrease in PEEP given anticipated large volume fluid\n resusutation. LS: diminished bibasilar. Left posterior pigtail chest\n tube remains intact, noted rare leak at water seal, -fluctuation,\n -crepitus. Dressing D&I, drained 320cc serosang fluid. Gross anasarca\n persists, noting increase in extremity edema (dependent) with fluid\n boli.\n Action:\n Vent changes to improve ventilation\n Response:\n Ventilation improved w/increase in TV\n Plan:\n Cont w/VAP prevention. Cont to assess tolerance to ventilator.\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498214,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD.\n At pt was noted to be in ARF w/ Cr of 2.5. She was\n also noted to have leukocytosis. CT abdomen was performed and notable\n for ascites and diffuse nodular changes in peritoneal cavity and on\n omentum suggesting carcinomatosis. The stomach is herniated into chest\n cavity. CT of lungs was significant for collapsed left lung with left\n chest cavity filled with fluid.\n She was also noted to be hypotensive to 80/50 after CT scan and was\n bolused with fluids & given Vanco and Zosyn for presumed sepsis and\n transferred to for further care.\n Hypotension (not Shock)\n Assessment:\n Remains pressor dependent on levophed and vasopressin. Rec\nd total of\n 3L IVF boluses for b/p and would respond well initially & able to\n lower levophed dose and then appear to equilibrate and require\n increased dose of levophed. Quad lumen catheter placed this evening in\n left IJ, required total of 2mg versed and 50mcg fentanyl for patient\n comfort.\n Action:\n 3L IVF boluses. Titrating levophed accordingly.\n Response:\n Appears fluid responsive.\n Plan:\n f/u w/CXR for line placement, once confirmed obtain CVP and venous ABG\n via new quad lumen and d/c femoral. ICU team plan is to change a-line\n from femoral to radial this evening.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Pt\ns 4 children spoke w/OB/GYN and ICU team re: CT results and ICU\n plan of care. Await cytology report for definitive diagnosis of\n ?ovarian CA vs lymphoma to direct care. Pt\ns dtr (HCP and RN)\n took me aside to discuss possibility of comfort care.\n Action:\n Family spoke w/surgery and ICU team\n Response:\n Await cytology results for definitive diagnosis.\n Plan:\n F/u w/results, assist patient\ns family to understand diagnosis and\n treatment possibilities.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, AC mode, increased tV to 35Occ w/improvement in\n ventilation. PEEP decreased from 10 to 8 and paO2 remains 120s, no\n further decrease in PEEP given anticipated large volume fluid\n resusutation. LS: diminished bibasilar. Left posterior pigtail chest\n tube remains intact, noted rare leak at water seal, -fluctuation,\n -crepitus. Dressing D&I, drained 320cc serosang fluid. Gross anasarca\n persists, noting increase in extremity edema (dependent) with fluid\n boli.\n Action:\n Vent changes to improve ventilation\n Response:\n Ventilation improved w/increase in TV\n Plan:\n Cont w/VAP prevention. Cont to assess tolerance to ventilator.\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-08 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 499361,
"text": "Chief Complaint: respiratory failure, pleural effusion\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:08 PM\n MULTI LUMEN - STOP 10:20 PM\n Off pressors\n Central line discontinued\n Epistaxis resolved\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:08 PM\n Vancomycin - 12:34 AM\n Piperacillin/Tazobactam (Zosyn) - 08:15 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 03:30 AM\n Heparin Sodium (Prophylaxis) - 08:22 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.8\nC (96.5\n HR: 71 (67 - 93) bpm\n BP: 120/70(80) {95/43(53) - 120/87(92)} mmHg\n RR: 19 (17 - 31) insp/min\n SpO2: 94%\n Heart rhythm: AV Paced\n Total In:\n 2,848 mL\n 865 mL\n PO:\n 960 mL\n TF:\n IVF:\n 1,788 mL\n 865 mL\n Blood products:\n 100 mL\n Total out:\n 1,440 mL\n 740 mL\n Urine:\n 1,140 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,408 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///19/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.7 g/dL\n 391 K/uL\n 95 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 26 mg/dL\n 112 mEq/L\n 144 mEq/L\n 31.3 %\n 9.1 K/uL\n [image002.jpg]\n 05:01 AM\n 10:06 AM\n 08:42 PM\n 04:00 AM\n 02:06 PM\n 05:01 PM\n 10:16 PM\n 04:20 AM\n 03:51 AM\n 03:07 AM\n WBC\n 11.0\n 13.8\n 10.2\n 9.1\n Hct\n 28.1\n 34.2\n 31.7\n 31.3\n Plt\n 91\n Cr\n 1.3\n 1.2\n 1.1\n 0.9\n TCO2\n 25\n 24\n 23\n 23\n 21\n 22\n Glucose\n 144\n 102\n 99\n 95\n Other labs: PT / PTT / INR:13.6/38.5/1.2, ALT / AST:24/27, Alk Phos / T\n Bili:61/0.5, Differential-Neuts:78.3 %, Lymph:11.4 %, Mono:7.6 %,\n Eos:2.4 %, Lactic Acid:1.7 mmol/L, Albumin:2.6 g/dL, LDH:300 IU/L,\n Ca++:6.9 mg/dL, Mg++:2.3 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN): Adequately controlled on prn\n morphine\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Stable. Persistent\n pleural effusion, chest tube in place.\n SEPTIC SHOCK: Resolved, stable off pressors. Continues on abx for\n presumed sepsis, no new culture data. WBC trending down.\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL): No confirmation on cytology.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Slightly positive\n fluid balance over the day yesterday. Cr continues to improve to 0.9,\n near baseline.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 05:37 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498281,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP.\n SHIFT EVENTS:\n -As pt. has R femoral groin line and L femoral ALine, MDs placed new L\n IJTL yesterday . CXR showed line not in place. MDs attempted to\n reposition line last night but were unsuccessful. New Central line to\n be placed today. Also, ALine extremely dampened. MD\ns unable to place\n radial ALine at this time. Another attempt will be made today with\n attending MD.\n -TFeeds started at 10cc/hr at midnight. (Goal 30cc/hr)\n Hypotension (not Shock)\n Assessment:\n SBP ranging from 90\ns to 140\ns. ALine dampened as noted above. Using\n non-invasive cuff at this time, as it correlated with A-Line earlier in\n the day. Remains pressor dependent on levophed and vasopressin.\n Action:\n Pt. received a total of 1L NS bolus for low BP and UO. Titrating\n levophed at this time.\n Response:\n Ongoing assessment.\n Plan:\n Continue to titrate pressors at tolerated. MDs to place new radial\n A-Line and central line today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. intubated for increased respiratory distress. Remains\n intubated, AC mode, increased tV to 45Occ w/improvement in ventilation.\n PEEP decreased from 8 to 5 and paO2 remains 120s, rate decreased to 16\n from 28. Breath sounds diminished bibasilar. Left posterior pigtail\n chest tube remains intact, noted rare leak at water seal, -fluctuation,\n -crepitus. Dressing D&I, drained ___cc serosang fluid. Gross anasarca\n persists, noting increase in extremity edema.\n Action:\n Bleed gases monitored closely and vent changes made according to\n results. (see metavision) Pt. turned Q2h. Mouth care Q4h. Sedated on\n fentanyl 50mcg and versed 2mg for pt. comfort. Also being empirically\n treated with vanco/zosyn as pt. with history of recent pneumonia.\n Response:\n Blood gases continue to improve. Pt. appears comfortable at this time.\n Plan:\n Cont w/VAP prevention. Cont to wean vent as tolerated. Plan is to wean\n vent in hopes for possible extubation within the next couple of days.\n Cancer (Malignant Neoplasm), Gynecological (Ovarian, Uterine, Cervical,\n Endometrial)\n Assessment:\n Pt\ns 4 children spoke w/OB/GYN and ICU team re: CT results and ICU\n plan of care yesterday. Awaiting cytology report for definitive\n diagnosis of probable ovarian CA vs lymphoma to direct care. Pt\ns dtr\n (HCP and RN) took RN aside to discuss possibility of comfort\n care.\n Action:\n Family spoke w/surgery and ICU team. Discussing plan of care amongst\n siblings.\n Response:\n Awaiting cytology results for definitive diagnosis.\n Plan:\n F/u w/results, assist patient\ns family to understand diagnosis and\n treatment possibilities.\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 499285,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Off pressors\n D/c central line- leaking (pulled at 2300)\n PICC consult in\n c/o in AM\n Dr met w/ family re: code status, she is DNR (chest compressions\n no?) but can be intubated for short periods of time\n Got a baby dose of Ativan for sleep.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:08 PM\n Vancomycin - 12:34 AM\n Piperacillin/Tazobactam (Zosyn) - 02:14 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:33 AM\n Morphine Sulfate - 03:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.8\nC (96.5\n HR: 93 (67 - 93) bpm\n BP: 102/71(79) {95/43(53) - 117/75(80)} mmHg\n RR: 17 (17 - 31) insp/min\n SpO2: 95%\n Heart rhythm: AV Paced\n Total In:\n 2,848 mL\n 720 mL\n PO:\n 960 mL\n TF:\n IVF:\n 1,788 mL\n 720 mL\n Blood products:\n 100 mL\n Total out:\n 1,440 mL\n 700 mL\n Urine:\n 1,140 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,408 mL\n 20 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///19/\n Physical Examination\n GENERAL: Alert, responsive, NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: Crackles b/l, decreased breath sounds\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent, but difficulty\n competing sentences Moves all extremities.\n Labs / Radiology\n 391 K/uL\n 9.7 g/dL\n 95 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 26 mg/dL\n 112 mEq/L\n 144 mEq/L\n 31.3 %\n 9.1 K/uL\n [image002.jpg]\n 05:01 AM\n 10:06 AM\n 08:42 PM\n 04:00 AM\n 02:06 PM\n 05:01 PM\n 10:16 PM\n 04:20 AM\n 03:51 AM\n 03:07 AM\n WBC\n 11.0\n 13.8\n 10.2\n 9.1\n Hct\n 28.1\n 34.2\n 31.7\n 31.3\n Plt\n 91\n Cr\n 1.3\n 1.2\n 1.1\n 0.9\n TCO2\n 25\n 24\n 23\n 23\n 21\n 22\n Glucose\n 144\n 102\n 99\n 95\n Other labs: PT / PTT / INR:13.6/38.5/1.2, ALT / AST:24/27, Alk Phos / T\n Bili:61/0.5, Differential-Neuts:78.3 %, Lymph:11.4 %, Mono:7.6 %,\n Eos:2.4 %, Lactic Acid:1.7 mmol/L, Albumin:2.6 g/dL, LDH:300 IU/L,\n Ca++:6.9 mg/dL, Mg++:2.3 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n yo F w/ CAD s/p CABG (), x-fer from for hypotension,\n renal failure and cancer workup, likely ovarian primary.\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock. There is no pericardial effusion in TTE. stim\n test demostrated appropriate response. PE is highly unlikely.\n Increasing leukocytosis today and persistent hypotension, although no\n fevers, decent UOP.\n - Vanc and Zosyn, currently day 5.\n - Obtain Vanc trough\n - f/u cultures from as well as (blood, sputum, urine)\n - hold anti-HTN and lasix\n - continue Levophed as needed for MAP >60, SBP >90. Wean as\n tolerated.\n - Minimal IVF boluses, as needed to keep MAP > 60.\n .\n # Pleural effusions / Respiratory status:\n -Monitor resp. status closely today. Repeat CXR if increasing work of\n breathing, tachypnea.\n -Continue Vanc/zosyn\n -Minimize IVF as they may lead to reaccumulation of fluid\n .\n #. Oliguric renal failure: Cr 1.1 and improving, likely pre-renal /\n secondary to hypotension. No evidence of obstruction / no\n hydronephrosis on OSH CT.\n - Hold lasix and anti-HTN\n - Monitor UOP and Cr daily\n -Renally dose meds and avoid nephrotoxins\n .\n #. New carcinomatosis on CT / pleural effusions: last CA screening\n (mammogram, pap and colonoscopy 10-20 years ago). Concerning due to\n elevated CEA and CA125.\n -Cytologies from OSH recent thoracentesis\n -F/u cytologies from pleural fluid here\n -Discussion with family and patient today\n -Morphine PRN for pain\n -Gyn/onc recs\n .\n #. hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n PPX:\n -DVT ppx with heparin SC and Boots\n ICU Care\nNutrition: thin liquids and moist, ground solids\n Glycemic Control:\n Lines:\n PIV\n Arterial Line\n Prophylaxis:\n DVT: Boots / Heparin SC\n Stress ulcer: None\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 498962,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n [ ]f/u micro data\n urine culture: <10K, mixed gram positive flora\n [ ]repeat cultures\n [ ]add differential to Hct\n [ ]give albumin rather than crystalloid to support BP\n [ ]f/u gyn/onc recs\n [ ]f/u cytology, path\n [ ]discuss diagnosis with patient - patient aware\n [ ]check vanc trough\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:08 PM\n Vancomycin - 12:50 AM\n Piperacillin/Tazobactam (Zosyn) - 02:31 AM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:06 AM\n Morphine Sulfate - 12:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36\nC (96.8\n HR: 75 (63 - 95) bpm\n BP: 105/46(63) {74/38(50) - 144/68(94)} mmHg\n RR: 24 (14 - 29) insp/min\n SpO2: 98%\n Heart rhythm: AV Paced\n Total In:\n 2,127 mL\n 772 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,787 mL\n 772 mL\n Blood products:\n 100 mL\n Total out:\n 1,649 mL\n 570 mL\n Urine:\n 959 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 478 mL\n 202 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///20/\n Physical Examination\n GENERAL: Alert, responsive, NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: Crackles b/l, decreased breath sounds compared to yesterday\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent, but difficulty\n competing sentences Moves all extremities.\n Labs / Radiology\n 399 K/uL\n 9.8 g/dL\n 99 mg/dL\n 1.1 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 34 mg/dL\n 114 mEq/L\n 144 mEq/L\n 31.7 %\n 10.2 K/uL\n [image002.jpg]\n 04:54 AM\n 05:01 AM\n 10:06 AM\n 08:42 PM\n 04:00 AM\n 02:06 PM\n 05:01 PM\n 10:16 PM\n 04:20 AM\n 03:51 AM\n WBC\n 13.0\n 11.0\n 13.8\n 10.2\n Hct\n 30.8\n 28.1\n 34.2\n 31.7\n Plt\n 381\n 340\n 431\n 399\n Cr\n 2.1\n 1.3\n 1.2\n 1.1\n TCO2\n 25\n 24\n 23\n 23\n 21\n 22\n Glucose\n 136\n 144\n 102\n 99\n Other labs: PT / PTT / INR:13.1/34.3/1.1, ALT / AST:27/28, Alk Phos / T\n Bili:64/0.4, Differential-Neuts:76.7 %, Lymph:12.0 %, Mono:8.9 %,\n Eos:2.2 %, Lactic Acid:1.7 mmol/L, Albumin:2.6 g/dL, LDH:300 IU/L,\n Ca++:6.8 mg/dL, Mg++:2.3 mg/dL, PO4:2.2 mg/dL\n Assessment and Plan\n yo F w/ CAD s/p CABG (), x-fer from for hypotension,\n renal failure and cancer workup, likely ovarian primary.\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock. There is no pericardial effusion in TTE.. \n stim test demostrated appropriate response. PE is highly unlikely.\n Increasing leukocytosis today and persistent hypotension, although no\n fevers, decent UOP.\n - Vanc and Zosyn, currently day 4.\n - Obtain Vanc trough\n - Obtain WBC differential\n - f/u cultures from as well as \n -Send new Blood, sputum, urine cx given increasing leukocytosis\n - hold anti-HTN and lasix\n - continue Levophed and vasopressin as needed for MAP >60, SBP >90.\n Wean as tolerated.\n - Minimal IVF boluses, as needed to keep MAP > 60. Try colloid instead\n of crystalloid given low Albumin.\n .\n # Pleural effusions / Respiratory status:\n -Monitor resp. status closely today. Repeat CXR if increasing work of\n breathing, tachypnea.\n -Continue Vanc/zosyn\n -Minimize IVF as they may lead to reaccumulation of fluid\n .\n #. Oliguric renal failure: Cr 1.2 and improving, likely pre-renal /\n secondary to hypotension. No evidence of obstruction / no\n hydronephrosis on OSH CT.\n - Hold lasix and anti-HTN\n - Monitor UOP and Cr daily\n -Renally dose meds and avoid nephrotoxins\n .\n #. New carcinomatosis on CT / pleural effusions: last CA screening\n (mammogram, pap and colonoscopy 10-20 years ago). Concerning due to\n elevated CEA and CA125.\n -Cytologies from OSH recent thoracentesis\n -F/u cytologies from pleural fluid here\n -Discussion with family and patient today\n -Morphine PRN for pain\n -Gyn/onc recs\n .\n #. hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n PPX:\n -DVT ppx with heparin SC and Boots\n ICU Care\n Nutrition: Speech and swallow today. Advance as tolerated\n Glycemic Control:\n Lines:\n Multi Lumen - 12:31 AM\n Arterial Line\n Prophylaxis:\n DVT: Boots / Heparin SC\n Stress ulcer: None\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 499275,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP.\n Hypotension (not Shock)\n Assessment:\n Patient off pressors since 1300 on . . Hr in 70-90 AV paced. Sbp\n 110-130 B/L arm edema. Difficult to palpate pulses. UOP 30-40cc/hr\n Action:\n Remains of f pressors. continue ABX\n Response:\n Ongoing\n Plan:\n Continue to monitor hemodynamic status, f/u cx data, ID consult if\n needed.\n Neuro: alert oriented X1-2, follows commands.\n Resp: extubated on . On NC 5 L with sats at mid 90\ns. B/L LS clear\n w/crackles at the bases. LT CT to water seal draining serosang. Patient\n denies resp distress when asked.\n GI: abd soft non tender, positive for BS. 1-2X BM this shift. Regular\n diet. Denies nausea, vomiting\n GU: clear yellow urine via foley. 30-40cc/hr\n IV access: 22G LT PIV, to IR for PICC placement\n Social: patient is a DNR, ok to intubate>\n"
},
{
"category": "Respiratory ",
"chartdate": "2117-10-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 498152,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum source/amount: / None\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt on the vent no changes made tol well. See respiratory page of meta\n vision for more information.\n"
},
{
"category": "Respiratory ",
"chartdate": "2117-10-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 498280,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear /\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Sedation off pt still unable to do RSBI at this time.Low vts\n and ve.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved; Comments: Will cont to monitor resp status and ability to\n protect airway.\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Plan is to wean to extubate when more awake.\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 499154,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP, now on levophed for b/p\n support. Extubated , now on 2L NC breathing w/some effort at\n rate 20-26bpm.\n Hypotension (not Shock)\n Assessment:\n Levophed weaned off today, off since 1300. Albumin 25% administered as\n ordered @ 1730. TLC appears out by 10cm today. Bed linens soaked w/what\n appears to be IVF. IVF infusions stopped, assessed by IV RN for PICC\n and d/t difficulties w/TLC placement and pacemaker will have PICC\n placed by IR tomorrow. ICU team to d/c TLC.\n Action:\n Levophed off, albumin administered again today.\n Response:\n Normotensive.\n Plan:\n Cont to monitor b/p, if hypotensive rx w/fluids and colloids vs\n pressors as central line to be d/c\nd as not functioning properly.\n Pain control (acute pain, chronic pain)\n Assessment:\n Denies abd pain today. C/o discomfort after about 2 hours and relieved\n w/position change.\n Action:\n Position changes every 2 hours, OOB to stretcher chair for 1hour\n w/slide board, tolerated well.\n Response:\n Pt requiring q2hour position changes for comfort. Patient appreciated\n back rubs and hair being combed.\n Plan:\n Cont to assess for pain, reposition at least q2hours w/back rubs for\n comfort and continual assessment of stage 1 pressure ulcer @ coccyx.\n"
},
{
"category": "Rehab Services",
"chartdate": "2117-10-06 00:00:00.000",
"description": "Bedside Swallowing Evaluation",
"row_id": 498715,
"text": "TITLE: BEDSIDE SWALLOWING EVALUATION\n HISTORY\n Thank you for referring this year old woman admitted from OSH on\n with ARF and likely sepsis from possibly PNA. She also\n complained of urinary retention and suprapubic pain on the day prior to\n admission. Pt had a thoracentesis 2wks ago. CT abdomen at OSH was\n notable for ascites and diffuse nodular changes in peritoneal cavity\n and on omentum suggesting carcinomatosis. The stomach was herniated\n into chest cavity. CT of lungs was significant for collapsed left lung\n with left chest cavity filled with fluid, significant compression and\n collapse of the right lower lobe with large right pleural effusion. Pt\n underwent pigtail catheter on L on . CXR on indicates \"No\n newly appeared focal parenchymal opacities suggesting pneumonia.\"\n Extubated on @ 16:00. WBC counts have been elevated. We were\n consulted to evaluate oral and pharyngeal swallow function to determine\n the safest diet s/p extubation. RN, voice hoarse, tolerated jell-o\n this morning but only took one sip of gingerale concern for\n aspiration.\n PAST MEDICAL HISTORY:\n Hypertension\n Hyperlipidemia\n CAD s/p CABG\n PCM placement\n Quit smoking at the age of 30\n EVALUATION:\n The examination was performed while the patient was seated mostly\n upright in the bed (could not tolerate full 90 degree positioning) in\n . Daughters present for feedback portion of today's evaluation.\n Cognition, language, speech, voice:\n Awake but lethargic and inattentive with eyes closed during\n evaluation. Oriented to self, \"hospital\" and \".\" Also able to\n relate personal history including # of children, grandchildren, etc.\n Answers y/n questions appropriately. Follows simple commands.\n Expressive language fluent but limited by breath support. Speech\n clear. Voice hypophonic, occasionally hoarse when she attempts to\n increase volume.\n Teeth: edentulous\n Secretions: WNL in oral cavity\n ORAL MOTOR EXAM:\n Face grossly symmetrical. Tongue protrudes minimally past labial\n border with reduced strength and ROM. Labial seal reduced. Palatal\n elevation symmetrical. No overt gag observed, but pt demonstrated\n significant discomfort on brief attempt.\n SWALLOWING ASSESSMENT:\n Pt offered ice chips, thin liquids (tspn, straw), nectar thick liquids\n (tspn, straw), pureed solids. Oral phase for these limited\n consistencies remarkable only for mild difficulty extracting nectar\n thick from straw. No oral cavity residue. Laryngeal elevation\n adequate and timely to palpation. Pt had overt, immediate coughing on\n tspn of thin liquid, delayed intermittent cough with straw sip of thin\n liquid. No other throat clearing, coughing, choking, O2 desats, or\n vocal quality changes. Pt denied sensation of pharyngeal residue.\n Endorsed intermittent aspiration of thin and sensation of odynophagia,\n even with dry swallow.\n SUMMARY / IMPRESSION:\n Today's results are limited, as pt took limited volumes and then\n refused further assessment. On limited trials, presented with\n intermittent s/sx of aspiration of thin liquids. Chewable solids not\n assessed edentulous status. Would recommend cautiously initiating\n small volumes of pureed solids and nectar thick liquids with strict\n aspiration precautions. If PO intake is poor, Nutrition consult may be\n indicated. We will f/u tomorrow to ensure diet tolerance and consider\n diet upgrade as pt continues to improve. If there is any concern for\n aspiration on the current diet, please hold tray pending repeat\n evaluation.\n This swallowing pattern correlates to a Functional Oral Intake Scale\n (FOIS) rating of 5 out of 7.\n RECOMMENDATIONS:\n 1. PO diet: pureed solids, nectar thick liquids\n 2. PO meds crushed in puree or whole with puree/nectar as tolerated at\n RN discretion.\n 3. Q4 oral care\n 4. 1:1 supervision by RN staff with all PO intake to maintain strict\n aspiration precautions. Hold tray if there is concern for aspiration.\n 5. Nutrition f/u may be indicated\n 6. Repeat speech + swallow evaluation on Thurs .\n These recommendations were shared with the patient, nurse and medical\n team.\n ____________________________________\n M.S., CCC-SLP\n Pager # \n Face time: 11:00-11:15\n Total time: 45 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2117-10-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 499216,
"text": " yo F with CAD s/p CABG in 89 transferred from for\n sepsis and probable CA w/u. The patient reports that she was treated\n for PNA with abx & thoracentesis 2 weeks ago. Pt reports difficulty\n urinating and recent visit to renal MD. pt was noted\n to be in ARF w/ Cr of 2.5. She was also noted to have leukocytosis. CT\n abdomen was performed and notable for ascites and diffuse nodular\n changes in peritoneal cavity and on omentum suggesting carcinomatosis.\n The stomach is herniated into chest cavity. CT of lungs was significant\n for collapsed left lung with left chest cavity filled with fluid. She\n was also noted to be hypotensive to 80/50 after CT scan and was bolused\n with fluids & given Vanco and Zosyn for presumed sepsis and transferred\n to for further care. Upon arrival to ICU on pt. was\n intubated for resp. distress and L posterior chest tube placed. Pt. has\n required multiple pressors to maintain BP.\n Hypotension (not Shock)\n Assessment:\n Patient off pressors since 1300 on . . Hr in 70-90 AV paced. Sbp\n 110-130 B/L arm edema. Difficult to palpate pulses. UOP 30-40cc/hr\n Action:\n Remains of f pressors. continue ABX\n Response:\n Ongoing\n Plan:\n Continue to monitor hemodynamic status, f/u cx data, ID consult if\n needed.\n Neuro: alert oriented X1-2, follows commands.\n Resp: extubated on . On NC 5 L with sats at mid 90\ns. B/L LS clear\n w/crackles at the bases. LT CT to water seal draining serosang. Patient\n denies resp distress when asked.\n GI: abd soft non tender, positive for BS. 1-2X BM this shift. Regular\n diet. Denies nausea, vomiting\n GU: clear yellow urine via foley. 30-40cc/hr\n IV access: 22G LT PIV, to IR for PICC placement\n Social: patient is a DNR, ok to intubate>\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 498484,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Tidal volume was increased after the patient\ns left lung re-expanded\n - The patient received several IVF boluses, continued on levophed/\n vasopressin\n - Tube feeds were started\n - Family meeting was held along with Ob/Gyn doctors to discuss\n \n - New IJ CVL was placed, but was found to be in azygous v., was pulled\n back, but is still not in proper position. The patient continues to\n have femoral CVL for now.\n This AM, the pt. opens eyes, nods to voice command. Denies having\n pain.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Piperacillin - 10:55 PM\n Vancomycin - 01:34 AM\n Infusions:\n Vasopressin - 1.2 units/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:55 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.2\n HR: 76 (60 - 76) bpm\n BP: 94/50(64) {52/35(42) - 148/82(96)} mmHg\n RR: 16 (11 - 29) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n CVP: 8 (6 - 8)mmHg\n Total In:\n 6,160 mL\n 1,518 mL\n PO:\n TF:\n 5 mL\n 71 mL\n IVF:\n 6,095 mL\n 1,448 mL\n Blood products:\n Total out:\n 1,720 mL\n 790 mL\n Urine:\n 1,250 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,440 mL\n 728 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (280 - 450) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 17 cmH2O\n Plateau: 15 cmH2O\n Compliance: 45 cmH2O/mL\n SpO2: 99%\n ABG: 7.41/35/130/22/-1\n Ve: 6.6 L/min\n PaO2 / FiO2: 325\n Physical Examination\n GENERAL: intubated, opens eyes, nods to voice commands\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: CTAB, significantly improved air movement on L side\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent, but difficulty\n competing sentences Moves all extremities.\n Labs / Radiology\n 340 K/uL\n 8.9 g/dL\n 144 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 42 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.1 %\n 11.0 K/uL\n [image002.jpg] ABG: 7.41/35/130/23/-1\n 09:04 AM\n 01:45 PM\n 11:13 PM\n 11:23 PM\n 03:05 AM\n 04:54 AM\n 05:01 AM\n 10:06 AM\n 08:42 PM\n 04:00 AM\n WBC\n 13.8\n 13.0\n 11.0\n Hct\n 35.8\n 31\n 30.8\n 28.1\n Plt\n 399\n 381\n 340\n Cr\n 2.3\n 2.1\n 1.3\n TCO2\n 31\n 29\n 27\n 26\n 25\n 24\n 23\n Glucose\n 124\n 136\n 144\n Other labs: PT / PTT / INR:13.3/35.5/1.1, ALT / AST:14/20, Alk Phos / T\n Bili:67/0.3, Differential-Neuts:85.5 %, Lymph:7.6 %, Mono:5.8 %,\n Eos:1.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.3 g/dL, LDH:192 IU/L,\n Ca++:6.7 mg/dL, Mg++:1.7 mg/dL, PO4:2.7 mg/dL\n Pleural fluid: Gram Stain PMN 1+, no microorganisms, Cx pending.\n Urine, Blood Cx pending\n Assessment and Plan\n yo F w/ CAD s/p CABG (), x-fer from for hypotension,\n renal failure and cancer workup, likely ovarian primary.\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock. There is no pericardial effusion in TTE.. \n stim test demostrated appropriate response. PE is highly unlikely.\n - Vanc and Zosyn, currently day 3. Switch Vanc to daily dosing based\n on improved renal function.\n - hold anti-HTN and lasix\n - continue Levophed and vasopressin as needed for MAP >60, SBP >90.\n Wean as tolerated.\n -Use IVF boluses, as needed to keep MAP > 60\n - f/u cultures from as well as \n .\n # Hypoxic respiratory failure, likely to significant effusions,\n left lung collapse, +/- PNA. Significantly worsening this AM.\n -SBT today. Extubate if tolerates\n -F/u serial ABGs\n -Re-site Arterial line\n -Continue Vanc/zosyn\n .\n #. Oliguric renal failure: Cr 1.3 and improving, likely pre-renal /\n secondary to hypotension. No evidence of obstruction / no\n hydronephrosis on OSH CT.\n - Hold lasix and anti-HTN\n - Monitor UOP and Cr daily\n -Renally dose meds and avoid nephrotoxins\n .\n #. New carcinomatosis on CT / pleural effusions: last CA screening\n (mammogram, pap and colonoscopy 10-20 years ago). Concerning due to\n elevated CEA and CA125.\n -Cytologies from OSH recent thoracentesis\n -F/u cytologies from pleural fluid here\n - gyn/onc recs\n .\n #. hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n FEN: regular diet\n .\n PPX:\n -DVT ppx with heparin SC\n ICU Care\n Nutrition: Hold tube feeds for now\n Glycemic Control:\n Lines:\n Multi Lumen - 12:31 AM\n 22 Gauge - 12:43 AM\n Prophylaxis:\n DVT: Boots / Heparin SC\n Stress ulcer: pantoprazole\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 498353,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - hypercarbic resp acidosis on ABG, will up Vt\n - bolus 1 L NS, still on levophed/ vasopressin\n - re-site central line (fem to IJ) and fem art to radial\n - started TF today, nutrition recs are in!\n - ct zosyn, vanc per renal dosing recs (cr 2.1 today slightly improved)\n - gyn onc c/s\n - f/u OSH recs\n - need to fix central line (tried pulling it back 5cm and repositioning\n but still not right- will try again in AM, pt has fem line working)\n - did not re-site fem a-line d/t possible extubation in AM, will try PS\n sbt\n - d/c vigileo (vigi-who?) after re-siting or d/c-ing fem line\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Piperacillin - 10:55 PM\n Vancomycin - 01:34 AM\n Infusions:\n Vasopressin - 1.2 units/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:55 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.2\nC (97.2\n HR: 76 (60 - 76) bpm\n BP: 94/50(64) {52/35(42) - 148/82(96)} mmHg\n RR: 16 (11 - 29) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n CVP: 8 (6 - 8)mmHg\n Total In:\n 6,160 mL\n 1,518 mL\n PO:\n TF:\n 5 mL\n 71 mL\n IVF:\n 6,095 mL\n 1,448 mL\n Blood products:\n Total out:\n 1,720 mL\n 790 mL\n Urine:\n 1,250 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,440 mL\n 728 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (280 - 450) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: No Spon Resp\n PIP: 17 cmH2O\n Plateau: 15 cmH2O\n Compliance: 45 cmH2O/mL\n SpO2: 99%\n ABG: 7.41/35/130/22/-1\n Ve: 6.6 L/min\n PaO2 / FiO2: 325\n Physical Examination\n GENERAL: intubated, sedated\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: CTAB, decreased breaths sounds bilaterally.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent, but difficulty\n competing sentences Moves all extremities.\n Labs / Radiology\n 340 K/uL\n 8.9 g/dL\n 144 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 42 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.1 %\n 11.0 K/uL\n [image002.jpg]\n 09:04 AM\n 01:45 PM\n 11:13 PM\n 11:23 PM\n 03:05 AM\n 04:54 AM\n 05:01 AM\n 10:06 AM\n 08:42 PM\n 04:00 AM\n WBC\n 13.8\n 13.0\n 11.0\n Hct\n 35.8\n 31\n 30.8\n 28.1\n Plt\n 399\n 381\n 340\n Cr\n 2.3\n 2.1\n 1.3\n TCO2\n 31\n 29\n 27\n 26\n 25\n 24\n 23\n Glucose\n 124\n 136\n 144\n Other labs: PT / PTT / INR:13.3/35.5/1.1, ALT / AST:14/20, Alk Phos / T\n Bili:67/0.3, Differential-Neuts:85.5 %, Lymph:7.6 %, Mono:5.8 %,\n Eos:1.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.3 g/dL, LDH:192 IU/L,\n Ca++:6.7 mg/dL, Mg++:1.7 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n yo F w/ CAD s/p CABG (), x-fer from for hypotension,\n renal failure and cancer workup, likely ovarian primary.\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock . Pericardial effusion is also unlikely w/o low\n voltage EKG and no JVD, no effusion of CT chest. Infectious sources\n could be GI given carcinomatosis as well as pulmonary given recent dx\n PNA. Although there was no definate infiltrate on CT chest, there was\n significant lung collapse and effusion to make evaluation difficult. UA\n neg.\n - Vanc and Zosyn, will need to dose vanc by level (holding for now\n given renal function)\n - hold anti-HTN and lasix\n - continue Levophed and vasopressin as needed for MAP >60, SBP >90.\n -Minimize IVF boluses, but use as needed to keep MAP > 60\n - f/u cultures from as well as \n - stim test\n .\n # Hypoxic respiratory failure, likely to significant effusions,\n left lung collapse, +/- PNA. Significantly worsening this AM.\n -Intubate, start on mechanical ventilation with AC, tidal volume\n 4ml/kg, FiO2 at 100% (wean as tolerated), PEEP .\n -Sedation with Versed and Fentanyl.\n -CXR to evaluate ETT tube and OGT placement\n -Chest tube to decompress pleural space\n - will need thoracentesis\n -F/u serial ABGs\n -Arterial line\n -CT of chest and a/p today (without IV contrast)\n -Hard copies of scans from OSH, cytologies from OSH\n - Vanc/zosyn\n - increase tidal volume\n - consider decreasing PEEP to 8 from 10\n .\n #. Oliguric renal failure: cr 2.5 this AM, slightly improved, bland\n sediment, minimal UOP - pre-renal vs ATN. Renal failure may be\n secondary to low BP, but may also have a component of a more chronic\n process. No evidence of obstruction / no hydronephrosis on OSH CT.\n - hold lasix and anti-HTN\n - urine lytes\n - f/u CT a/p\n - urine eos\n - renal consult\n - monitor UOP\n .\n #. New carcinomatosis on CT / pleural effusions: last CA screening\n (mammogram, pap and colonoscopy 10-20 years ago). Concerning due to\n elevated CEA and CA125.\n -Cytologies from OSH recent thoracentesis\n -F/u cytologies from pleural fluid here\n - gyn/onc cs\n .\n #. hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n FEN: regular diet\n .\n PPX:\n -DVT ppx with heparin SC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:31 AM\n 22 Gauge - 12:43 AM\n Prophylaxis:\n DVT: Boots / Heparin SC\n Stress ulcer: pantoprazole\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Social Work",
"chartdate": "2117-10-07 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 499081,
"text": "Family Information\n Next of : , (Daughter)\n Health Care Proxy appointed: - Info Provided\n Family Spokesperson designated: Same (; (W) )\n Communication or visitation restriction: None\n Patient Information:\n Previous living situation: Home alone\n Previous level of functioning: Independent\n Previous or other hospital admissions: This admission is pt's\n first at ; she had previously been at .\n Past psychiatric history: None known.\n Past addictions history: None known.\n Employment status: Retired\n Legal involvement: None known.\n Additional Information:\n Patient / Family Assessment: Dr. admitted this y/o WWF with\n sepsis. This alert and oriented woman had been driving prior to her\n recent illness and hospitalizations. She has 13 children, eight of whom\n are still living; she has approximately 100 grandchildren and great\n grandchildren.\n SW met briefly with pt and one of her sons, his wife, and daughter, all\n of whom reported that they felt things were going well, but Mr. \n said they were waiting to receive the cytology report. Pt expressed no\n concerns. Asked to what she attributed her longevity and good health,\n she responded,\nI kept busy.\n ADDENDUM (): Ms. mentioned the possibility that she\n might had CA, but she had not yet heard the results of the tests. Asked\n what it would be like for her if she were to learn that she had CA, Ms.\n said,\nWell, there\ns nothing I could do\nI would like to live\n another 3-4 years.\n The pt said that her spirits were\ngood.\n Assessment: Both pt and family seem to be coping well, with pt\n exhibiting a great deal of emotional strength, manifest, e.g., with her\n joking with this writer.\n Clergy Contact: \n Communication with Team:\n Primary Nurse: \n Attending: \n Plan / Follow up:\n 1. SW will continue to meet with pt and family while in the \n to assess their psychosocial functioning and offer support.\n PAGE \n"
},
{
"category": "Nursing",
"chartdate": "2117-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 498540,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented. Gd O2sats. Gd ABG on PSV 5/5. Waking up and responsive.\n Afebrile on Vanco and Zosyn. CT drained 300cc serous fluid.\n Action:\n Weaned and extubated.\n Response:\n Gd ABG on 50% FT neb. Expectorated thick tan sputum. Maintaining gd\n O2sats.\n Plan:\n Monitor O2sats.\n Hypotension (not Shock)\n Assessment:\n On Vassopressin at 1.2 and Levophed at .08. Given 1L NS IVB. UO\n ~25cc/hr. Slight, transient increase after fluid bolus.\n Action:\n Vasopressors weaned off. R radial art line placed. L femoral art line\n dc\n Response:\n Marginal BP. Given second liter bolus. BP 90-100s systolic. MAPs 58-70.\n Better wave form with new art line.\n Plan:\n Continue to monitor BP. IVBs as per team.\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-06 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 498690,
"text": "Chief Complaint: respiratory failure, hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - START 03:13 PM\n MULTI LUMEN - STOP 03:43 PM\n ARTERIAL LINE - STOP 03:49 PM\n INVASIVE VENTILATION - STOP 04:03 PM\n Continues extubated\n Hypotension overnight requiring fluid boluses with some response;\n restarted on vasopressin after >2 L boluses\n C/O abdominal discomfort this am; received 0.5 mg IV morphing\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:08 PM\n Vancomycin - 12:43 AM\n Piperacillin/Tazobactam (Zosyn) - 02:31 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:42 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Gastrointestinal: Abdominal pain\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Psychiatric / Sleep: depressed affect\n Flowsheet Data as of 10:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 35.4\nC (95.8\n HR: 70 (67 - 85) bpm\n BP: 74/38(50) {67/38(49) - 135/97(113)} mmHg\n RR: 24 (16 - 31) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Total In:\n 5,400 mL\n 659 mL\n PO:\n TF:\n 120 mL\n IVF:\n 5,280 mL\n 659 mL\n Blood products:\n Total out:\n 1,590 mL\n 784 mL\n Urine:\n 1,000 mL\n 434 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,810 mL\n -125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n PS : 5 cmH2O\n RR (Set): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 82\n PIP: 17 cmH2O\n Plateau: 12 cmH2O\n SpO2: 99%\n ABG: 7.35/39/92/19/-3\n Ve: 8.1 L/min\n PaO2 / FiO2: 230\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Diminished: way up on right,\n way up on left albeit doesn't take deep breaths)\n Abdominal: Soft, Non-tender, Bowel sounds present, Tender: minimal\n lower abdominal pain with palpation, no guarding\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.5 g/dL\n 431 K/uL\n 102 mg/dL\n 1.2 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 40 mg/dL\n 110 mEq/L\n 139 mEq/L\n 34.2 %\n 13.8 K/uL\n [image002.jpg]\n 03:05 AM\n 04:54 AM\n 05:01 AM\n 10:06 AM\n 08:42 PM\n 04:00 AM\n 02:06 PM\n 05:01 PM\n 10:16 PM\n 04:20 AM\n WBC\n 13.0\n 11.0\n 13.8\n Hct\n 31\n 30.8\n 28.1\n 34.2\n Plt\n 381\n 340\n 431\n Cr\n 2.1\n 1.3\n 1.2\n TCO2\n 26\n 25\n 24\n 23\n 23\n 21\n 22\n Glucose\n 136\n 144\n 102\n Other labs: PT / PTT / INR:12.6/32.8/1.1, ALT / AST:14/20, Alk Phos / T\n Bili:67/0.3, Differential-Neuts:85.5 %, Lymph:7.6 %, Mono:5.8 %,\n Eos:1.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.3 g/dL, LDH:192 IU/L,\n Ca++:6.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.1 mg/dL\n Imaging: CXR: effusions R>L same to slightly increased given different\n technique between films\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): In setting of large\n pleural effusion, ?malignant. Requiring 5 L NC to maintain saturations\n >93%. CT in place.\n HYPOTENSION (NOT SHOCK): Combination of low oncotic pressure and\n possible early sepsis given elevated WBC. Check differential, repeat\n blood and urine cultures. Continue on current antibiotics unless she\n decompensates further.\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL): Awaiting final path/cytology.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Cr continues to\n improve. Adjust med dosing accordingly. Good urine output.\n LEUKOCYTOSIS: WBC slightly increased from yesterday.\n DEPRESSION: Reactive depression to recently finding out probable\n diagnosis of malignancy.\n ABDOMINAL PAIN: Abdomen remains nondistended. Minimally tender in\n lower quadrants, no guarding. Likely related to underlying\n malignancy. Minimal ascites on prior CT albeit with increased WBC may\n consider reimaging to see if there is enough for a diagnostic\n pericentesis.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 06:30 PM\n Arterial Line - 03:13 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2117-10-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 498695,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n -Extubated, pressors d/c'd, mentating well.\n -However, later in PM, hypotensive to SBP of 70, continues to mentate\n normally\n -Transiently responded to IVF boluses x3, but we did not want to\n continue load the pt. with IVF as she was getting very edematous , and\n there was concern about accumulation of pleural fluid, which would\n likely require re-intubation. The patient was re-started on Levophed.\n -ABG at 10pm: 7.35/39/92/22/-3\n This AM, concern about leaking from a CVL as well as movement of CVL.\n Re-stiched at a closer site to insertion. Switched from Levophed to\n Vasopressin due to concern over levophed leaking out / skin necrosis.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 02:08 PM\n Vancomycin - 12:43 AM\n Piperacillin/Tazobactam (Zosyn) - 02:31 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:03 AM\n Heparin Sodium (Prophylaxis) - 12:42 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.3\nC (97.4\n HR: 79 (72 - 85) bpm\n BP: 87/51(63) {67/38(49) - 135/97(113)} mmHg\n RR: 27 (15 - 31) insp/min\n SpO2: 100% on 5L NC\n Heart rhythm: AV Paced\n Total In:\n 5,400 mL\n 588 mL\n PO:\n TF:\n 120 mL\n IVF:\n 5,280 mL\n 588 mL\n Blood products:\n Total out:\n 1,590 mL\n 635 mL\n Urine:\n 1,000 mL\n 285 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,810 mL\n -47 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 82\n PIP: 17 cmH2O\n Plateau: 12 cmH2O\n SpO2: 100%\n ABG: 7.35/39/91./19/-3\n Ve: 8.1 L/min\n PaO2 / FiO2: 230\n Physical Examination\n GENERAL: Alert, responsive, NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur at LUSB.\n LUNGS: Crackles b/l, decreased breath sounds compared to yesterday\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: Alert, oriented and appropriate. Speech fluent, but difficulty\n competing sentences Moves all extremities.\n Labs / Radiology\n 431 K/uL\n 10.5 g/dL\n 102 mg/dL\n 1.2 mg/dL\n 19 mEq/L\n 3.9 mEq/L\n 40 mg/dL\n 110 mEq/L\n 139 mEq/L\n 34.2 %\n 13.8 K/uL\n [image002.jpg]\n 03:05 AM\n 04:54 AM\n 05:01 AM\n 10:06 AM\n 08:42 PM\n 04:00 AM\n 02:06 PM\n 05:01 PM\n 10:16 PM\n 04:20 AM\n WBC\n 13.0\n 11.0\n 13.8\n Hct\n 31\n 30.8\n 28.1\n 34.2\n Plt\n 381\n 340\n 431\n Cr\n 2.1\n 1.3\n 1.2\n TCO2\n 26\n 25\n 24\n 23\n 23\n 21\n 22\n Glucose\n 136\n 144\n 102\n Other labs: PT / PTT / INR:12.6/32.8/1.1, ALT / AST:14/20, Alk Phos / T\n Bili:67/0.3, Differential-Neuts:85.5 %, Lymph:7.6 %, Mono:5.8 %,\n Eos:1.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.3 g/dL, LDH:192 IU/L,\n Ca++:6.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n yo F w/ CAD s/p CABG (), x-fer from for hypotension,\n renal failure and cancer workup, likely ovarian primary.\n #. Hypotension: Low BP and elevated WBC suggest possible sepsis,\n distrubutive shock. There is no pericardial effusion in TTE.. \n stim test demostrated appropriate response. PE is highly unlikely.\n Increasing leukocytosis today and persistent hypotension, although no\n fevers, decent UOP.\n - Vanc and Zosyn, currently day 4.\n - Obtain Vanc trough\n - Obtain WBC differential\n - f/u cultures from as well as \n -Send new Blood, sputum, urine cx given increasing leukocytosis\n - hold anti-HTN and lasix\n - continue Levophed and vasopressin as needed for MAP >60, SBP >90.\n Wean as tolerated.\n - Minimal IVF boluses, as needed to keep MAP > 60. Try colloid instead\n of crystalloid given low Albumin.\n .\n # Pleural effusions / Respiratory status:\n -Monitor resp. status closely today. Repeat CXR if increasing work of\n breathing, tachypnea.\n -Continue Vanc/zosyn\n -Minimize IVF as they may lead to reaccumulation of fluid\n .\n #. Oliguric renal failure: Cr 1.2 and improving, likely pre-renal /\n secondary to hypotension. No evidence of obstruction / no\n hydronephrosis on OSH CT.\n - Hold lasix and anti-HTN\n - Monitor UOP and Cr daily\n -Renally dose meds and avoid nephrotoxins\n .\n #. New carcinomatosis on CT / pleural effusions: last CA screening\n (mammogram, pap and colonoscopy 10-20 years ago). Concerning due to\n elevated CEA and CA125.\n -Cytologies from OSH recent thoracentesis\n -F/u cytologies from pleural fluid here\n -Discussion with family and patient today\n -Morphine PRN for pain\n -Gyn/onc recs\n .\n #. hx CAD s/p CABG years ago:\n - cont asa, statin\n - hold BB\n .\n PPX:\n -DVT ppx with heparin SC and Boots\n ICU Care\n Nutrition: Speech and swallow today. Advance as tolerated\n Glycemic Control:\n Lines:\n Multi Lumen - 12:31 AM\n Arterial Line\n Prophylaxis:\n DVT: Boots / Heparin SC\n Stress ulcer: None\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1108357,
"text": " 9:03 AM\n CHEST (PA & LAT) Clip # \n Reason: Assess for reaccumulation on left after removal of chest tub\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with pleural effusions\n REASON FOR THIS EXAMINATION:\n Assess for reaccumulation on left after removal of chest tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: To assess reaccumulation of left pleural effusion after removal\n of chest tube.\n\n COMPARISON: A chest radiograph from .\n\n PA AND LATERAL CHEST RADIOGRAPHS: In comparison to the recent study, there\n has been no significant change in the moderate-to-large left pleural effusion\n and associated left base atelectasis. Also noted is a moderate right pleural\n effusion with associated atelectasis, unchanged since the prior study. Stable\n moderate cardiomegaly is again noted. The hilar and mediastinal contours are\n normal. Atheromatous calcification of the aortic knob is noted. No evidence\n of pneumothorax.\n\n A right-sided pacemaker with the leads in stable position.\n\n A malpositioned left PICC line has been removed.\n\n IMPRESSION: No significant change in bilateral moderate-to-large pleural\n effusions and associated atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-13 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 1108212,
"text": " 10:24 AM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: Evidence of clot?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with presumed ovarian cancer that presents with acute onset\n Raynaud's in right hand.\n REASON FOR THIS EXAMINATION:\n Evidence of clot?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with presumed ovarian cancer that presents with\n acute onset really Raynaud's not in right hand. Evaluate for evidence of\n clot.\n\n COMPARISON: None.\n\n TECHNIQUE: UNILATERAL UPPER EXTREMITY VEIN ULTRASOUND ON THE RIGHT:\n\n FINDINGS: Grayscale and Doppler son of internal jugular, axillary,\n subclavian, brachial, basilic, and cephalic veins were performed.\n Compressibility, augmentation, and wall-to-wall flow was demonstrated within\n the right internal jugular, axillary, both brachials, and cephalic veins.\n Normal wall-to-wall flow and waveform was noted in the right and left\n subclavian veins. The right basilic vein was noted to not compress consistent\n with occlusive thrombus. The left subclavian has a PICC line coursing through\n it with normal flow and normal waveforms noted.\n\n IMPRESSION:\n 1. Occlusive thrombus in right basilic vein.\n 2. PICC line within left subclavian with normal flow and normal waveform\n noted.\n\n Dr. was notified of results.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-03 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1106719,
"text": " 2:33 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: evaluate torso for masses, effusions, infiltrates\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with collapsed left lung and right lower lobe, large\n bilateral pleural effusions, possible omental carcinomatosis, intubated today.\n REASON FOR THIS EXAMINATION:\n evaluate torso for masses, effusions, infiltrates\n CONTRAINDICATIONS for IV CONTRAST:\n acute renal failure\n ______________________________________________________________________________\n WET READ: JXKc SUN 3:32 PM\n 1. Large left pleural effusion with near complete collapse of left lung.\n 2. Moderate to large right pleural effusion.\n 3. Large hiatal hernia.\n 4. Ascites with diffuse nodularity of peritoneum, raises concern for\n peritoneal carcinomatosis.\n 5. Ill defined lesion in pelvis with calcifications. Origin and etiology are\n unclear without IV contrast, but is in expected location of uterus and adnexa,\n 6. Diverticulosis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old female with collapsed left lung and right lower lobe,\n large bilateral pleural effusions, and possible omental carcinomatosis,\n intubated today. Evaluate for masses, effusions, infiltrates.\n\n COMPARISON: No prior studies.\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n symphysis pubis without the administration of IV contrast Secondary to renal\n failure. Oral contrast was administered. Coronal and sagittal reformations\n were obtained.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: Coronary artery calcifications are\n noted. The ascending aorta is aneurysmal, measuring 4.9 cm x 5.1 cm.\n Atherosclerotic calcifications of the aortic arch are noted. Assessment of\n the vessels are limited without IV contrast. There are a few scattered\n mediastinal lymph nodes, which are not enlarged by CT size criteria, with the\n largest measuring up to 7 mm in short axis within the right paratracheal\n station.\n\n There is a large left pleural effusion, which measures fluid in attenuation,\n with atelectasis and consolidation of the adjacent lung. A small portion of\n the left upper lobe is aerated.\n\n There is a moderate-to-large right pleural effusion, with associated opacity\n of the adjacent lung, which also may reflect atelectasis or consolidation.\n\n No pneumothorax is identified.\n\n (Over)\n\n 2:33 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: evaluate torso for masses, effusions, infiltrates\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n An endotracheal tube is seen, with tip approximately 2 cm from the carina.\n\n A large hiatal hernia is noted.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Limited non-contrast evaluation of the\n liver, gallbladder, spleen, pancreas, and right adrenal gland are\n unremarkable. The left adrenal gland appears slightly thickened, without a\n discrete nodule identified. There is a punctate hyperdensity in the lower\n pole of the left kidney (2:75), which could reflect a non-obstructing stone.\n Within the right kidney is a 5.1 cm x 4.4 cm exophytic lesion, incompletely\n characterized without IV contrast, and could reflect a cyst. There is an ill-\n defined low-attenuating lesion within the lower pole of the left kidney\n measuring approximately 1.5 cm, which could reflect an additional cyst, but is\n incompletely characterized.\n\n Again noted is intrathoracic stomach, with a large hiatal hernia. NG tube tip\n terminates within the body of the stomach. Contrast is seen to extend through\n to colon, without evidence of obstruction. Mild dilation of small bowel loops\n in the lower pelvis (2:97) is nonspecific.\n\n There is diverticulosis of the colon, without evidence of diverticulitis.\n Contrast fills the cecum irregularly with feces seen, and apparent mild\n prominence of the folds and wall. Similarly, the sigmoid colon is collapsed\n with prominence of the wall. These findings are incompletely characterized.\n\n There is moderate amount of ascites. Additionally, there is diffuse\n nodularity of the peritoneum and mesentery, which is suspicious for peritoneal\n carcinomatosis. Multiple enlarged mesenteric lymph nodes are noted.\n\n No free air is identified. There is atherosclerotic calcification of the\n abdominal aorta.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: Urinary bladder contains a Foley.\n Rectum is unremarkable. There is an ill-defined calcified lesion within the\n pelvis, measuring approximately 4 cm, in the expected location of the uterus\n and adnexa. The exact origin is unclear without intravenous contrast, and may\n reflect a uterine fibroid, or an adnexal lesion.\n\n Small inguinal hernias, fat-containing are noted bilaterally.\n\n A central line is noted within the right common femoral , with small\n locules of air seen within the right external iliac , reflect sequela\n of injection.\n\n OSSEOUS STRUCTURES: There is a left femoral screw, with lucencies surrounding\n (Over)\n\n 2:33 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: evaluate torso for masses, effusions, infiltrates\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the margin of the screw, of indeterminate chronicity. Extensive degenerative\n changes are noted at the symphysis pubis. No suspicious lytic or sclerotic\n lesions are identified. There are multilevel degenerative changes of the\n thoracolumbar spine, with a grade 1 anterolisthesis of L4 on L5.\n\n IMPRESSION:\n 1. Large left pleural effusion, with near complete collapse and consolidation\n of the left lung.\n 2. Moderate-to-large right pleural effusion.\n 3. Ascites, with diffuse nodularity of the peritoneum, suspicious for\n peritoneal carcinomatosis.\n 4. Mesenteric lymphadenopathy.\n 5. Ill-defined lesion within the left lower pelvis, in the expected location\n of the uterus and adnexa, with calcifications seen. The origin and etiology\n of this lesion is unclear without intravenous contrast, and could reflect a\n uterine fibroid, or adnexal lesion. This can be correlated by ultrasound if\n clinically indicated.\n 6. Prominence of the cecal and sigmoid colonic walls. Correlate with\n colonoscopy findings.\n\n Findings were discussed with Dr. at the time of interpretation.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1106643,
"text": " 9:27 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval for placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with new line placement\n REASON FOR THIS EXAMINATION:\n eval for placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: New line placement.\n\n COMPARISON: None.\n\n SINGLE FRONTAL VIEW OF THE CHEST: There is a right-sided pacemaker with leads\n overlying the right atrium and right ventricle. There is a right-sided\n subclavian access CV catheter which courses into the right neck, likely into\n the RIJ with tip not seen.\n\n There is complete opacification of the left hemithorax with no significant\n shift of the mediastinum, which may represent a combination of pleural\n effusion and atelectasis. Underlying pneumonia - aspiration cannot be\n excluded. Sternal wires are noted. Right-sided pleural effusion with\n adjacent atelectasis is noted.\n\n IMPRESSION:\n 1. Malpositioned right-sided subclavian cv catheter extending into the right\n neck. Clinical correlation and repositioning is recommended.\n 2. Complete opacification of the left hemithorax may represent pleural\n effusion- atelectasis. Underlying pneumonia - aspiration is not excluded.\n 3. Right small pleural effusion with adjacent atelectasis.\n Discussed with Dr. at 3 am .\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1107056,
"text": " 3:02 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with TLC changed over wire in left IJ.\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assessment of triple lumen catheter change in the left IJ line.\n\n SINGLE AP CHEST RADIOGRAPH: Again noted is a left IJ catheter following a\n normal course but extending across to the midline and slightly coursing\n upwards, suggesting that the tip might be in the proximal right\n brachiocephalic . No evidence of pneumothorax. The cardiopulmonary\n findings are stable since the prior study with bilateral pleural effusions and\n left lung base atelectasis. Nasogastric tube is seen coiling patient's known\n hiatal hernia and coursing through the stomach. Endotracheal tube is in\n appropriate position. Right pectoral pacemaker with leads in standard\n position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1107780,
"text": " 2:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: position of pigtail catheter, status of pleural effusion\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with pleural effusion metastatic carcinoma of unknown\n primary.\n REASON FOR THIS EXAMINATION:\n position of pigtail catheter, status of pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: Patient with pigtail catheter for pleural effusion. Evaluate\n position.\n\n FINDINGS: Comparison is made to previous study from .\n\n There is again seen a left basilar pigtail catheter. There remains a small\n left-sided pleural effusion and a left retrocardiac opacity. There is a\n moderate right-sided pleural effusion which is stable allowing for differences\n in patient positioning. Pacemaker is unchanged. There are no pneumothoraces.\n There is also a left-sided central venous catheter whose distal tip is in the\n brachiocephalic . This could be advanced at least 7 to 8 cm for more\n optimal placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1108151,
"text": " 12:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for ptx, reacumulation of fluid\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with acutely worsening hypoxia s/p chest tube removal\n REASON FOR THIS EXAMINATION:\n assess for ptx, reacumulation of fluid\n ______________________________________________________________________________\n WET READ: ENYa WED 1:24 AM\n Interval removal of the left pigtail drain. No PTX. Worse right pleural\n effusion. Left hemithorax unchanged. PICC tip now in the left IJ. EYeh d/w\n with at 1:20AM.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 1:08 A.M. ON \n\n HISTORY: -year-old woman with acutely worsening hypoxia after chest tube\n removal, assess for pneumothorax or reaccumulation of fluid.\n\n IMPRESSION: AP chest read in conjunction with chest radiographs since\n including torso CT on , most recently chest radiograph on\n :\n\n Pigtail catheter in the left diaphragmatic region has been removed. There is\n no appreciable pneumothorax or increase in the residual probably\n small-to-moderate loculated left pleural effusion. Also unchanged is severe\n atelectasis in the left lower lobe. The large right pleural effusion,\n however, has increased and may be responsible for new dyspnea.\n Moderate-to-severe cardiomegaly is longstanding, exaggerated by a large hiatus\n hernia, now fluid filled. Left PIC catheter has repositioned from the left\n subclavian to a headed toward the neck. No pneumothorax.\n Transvenous right atrial and right ventricular pacer leads are unchanged in\n their respective positions. Dr. discussed these findings with Dr. \n at 1:20 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106737,
"text": " 6:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: any evidence of PTX?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p thoracentesis\n REASON FOR THIS EXAMINATION:\n any evidence of PTX?\n ______________________________________________________________________________\n WET READ: JXKc SUN 9:30 PM\n Interval placement of pigtail drain, presumably in pleural space, with\n decrease in left pleural effusion, still moderately large in size. Improved\n aeration of left upper lobe. Moderate sized right pleural effusion and\n atelectasis/consolidation of the adjacent lung. ET tube 2.5 cm from carina.\n NG tube partially coiled within large hiatal hernia with tip in stomach. No\n pneumothorax. -jkang.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST AT 6:58 P.M ON \n\n HISTORY: Status post thoracentesis.\n\n IMPRESSION: AP chest compared to 7:21 a.m.:\n\n Small left pleural effusion has decreased substantially since earlier in the\n day following insertion of left pigtail pleural drain at the level of the left\n hemidiaphragm. Mediastinum has returned to the midline. Small-to-moderate\n right pleural effusion unchanged. No pneumothorax. Nasogastric tube is\n coiled in a moderate hiatus hernia. ET tube tip now less than 2.5 cm above\n the carina. Transvenous right atrial and right ventricular pacer leads are\n unchanged in their respective positions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106943,
"text": " 10:06 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval line placement.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with newly plac ed CVL in azygous, now repositioned\n REASON FOR THIS EXAMINATION:\n please eval line placement.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n FINDINGS: In comparison with earlier study of this date, there is little\n overall change in the appearance of the tip of the left IJ catheter. This\n could be heading backwards into the azygos region or upward into the right\n brachiocephalic area.\n\n Otherwise, little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-08 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1107475,
"text": " 8:43 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC line, IV team defers and feels that fluoro\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 15\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with probable ovarian CA, resolved sepsis\n REASON FOR THIS EXAMINATION:\n please place PICC line, IV team defers and feels that fluoroscopy is needed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old female with probable ovarian cancer and resolving\n sepsis. PICC line requested for IV antibiotic therapy.\n\n OPERATORS: Drs. and .\n\n PROCEDURE: After the procedure was explained to the patient, she was brought\n to the angiography suite and placed supine on the table. Her right arm was\n prepped and draped in standard sterile fashion. A pre-procedure timeout and\n huddle were performed per standard protocols.\n\n Under son guidance with hard copy images on file, the right basilic\n was cannulated and a microwire was advanced to the right subclavian .\n Within this , the wire came into contact with two pacer wires. Upon\n trying to bypass the pacer wires, the wire coiled into a knot. The knot could\n not be undone. As such using a 4 French, 5 French, and microcatheter, the knot\n was eventually cinched and pulled into the tip of a 5 French straight\n catheter. The wire and catheter were pulled through the micropuncture sheath.\n The micropuncture sheath was removed and hemostasis achieved with manual\n compression. All of the contents of the wire were removed. The pacer wires\n were unchanged and intact.\n\n Attention was focused toward the left arm given the lack of pacer wires within\n the left great veins. The left arm was prepped and draped in standard sterile\n fashion. Under son guidance, the left brachial was cannulated\n with a micropuncture needle, through which a microwire was advanced to the\n SVC. The wire was stopped just before the pacer wire in the SVC. The\n catheter length was determined and the catheter cut to 32 cm. A double-lumen\n PICC was placed over the wire with tip terminating in the SVC. The wire was\n removed. The catheter was aspirated and flushed easily. It was secured to\n the skin with StatLock and capped and dressed appropriately. There were no\n immediate complications. A final fluoroscopic image of the chest was\n performed demonstrating tip of the catheter terminating in the SVC. There\n were no immediate complications.\n\n IMPRESSION:\n 1. Initial attempt to place a PICC through the right basilic \n unsuccessful due to high grade narrowing of the right subclavian around\n (Over)\n\n 8:43 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC line, IV team defers and feels that fluoro\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the existing pacer wires.\n 2. Successful placement of double-lumen PICC through the left brachial .\n Tip terminates in the SVC. The line is ready to use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1106915,
"text": " 6:22 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: confirm placement L- IJ central line\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n F w/CAD s/p CABG()and PCM intubated for hypotension, renal failure here\n for cancer w/u (metastatic ovarian CA)\n REASON FOR THIS EXAMINATION:\n confirm placement L- IJ central line\n ______________________________________________________________________________\n WET READ: SBNa MON 8:32 PM\n Left IJ entering possibly the azygous or other tributary of svc. large\n hiatal hernia containing coiled NGT. Otherwise no change. D/w Dr. \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: IJ catheter placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a left IJ catheter that appears to cross the midline into the\n left brachiocephalic system. Nasogastric tube is coiled within a large hiatal\n hernia. Otherwise little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-10-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106783,
"text": " 5:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for ET tube placement, pneumothorax, effusions, int\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with bilateral pleural effusions, likely peritoneal\n carcinomatosis, intubated\n REASON FOR THIS EXAMINATION:\n evaluate for ET tube placement, pneumothorax, effusions, interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Bilateral pleural effusions, evaluation for endotracheal tube\n placement and interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the endotracheal tube has\n been pulled back, the tip of the tube now projects 3.5 cm above the carina.\n The other monitoring and support devices are in unchanged position. The\n extent of the left-sided pleural effusion has decreased, as a consequence the\n resulting atelectasis is less severe than on the previous image. The\n right-sided pleural effusion is of different distribution but unchanged in\n overall extent. No newly appeared focal parenchymal opacities suggesting\n pneumonia.\n\n\n"
}
] |
15,972 | 142,061 | An 80-year-old male with a history of COPD and BPH was found unresponsive down from unclear etiology with tachycardia and EKG changes at the outside hospital and was transferred to . On arrival, repeat labs showed shocked liver (ALT was 1584, AST was 2328, total bilirubin was 1.9), renal failure with a creatinine of 3.2, with CK elevation to 4091, and likely DIC with elevated anticoagulation profile and low platelets. On admission, overall picture was extremely grim and concerning for anoxic brain injury with neuro exam significant for dolls eyes and sluggish minimally reactive dilated pupils. There was also evidence of multiorgan system failure with increased LFTs and possible DIC. On admission, the family did not feel that the patient would want any aggressive measures. His healthcare proxy - the patient's daughter () and son - did not want central venous lines, chest x-ray or other diagnostic or therapeutic procedures and made the patient CMO. This was communicated to Dr. and to the cardiology fellow on call. The cardiology fellow on call agreed with present management, and the patient was placed on a morphine and expired shortly thereafter. | Pt. Pt. Pt. Pt. Pt. Pt. Pt. was found to be in SVT, brought to Hosp. Dr. in to pronounce. CMO. EMS called. Transfered to for further care. extubated at 0200 and pressors d/c'd. Also given VEcuronium, Ativan for agitation in transit. Family in to see pt. Dr. notified of pt's death. arrived at 2330 on Dopa, Levo for hypotensive episode at OSH. expired at 0315 with family at bedside. Decision made by son, daughter (and girlfriend who was notified by phone of pt.s condition) to make pt. is a 80 y/o man accepted in transfer from Hosp. He was intubated, given adenosine, lopressor and converted to SR. Labs showed elevated trop 5.1, ck 400's, elevated LFT's, Creat 3.5. he was found down by girlfriend at home, length of downtime unknown. given morphine sulfate 4mg ivp for comfort. | 1 | [
{
"category": "Nursing/other",
"chartdate": "2149-10-11 00:00:00.000",
"description": "Report",
"row_id": 1470171,
"text": "Pt. is a 80 y/o man accepted in transfer from Hosp. he was found down by girlfriend at home, length of downtime unknown. EMS called. Pt. was found to be in SVT, brought to Hosp. He was intubated, given adenosine, lopressor and converted to SR. Labs showed elevated trop 5.1, ck 400's, elevated LFT's, Creat 3.5. Transfered to for further care. Pt. arrived at 2330 on Dopa, Levo for hypotensive episode at OSH. Also given VEcuronium, Ativan for agitation in transit. Pt. unresponsive on arrival, not responding to name or painful stimuli, pupils 2mm bilat, sluggish. Family in to see pt. Decision made by son, daughter (and girlfriend who was notified by phone of pt.s condition) to make pt. CMO. Pt. extubated at 0200 and pressors d/c'd. Pt. given morphine sulfate 4mg ivp for comfort. Pt. expired at 0315 with family at bedside. Dr. notified of pt's death. Dr. in to pronounce.\n"
}
] |
95,312 | 181,774 | After the initial passage of barium bolus, there is an ill-defined residual opacity posterior to the upper esophagus seen only on real time fluoroscopy. Persistent opacity posterior to the upper esophagus, incompletely assessed in the current study. Persistent opacity posterior to the upper pharynx, incompletely assessed in the current study. IMPRESSION: Aspiration of thin and thick as well as pureed consistencies complicated by aspiration of esophageal regurgitation. FINDINGS: The endotracheal tube has been removed. FINDINGS: On the scout view dense material is seen posterior to the pharynx which is likely post-surgical. The patient demonstrates laryngeal penetration and aspiration with thin thickened pureed consistencies. Probable slight volume loss with leftward shift of the mediastinum. Evaluation of the distal pharynx and upper esophagus is limited by the patient's high shoulder positioning. Compared with , there is a new small to moderate-sized left effusion with underlying collapse and/or consolidation. Patient has difficulty clearing aspirated secretions with cough. Volume loss/early infiltrates are present in both lower lungs. New small-to-moderate left effusion, with underlying collapse and/or consolidation. If clinical suspicion is high, consider direct visualized with endoscopy. Alternatively, a dedicated pharyngogram could be performed. Now evaluate for speech and swallow difficulty. Prompt oral contrast passage into the stomach. There are bilateral pleural effusions and pulmonary vascular re-distribution consistent with CHF. If clinical suspicion is high, consider direct visualization with endoscopy. Minimal blunting of the right costophrenic angle. While this finding is non-specific, suspicion is raised for a residual Zenker's diverticulum. The patient had difficulty clearing these secretions with cough. Additionally she has esophageal regurgitation during cough with subsequent aspiration. Continued enlargement of the cardiac silhouette with evidence of vascular congestion and left pleural effusion with compressive atelectasis. FINDINGS: In comparison with study of , the tip of the endotracheal tube measures approximately 2.7 cm above the carina. Suspect some degree of volume loss on left, with leftward shift of the mediastinum. Please refer to the concurrent speech and swallow study to assess for pharyngeal abnormalities. The patient continues to be in interstitial pulmonary edema, moderate. Evaluation of the pharynx was limited by non-diagnostic imaging quality. Findings could represent a residual Zenker's diverticulum, but a contained perforation cannot be completely excluded. Multiple consistencies of barium were administered. The degree of opacification at the left base has decreased, consistent with decreasing pleural fluid and compressive atelectasis. Elevation of pulmonary venous pressure persists. FINAL REPORT CHEST TWO VIEWS ON HISTORY: Increased respiratory secretions, question aspiration. FINDINGS: There is mild penetration with thin barium, but no aspiration. TECHNIQUE: Swallowing oropharyngeal fluoroscopy was performed in conjunction with the speech and swallow division. There is prompt passage of barium through the mid-to-lower esophagus into the stomach, without evidence of extraluminal contrast to suggest leak. Tip of the endotracheal tube is approximately 2.3 cm above the carina. A curvilinear density overlies the medial aspect of the right chest, but may represent artifact due to skin fold. Bilateral, left more than right, opacities are highly concerning for focal areas of consolidation due to aspiration or infection. Portable AP radiograph of the chest was reviewed in comparison to . COMPARISON: TECHNIQUE: Barium containing foods of various consistencies were administered by the speech pathologist and swallowing monitored fluoroscopically. The patient was instructed to swallow multiple sips of thin barium. Tubing overlies the left chest, but is probably unrelated to the chest. The study is targeted on the mid-to-lower esophagus, as the upper esophagus and pharnyx will be evaluated during the concurrent speech and swallow study. An underlying infectious infiltrate in the lower lobes cannot be totally excluded. IMPRESSION: CHF. Bilateral pleural effusion cannot be entirely excluded. An ET tube is present, tip in satisfactory position approximately 4.2 cm above the carina. Please see the speech pathologist's report for further details. Mild penetration with thin barium, but no aspiration. Mild penetration with thin barium, but no aspiration. (Over) 8:55 AM VIDEO OROPHARYNGEAL SWALLOW Clip # Reason: please eval swallow Admitting Diagnosis: ZENKER'S DIVERTICULUM/SDA FINAL REPORT (Cont) Patient was able to pass other thicker consistency of barium without difficulty. Again, the possibly of supervening pneumonia would have to be considered in the appropriate clinical setting. Limited images were taken only in the lateral and AP projections. 10:49 AM CHEST (PA & LAT) Clip # Reason: CONSOLIDATION, BRONCOASPIRATION ? Other maneuvers of standard barium swallow esophagram were not performed due to patient's limited tolerance. REFERENCE EXAM: . A dedicated pharyngogram could be performed to evaluate further if needed since visualization of the pharnyx on the stored images is not diagnostic for assessing the post-operative anatomy. CHEST, SINGLE AP PORTABLE VIEW. 4:21 AM CHEST (PORTABLE AP) Clip # Reason: Please eval for interval change Admitting Diagnosis: ZENKER'S DIVERTICULUM/SDA MEDICAL CONDITION: 80 year old woman with h/o zenker's diverticulum repair, w/ acute desaturation on the floor and possible allergic rxn REASON FOR THIS EXAMINATION: Please eval for interval change FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient after Zenker's diverticulum repair with acute desaturation. | 8 | [
{
"category": "Radiology",
"chartdate": "2122-07-30 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1195232,
"text": " 8:55 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: please eval swallow\n Admitting Diagnosis: ZENKER'S DIVERTICULUM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with angioedema s/p recent intubation\n REASON FOR THIS EXAMINATION:\n please eval swallow\n ______________________________________________________________________________\n WET READ: ENYa FRI 10:13 AM\n 1. Mild penetration with thin barium, but no aspiration.\n 2. Persistent opacity posterior to the upper esophagus, incompletely assessed\n in the current study. Findings could represent a residual Zenker's\n diverticulum, but a contained perforation cannot be completely excluded. If\n clinical suspicion is high, consider direct visualized with endoscopy.\n Alternatively, a dedicated pharyngogram could be performed.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old woman, recently status post reduction of Zenker's\n diverticulum and also, recently extubated. Now evaluate for speech and\n swallow difficulty.\n\n COMPARISON: None.\n\n TECHNIQUE: Swallowing oropharyngeal fluoroscopy was performed in conjunction\n with the speech and swallow division. Multiple consistencies of barium were\n administered.\n\n FINDINGS: There is mild penetration with thin barium, but no aspiration.\n Patient was able to pass other thicker consistency of barium without\n difficulty.\n\n Evaluation of the pharynx was limited by non-diagnostic imaging quality.\n After the initial passage of barium bolus, there is an ill-defined residual\n opacity posterior to the upper esophagus seen only on real time fluoroscopy.\n The opacity persists and does not spread over time. While this finding is\n non-specific, suspicion is raised for a residual Zenker's diverticulum.\n\n IMPRESSION:\n\n 1. Mild penetration with thin barium, but no aspiration.\n\n 2. Persistent opacity posterior to the upper pharynx, incompletely assessed\n in the current study. If clinical suspicion is high, consider direct\n visualization with endoscopy. A dedicated pharyngogram could be performed to\n evaluate further if needed since visualization of the pharnyx on the stored\n images is not diagnostic for assessing the post-operative anatomy.\n\n Please refer to the speech therapist's report for detailed evaluation and\n recommendations for the swallowing study.\n (Over)\n\n 8:55 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: please eval swallow\n Admitting Diagnosis: ZENKER'S DIVERTICULUM/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-30 00:00:00.000",
"description": "ESOPHAGUS",
"row_id": 1195233,
"text": " 8:55 AM\n ESOPHAGUS; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: please perform barium swallow to eval for esophageal leak\n Admitting Diagnosis: ZENKER'S DIVERTICULUM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p Zenker's diverticulectomy and cricopharyngeal myotomy\n REASON FOR THIS EXAMINATION:\n please perform barium swallow to eval for esophageal leak\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old woman, status post Zenker's diverticulectomy, and\n cricopharyngeal myotomy, now assess for potential esophageal leak.\n\n COMPARISON: None.\n\n PROCEDURES/FINDING: The patient is wheelchair bound, and cannot tolerate\n standing upright. Limited images were taken only in the lateral and AP\n projections. The study is targeted on the mid-to-lower esophagus, as the\n upper esophagus and pharnyx will be evaluated during the concurrent speech and\n swallow study.\n\n The patient was instructed to swallow multiple sips of thin barium. There is\n prompt passage of barium through the mid-to-lower esophagus into the stomach,\n without evidence of extraluminal contrast to suggest leak. Other maneuvers of\n standard barium swallow esophagram were not performed due to patient's limited\n tolerance.\n\n IMPRESSION: No evidence of obstruction or perforation. Prompt oral contrast\n passage into the stomach.\n\n Please refer to the concurrent speech and swallow study to assess for\n pharyngeal abnormalities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1194741,
"text": " 4:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change\n Admitting Diagnosis: ZENKER'S DIVERTICULUM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with h/o zenker's diverticulum repair, w/ acute desaturation\n on the floor and possible allergic rxn\n REASON FOR THIS EXAMINATION:\n Please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after Zenker's diverticulum\n repair with acute desaturation.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n The ET tube tip is 3 cm above the carina. Cardiomediastinal silhouette is\n unchanged. The patient continues to be in interstitial pulmonary edema,\n moderate. Bilateral, left more than right, opacities are highly concerning\n for focal areas of consolidation due to aspiration or infection. Bilateral\n pleural effusion cannot be entirely excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1194634,
"text": " 7:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ETT position and pulm edema\n Admitting Diagnosis: ZENKER'S DIVERTICULUM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p Zenker's diverticulectomy now s/p emergent intubation for\n resp distress\n REASON FOR THIS EXAMINATION:\n eval for ETT position and pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Zenker's diverticulectomy and emergent intubation for respiratory\n distress, assess for pulmonary edema.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n An ET tube is present, tip in satisfactory position approximately 4.2 cm above\n the carina.\n\n Compared with , there is a new small to moderate-sized left effusion\n with underlying collapse and/or consolidation. Probable slight volume loss\n with leftward shift of the mediastinum. There is upper zone redistribution\n and increased interstitial markings, consistent with CHF. Minimal blunting of\n the right costophrenic angle.\n\n A curvilinear density overlies the medial aspect of the right chest, but may\n represent artifact due to skin fold. Tubing overlies the left chest, but is\n probably unrelated to the chest.\n\n IMPRESSION:\n\n 1. New small-to-moderate left effusion, with underlying collapse and/or\n consolidation.\n\n 2. Suspect some degree of volume loss on left, with leftward shift of the\n mediastinum.\n\n 3. Interval increase in the interstitial markings, consistent with CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1195046,
"text": " 4:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ZENKER'S DIVERTICULUM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p zenker's diverticulectomy re-intubated postop for\n respiratory distress\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Zenker's diverticulum with reintubation and respiratory distress.\n\n FINDINGS: In comparison with the study of , there is little change. Tip\n of the endotracheal tube is approximately 2.3 cm above the carina. Continued\n enlargement of the cardiac silhouette with evidence of vascular congestion and\n left pleural effusion with compressive atelectasis. Again, the possibly of\n supervening pneumonia would have to be considered in the appropriate clinical\n setting.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-07-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1194889,
"text": " 3:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ZENKER'S DIVERTICULUM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman s/p Zenker's diverticulectomy re-intubated postop for\n respiratory distress\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Zenker's diverticulum with reintubation and respiratory distress.\n\n FINDINGS: In comparison with study of , the tip of the endotracheal tube\n measures approximately 2.7 cm above the carina. The degree of opacification\n at the left base has decreased, consistent with decreasing pleural fluid and\n compressive atelectasis. The possibility of supervening pneumonia cannot be\n excluded. Elevation of pulmonary venous pressure persists.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-08-03 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1195817,
"text": " 9:38 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: Pharygeal esophageal asssesment\n Admitting Diagnosis: ZENKER'S DIVERTICULUM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with s/p cricopharyngeal myotomy, diverticulotomy repair \n for recurrent Zenker's diverticulum \n REASON FOR THIS EXAMINATION:\n Pharygeal esophageal asssesment\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 80-year-old female status post cricopharyngeal myotomy\n and Zenker's diverticulum repair with dysphagia.\n\n COMPARISON: \n\n TECHNIQUE: Barium containing foods of various consistencies were administered\n by the speech pathologist and swallowing monitored fluoroscopically.\n\n FINDINGS: On the scout view dense material is seen posterior to the pharynx\n which is likely post-surgical. The patient demonstrates laryngeal penetration\n and aspiration with thin thickened pureed consistencies. Additionally she has\n esophageal regurgitation during cough with subsequent aspiration. Evaluation\n of the distal pharynx and upper esophagus is limited by the patient's high\n shoulder positioning. There is frequent vallecular pooling. Patient has\n difficulty clearing aspirated secretions with cough.\n\n IMPRESSION: Aspiration of thin and thick as well as pureed consistencies\n complicated by aspiration of esophageal regurgitation. The patient had\n difficulty clearing these secretions with cough. Please see the speech\n pathologist's report for further details.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-08-02 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1195708,
"text": " 10:49 AM\n CHEST (PA & LAT) Clip # \n Reason: CONSOLIDATION, BRONCOASPIRATION ?\n Admitting Diagnosis: ZENKER'S DIVERTICULUM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with COPD s/p s/p cricopharyngeal myotomy, diverticulotomy\n repair increase respiratory secretions\n REASON FOR THIS EXAMINATION:\n CONSOLIDATION, BRONCOASPIRATION ?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS ON \n\n HISTORY: Increased respiratory secretions, question aspiration.\n\n REFERENCE EXAM: .\n\n FINDINGS: The endotracheal tube has been removed. The heart is moderately\n enlarged and slightly larger than on the prior study. There are bilateral\n pleural effusions and pulmonary vascular re-distribution consistent with CHF.\n Volume loss/early infiltrates are present in both lower lungs.\n\n IMPRESSION: CHF. An underlying infectious infiltrate in the lower lobes\n cannot be totally excluded.\n\n\n"
}
] |
|
50,237 | 149,775 | 77M CHF, s/p R toe amp + osteomyelitis, history of afib on coumadin, recent admission for toe amputation with long course of antibiotics for osteo presenting from OSH for new onset respiratory distress. . . ACTIVE ISSUES: # Respiratory Distress: Patient initially presented with leukocytosis of 24 with banemia of 10%, in addition to tachypnea. Lactate was normal at 1.8 and patient was hemodynamically stable. Most likely source of infection was aspiration pneumonia given frequent observed aspirations. Rapid respiratory viral screen negative but culture pending. Also patient has several risk factors for developing transient bacteremia including osteo and PICC site. However, on arrival to the ICU, he stabilized very quickly. Lactate never increased, and leukocytosis/bandemia resolved by HD 1. Patient was continued on vancomycin and meropenem to cover HCAP as well as osetomyelitis. Diuresed agressively. Likely diagnosis is flash pulmonary edema in the setting of aspiration PNA. His cultures remained negative. The patient was HD stable and was transferred to the medical floor. On the medical floor the patient continued to do well. Vancomycin was held due to elevated troughs. At the time of discharge, trough was 20.8. After discussion with ID and pharmacy, decision was made to restart vancomycin 500 mg IV q48 hours, with plan to check level on Monday, . He will have close follow up with Dr. in ID for adjustment of medication. . # Osteomyelitis: Patient has chronic osteomyelitis s/p amputation and multiple debridements. Prior to admission, he was undergoing a course of vanc/meropenem via PICC followed by Dr. at OPAT. Xray of the feet done here as described prior and will be followed by ID. Vancomycin dosing was changed, as described above. . # CKD: stage 4, baseline ~2.5, briefly on HD during recent admission which was stopped on discharge. Patient's creatinine was at his baseline throughout admission. He was continued on home renagel and medications were all renally dosed. . # Anemia: HCT ~30 with elevated MCV (103). Labs consistent with anemia of chronic disease, and B12 and folate levels normal. Therefore, unclear why he has a macrocytosis. Further eval on an outpatient basis. . # AF: Coumadin held on admission for supratherapeutic INR of 3.9 This rose to 5.0 on HD1, likely due to underlying poor liver function. Would be less likely that this is related to antibiotics as patient has been on this regimen for several weeks. Patient was given vitamin K on HD1 and INR improved. Coumadin restarted at 2.5mg on day of discharge. . # Swallowing: Concern for aspiration PNA given presentation. Was initally made NPO. Underwent swallow study which the patient did well on. Recommended regular diet with thin liquids and PO meds with puree. . . TRANSITIONAL ISSUES: # Vancomycin dosing has been reducsed by half. Patient should have level checked on Monday, , with results faxed Dr. in ID. # Please continue to monitor patient's INR. | There is a trivial/physiologicpericardial effusion.IMPRESSION: Moderate biatrial enlargement. An eccentric,posteriorly directed jet of mild to moderate (+) mitral regurgitation isseen. Mild aorticstenosis. At least moderate tricuspid regurgitation is seen. Paradoxic septalmotion consistent with conduction abnormality/ventricular pacing.AORTA: Mildy dilated aortic root. There is moderatepulmonary artery systolic hypertension. The aortic root is mildlydilated at the sinus level. The right ventricular cavityis dilated with depressed free wall contractility. Trace AR.MITRAL VALVE: Moderate mitral annular calcification. Mild symmetric left ventricularhypertrophy with normal cavity size and rpreserved global and regionalbiventricular systolic function. Suboptimalimage quality - poor suprasternal views.Conclusions:The left atrium is moderately dilated. At least moderate tricuspidregurgitation. There is mild aortic valve stenosis(valve area 1.2-1.9cm2). MildPR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Mild to moderate mitral regurgitation. Mildly dilated aortic root and ascending aorta. The ascending aorta is mildly dilated. Inferior wallmyocardial infarction of indeterminate age. Moderate pulmonary artery systolic hypertension.Compared with the prior study (images reviewed) of , the findings aresimilar. Dilated right ventricle with impairedsystolic function. Mildly dilated ascending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Moderate to severe [3+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Mild to moderate (+) MR. (<140ms)transmitral E-wave decel time.TRICUSPID VALVE: Normal tricuspid valve leaflets. Low voltage in conductedcomplexes. Mild thickening of mitralvalve chordae. Trace aortic regurgitation is seen. Mild AS (area1.2-1.9cm2). The RA pressure could not be estimated.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). Respiratory decompensation.Height: (in) 60Weight (lb): 213BSA (m2): 1.92 m2BP (mm Hg): 121/80HR (bpm): 67Status: InpatientDate/Time: at 12:13Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. ST-T wave abnormalities. The right atrium is moderately dilated.There is mild symmetric left ventricular hypertrophy with normal cavity sizeand regional/global systolic function (LVEF>55%). Intraventricular conduction delay. RV function depressed. Probable atrial fibrillation. The aorticvalve leaflets (3) are mildly thickened. Left axis deviation. Since the previous tracing of the rate has decreased. No resting LVOT gradient.RIGHT VENTRICLE: Dilated RV cavity. The IVC was notvisualized. Rightbundle-branch block. Eccentric MR jet. PATIENT/TEST INFORMATION:Indication: Congestive heart failure. | 2 | [
{
"category": "Echo",
"chartdate": "2112-01-14 00:00:00.000",
"description": "Report",
"row_id": 66181,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Respiratory decompensation.\nHeight: (in) 60\nWeight (lb): 213\nBSA (m2): 1.92 m2\nBP (mm Hg): 121/80\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 12:13\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. The IVC was not\nvisualized. The RA pressure could not be estimated.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Dilated RV cavity. RV function depressed. Paradoxic septal\nmotion consistent with conduction abnormality/ventricular pacing.\n\nAORTA: Mildy dilated aortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild AS (area\n1.2-1.9cm2). Trace AR.\n\nMITRAL VALVE: Moderate mitral annular calcification. Mild thickening of mitral\nvalve chordae. Eccentric MR jet. Mild to moderate (+) MR. (<140ms)\ntransmitral E-wave decel time.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PS. Mild\nPR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal\nimage quality - poor suprasternal views.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand regional/global systolic function (LVEF>55%). The right ventricular cavity\nis dilated with depressed free wall contractility. The aortic root is mildly\ndilated at the sinus level. The ascending aorta is mildly dilated. The aortic\nvalve leaflets (3) are mildly thickened. There is mild aortic valve stenosis\n(valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. An eccentric,\nposteriorly directed jet of mild to moderate (+) mitral regurgitation is\nseen. At least moderate tricuspid regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. There is a trivial/physiologic\npericardial effusion.\n\nIMPRESSION: Moderate biatrial enlargement. Mild symmetric left ventricular\nhypertrophy with normal cavity size and rpreserved global and regional\nbiventricular systolic function. Dilated right ventricle with impaired\nsystolic function. Mildly dilated aortic root and ascending aorta. Mild aortic\nstenosis. Mild to moderate mitral regurgitation. At least moderate tricuspid\nregurgitation. Moderate pulmonary artery systolic hypertension.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2112-01-12 00:00:00.000",
"description": "Report",
"row_id": 139100,
"text": "Probable atrial fibrillation. Intraventricular conduction delay. Inferior wall\nmyocardial infarction of indeterminate age. Left axis deviation. Right\nbundle-branch block. ST-T wave abnormalities. Low voltage in conducted\ncomplexes. Since the previous tracing of the rate has decreased.\n\n"
}
] |
8,134 | 112,290 | The patient had been in the operating room undergoing a surgical procedure and had a successful laparascopic gastric band procedure. At the end of the surgical procedure the patient was extubated, had loss of airway and underwent emergency tracheotomy. After the airway was secured, the throat was examined. It was noted that the tracheotomy was performed at a higher level than normal, and this was moved down to the second and third tracheal ring. ENT was called for evaluation of injury to the larynx. Upon arrival the laryngeal injury appeared to be a vertical incision on the left side of the thyroid cartilage, which extended the length of the thyroid cartilage, through the thyroid cartilage into the larynx. A laryngoscope was passed. There was noted to be mucosal tear around the false cord extending to the retinoid region. The subglottic region was normal. The vocal cords appeared to be both intact without injury. Externally the injury site was examined. There was noted to be a second opening into the trachea between the cricoid thyroid membranes, which appeared to be a clean horizontal incision. The patient had an ORIF of the tracheal injury. Postoperatively, the patient was vented and admitted to the intensive care unit. the patient was weaned off of the vent on postoperative day 2 without difficulty and the patient tolerated CPAP well. on postoperative day 3, the patient had a trach mask trial and she was successfully weaned from the vent by postoperative day 4. ENT continued to evaluate the patient and requested that the patient have antibiotics including ancef and flagyl. an NG tube remained in place. Nutrition services was consulted for TPN initiation. She was transferred to the surgical floor by postoperative day 4. On post operative day 8, the patient returned to the operating room for direct laryngoscopy and a downsizing of her trach. She also recieved 3 doses of IV decadron and transitioned to PO prednisone. The patient was then given a cap trial on Postoperative day , which she tolerated well. At this time the patient was also evaluated by speech and swallow and had an upper GI (which was negative) and she was started on a stage I diet. The trach was removed by postoperative day , and the patient was breathing comfortably. She was advanced to a stage III diet which she was tolerating well. The patient was stable and ready for discharge to home on postoperative days 13/5, with ENT/speech and swallow and general surgery follow up. The patient will remain on voice rest until follow up with ENT. | There is opacity of the left retrocardiac area, representing collapse/consolidation, and is unchanged from previous exam. FINDINGS: AP portable abdominal film shows mild to moderate gastric distention. Confirmation with standard angulation AP or PA technique reccommended. Sq heparin and pboots cont.GI: NGT to LCS with moderate bilious output. Abd obese and soft with absent BS.GU: Adequate u/o via foley. Tracheostomy tube is again seen and unchanged in position. Lung volumes are slightly reduced, and there are bilateral perihilar opacities. Mild pulmonary vascular congestion and probable left basialr atelectasis. C+DB enc'd using splint pillow and PCA prior to coughing.CV: HR 60s NSR, no ectopy noted. Trach gently resecured with twill tape now that patient is less sedated. BP 120s-160s/50s-70s.HEME: H/H stable. Kefzol cont.ENDO: No coverage per RISS.SKIN: Small skin tear noted to middle of back. Left retrocardiac collapse/consolidation is unchanged. Left retrocardiac opacity is again seen and unchanged. PCA Morphine started with good pain control.CV: HR 70's SR no ectopy noted. IMPRESSION: Slight improvement in prominence of the pulmonary vasculature. Previously noted congestion of the pulmonary vasculature is slightly improved on today's exam. IMPRESSION: Slight interval improvement in the bilateral atelectasis. FINDINGS: Portable AP abdominal film shows gastric band visualized in the LUQ at the proximal stomach with apparent normal location and angulation. Left retrocardiac opacity is again seen, representing atelectasis/consolidation. There is slight improvement in the previously noted bilateral atelectasis. There is a probable small amount of biapical pleural fluid. BS bilat with decreased bases. RESP CARE: Pt remains / on vent on CPAP/PSV 8/5/.40. FINDINGS: Preliminary scout film demonstrates a gastric band around the proximal stomach, in expected location and alignment. There is decreased inspiratory effort and lung volumes on this exam in comparison to previous exam, with secondary increased prominence of the vasculature. Pt c/o "numbness" to left cheek under eye. Marking remains at 12 by stoma and cuff remains inflated with minimal air necessary to prevent leakage. Heart size and mediastinal contours are unchanged. IMPRESSION: Tracheosotmy tip likely in satisfactory position. History of recent gastric banding, status post tracheostomy. NG tube is again seen extending beyond the inferior margin of the imaged field with the tip not visualized. Requires minimal suctioning. 10:42 AM ABDOMEN (SUPINE ONLY) PORT Clip # Reason: ? NPO, Protonix, NGT to LIWS with bilious drainage.ID: Tmax 99.8 orally, on flagyl and kefzol.IV Access: Poor iv access, due to antibiotics and IVF and ? Lap sites x 5 intact.SOCIAL: No contacts from family this shift.ASMT: Pt s/p gastric banding complicated by failed extubation and laryngeal injury during emergecy trach. Left-sided PICC line is seen with tip positioned in the mid SVC. IMPRESSION: Satisfactory placement of left sided PICC line. Respiratory alkalosis corrected- see CareVue.Trach site: sutures intact, penrose drain in place. REFER TO CAREVIEW FOR ABG DATA.GI: ABD OBESE/SOFT/BS ABSENT/NO BM - NPO W/IVF LR W/40KCL INFUSING AS ORDERED. MEDICATED W/ MSO4 PRN PRIOR TO TURNS/REPOSITIONING.CV: HR SR/SB 58-60'S, SBP 100-120'S, NO ECTOPY NOTED ON TELEMETRY, PULSES EASILY PALPABLE, PB'S ON FOR DVT PROPHYLAXIS, HEPARIN GIVEN AS ORDERED. As noted above, when light pt begins coughing .skin- intact. NPO W/ IVF HYDRATION, LR W/40KCL INFUSING.GU: U/O YELLOW/CONCENTRATED/MINIMAL SEDIMENT NOTED - ADEQUATE HOURLY OUTPUTS. SKIN PINK/WARM/DRY.RESP: LUNG SOUNDS CLEAR THROUGHOUT, MINIMALLY DECREASED AT BASES - STRONG PRODUCTIVE COUGH EFFORT, SXN'D PRN FOR SM<->MOD AMTS THICK BLD TINGED SECRETIONS. 'GI pt has NG tube in place draining bile , abd remains obese and soft, with small incisions from laproscopic surgery.GU- adequate u/o. ABG'S STABLE - >CAREVIEW.GI: ABD OBESE/SOFT/BS ABSENT - NGT TO LWIS DRAINING 200CC BILIOUS EFFLUENT THIS SHIFT. Nursing Progress Note:Please see CareVue.Pt condition essentially stable.On exam,Resp:Chest clear, vigorous productive cough, secretions bloodstained and thin. T/SICU NPN 2300-0700:REVIEW OF SYSTEMS:NEURO: SEDATED ON PROPOFOL - NOT LIGHTENED FOR EXAMS; COUGH/GAG STRONG/INTACT, PERRLA 3MM/BSK. STABLE BP, 100-140/50-60.RESP: #8 BIOVANA TRACH IN PLACE, SUTURED TO SKIN. BACKSIDE INTACT.PROPHYLAXIS: FAMOTADINE, PROTONIX, HEPARIN AND PNEUMO BOOTS.A: STABLE S/P SURGERY.P: CONT TO MONITOR AND MAINTAIN SEDATED UNTIL CONSIDERED SAFE TO MOVE AROUND W/ PRESENT INJURY. PB'S/HEPARIN FOR DVT PROPHYLAXIS.RESP: LUNG SOUNDS CLEAR, STRONG/PRODUCTIVE COUGH EFFORT, SXN'D FOR SM AMTS THICK/TAN SECRETIONS. PAIN WELL MANAGED W/PRN MSO4 - ATIVAN 1MG X1 FOR MILD ANXIETY - (+)EFFECT - RESTING COMFORTABLY.CV: HR SR 60'S, NO ECTOPY ON TELEMETRY, SBP STABLE. PROTONIX FOR GI PROPHYLAXIS - NGT TO SXN DRAINING BILIOUS EFFLUENT ~200CC'S.GU: U/O VIA FOLEY CATHETER NOTED TO HAVE SEDIMENT, COLOR YELLOW->PROGRESSED DURING THIS SHIFT TO AMBER/BLD TINGED - NO BLADDER TRAUMA NOTED. ABD OBESE, BS ABSENT.HEME: STABLEID: AFEBRILE AND CONT ON CEFAZOLIN AND FLAGYL.SKIN: TRACH SITE AS ABOVE W/ SM AMT BLOODY DNGE, NO REDNESS, NO ODOR.ABD DSG SITES INTACT. Trach is noted to be slightly positional and care is taken with repositioning of patient and vent circuitry. Slight hemoserous ooze to trach dressing.Hemodynamically:SR initially, became bradycardic with dexmedetomidine infusion. on back and buttucks, incision site at trach is intact with small penrose drain in place. PT ANXIOUS/EMOTIONAL AT TIMES OVER , SUPPORT/ENCOURAGEMENT GIVEN W/EFFECT - PT RESPONDS WELL TO VERBAL REASSURANCE - RECOVERS WELL - ONGOING SUPPORT - SW UPDATED BY THIS RN AND WILL PLAN TO VISIT W/ PT TODAY.A/P: STABLE, TOLERATING VENT WEAN, PAIN WELL CONTROLLED. MG+ REPLETED.ENDO: 105 - NO SSRI COVERAGE REQUIRED.ID: TMAX 99.3->98.8, CONTINUES ON FLAGYL/CEFAZOLIN.SKIN: BACK/BUTTOCKS INTACT - TRACH SITE W/PENROSE DRAIN->SM AMT SERO/SANG DRAINAGE OUT - LAP SITES WNL.SOCIAL: NO FAMILY CONTACT OVER .A/P: HEMODYNAMICALLY STABLE - CONTINUES SEDATED TO MINIMIZE POST-OP TRAUMA TO LARYNGEAL SURGICAL SITE. Placed back on vent with increase in sats, decrease of RR, and patient stating breathing much easier.GU/GI: Foley with dark amber urine with sedements, throughout day turining dark yellow, with sedement. She is sedated on precedex and propofol and appears comfortable at this time. | 21 | [
{
"category": "Radiology",
"chartdate": "2141-08-10 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 837158,
"text": " 4:27 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval lung fields & position of gastric band & NGT\n Admitting Diagnosis: MORBID OBESITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman s/p gastric banding s/p trach\n REASON FOR THIS EXAMINATION:\n eval lung fields & position of gastric band & NGT\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMINAL FILM\n\n INDICATION: Abdominal pain status post gastric banding, please evaluate\n gastric band position.\n\n FINDINGS: Portable AP abdominal film shows gastric band visualized in the\n LUQ at the proximal stomach with apparent normal location and angulation.\n allowing for suboptimal detail due to the habitus of the patient. The\n diaphragms and right portion of the abdomen are not optimally visualized.\n\n IMPRESSION: Satisfactory positioning and angulation of the gastric band at\n the proximal stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-08-09 00:00:00.000",
"description": "P ABDOMEN (SUPINE ONLY) PORT",
"row_id": 837093,
"text": " 10:42 AM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: ? decompression of stomach\n Admitting Diagnosis: MORBID OBESITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman s/p gastric bypass\n REASON FOR THIS EXAMINATION:\n ? decompression of stomach\n ______________________________________________________________________________\n FINAL REPORT\n (This report replaces all previous reports under this clip number).\n\n INDICATION: Abdominal pain status post gastric bypass, please evalute for\n decompression of the stomach.\n\n FINDINGS: AP portable abdominal film shows mild to moderate gastric\n distention. The upper abdomen, diaphragms, and flanks are not fully included\n on this film. Otherwise, there is scant air seen in the colon with no\n evidence of obstruction of ileus. There are no soft tissue calcifications\n seen. Did this patient have gastric bypass as stated in clinical request or\n gastric banding?\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-08-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837057,
"text": " 5:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess bilat atelectasis\n Admitting Diagnosis: MORBID OBESITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with s/p trach\n\n REASON FOR THIS EXAMINATION:\n reassess bilat atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P trach. Evaluate for bilateral atelectasis.\n\n PORTABLE AP CHEST X RAY: Comparison made to study from . A tracheostomy\n tube is again seen with the tip approximately 3-4 cm above the carina, and\n appears to have been changed in comparison to the tube seen in the previous\n exam. NG tube is again seen extending beyond the inferior margin of the imaged\n field with the tip not visualized. Left retrocardiac opacity is again seen,\n representing atelectasis/consolidation. There is decreased inspiratory effort\n and lung volumes on this exam in comparison to previous exam, with secondary\n increased prominence of the vasculature. There is slight improvement in the\n previously noted bilateral atelectasis. Heart size and mediastinal contours\n are unchanged. No pneumothorax is seen.\n\n IMPRESSION: Slight interval improvement in the bilateral atelectasis. Left\n retrocardiac collapse/consolidation is unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-08-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837252,
"text": " 5:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement of L Picc line\n Admitting Diagnosis: MORBID OBESITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman s/p gastric banding s/p trach\n\n REASON FOR THIS EXAMINATION:\n eval placement of L Picc line\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST\n\n INDICATION: Newly inserted left PICC line. Please check placement. History\n of recent gastric banding, status post tracheostomy.\n\n Comparison is made to the previous examination of .\n\n FINDINGS: Tracheostomy tube is seen in the trachea approximately 1 cm above\n the carina. Lung volumes are low. A newly inserted PICC line has it's tip at\n the SVC/RA junction. NG tube is seen coursing through the stomach but exits\n the field of view. No pneumothorax appreciated. There is a probable small\n amount of biapical pleural fluid. There is crowding of the pulmonary\n vasculature given low lung volumes, but more than expected. Left sided\n retrocardiac opacity likely relates to atelectasis, but consolidation can't be\n excluded.\n\n IMPRESSION: Satisfactory placement of left sided PICC line. Mild pulmonary\n vascular congestion and probable left basialr atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-08-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836885,
"text": " 7:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: trach placement\n Admitting Diagnosis: MORBID OBESITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with s/p trach\n REASON FOR THIS EXAMINATION:\n trach placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tracheostomy placement.\n\n SUPINE PORTABLE AP CHEST: No prior studies are available for comparison. The\n newly inserted tracheostomy tube is likely in the mid-trachea several cm above\n the carina, but exact positioning is difficult to assess due to the apical\n nature of the film. An NG tube is also present with the tip not visualized,\n but below the inferior film edge. Lung volumes are slightly reduced, and\n there are bilateral perihilar opacities. There is increased opacity in the\n retrocardiac left lower lobe, as well as the right lower lobe, which could be\n due to atelectasis, aspiration, or possibly pneumonia.\n\n IMPRESSION:\n Tracheosotmy tip likely in satisfactory position. Confirmation with standard\n angulation AP or PA technique reccommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-08-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837759,
"text": " 10:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltate\n Admitting Diagnosis: MORBID OBESITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman s/p gastric banding s/p trach\n\n REASON FOR THIS EXAMINATION:\n r/o infiltate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for infiltrate.\n\n PORTABLE AP CHEST X-RAY: Comparison made to study dated . Tracheostomy\n tube is again seen and unchanged in position. Left-sided PICC line is seen\n with tip positioned in the mid SVC. Previously noted congestion of the\n pulmonary vasculature is slightly improved on today's exam. Cardiomegaly is\n unchanged. There is opacity of the left retrocardiac area, representing\n collapse/consolidation, and is unchanged from previous exam. No pleural\n effusions are seen. No pneumothorax is identified. Mediastinal contours are\n unchanged.\n\n IMPRESSION: Slight improvement in prominence of the pulmonary vasculature.\n Left retrocardiac opacity is again seen and unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-08-17 00:00:00.000",
"description": "BAS/UGI W/KUB",
"row_id": 837915,
"text": " 10:28 AM\n BAS/UGI W/KUB Clip # \n Reason: r/o leak, stricture--please administer thin barium\n Admitting Diagnosis: MORBID OBESITY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with lap gastric band\n REASON FOR THIS EXAMINATION:\n r/o leak, stricture--please administer thin barium\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P laparoscopic gastric banding.\n\n FINDINGS: Preliminary scout film demonstrates a gastric band around the\n proximal stomach, in expected location and alignment. Clips are noted within\n the gallbladder fossa consistent with prior cholecystectomy. There is no\n evidence of free air under the diaphragms.\n Water soluble contrast followed by thin barium was administered to the patient\n in the standing position. Contrast flowed freely from the esophagus into the\n gastric pouch, through the band and into the distal stomach. There is no\n evidence of obstruction or leakage. Contrast emptied from the distal stomach\n into the small bowel after approximately 15 minutes.\n\n IMPRESSION: No evidence of obstruction or leakage s/p gastric banding.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-08-10 00:00:00.000",
"description": "Report",
"row_id": 1370301,
"text": "T/SICU RN Progress Note\nNeuro: Alert and pleasant, mouthing words, appropriate, following all commands. PCA Morphine started with good pain control.\n\nCV: HR 70's SR no ectopy noted. ABP systolic 140-160's. IVF decreased to 75cc/hr. P-boots/SQ Heparin.\n\nResp: Placed on trach collar at 0730 this am, tolerating well throughout day. Strong cough able to expectorate thick tan secretions. Lungs clear. Trach intact cuff inflated at all times.\n\nGU/GI: Foley with clear yellow urine, autodiuresis 200-400 Q2hrs. NPO, Protonix, NGT to LIWS with bilious drainage.\n\nID: Tmax 99.8 orally, on flagyl and kefzol.\n\nIV Access: Poor iv access, due to antibiotics and IVF and ? nutrition needs PICC line placed.\n\nEndo: No coveage needed per RISS.\n\nSocial: Sisters, brother, mom and dad visited today updated. Left form to be signed by Dr. in front of chart for leave of absence from work.\n\nPlan: Cont trach collar as tolerated, cont to monitor and support, follow plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-08-11 00:00:00.000",
"description": "Report",
"row_id": 1370302,
"text": "NPN 1900-0700\nNEURO: Pt alert, communicates appropriately via nodding and mouthing words. MAE, follows commands. MSO4 PCA for pain with effect. Pt c/o \"numbness\" to left cheek under eye. Denies blurred vision. No neuro deficits noted. Pt requested change in pain med, as she indicated that the numbness was not present when she did not use PCA. Dr. called, ordered to try decrease in PCA dose if pt agreed. MSO4 PCA now at as of 0400; effects pending.\n\nRESP: Pt initially on 50% trach mask. Sats 95-97%. Strong productive cough. Requires minimal suctioning. At approximately 2330, pt began to have decrease in sats (90-94%) despite suctioning and repositioning. Pt placed on t-piece trach mask at 50%. Sats then 98-100, however AM ABG taken with t-piece revealed Pco2 52. Resp therapy attributes high CO2 to ?of dead space in t-piece set up. Pt placed on high flow neb and ABG is pending at this time. LS diminshed throughout. C+DB enc'd using splint pillow and PCA prior to coughing.\n\nCV: HR 60s NSR, no ectopy noted. BP 120s-160s/50s-70s.\n\nHEME: H/H stable. Sq heparin and pboots cont.\n\nGI: NGT to LCS with moderate bilious output. No BM this shift. Abd obese and soft with absent BS.\n\nGU: Adequate u/o via foley. Bag #2 of LR w/ 40meqK+ hung. Mag repleted.\n\nID: Temp 99. Kefzol cont.\n\nENDO: No coverage per RISS.\n\nSKIN: Small skin tear noted to middle of back. No drainage noted. Buttocks intact. Lap sites x 5 intact.\n\nSOCIAL: No contacts from family this shift.\n\nASMT: Pt s/p gastric banding complicated by failed extubation and laryngeal injury during emergecy trach. Hemodynamically stable. Needs enc to C+DB to maintain adequate sats.\n\nPLAN: Cont to monitor VS, aggressive pulmonary hygiene, enc C+DB, labs, skin care, pain mgmt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-08-09 00:00:00.000",
"description": "Report",
"row_id": 1370297,
"text": "Respiratory Care Note:\n Patient weaned to a trach collar today for several hours before noted drop in oxygen saturation. Placed back on PSV of 5 and +10 PEEP, 40% with no more complaints of shortness of breath. BS bilat with decreased bases. Suctioned for small to medium amounts of thick blood tinged secretions. Trach gently resecured with twill tape now that patient is less sedated. Marking remains at 12 by stoma and cuff remains inflated with minimal air necessary to prevent leakage. Plan to continue with periods of weaning to trach collar and return to vent as needed for alveolar recruitment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-08-10 00:00:00.000",
"description": "Report",
"row_id": 1370298,
"text": "RESP CARE: Pt remains / on vent on CPAP/PSV 8/5/.40. RSBI-73.5/Continue trach collar wean as tol\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-08-10 00:00:00.000",
"description": "Report",
"row_id": 1370299,
"text": "T/SICU NPN 1900-0700:\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT OFF SEDATION DURING DAY SHIFT - AFFECT APPROPRIATE - ABLE TO EFFECTIVELY COMMUNICATE NEEDS AND PARTICIPATE W/SOME ADL'S. MAE'S EQUALLY/CONSISTENTLY. COUGH/GAG INTACT. PERRLA 3MM/BSK. PAIN WELL MANAGED W/PRN MSO4 - ATIVAN 1MG X1 FOR MILD ANXIETY - (+)EFFECT - RESTING COMFORTABLY.\n\nCV: HR SR 60'S, NO ECTOPY ON TELEMETRY, SBP STABLE. PERIPHERAL PULSES EASILY PALPABLE. SKIN PINK/WARM/DRY. PB'S/HEPARIN FOR DVT PROPHYLAXIS.\n\nRESP: LUNG SOUNDS CLEAR, STRONG/PRODUCTIVE COUGH EFFORT, SXN'D FOR SM AMTS THICK/TAN SECRETIONS. TOLERATED TRACH MASK FOR SEVERAL HOURS YESTERDAY, REST ON VENT CPAP+PS OVER - BREATHING EQUAL/UNLABORED. RR 14-22, SATS 97-100%. DENIES DOE/SOB. ABG'S STABLE - >CAREVIEW.\n\nGI: ABD OBESE/SOFT/BS ABSENT - NGT TO LWIS DRAINING 200CC BILIOUS EFFLUENT THIS SHIFT. PROTONIX FOR GI PROPHYLAXIS. NPO W/ IVF HYDRATION, LR W/40KCL INFUSING.\n\nGU: U/O YELLOW/CONCENTRATED/MINIMAL SEDIMENT NOTED - ADEQUATE HOURLY OUTPUTS. MG+CA+ REPLETED.\n\nENDO: NO SSRI COVERAGE REQUIRED.\n\nID: TMAX 99.3 - CONTINUES ON FLAGYL, CEFAZOLIN.\n\nSKIN: NO ISSUES - LAP SITES INTACT - SCANT SERO/SANG DRAINAGE FROM PENROSE DRAIN @ TRACH SITE.\n\nSOCIAL: SUPPORTIVE SISTERS AT BEDSIDE YESTERDAY INTO THE EVENING. AFFECT/QUESTIONS/CONCERNS APPROPRIATE. PT ANXIOUS/EMOTIONAL AT TIMES OVER , SUPPORT/ENCOURAGEMENT GIVEN W/EFFECT - PT RESPONDS WELL TO VERBAL REASSURANCE - RECOVERS WELL - ONGOING SUPPORT - SW UPDATED BY THIS RN AND WILL PLAN TO VISIT W/ PT TODAY.\n\nA/P: STABLE, TOLERATING VENT WEAN, PAIN WELL CONTROLLED. CONTINUE VENT WEAN AS TOLERATED, CONTINUE PER PLAN OF CARE. FULL SUPPORT/COMFORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-08-10 00:00:00.000",
"description": "Report",
"row_id": 1370300,
"text": "Respiratory Care Note:\n Patient remains on trach collar this afternoon with less secretions today. BS=bilat, diminished t/o. #8 trach secure, 12cm at stoma. Plan to maintain on trach collar as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-08-09 00:00:00.000",
"description": "Report",
"row_id": 1370294,
"text": "Resp Care: Pt continues sedated, with #8 tube @ 12 cm with minimal occ positional leak and on ventilatory support with a/c, no vent changes overnoc maintaining good abg; bs coarse/occ tight wheeze, sxn thick blood tinged secretions, unable to assess rsbi d/t sedation, will cont full support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-08-09 00:00:00.000",
"description": "Report",
"row_id": 1370295,
"text": "T/SICU NPN 2300-0700:\n\nREVIEW OF SYSTEMS:\n\nNEURO: SEDATED ON PROPOFOL - NOT LIGHTENED FOR EXAMS; COUGH/GAG STRONG/INTACT, PERRLA 3MM/BSK. MEDICATED W/ MSO4 PRN PRIOR TO TURNS/REPOSITIONING.\n\nCV: HR SR/SB 58-60'S, SBP 100-120'S, NO ECTOPY NOTED ON TELEMETRY, PULSES EASILY PALPABLE, PB'S ON FOR DVT PROPHYLAXIS, HEPARIN GIVEN AS ORDERED. SKIN PINK/WARM/DRY.\n\nRESP: LUNG SOUNDS CLEAR THROUGHOUT, MINIMALLY DECREASED AT BASES - STRONG PRODUCTIVE COUGH EFFORT, SXN'D PRN FOR SM<->MOD AMTS THICK BLD TINGED SECRETIONS. CONTINUES ON A/C 800X10/40%/10PEEP, RARELY OVERBREATHES SETTINGS 1-2 BREATHS. SATS 99-100%. REFER TO CAREVIEW FOR ABG DATA.\n\nGI: ABD OBESE/SOFT/BS ABSENT/NO BM - NPO W/IVF LR W/40KCL INFUSING AS ORDERED. PROTONIX FOR GI PROPHYLAXIS - NGT TO SXN DRAINING BILIOUS EFFLUENT ~200CC'S.\n\nGU: U/O VIA FOLEY CATHETER NOTED TO HAVE SEDIMENT, COLOR YELLOW->PROGRESSED DURING THIS SHIFT TO AMBER/BLD TINGED - NO BLADDER TRAUMA NOTED. AVG HOURLY OUTPUT 30-40CC/HR. MG+ REPLETED.\n\nENDO: 105 - NO SSRI COVERAGE REQUIRED.\n\nID: TMAX 99.3->98.8, CONTINUES ON FLAGYL/CEFAZOLIN.\n\nSKIN: BACK/BUTTOCKS INTACT - TRACH SITE W/PENROSE DRAIN->SM AMT SERO/SANG DRAINAGE OUT - LAP SITES WNL.\n\nSOCIAL: NO FAMILY CONTACT OVER .\n\nA/P: HEMODYNAMICALLY STABLE - CONTINUES SEDATED TO MINIMIZE POST-OP TRAUMA TO LARYNGEAL SURGICAL SITE. F/U W/ ENT TEAM TO ASSESS WHEN PT ABLE TO PHYSICALLY TOLERATE COUGHING EPISODES TO AID IN DETERMINING A PLAN TO WEAN PT OFF SEDATION. CONTINUE PER CURRENT PLAN OF CARE IN INTERRIM - FULL SUPPORT/COMFORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-08-09 00:00:00.000",
"description": "Report",
"row_id": 1370296,
"text": "T/SICU RN Progress Note\nNeuro: Propofol off, eyes open following commands, periods to crying about trach and set back. Sisters in and patient brighter with company and actively participating in conversation by mouthing words and writing. Morphine for pain with effect.\n\nCV: HR 60's SR no ectopy noted. ABP systolic 160's. IVF LR with 40KCL @125cc/hr. SQ Heparin and P-boots.\n\nResp: , off vent on trach mask from 1300-1700 patient then with increased RR, dropping Sats, and patient complaining of increased work of breathing. Placed back on vent with increase in sats, decrease of RR, and patient stating breathing much easier.\n\nGU/GI: Foley with dark amber urine with sedements, throughout day turining dark yellow, with sedement. NPO, Protonix, NGT to wall suction with bilious drainage. Abd obease with lap sites intact, no drainage noted.\n\nSkin/Mobility: Remains in big boy bed. Skin grossly intact. Trach site with s/s drainage.\n\nID: Tmax 99.7 remains on Kefzol and Flagyl.\n\nSocial: Sisters at bedside spoke with Dr. , and Dr. .\n\nPlan: Cont to monitor resp function, wean as tolerated, cont to monitor and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-08-08 00:00:00.000",
"description": "Report",
"row_id": 1370291,
"text": "Respiratory Care Note:\n Patient with #8.0 air-cuff trach, extra long, noted to be 12cm at stoma marking. It is sutured in place. BS= bilat with good aeration, slightly decreased bases. Suctioned today for small-med amounts of thick blood-tinged secretions. ENT requests that cuff on trach remain insufflated at all times and is to remain in position below laryngeal tear. Trach is noted to be slightly positional and care is taken with repositioning of patient and vent circuitry. She is sedated on precedex and propofol and appears comfortable at this time. No subcutaneous emphysema noted around tracheostomy. Plan to maintain present level of support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-08-08 00:00:00.000",
"description": "Report",
"row_id": 1370292,
"text": "Nursing Progress Note:\nPlease see CareVue.\n\nPt condition essentially stable.\n\nOn exam,\n\nResp:\nChest clear, vigorous productive cough, secretions bloodstained and thin. Respiratory alkalosis corrected- see CareVue.\nTrach site: sutures intact, penrose drain in place. Positional cuff leak , team informed. Slight hemoserous ooze to trach dressing.\n\nHemodynamically:\nSR initially, became bradycardic with dexmedetomidine infusion. Has maintained SBP> 100. Peripherally warm and well perfused.\nPeripheral IVs patent. LR with KCl repletion in progress.\n\nNeuro:\nPt requiring large doses of sedation, coughs vigorously when lightened, requires boluses before full exam attended. PEARL. Moves all limbs. Commenced dexmedetomidine infusion and intermitant morphine but unable to wean propofol. Have discussed with team.\n\nEndocrine:\nCovered for hyperglycemia with insulin per sliding scale.\n\nGI:\nAbd obese, soft, NGT to intermittant suction with bilious output.\n\nID:\nAfebrile.\n\nSkin:\nSeveral puncture sites to abd, remain covered with dry dressing.\n\nRenal:\nGood urine output with sediment.\n\nSocial:\nVisited by family.\n\nPlan:\nContinue to monitor and wean propofol as tolerated.\nContinued support for family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-08-08 00:00:00.000",
"description": "Report",
"row_id": 1370293,
"text": "Nursing Progress Note\nS/O- ROS\n pt has been sedated on presidex and propofol, unable to come off of propofol, pt would begin coughing and needed propofol to quiet her. Presidex has been D/C'd, propofol increased to 60 mcg/kg/min. MSO4 2mg q2. unable to assess neuro status,due to coughing when somewhat light. PERL.\n pt has been in sinus bradycardia , with no ectopi, adequate B/P, Ca repleted. K 3.5 and IVF of RL with 20 meq of KCL will be increased to 40 meq. '\nGI_ pt has NG tube in place draining bile , abd remains obese and soft, with small incisions from laproscopic surgery.\nGU- adequate u/o.\n pt reamins vented on 800x10 with 10 peep on 40 % FIO2. pt has been suctioned for small amts of serosang thin secretions. Air leak present at times and is positional. As noted above, when light pt begins coughing .\nskin- intact. on back and buttucks, incision site at trach is intact with small penrose drain in place.\n pt 2 sisters in for several hours, pt has only told them of her surgery, they have now informed other family members.\nA/P- Plan is to keep pt sedated and will evaluate by .Direct laraynscopy before removing trach.Pt remains hemodynamically stable. Difficult to assess neuro status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-08-08 00:00:00.000",
"description": "Report",
"row_id": 1370289,
"text": "RESP CARE\nPT REMAINS AND VENTED ON A/C 800 X 13 PEEP 5 60% VIA #8 TUBE S/P GASTRIC BANDING. ABG WITHIN NORMAL LIMITS WITH SPO2 IN THE UPPER 90S T/O SHIFT. BS COURSE AT TIMES SXING FOR SMALL AMTS OF THICK BLOOD TINGED SECRETIONS. BS IMPROVED SLIGHTLY POST SXING. NO MDIS ORDERED. WILL CONT TO MONITOR AND ASSESS FOR READINESS TO WEAN WHEN SEDATION LIGHTENS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2141-08-08 00:00:00.000",
"description": "Report",
"row_id": 1370290,
"text": "TSICU NSG ADMIT NOTE\nO: 47 Y/O MORBIDLY OBESE FEMALE S/P GASTRIC BANDING TODAY WHO DID WELL DURING PROCEDURE, WAS REVERSED AND EXTUBATED AND QUICKLY DESATURATED TO AS LOW AS 47% FOR <1MIN. ATTEMPT MADE TO REINTUBATE WAS UNSUCCESSFUL. TRACHEOTOMY ATTEMPTED W/ LARYNGEAL INJURY. ENT CALLED AND PERFORMED OPEN TRACH AND REPAIR OF LARYNGEAL TEAR W/ PLATE PLACED.\nPT ADMITTED TO TSICU AT 10:30PM FOR AIRWAY MANAGEMENT AND POST-OP CARE.\n\nPMH:\nMORBID OBESITY W/ SEVERAL ATTEMPTS AT WT LOSS W/ REGAINING (80LBS)\nBORDERLINE HTN\nANXIETY\nDEPRESSION\nOSTEOARTHRITIS IN KNEES\nS/P LAP CHOLE \n\nALLERGIES: NKDA\n\nMEDS: XANAX\n\nSH: PT LIVES W/ SISTER WHO IS AWARE OF SURGERY AND RECENT EVENTS. WORKS AS A NURSE.\n\nNON SMOKER, -ETOH.\n\nROS:\nNEURO: REMAINS SEDATED ON PROPOFOL. LIGHTENED UPON ARRIVAL. AWOKE CALM, MAE AND FOLLOWS COMMANDS. ABLE TO COMMUNICATE BY MOUTHING WORDS. DENIES PAIN.\n\nCV: HR 60-70 NSR, NO ECTOPY. STABLE BP, 100-140/50-60.\n\nRESP: #8 BIOVANA TRACH IN PLACE, SUTURED TO SKIN. PENROSE DRAIN OUT OF L SIDE OF TRACH SITE W/ SUTURED INCISION C&D. DRAINING SM AMT BLOODY DNGE AROUND TRACH. REMAINS FULLY VENTED ON AC 800X13, 60% AND 5PEEP WITH STABLE ABG AND 02SATS. SXNED FOR THICK BLOODY SECRETIONS, SM AMT.\n\nRENAL: IVF AT 200CC/HR. BRISK U/O, AUTODIURESISNG. CA, MG AND KCL ALL REPLETED.\n\nGI: NGT LIS W/ THICK BROWNISH DNGE, SM AMT. ABD OBESE, BS ABSENT.\n\nHEME: STABLE\n\nID: AFEBRILE AND CONT ON CEFAZOLIN AND FLAGYL.\n\nSKIN: TRACH SITE AS ABOVE W/ SM AMT BLOODY DNGE, NO REDNESS, NO ODOR.\nABD DSG SITES INTACT. BACKSIDE INTACT.\n\nPROPHYLAXIS: FAMOTADINE, PROTONIX, HEPARIN AND PNEUMO BOOTS.\n\nA: STABLE S/P SURGERY.\n\nP: CONT TO MONITOR AND MAINTAIN SEDATED UNTIL CONSIDERED SAFE TO MOVE AROUND W/ PRESENT INJURY. LIGHTEN QSHIFT FOR NEURO EXAM. CONT PULM TOILET. MAINTAIN NPO W/ IVF AND NGT TO LWS. MONITOR FLUID BALANCE AND REPLETE LYTES. CONT ABX. PT AND FAMILY SUPPORT.\n"
}
] |
3,929 | 143,450 | 1. Acute pulmonary edema: The patient was diuresed in the Medical Intensive Care Unit with resolution of hypoxemia. He was then transferred to the floor, given one more dose of intravenous Lasix with subsequent diuresis. The patient continued with Lopressor 25 t.i.d., and I&Os were monitored, and a follow-up chest x-ray showed improvement in bilateral effusion. 2. Cardiology: The patient was ruled out for myocardial infarction, and it was noted that he had an MIBI which showed severe perfusion defect in the apex, moderate perfusion defect in the inferior wall, moderate perfusion defect in the septum, all partially reversible, with an ejection fraction of 47%, and septal hypokinesis. There were no electrocardiogram changes and no angina. Cardiac catheterization was considered at that time but was deferred because of worsening renal function. On this admission, Cardiology was reconsulted, and given that the patient had pulmonary edema, it was felt that it would be prudent to proceed with cardiac catheterization at the soonest possible time, as long as the patient's renal function was stabilized. In addition, the patient was started on an Aspirin a day after discussion with his ophthalmologist about a slight increased risk of retinal hemorrhages. It was decided that even in this patient with a history of retinal hemorrhages, that in light of his significant coronary artery disease, it would be unwise to not give him Aspirin. In addition, he was continued on his Lopressor 25 b.i.d., and he was continued on his Procardia 120 XL q.d. for blood pressure control, as well as his Pravachol 40 q.d. After discussion with the patient and his attending, as well as Cardiology, it was decided that the patient could come back for an elective catheterization within the next two weeks after discharge. He will likely need admission prior to catheterization for intravenous hydration, given his renal function. 3. Renal function: The patient, on the hospital floor, developed worsening creatinine to a peak creatinine of 4.0 on the 29th; however, his urine output continued to be adequate, and he continued to have actually high urine output even after Lasix was discontinued. The etiology of this renal failure was unclear. Cyclosporin toxicity was considered, and the trough was checked which was normal at 163. It was felt that overdiuresis could be contributing to the acute renal failure. Lasix was held, and the creatinine actually improved to a creatinine of 2.9 at the time of discharge. Because of his high urine output, which was consistent with an ATN-like picture, the patient was instructed to maintain p.o. intake to greater than 2 L to avoid dehydration. In addition, on arrival to the hospital floor, the patient's bicarb was extremely low, and this was followed, and the patient was started on Bicitra to maintain his bicarb level as well. 4. Infectious disease: The patient had a temperature to 101.4?????? on admission. Blood cultures, urine cultures were negative. Chest x-ray however showed a retrocardiac opacity which remained even after diuresis; however, the patient was afebrile on the floor. He was treated however with Levaquin which was renally dosed at 250 q.d., and the patient was continued for a full 14-day course of Levaquin; however, he had no elevation in white count and had no fevers on the Medical floor at all. 5. Hematology: The patient had anemia with a hematocrit of 29 post-diuresis. Since Cyclosporin can cause hemolytic anemia, haptoglobin was checked which was 136, not decreased, and thus this was deemed very unlikely. He will need follow-up as an outpatient for this anemia. | Again seen are bilateral small pleural effusions. Again seen are bilateral low lung volumes. There is a patchy dense retrocardiac opacity which obscures the left hemidiaphragm. TECHNIQUE: Chest PA and lateral. TECHNIQUE: Chest, PA and lateral. Also noted are small bilateral pleural effusions, left greater than right. 2) Bilateral pleural effusions. There is a dense retrocardiac opacity. There is bilateral perihilar haziness and bilateral interstitial opacities. Previously described abnormalities persist.TRACING #1 2) Left lower lobe dense opacity may be related to atelectasis/consolidation. There are bilateral low lung volumes. 3) Retrocardiac opacity may be related to atelectasis/consolidation. Also noted are subtle B-lines. There are bilateral interstitial opacities with upper zone redistribution, perihilar haziness, and septal lines. IMPRESSION: 1) CHF with bilateral pleural effusions, greater on the left. Again seen is a left lower lobe opacity. The left CP angle is not entirely included on the present exam. COMPARISON: Prior chest x-ray from . Sinus rhythm. Sinus rhythm. Sinus rhythm. Comparison with prior chest x-ray from . The osseous structures reveal demineralization. There is upper zone redistribution and bilateral interstitial opacities with perihilar haziness and septal lines which appear essentially stable in the interval. Again seen is slight LV enlargement, the heart size is within normal limits. The heart is probably within normal limits. COMPARISON: Prior x-rays from and . 2) Retrocardiac opacity may be related to consolidation/collapse. Since the previous tracing of lateral ST-T waveabnormalities are improved. IMPRESSION: 1) Mild CHF. Thetracing is otherwise unchanged and continues to show previous anteroseptalmyocardial infarction. Since the previous tracing of T wave inversions are moremarked in leads I, aVL and V5-V6. TECHNIQUE: Portable upright chest x-ray. The aorta is unfolded. The aorta is unfolded. IMPRESSION: 1) Heart failure with interstitial edema, not significantly changed in the interval. It is difficult to assess the cardiac size. R/o infiltrate FINAL REPORT HISTORY: Fever, cough, status post transplant. The abnormalities are non-specific. FINAL REPORT HISTORY: Renal transplant, probable pneumonia, need better view of bases. The left CP angle is not displayed on the present exam. Since the previous tracing of no change.TRACING #2 The osseous structures are unremarkable. 1:26 PM CHEST (PA & LAT) Clip # Reason: 56 yo male with probable pneumonia, need better view of base MEDICAL CONDITION: 55 year old man with renal transplant, HTN REASON FOR THIS EXAMINATION: 56 yo male with probable pneumonia, need better view of bases. 8:25 PM CHEST (PA & LAT) Clip # Reason: evaluate for progression/resolution of bilateral pulmonary i MEDICAL CONDITION: 55 year old man with renal transplant, HTN, resolving hypoxemic respiratory event REASON FOR THIS EXAMINATION: evaluate for progression/resolution of bilateral pulmonary infiltrates and LLL consolidation FINAL REPORT HISTORY: Renal transplant, hypertension, respiratory failure. | 6 | [
{
"category": "ECG",
"chartdate": "2139-07-07 00:00:00.000",
"description": "Report",
"row_id": 128543,
"text": "Sinus rhythm. Since the previous tracing of no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2139-07-06 00:00:00.000",
"description": "Report",
"row_id": 128544,
"text": "Sinus rhythm. Since the previous tracing of lateral ST-T wave\nabnormalities are improved. Previously described abnormalities persist.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2139-07-05 00:00:00.000",
"description": "Report",
"row_id": 128545,
"text": "Sinus rhythm. Since the previous tracing of T wave inversions are more\nmarked in leads I, aVL and V5-V6. The abnormalities are non-specific. The\ntracing is otherwise unchanged and continues to show previous anteroseptal\nmyocardial infarction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-07-05 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 739459,
"text": " 1:26 PM\n CHEST (PA & LAT) Clip # \n Reason: 56 yo male with probable pneumonia, need better view of base\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with renal transplant, HTN\n REASON FOR THIS EXAMINATION:\n 56 yo male with probable pneumonia, need better view of bases.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Renal transplant, probable pneumonia, need better view of bases.\n\n TECHNIQUE: Chest, PA and lateral.\n\n COMPARISON: Prior x-rays from and .\n\n Again seen are bilateral low lung volumes. The heart is probably within\n normal limits. The aorta is unfolded. There are bilateral interstitial\n opacities with upper zone redistribution, perihilar haziness, and septal\n lines. Also noted are small bilateral pleural effusions, left greater than\n right. Again seen is a left lower lobe opacity. The osseous structures are\n unremarkable.\n\n IMPRESSION:\n 1) CHF with bilateral pleural effusions, greater on the left.\n 2) Left lower lobe dense opacity may be related to atelectasis/consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-07-06 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 739472,
"text": " 8:25 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for progression/resolution of bilateral pulmonary i\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with renal transplant, HTN, resolving hypoxemic respiratory\n event\n REASON FOR THIS EXAMINATION:\n evaluate for progression/resolution of bilateral pulmonary infiltrates and LLL\n consolidation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Renal transplant, hypertension, respiratory failure.\n\n TECHNIQUE: Chest PA and lateral.\n\n Comparison with prior chest x-ray from .\n\n Again seen is slight LV enlargement, the heart size is within normal limits.\n The aorta is unfolded. There is upper zone redistribution and bilateral\n interstitial opacities with perihilar haziness and septal lines which appear\n essentially stable in the interval. The left CP angle is not displayed on the\n present exam. There is a patchy dense retrocardiac opacity which obscures the\n left hemidiaphragm. Again seen are bilateral small pleural effusions.\n\n IMPRESSION:\n 1) Heart failure with interstitial edema, not significantly changed in the\n interval.\n 2) Bilateral pleural effusions.\n 3) Retrocardiac opacity may be related to atelectasis/consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-07-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 739458,
"text": " 12:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: male s/p renal transplant, now with fever/ cough, low O2 sat\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with renal transplant, cpap at night\n REASON FOR THIS EXAMINATION:\n male s/p renal transplant, now with fever/ cough, low O2 sat. R/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever, cough, status post transplant.\n\n TECHNIQUE: Portable upright chest x-ray.\n\n COMPARISON: Prior chest x-ray from .\n\n There are bilateral low lung volumes. It is difficult to assess the cardiac\n size. There is bilateral perihilar haziness and bilateral interstitial\n opacities. Also noted are subtle B-lines. The left CP angle is not\n entirely included on the present exam. There is a dense retrocardiac opacity.\n The osseous structures reveal demineralization.\n\n IMPRESSION:\n 1) Mild CHF.\n 2) Retrocardiac opacity may be related to consolidation/collapse.\n\n\n"
}
] |
55,078 | 138,121 | The patient was admitted to the hospital on (day before surgery) since she was on Coumadin and admitted for Heparin and pre-op work-up. She was brought to the operating room on where the patient underwent Redo sternotomy and mitral valve repair with a 26-mm Annuloplasty band and tricuspid valve repair with the 28-mm Contour 3-D Annuloplasty ring. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and titrated up. The patient was gently diuresed toward the preoperative weight. CXR showed pulmonary edema and Lasix was subsequently increased. She was restarted on Coumadin at her home dose for chronic atrial fibrillation and her INR was slowly increasing towards goal of 2.0-2.5. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating with assistance, the wound was healing well and pain was controlled with oral analgesics. The patient was discharged Nursing and Rehab in good condition with appropriate follow up instructions. . Pacemaker interrogation : -Presenting rhythm: AV asynchronous pacing -Intrinsic Rhythm: AF with controlled ventricular response -Ventricular sensitivity decreased to 0.5mV -Rate increased to 70 bpm at request of primary team | There are simple atheroma in theascending aorta. Simple atheroma in aortic arch. FINDINGS: Compared to the prior radiograph, the right intrenal jugular central line has been removed. Simple atheroma in ascending aorta.Normal aortic arch diameter. There are simple atheroma in the aortic arch. Normalregional LV systolic function. Nospontaneous echo contrast in the body of the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. See Conclusions for post-bypass dataConclusions:PRE-BYPASS: The left atrium is markedly dilated. Mild interstitial lung abnormality with basilar predominance. Severe [4+] TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 85/19, 88/22, 103/24, cm/sec. Right ventricularfunction is mildly depressed. There is mild tortuosity of thoracic aorta and mild calcifications at the aortic arch. A small right pleural effusion is noted. FINDINGS: Right-sided chest tube and the mediastinal drains have been removed. aortic and major artery branches including within visualized abdomen also heavily calcified 2. single lead pacemaker with tip in right ventricle. Traceaortic regurgitation is seen. EXAMINATION: PA and lateral chest radiographs. Mild mitral annularcalcification. There is a well-seated mitral annuloplasty ringin place. There is mildly enlarged cardiac silhouette. Mild (1+) tricuspid regurgitation isseen. Peripheral, atherosclerotic calcifications are present in the thoracic aorta, most marked within the aortic arch and descending thoracic aorta, as well as within the region of the branch vessels from the aortic arch. Stable pulmonary edema and cardiomegaly. Dilated coronary sinus. There is antegrade right vertebral artery flow. Therhythm appears to be atrial fibrillation. Demand VVI right ventricular pacing. IMPRESSION: Small right pleural effusion. Findings: Duplex evaluation was performed of bilateral carotid arteries. Complex (>4mm) atheroma in the descending thoracic aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Single enlarged mediastinal lymph node is of uncertain clinical significance. milder mitral and aortic valve calcifications. There is antegrade left vertebral artery flow. Numerous lymph nodes are present throughout the mediastinum, only one of which measures greater than 1 cm in short axis dimension, located in the right tracheobronchial angle and measuring 1.2 cm in short axis (86, 4). There arecomplex (>4mm) atheroma in the descending thoracic aorta. Normal descendingaorta diameter. There is stable pulmonary edema and widening of the cardiomediastinal contours. There is a well-seatedtricuspid annuloplasty ring in place. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate to severe (3+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Within the lungs, mild centrilobular emphysema is present as well as a nonspecific peripheral reticular pattern that is most marked within the lung bases. The right atrium ismoderately dilated. Enlarged cardiac silhouette. Atrial fibrillation. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 129/31, 81/23,95/16 cm/sec. CORONARY ARTERY BYPASS GRAFT Admitting Diagnosis: MITRAL VALVE DISORDER\RE-DO STERNOTOMY MITRAL VALVE REPLACEMENT; TRICUSPID VALVE REPLACEMENT; ? The left atrium is elongated.The coronary sinus is dilated. The mitral valve leaflets are mildly thickened.Moderate to severe (3+) mitral regurgitation is seen. Thoracic aortic calcifications, most prominent in the aortic arch and descending thoracic aorta. The aortic valveleaflets (3) are mildly thickened. Endotracheal tube is removed. Left ventricular function. COMPARISON: Chest radiograph . There is mild hypokinesis of the mid inferior wall. There is evidence of a right mastectomy and surgical clips in the right axilla. ECA peak systolic velocity is 93 cm/sec. Hypertension. no pericardial effusion 4. s/p right mastectomy and axillary dissection. The left ventricular cavity sizeis normal. Mitral valve disease. There is nopericardial effusion. Extensive coronary artery calcifications. The aorta is intact post-decannulation. Valvular heart disease.Height: (in) 66Weight (lb): 147BSA (m2): 1.76 m2BP (mm Hg): 125/75HR (bpm): 60Status: InpatientDate/Time: at 11:30Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Marked LA enlargement. Chest wall structures are remarkable for previous right mastectomy. FINDINGS: In comparison with the preoperative study, there are new midline sternal wires in place. LINE PLACEMENT Clip # Reason: FAST TRACK EXTUBATION CARDIAC SURGERY;r/o effusion,ptx,htx;c Admitting Diagnosis: MITRAL VALVE DISORDER\RE-DO STERNOTOMY MITRAL VALVE REPLACEMENT; TRICUSPID VALVE REPLACEMENT; ? Status post previous coronary bypass surgery with diffuse calcification of the native coronary arteries. In the interval compared to prior radiograph from , there is a new pacermaker with a single lead and tip in appropriate position. There is a right IJ line with tip in the SVC. Ascending aortic calcifications are mild in degree. FINAL REPORT CT CHEST OF COMPARISON: Chest radiograph of the same date. Right IJ catheter appears to extend to the right atrium, with the tip pointed towards the right. On the right there is mild heterogeneous plaque seen in the ICA. 3. moderate cardiomegaly. Severe [4+] tricuspidregurgitation is seen. CORONARY ARTERY BYPASS GRAFT FINAL REPORT (Cont) Skeletal structures demonstrate evidence of previous sternotomy. 9:39 PM CT CHEST W/O CONTRAST Clip # Reason: redo sternotomy - preop for MVR - no IV contrast - if questi Admitting Diagnosis: MITRAL VALVE DISORDER\RE-DO STERNOTOMY MITRAL VALVE REPLACEMENT; TRICUSPID VALVE REPLACEMENT; ? Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending aorta diameter. FINDINGS: The patient is status post median sternotomy and previous coronary bypass surgery. | 9 | [
{
"category": "Echo",
"chartdate": "2171-11-01 00:00:00.000",
"description": "Report",
"row_id": 65803,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Hypertension. Left ventricular function. Mitral valve disease. Shortness of breath. Valvular heart disease.\nHeight: (in) 66\nWeight (lb): 147\nBSA (m2): 1.76 m2\nBP (mm Hg): 125/75\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 11:30\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement. Elongated LA. Dilated coronary sinus. No\nspontaneous echo contrast in the body of the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta.\nNormal aortic arch diameter. Simple atheroma in aortic arch. Normal descending\naorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. No MS. Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No TS. Severe [4+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\nrhythm appears to be atrial fibrillation. The patient is in a ventricularly\npaced rhythm. Results were personally reviewed with the MD caring for the\npatient. See Conclusions for post-bypass data\n\nConclusions:\nPRE-BYPASS: The left atrium is markedly dilated. The left atrium is elongated.\nThe coronary sinus is dilated. No spontaneous echo contrast is seen in the\nbody of the left atrium or left atrial appendage. The right atrium is\nmoderately dilated. No atrial septal defect is seen by 2D or color Doppler.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. There are simple atheroma in the\nascending aorta. There are simple atheroma in the aortic arch. There are\ncomplex (>4mm) atheroma in the descending thoracic aorta. The aortic valve\nleaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nModerate to severe (3+) mitral regurgitation is seen. Severe [4+] tricuspid\nregurgitation is seen. The tricuspid annulus diameter is 4.3 mm. There is no\npericardial effusion. Dr. was notified in person of the results at\ntime of surgery.\n\nPOST-BYPASS: The patient is V paced. The patient is on epinephrine and\nmilrinone infusions. Left ventricular function is mildly depressed (EF\n50-55%). There is mild hypokinesis of the mid inferior wall. Right ventricular\nfunction is mildly depressed. There is a well-seated mitral annuloplasty ring\nin place. No mitral regurgitation is seen. There is a mean gradient of 4 mmHg\nacross the mitral valve at a blood pressure of 125/63. There is a well-seated\ntricuspid annuloplasty ring in place. Mild (1+) tricuspid regurgitation is\nseen. No tricuspid stenosis is seen. The aorta is intact post-decannulation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-11-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1213492,
"text": " 4:10 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY;r/o effusion,ptx,htx;c\n Admitting Diagnosis: MITRAL VALVE DISORDER\\RE-DO STERNOTOMY MITRAL VALVE REPLACEMENT; TRICUSPID VALVE REPLACEMENT; ? CORONARY ARTERY BYPASS GRAFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p redo sternotomy/MV repair/TV repair\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY;r/o effusion,ptx,htx;contact \n # if abnormal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiac surgery.\n\n FINDINGS: In comparison with the preoperative study, there are new midline\n sternal wires in place. Endotracheal tube tip is at the clavicular level,\n approximately 5 cm above the carina. Right IJ catheter appears to extend to\n the right atrium, with the tip pointed towards the right. Nasogastric tube\n extends to the stomach, with the side hole in the region of the\n esophagogastric junction. Right chest tube is in place with no evidence of\n pneumothorax. Continued enlargement of the cardiac silhouette with elevated\n pulmonary venous pressure and bibasilar atelectasis and probable small left\n effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-11-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1213611,
"text": " 4:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax s/p chest tube removal\n Admitting Diagnosis: MITRAL VALVE DISORDER\\RE-DO STERNOTOMY MITRAL VALVE REPLACEMENT; TRICUSPID VALVE REPLACEMENT; ? CORONARY ARTERY BYPASS GRAFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p MVrepair, TV repair\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Mitral and tricuspid valve repair, status post chest tube removal.\n\n REFERENCE EXAM: .\n\n FINDINGS: Right-sided chest tube and the mediastinal drains have been\n removed. Endotracheal tube is removed. There is a right IJ line with tip in\n the SVC. There is severe cardiomegaly with pulmonary vascular redistribution\n similar to film from the prior day.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-11-04 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1213739,
"text": " 9:15 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: MITRAL VALVE DISORDER\\RE-DO STERNOTOMY MITRAL VALVE REPLACEMENT; TRICUSPID VALVE REPLACEMENT; ? CORONARY ARTERY BYPASS GRAFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p mv repair, tv repair\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for effusion in patient recently status post mitral and\n tricuspid valve repair.\n\n EXAMINATION: PA and lateral chest radiographs.\n\n COMPARISONS: A series of chest radiographs from dating back\n to .\n\n FINDINGS:\n\n Compared to the prior radiograph, the right intrenal jugular central line has\n been removed. There is stable pulmonary edema and widening of the\n cardiomediastinal contours. A small right pleural effusion is noted. On\n review of the prior radiograph, a small nondisplaced rib fracture is noted in\n the lateral left 7th rib, which may have been understandably missed due to its\n location. It is not well imaged on the current study.\n\n IMPRESSION: Small right pleural effusion. Stable pulmonary edema and\n cardiomegaly. Possible left 7th rib fracture which could be better seen on\n dedicated rib radiographs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-10-31 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1213353,
"text": " 4:57 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: MITRAL VALVE DISORDER\\RE-DO STERNOTOMY MITRAL VALVE REPLACEMENT; TRICUSPID VALVE REPLACEMENT; ? CORONARY ARTERY BYPASS GRAFT\n Admitting Diagnosis: MITRAL VALVE DISORDER\\RE-DO STERNOTOMY MITRAL VALVE REPLACEMENT; TRICUSPID VALVE REPLACEMENT; ? CORONARY ARTERY BYPASS GRAFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with preop Redo , MVR, TVR\n REASON FOR THIS EXAMINATION:\n evaluate for acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Preoperative radiograph for redo sternotomy with mitral valve\n replacement.\n\n TECHNIQUE: Chest radiograph, two views.\n\n COMPARISON: Chest radiograph .\n\n FINDINGS: There is no pneumonia. There is no pleural effusion or\n pneumothorax. There is evidence of a right mastectomy and surgical clips in\n the right axilla. There is evidence of prior CABG. In the interval compared\n to prior radiograph from , there is a new pacermaker with a single lead\n and tip in appropriate position. There is mild tortuosity of thoracic aorta\n and mild calcifications at the aortic arch. There is mildly enlarged cardiac\n silhouette.\n\n IMPRESSION: No pneumonia. Enlarged cardiac silhouette. Interval pacemaker\n placement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-10-31 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 1213349,
"text": " 4:31 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: please eval for carotid stenosis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with as\n REASON FOR THIS EXAMINATION:\n please eval for carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n\n Study: Carotid Series Complete\n\n Reason: 82 year old woman pre/op AVR.\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is mild heterogeneous plaque seen in the ICA. On the left\n there is moderate heterogeneous plaque seen in the ICA.\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 85/19, 88/22, 103/24, cm/sec. CCA peak systolic\n velocity is 56 cm/sec. ECA peak systolic velocity is 93 cm/sec. The ICA/CCA\n ratio is 1.8 These findings are consistent with <40% stenosis.\n\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 129/31, 81/23,95/16 cm/sec. CCA peak systolic\n velocity is 67 cm/sec. ECA peak systolic velocity is 89 cm/sec. The ICA/CCA\n ratio is 1.9. These findings are consistent with 40-59% stenosis.\n\n There is antegrade right vertebral artery flow.\n There is antegrade left vertebral artery flow.\n\n Impression: Right ICA <40% stenosis.\n Left ICA 40-59% stenosis.\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2171-11-02 00:00:00.000",
"description": "Report",
"row_id": 139907,
"text": "Demand ventricular pacing alternating with possible junctional rhythm with\ninferior and lateral T wave abnormalities which are more pronounced than\npreviously seen.\n\n"
},
{
"category": "ECG",
"chartdate": "2171-10-31 00:00:00.000",
"description": "Report",
"row_id": 139908,
"text": "Atrial fibrillation. Demand VVI right ventricular pacing. Frequent ventricular\npremature beats.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-10-31 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1213379,
"text": " 9:39 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: redo sternotomy - preop for MVR - no IV contrast - if questi\n Admitting Diagnosis: MITRAL VALVE DISORDER\\RE-DO STERNOTOMY MITRAL VALVE REPLACEMENT; TRICUSPID VALVE REPLACEMENT; ? CORONARY ARTERY BYPASS GRAFT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with preop MVR redo sternotomy\n REASON FOR THIS EXAMINATION:\n redo sternotomy - preop for MVR - no IV contrast - if questions page \n thank you\n CONTRAINDICATIONS for IV CONTRAST:\n increased cr\n ______________________________________________________________________________\n WET READ: 10:44 PM\n 1. Extensive coronary artery calcifications. s/p CABG. patency of grafts not\n evaluated on this non-con study. milder mitral and aortic valve\n calcifications. aortic and major artery branches including within visualized\n abdomen also heavily calcified\n 2. single lead pacemaker with tip in right ventricle.\n 3. moderate cardiomegaly. no pericardial effusion\n 4. s/p right mastectomy and axillary dissection.\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST OF \n\n COMPARISON: Chest radiograph of the same date. No prior chest CT scans.\n\n TECHNIQUE: Volumetric, multidetector CT of the chest was performed without\n intravenous or oral contrast administration. Images are presented for display\n in the axial plane at 5-mm and 1.25-mm collimation. A series of multiplanar\n reformation images are also submitted for review.\n\n FINDINGS: The patient is status post median sternotomy and previous coronary\n bypass surgery. The heart is enlarged, and diffuse calcifications are present\n throughout the native coronary arteries. Peripheral, atherosclerotic\n calcifications are present in the thoracic aorta, most marked within the\n aortic arch and descending thoracic aorta, as well as within the region of the\n branch vessels from the aortic arch. Ascending aortic calcifications are mild\n in degree. Mitral calcifications are also demonstrated.\n\n Numerous lymph nodes are present throughout the mediastinum, only one of which\n measures greater than 1 cm in short axis dimension, located in the right\n tracheobronchial angle and measuring 1.2 cm in short axis (86, 4).\n\n Within the lungs, mild centrilobular emphysema is present as well as a\n nonspecific peripheral reticular pattern that is most marked within the lung\n bases. This is accompanied by mild basilar septal thickening, but no evidence\n of honeycombing or traction bronchiectasis.\n\n Exam was not specifically tailored to evaluate the subdiaphragmatic region,\n but note is made of a 3-cm diameter low-attenuation lesion at the upper pole\n of the right kidney measuring fluid attenuation consistent with a cyst.\n\n (Over)\n\n 9:39 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: redo sternotomy - preop for MVR - no IV contrast - if questi\n Admitting Diagnosis: MITRAL VALVE DISORDER\\RE-DO STERNOTOMY MITRAL VALVE REPLACEMENT; TRICUSPID VALVE REPLACEMENT; ? CORONARY ARTERY BYPASS GRAFT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Skeletal structures demonstrate evidence of previous sternotomy. Chest wall\n structures are remarkable for previous right mastectomy.\n\n Note is also made of a hemangioma in the upper lumbar spine, incompletely\n imaged on this study.\n\n IMPRESSION:\n\n 1. Thoracic aortic calcifications, most prominent in the aortic arch and\n descending thoracic aorta. These images are available for review for\n preoperative planning.\n\n 2. Status post previous coronary bypass surgery with diffuse calcification of\n the native coronary arteries.\n\n 3. Cardiomegaly.\n\n 4. Mild interstitial lung abnormality with basilar predominance. Such\n findings can sometimes be observed in the elderly population in the absence of\n symptoms or pulmonary function abnormalities, but the appearance overlaps with\n nonspecific interstitial pneumonia (NSIP).\n\n 5. Single enlarged mediastinal lymph node is of uncertain clinical\n significance.\n\n"
}
] |
10,390 | 115,173 | Right bundle-branchblock and ventricular ectopy persist. Given one unit rbc with repeat hct 29.1. DR AWARE.HEME- HCT THIS AM 31.7. BS COARSE UPPER DIMINISHED AT BASES.CARDIAC- REMAINS IN AFIB. Combivent MDI given Qid and Serevent . Combivent MDI given Q6hr and Serevent . REPEAT HCT 32.4.ID- TEMP UP TO 100.6. UO 32-60CC/HR.HEME- HCT THIS AM 29.8. primary anterolateral ST-T waveabnormalities. PASSING BRBPR THIS AM APPEARS TO OOZE FROM HEMMORRHOID. ABD SOFTER TODAY WITH HYPOACTIVE BS. REPEAT K 4.2. FOCUS; ADDENDUMHEME- REPEAT HCT 27.7. Plan to extub in am. PREMED WITH TYLENOL AND BENADRYL.ACCESS- PER DR CXR CONFIRMS THAT RIGHT IJ CL OK TO USE. Inproving with ativan. rec. Pmicu nsg progress note Pt cont to pass sm amts brb around rectal tube. TYLENOL GIVEN. Restarted on ativan gtt with some improvement. suctioned scant thin white.Cardiac- A-Fib with run of SVT at 6am to 140. ABG THIS AM ON THIS SETTING WAS 7.46/39/88/29. Adequate Abg's. Cont with marginal uo. DR MADE AWARE. Restarted on ativan gtt with some improvement.Does have order for propofol if necessary. Combivent MDI given Q4 and Serevent . maintaining vols 400's with RR low 20's. tpn for nutrition.gu: uo approx. BP stable thoughout. follow crits and transfuse. sedated with ativan. CONTINUES OFF ANTICOAGULATION. suctioned for thick whiteish secretions.gi: one enema given earlier with little results. Will need repeat kub in am.cardiac- Cont on dilt gtt at 10mg/hr. CONTINUES ON DILTDRIP AT 10MG/HR. TYLENOL GIVEN WILL RECEIVE PRBC ONCE TEMP < 100. DR AWARE. DR AWARE. DR AWARE. some nonpurposeful movement noted in arms and legs.cad: hr afib 90-100 into 120-130 starting around 3am. ONE PORT LABELED FOR TPN WHICH WILL START TOMMORROW. ORDER FAXED TO BB. Atrial fibrillation. TEMP AT PRESENT IS 100.6. Pt. Pt. Pt. Pt. 2 FLEETS ENEMAS GIVEN AS ORDERED WITH BRB RESULTS. FOCUS; NURSING PROGRESS NOTE.REVIEW OF SYSTEMS-NEURO- PATIENT AGGITATED THIS AM OFF SEDATION. Sedation given with improvement. Remains NPO and NG draining bile. Mod amount liq stool out (rectal tube in place now) w/ additional incont volume.Inf DisT max 100.4 at . Post extubation abg was 7.46/44/110/32+6. STOOL GUAIC NEG AND HCT STABLE AT 30.4RENAL: UO ADEQUATE. HCT stable at 30.5.Neuro: Cont to have periods of agitation. albuterol nebs given today prn. bilat insp/exp wheeze- albuterol/atrovent nebs x2 w/o releif. ALTERED HEMODYNAMICSD: NEURO: PROPOFOL GTT D/C'D AT 0930 AND PT GIVEN 1 MG IVP ATIVAN. DILTIAZEM GTT AND PO MED D/C'D AND RESTARTED ON LOPRESSOR 75 MG QID VIA NGT. nsg progress note8 am hct 31.6, 1 pm hct 30.6. denies abd pain. WOULD CONTINUE WITH LACTULOSE 30CC'S QID FOR BOWEL REGIME. CONTINUES TO RECEIVE COUMADIN 2.5 MG QD AS WELL AS LOOVONOX 80 MG WITH PT OF 14.9 AND INR OF 1.5. 15:45 ABG results; 7.46-44-110-97%. sats 95-98 with 4l nasal . WILL FOLLOW HEMODYNAMICS AND MS. CONTINUE WITH DILTIAZEM GTT AT PRESENT RATE AND TITRATE TO KEEP HR<100 AND SBP AROUND 120. Arterial BP's monitored ranged from 120-140's/60-70's, short period of hypertension associated w/ tachycardia.Resp-Pt remains intubated, placed on weaning trials after rounds-CPCPA. PT13.4 AND PT IS ON DOSE OF COUMADIN AND TODAY HAS BEEN STARTED ON LOVENOX 80 MG SC BID. Placed on NC 3L w/ O2 sat >95%.GU/Integ: + foley. Team and RT noted, vent changes made (please refer to RT note); SIMV, 600x10, PS 10. Propofol slow to reach sedation level, but now w/ excellent sedating effect at 10.58mcg/kg/min.Pulm: Vent changed-> simv 550 x 10 fio2 40%-> abg 101/43/7.43. Lopressor iv 5mg given x 2-> w/ min reslts. CAPTOPRIL INITIATED 12.5MG VIA OGT TID AND LOPRESSOR 100MG VIA OGT TID BUT I QUESTION WETHER THES MEDS ARE BEING ABSORBED. PMICU Nuring Progress NoteReview Of Systems-allergies PCN, full code Pt in Afibrillation, frequent PVC's, HR 90-100 w/ bursts 120-130's. DOES GRIMACE AND WITHDRAW TO PAINFUL STIMULATION.MAX TEMP=99.6 AXILLARY WITH WBC=8.9. RECEIVING REGLAN 10 MG ELIXIR Q 6 HRS. One MOM enema given-moderate amt. Exam is degraded by respiratory motion and evaluation of cardiopulmonary status is limited. There is cardiomegaly with small bilateral pleural effusions and slight upper zone redistribution, consistent with CHF. Status post sternotomy. REASON FOR THIS EXAMINATION: e/f persistent stool, any air/fluid levels FINAL REPORT ABDOMEN, SINGLE FILM. IMPRESSION: 1) Small pleural effusions bilaterally and small amount of pelvic free fluid. A supine chest film is provided demonstrating sternotomy wires. NG tube extends below diaphragm. NG tube extends below diaphragm. FINAL REPORT INDICATION: Decreased breath sounds left lower lobe and expiratory wheezes. A nasogastric tube is in place, and terminates within the stomach. Nasogastric tube terminates below the diaphragm. 2) Rectal distention with stool. A collection of focal radiodensities is noted in the left mid abdomen, n. overlying left renal outline consistent with calculi. REASON FOR THIS EXAMINATION: decreased stool output FINAL REPORT ABDOMEN, SINGLE FILM. Mildly enlarged cricopharyngeus is seen. Deep laryngeal penetration was identified with thin liquids. Probable small right pleural effusion. The rectum is distended with stool. LS now clear - upper airways, crackles at bases.GI: Abdomen soft very distended at 12mn, +BS. care noteremains intubated and vented. CT ABDOMEN WITH CONTRAST: There are moderate pleural effusions bilaterally, with adjacent atelectasis. There is an enlarged cardiac silhouette with a tortuous calcified aorta. NG tube is in stomach. NG tube is in stomach. There is probably a small right pleural effusion. APPEARS TO HAVE DIFFICULTY SWALLOWING AFTER EXTUBATION. Previously noted focal calcifications in left mid zone overlying the left renal region are again demonstrated. FINAL REPORT ABDOMEN, SINGLE FILM. | 53 | [
{
"category": "ECG",
"chartdate": "2145-11-19 00:00:00.000",
"description": "Report",
"row_id": 138980,
"text": "Atrial fibrillation with rapid ventricular response\nRight bundle branch block\nInferior/lateral ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2145-11-16 00:00:00.000",
"description": "Report",
"row_id": 138981,
"text": "Atrial fibrillation\nRight bundle branch block\n Inferior/lateral ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2145-12-02 00:00:00.000",
"description": "Report",
"row_id": 138920,
"text": "Atrial fibrillation with a rapid ventricular response. Right bundle-branch\nblock. Left ventricular hypertrophy. Compared to the previous tracing\nof , the rate is faster.\n\n"
},
{
"category": "ECG",
"chartdate": "2145-12-02 00:00:00.000",
"description": "Report",
"row_id": 138921,
"text": "Atrial fibrillation. Right bundle-branch block. primary anterolateral ST-T wave\nabnormalities. Compared to the previous tracing of ventricular ectopy\nis no longer present. Otherwise, no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2145-11-27 00:00:00.000",
"description": "Report",
"row_id": 138922,
"text": "Atrial fibrillation with a decrease in the ventricular response as compared to\nthe previous tracing of . Lead V6 was not obtained. Right bundle-branch\nblock and ventricular ectopy persist. Otherwise, no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2145-11-26 00:00:00.000",
"description": "Report",
"row_id": 138923,
"text": "Atrial fibrillation with a rapid ventricular response. Right bundle-branch\nblock. Frequent ventricular ectopy including couplets. Compared to the previous\ntracing of the ventricular response has increased, ventricular ectopy\nhas appeared and the inferior ST-T wave abnormalities have increased slightly.\nOtherwise, no diagnostic change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2145-11-17 00:00:00.000",
"description": "Report",
"row_id": 138924,
"text": "Atrial fibrillation with ventricular response of 84\nRight atrial deviation\nRight bundle branch block\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2145-11-20 00:00:00.000",
"description": "Report",
"row_id": 138925,
"text": "Atrial fibrillation with rapid ventricular response\nRight bundle branch block\nInferior ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\nSince last ECG, no significant change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-21 00:00:00.000",
"description": "Report",
"row_id": 1399523,
"text": "PROGRESS NOTE\nREVIEW OF SYSTEMS-\nNEURO- SEDATED THIS AM ON 3MG ATIVAN. REPONDING TO PAINFUL STIMULI BY GRIMACING. ON ROUNDS DECISION MADE TO DECREASE ATIVAN TO 2MG/HR WHICH WAS DONE. PATIENT SLIGHTLY LIGHTER ON THIS. GRIMACING TO PAIN.\nRESP- CONTINUES ON 40% FIO2 WITH SATS 99-100%. CONTINUES ON PEEP 5 PS OF 10 WITH RESP RATE 22-23 WITH TV 350 TO 400. ABG THIS AM ON THIS SETTING WAS 7.46/39/88/29. SUCTIONED FOR THICK YELLOW SPUTUM. BS COARSE UPPER DIMINISHED AT BASES.\nCARDIAC- REMAINS IN AFIB. HR 70-100'S ON IV LOPRESSOR 5MG Q 6 HOURS. AT 1600 HR UP TO 150 FOR A SHORT BURST. BP STABLE AT THE TIME. DR NOTIFIED AND AN ADDITIONAL 5MG LOPRESSOR GIVEN IV. HR DOWN TO 90'S. ALSO WITH OCCASIONAL ECTOPI INCLUDING COUPLETS. K 3.5 THIS AM TX WITH 40MEQ KCL IV. REPEAT K 4.2. SBP 130-150'S. CONTINUES OFF ANTICOAGULATION. INR TODAY 1.8 NOT TX WITH VITAMIN K DUE TO AVR.\nGI- PER CT YESTERDAY PATIENT LOADED WITH STOOL. SHE HAS RECEIVED A TOTAL OF 4 MILK AND MOLASSES ENEMAS AND 2 FLEETS. RESULTS ARE BROWN LIQUID TO MUSHY STOOL THAT IS GUIAC POS. DR AWARE. TO CONTINUE WITH PRN MILK AND MOLASSES ENEMAS TILL FORM STOOL IS PASSED. PATIENT ALSO RRECEIVED LACTULOSE PER NG WHICH SHE HAS ORDERED PRN. ABD SOFTER TODAY WITH HYPOACTIVE BS. NG TO LOW INT SUCTION DRAINED APPROXIMATELY 50CC BILE COLORED MATERIAL THIS SHIFT. TPN STARTED TODAY.\nGU- FOLEY PATENT DRAINING CLEAR YELLOW URINE 35-60 CC/HR. PATIENT NEG 1700CC SO FAR SINCE MN. SHE HAD BEEN 1200 POS YESTERDAY. DR AWARE.\nHEME- HCT THIS AM 31.7. REPEAT HCT 32.4.\nID- TEMP UP TO 100.6. DR AWARE. BC X2 AND URINE SENT FOR CULT. TYLENOL GIVEN. WBC 9.0 TODAY.\nENDO- BS AT NOON 125. NO INSULIN REQUIRED.\nSOCIAL- DAUGHTERS BOTH CALLED TODAY AND UPDATED BY NURSE ON PHONE. PATIENT REMAINS A FULL CODE IN THE MICU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-22 00:00:00.000",
"description": "Report",
"row_id": 1399524,
"text": "Respiratory Care:\n\nPatient remains intubated on Psv. Vent settings Psv 10, Cpap 5, Fio2 40% with Flowby . Pt. maintaining vols 400's with RR low 20's. Adequate Abg's. Bs clear bilaterally. Sx'd for sm amount of thick white sputum. Combivent MDI given Q4 and Serevent . Pt. sedated with ativan. No further changes made. Continue with Psv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-22 00:00:00.000",
"description": "Report",
"row_id": 1399525,
"text": "Addendum: Secretions also thick yellow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-22 00:00:00.000",
"description": "Report",
"row_id": 1399526,
"text": "rn progress note\n 5am\nneuro; pt remains sedated atvan to 1.5 mg at 3am. pt nonresponsive except for some grimaceing and exts withdrawal with tactile stimulation. some nonpurposeful movement noted in arms and legs.\n\ncad: hr afib 90-100 into 120-130 starting around 3am. iv lopressor 5mg iv givne per prn. ? whether pt absorbed po lopressor given at 2200.\n\nresp: no vnet changes remains on cpcpa with ps 10 60% tv 300-470. rr 20's . suctioned for thick whiteish secretions.\n\ngi: one enema given earlier with little results. second enema pending. prev on shift pt had lard soft formed stool rectal bag replaced. rec. tpn for nutrition.\n\ngu: uo approx. 30-40cc/hr pt is 130+ for shift.\n\nid: remains with low grade temp in 100's.\n\nplan: cont with enema and other bowel regime to clear bowel and prep for colonoscopy to verify ? bleeding diverticuli, monitor hct and fluid status, cont with weaning sedation and weaning trails from vent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-20 00:00:00.000",
"description": "Report",
"row_id": 1399520,
"text": "FOCUS; ADDENDUM\nHEME- REPEAT HCT 27.7. PATIENT TO RECEIVE 2 U PRBC. ORDER FAXED TO BB. TEMP AT PRESENT IS 100.6. DR MADE AWARE. TYLENOL GIVEN WILL RECEIVE PRBC ONCE TEMP < 100. PREMED WITH TYLENOL AND BENADRYL.\nACCESS- PER DR CXR CONFIRMS THAT RIGHT IJ CL OK TO USE. ONE PORT LABELED FOR TPN WHICH WILL START TOMMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-21 00:00:00.000",
"description": "Report",
"row_id": 1399521,
"text": "Respiratory Care:\n\nPatient remains intubated on Psv. Vent settings Psv 10, Cpap 5, Fio2 40%, with Flowby . Spont vols 400's with RR 20's. Bs clear bilaterally. Sx'd for sm amounts of thick white sputum. Combivent MDI given Q6hr and Serevent . No further changes made. Pt. appears comfortable on above settings. Continue with Psv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-21 00:00:00.000",
"description": "Report",
"row_id": 1399522,
"text": "PMICU NSg progress note:\n\nNeuro- responding to painfuls stimuli, suctioning and turning. ativan remains at 3 mg IV hourly.\n\nResp- continues on PS, rate 20-26 with STV 400-500. Ciminished breath sounds at bases. suctioned scant thin white.\n\nCardiac- A-Fib with run of SVT at 6am to 140. Cardiazem off at 8pm and started on lopressor. Aline patent and VSS.\n\nGI-given SSE for large amount of brown water return with some clots. distant sluggishbowel sounds. rectal tube in place now to drain fluid with some effect. No stool presently in lower ectal vault. Remains NPO and NG draining bile. Mod amt bloody stool. 2 UPC infused and post crit was 31.\n\nGU-urine output neg for today and approx 1 liter pos for yesterday. Lasix 20 IV X2 after blood infused with good diuresis.\n\nRIJ patent and labs sent this am.\nPlan- continue to assist with constipation, follow labs and wean from vent when able. follow crits and transfuse. ? looking further for source of bleeding if she rebleeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-20 00:00:00.000",
"description": "Report",
"row_id": 1399517,
"text": "Respiratory Care:\n\nPatient remains intubated on Psv. Vent settings Psv 10, Cpap 5, with Fio2 40%. Spont vols 400-500's with RR 20-26. RR increasing mid 30's and vols decreasing to 300's with periods of agitation. Sedation given with improvement. Bs clear bilaterally. Combivent MDI given Qid and Serevent . Sx'd for moderate amount of thick rusty sputum and sm amounts of thick white sputum. No further changes made. Pt. appears comfortable on above settings. PLan: Continue to wean Psv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-20 00:00:00.000",
"description": "Report",
"row_id": 1399518,
"text": "Pmicu nsg progress note\n Pt cont to pass sm amts brb around rectal tube. Tube with brown ob pos stool. Hct at 8pm back at 28.4. Given one unit rbc with repeat hct 29.1. Pt c/o pressure from rectal tube. Becoming agitiated moving about in bed. Mushroom cath removed with some improvement. Cont on heparin gtt at 850u with am ptt pending. No other s/s increased bleeding. Abdomen remains distended but non-tender. Will need repeat kub in am.\ncardiac- Cont on dilt gtt at 10mg/hr. HR 100-120af. Pt with periods of increased hr 130-140 associated with increased agitiation. Inproving with ativan. BP stable thoughout. Cont with marginal uo. No further fluid boluses.\nResp- Remains intub on ps 10 5peep with stable 02 sats/abg. Pt uncomfortable with tube. Restarted on ativan gtt with some improvement. Plan to extub in am. Suctioned for sm amts brown secretions\nid- T-max 101.4 given tylenol with temp down to 100. Cultures pending.\n Pt able to follow simple commands. C/o discomfort with et tube/rectal tube. Restarted on ativan gtt with some improvement.\nDoes have order for propofol if necessary.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-20 00:00:00.000",
"description": "Report",
"row_id": 1399519,
"text": "FOCUS; NURSING PROGRESS NOTE.\nREVIEW OF SYSTEMS-\nNEURO- PATIENT AGGITATED THIS AM OFF SEDATION. RESPONDING TO PAINFUL STIMULI. MAE IN BED. AFTER DECISION MADE THAT PATIENT WOULD NOT BE EXTUBATED SHE WAS PLACED ON 3MG/HR OF ATIVAN IV. ON THIS SHE IS SEDATED RESPONDING TO PAINFUL STIMULI.\nRESP- CONTINUES ON 40% FIO2 WITH SATS MID TO HIGH90'S. RESP RATE AROUND 20 TV ON PEEP OF 5 WITH PS OF 10 400'S. BS COARSE. SUCTIONED FOR THICK YELLOW SPUTUM.\nCARDIAC- HR IN AFIB RATE OF 100-110 THIS AM. CONTINUES ON DILTDRIP AT 10MG/HR. SBP 112-140. HEPARIN DRIP SHUT OFF THIS AM AS ORDERED AS PATIENT HAVING BRBPR.\nGI- ABD DISTENDED BUT SOFT. NG TO LOW INTERMITTENT SUCTIONED DRAINED 50CC BILE SO FAR THAT IS GASTRO NEG. PASSING BRBPR THIS AM APPEARS TO OOZE FROM HEMMORRHOID. DR AWARE. KUB DONE SHOWING LARGE DILATED LOOPS OF BOWEL PER DR . 2 FLEETS ENEMAS GIVEN AS ORDERED WITH BRB RESULTS. NO TRUE STOOL OUT. TO HAVE SURGICAL CONSULT. ALSO TO HAVE CAT OF ABD WITH BARROCAT PREP.\nGU- FOLEY PATENT DRAINING CLEAR YELLOW URINE. UO 32-60CC/HR.\nHEME- HCT THIS AM 29.8. CHECKED WITH DR WHEN NEXT HCT TO BE CHECKED. HE WILL LET ME KNOW. INR THIS AM 1.6.\nENDO- BS 234 AT NOON. COVERED WITH SS INSULIN.\nK- K 3.4 TX WITH 40 MEQ KCL IV IN 500CC NS OVER 4 HOURS.\nSOCIAL- 2 DAUGHTERS CALLED TODAY AND UPDATED BY NURSING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-23 00:00:00.000",
"description": "Report",
"row_id": 1399529,
"text": "ALTERED HEMODYNAMICS\nD: NEURO: PROPOFOL GTT D/C'D AT 0930 AND PT GIVEN 1 MG IVP ATIVAN. PT RESTLESS AND MOVING ALL EXTREMITIES BUT DOES NOT OPEN EYES TO VOICE AND DOES NOT FOLLOW SIMPLE COMMANDS. FACIAL GRIMACING TO PAINFUL STIMULATION. PT HAS ORDER FOR ATIVAN 1-2 MG IVP Q 2 HRS PRN FOR SEVERE AGITATION.\n\nRESP: 40%CPAP WITH 5 OF PEEP AND IPS TURNED DOWN TO 5 OF IPS AND O2 SATS>97% BUT AFTER 3 HRS PT APPEARED TIRED. SHE WAS TACHYPNEIC AND HR INCREASED TO 100'S-130'S. AFTER IPS INCREASED TO 10 AND PT WAS GIVEN 5 MG IVP LOPRESSOR HR NOW 90-100'S. WILL REST OVERNOC AND ATTEMPT TO WEAN IN THE AM.\n\nCV: SBP 160-180'S. CAPTOPRIL INITIATED 12.5MG VIA OGT TID AND LOPRESSOR 100MG VIA OGT TID BUT I QUESTION WETHER THES MEDS ARE BEING ABSORBED. DR. AWARE AND LOPRESSOR 5 MG IVP GIVEN WITH GD EFFECT.\n\nGI: LACTULOSE 60 CC'S VIA OGT GIVEN Q 2RHS X 2 DOSES BUT WHEN OGT WAS ASPIRATED NOTHING HAD BEEN ABSORBED. MOM ENEMA GIVEN AND FIB WIHT APPROX 100CC'S BROWN STOOL. ABD SOFTER WITH HYPERACTIVE BS. RECEIVING REGLAN 10 MG ELIXIR Q 6 HRS. WILL CONITNUE WITH ENEMAS AS ORDERED AND WILL HOLD OFF WITH ATTEMPTING TUBE FDGS AT PRESENT WILL CONTINUE HA FOR NOW. BLOOD SUGARS BEING TX'D WITH SLIDING SCALE INSULIN AS NEEDED Q 6 HRS. STOOL GUAIC NEG AND HCT STABLE AT 30.4\n\n\nRENAL: UO ADEQUATE. BUN AND CREAT WNL. WILL FOLLOW I&O'S CAREFULLY.\n\nPT'S DAUGHTERS HAVE BEEN UPDATED BY PHONE AND PT REMAINS A FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-24 00:00:00.000",
"description": "Report",
"row_id": 1399530,
"text": "PMICU NURSING PROGRESS NOTE:\n\nCV: continues to have rate control issues. Rec'd total 30mg lopressor over shift (see med sheet). HR 90- 120 w/ bursts to 140's. Cont to have freq PVC's. Also rec'd 4mg total Ativan. Sbp 110-170. ? increase captopril? Tmax 100.5 po. HCT stable at 30.5.\n\nNeuro: Cont to have periods of agitation. Opened eyes spontanously x 1. Unable to follow commands.\n\nPulm: ^^rr to 35. O2 Sat 98-99%. cont on psv 10 peep 5 40%fiO2.\n\nGI/GU: Rec'd total of 90cc lactulose. Stool out ~600cc. cont on tpn/quick mix. covered via ssi. O/U 35-90cc/h. -1800cc/h\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-24 00:00:00.000",
"description": "Report",
"row_id": 1399531,
"text": "Resp.care note:\n Pt had Heart rate control issues throughout the day. Resp mech.were ok and pt extubated to 45% aerosol face mask this afternoon. Pt had a small amount of thin white secretions. Post extubation abg was 7.46/44/110/32+6. Plan is to continue to follow pts.resp status closely. For more informationplease refer to carevue charting.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-24 00:00:00.000",
"description": "Report",
"row_id": 1399532,
"text": "Nursing Progress Note.\nRESP: Pt received on MV c CPAP/PS. PS of 10, 5 of PEEP, and 40% FiO2. Scant sec per ETT, thin, frothy, clear. LS fairly clear to auscultation. Baseline ABG drawn at 08:00; 7.42-44-92-100%. Short trial on PS of 8 relatively well tol by pt for one hour. Per team, pt was electively extubated at 15:00 to 50% CSM successfully. 15:45 ABG results; 7.46-44-110-97%. Pt cont to do fairly well s/p extubation c RR in mid 20's and Sats > 97%. Pt does not appear dyspneic or SOB and LS remain fairly clear c good air movement. Pt has a weak, ineffective cough and marginal mental status and therefore will watch closely for decompensation.\nCV: Pt c fairly quiet am until approximately noon when she developed freq/continuous HR bursts 140-170 c freq PVC's. Pt had received 5 mg IV Lopressor around 09:00 for a HR burst to 140's, but team decided to d/c additional lopressor doses on rounds in favor of returning the pt to a Diltiazem gtt. Diltiazem gtt was started at 12:30 and rapidly titrated up at bs, in addition a total of four boluses of 5mg IV diltiazem were administered at the BS to more rapidly cntl bursts. Pt is now receiving 20mg/hr of diltiazem c relatively rare , a SBP in the one-teens and a HR 90-110 which the team feels is adequate rate cntl at the present time. Pt had labs redrawn this am from her TLC (hemolyzed specs sent from A-Line) c a K=3.5 (cov c 60MEQ KCL) and a Mg=1.8 (cov c 2gm MgSO4). Pt is in A Fib, 16:00 Digoxin dose admin. Pt also received her 16:00 dose of coumadin -- no evidence of bleeding evident (guaic negative stools). +2 edema noted in UE's, especially her hands. Hyperglycemia cov c ISS per protocol.\nMS: Pt was able to follow commands this am for a short period of time, o/w not following commands and doesn't appear to be purposeful. 2mg IV ativan provided for agitation at 12:00 c moderate affect. An additional 2mg IV MSO4 admin at 18:00 for agitation/discomfort. . . currently evaluating its affects. Restraints removed 2nd pt is extremely debilitated and weak and she is no longer intubated.\nGI: Pt cont to receive 30ml lactulose QID per NGT and IV reglan Q6hours. Stool is liquid and guiac negative. +BS, distended abd. FS Promote tube feeds started at 18:00 at 10ml/hr and will titrate up as tolerated(TPN D/C'ed). 150ml stool output thus far today per FIC bag. Pt has very poor dentition.\nSKIN: Very frail skin but no skin breakdown on back evident. Turning pt q 3-4 hours, the pt would benefit from a high tec/low air loss mattress.\nGU: No acute issues.\nFAMILY: DTR called this am and kept abreast of pt status/POC. The pt remains a full code.\nOTHER: Please see carevue for additional pt care data.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-25 00:00:00.000",
"description": "Report",
"row_id": 1399533,
"text": "NURSING NOTE\n\nNEURO: PT SLEPT MOST OF THE NIGHT, OPENS EYES TO VOICE, DOES NOT FOLLOW COMMANDS\n\nPULM/CV: VSS, BP 117/58- 143/71, HR AFIB 90'S WITH OCCAS PVC'S, TMAX 99.7 AX, CARDIZEM GTT CONTINUES @ 20MG/HR, PT STARTED ON 45MG PO CARDIZEM THIS AM, 4LNC O2 POX 98-100%, SUCTIONED COPIOUS AMTS SECRETIONS NASALLY THICK TAN, PT UNABLE TO EXPECTORATE SECRETIONS, R TLIJ IN PLACE, L RAD ALINE IN PLACE\n\nGI/GU: ABD SOFT, DISTENDED HYPOACTIVE BS, NO BM'S RECTAL BAG REMAINS IN PLACE, TF PROMOTE WITH FIBER @10CC/HR, MINIMAL TO ZERO RESIDUALS, NGT L NARE IN PLACE, MEDS GIVEN VIA NGT, ADEQUATE AMTS UOP 45-80CC/HR CLEAR YELLOW\n\nPT APPEARS COMFORTABLE, TURNED AND REPOSITIONED PRN, SEE CAREVUE FOR FULL ASSESSMENTS\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-25 00:00:00.000",
"description": "Report",
"row_id": 1399534,
"text": "Resp care note:\n Pt weaned down to 3l O2 nasal cannula. Pt has been in afib throughout the shift. Pt has a weak congested cough. pt's breath sounds are end exp wheezes and bilaterally decreased. albuterol nebs given today prn. Pt tolerates treatment well. Slight improvement with treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-25 00:00:00.000",
"description": "Report",
"row_id": 1399535,
"text": "ALTERED HEMODYNAMICS\nD: PT REMAINS LETHARGIC BUT THOUGH PT DES NOT FOLLOW SIMPLE COMMANDS. DOES GRIMACE AND WITHDRAW TO PAINFUL STIMULATION.\nMAX TEMP=99.6 AXILLARY WITH WBC=8.9. CONTINUES ON LEVAQUIN. O2 WEANED DOWN TO 3L/M NC WITH O2 SATS>95% CONTINUES TO RECEIVE NEBS AS ORDERED BECAUSE OF EPISODES OF INSP/EXP WHEEZES. CXR C/W CHF AND LASIX 2 MG IVP GIVEN AND WILL FOLLOW I&O. HR AFIB RATE O90'S AND OCCASIONALLY UP TO 120'S. REMAINS ON DIG AND CAPTOPRIL. DILTIAZEM GTT AND PO MED D/C'D AND RESTARTED ON LOPRESSOR 75 MG QID VIA NGT. SBP 115-157. PT13.4 AND PT IS ON DOSE OF COUMADIN AND TODAY HAS BEEN STARTED ON LOVENOX 80 MG SC BID. WILL FOLLOW COAGS AS ORDERED. GI: PT WITHOUT STOOL OUTPUT AND BECAUSE OF THE PROBLEM LAST WEEK WITH IMPACTION PT WAS GIVEN A TOTAL OF 4 DOSES OF 60 CC LACTULOSE VIA NGT WITH GOOD EFFECT. ONCE PT IS MORE AWAKE AND HER HR IS BETTER CONTROLLED PT BE TRANSFERED TO FLOOR. WOULD CONTINUE WITH LACTULOSE 30CC'S QID FOR BOWEL REGIME. PT'S FAMILY HAS NOT CALLED TODAY FOR UPDATE. SHE REMAINS A FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-26 00:00:00.000",
"description": "Report",
"row_id": 1399538,
"text": "altered hemodynamics\nd:THIS AM PT OPENED EYES TO NAME BEING CALLED AND OCCASIONALLY FOLLOWING SIMPLE COMMANDS. MAE'S AND RESTLESS IN BED-ROLLING FROM SIDE TO SIDE. O2 AT 3L/M NC WITH O2 SATS>95%. RECEIVING NEBS Q 6 HRS AS ORDERED. INSP/EXP WHEEZES BIL. MULTIPLE CARDIAC MEDS CHANGED. LOPRESSOR DOSE WAS DECREASED BECAUSE OF THE WHEEZES ON AUSCULTATION.AT 1200 HR CONSISTENTLY 160-180'S AFIB WITH SBP157-177. MEDICAL TEAM NOTIFIED. AT THE SAME TIME PT WAS RESTLESS AND AGITATED BUT NOT VERBALIZING. 3.5 MG IVP HALDOL GIVEN WITHOUT EFFECT. PT DIAPHORETIC BUT EKG WITHOUT CHANGES. AT 1430 DILTIAZEM GTT STARTED AT 20MG/HR AND ADDITIONAL 5 MG IVP HALDOL GIVEN WITH GOOD EFFECT. PT SLEEPING AND HR NOW 90-100'S WITH SBP120-140'S. ? WETHER THIS WAS AN ICU PSYCHOSIS RELATED EVENT.ABG CHECKED DURING THIS EPISODE TO R/O RESP EVENT AND RESULTS=7.7.46/45/64/33/6 WILL CONTINUE WITH DILT GTT AND D/C VERAPAMIL AND LOPRESSSOR FOR NOW. CONTINUE TO ASSESS MS AS NEEDED. PT'S FAMILY HAS BEEN UPDATED BY PHONE. BECAUSE OF THE INCREASED WHEEZES AND PT BEING FOR PNEUMONIA WITH PT GIVEN 1X DOSE OF PREDNISONE 60 MG PO. K+3.6 AND WAS REPLACED WITH 60 MEQ KCL VIA OGT. HCT STABLE AT 32.3. CONTINUES TO RECEIVE COUMADIN 2.5 MG QD AS WELL AS LOOVONOX 80 MG WITH PT OF 14.9 AND INR OF 1.5. ABD BENIGN ON EXAM AND RECTAL TUBE WITH APPROX 100CC'S LIQ BROWN STOOL. WILL FOLLOW HEMODYNAMICS AND MS. CONTINUE WITH DILTIAZEM GTT AT PRESENT RATE AND TITRATE TO KEEP HR<100 AND SBP AROUND 120. PT REMAINS A FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-27 00:00:00.000",
"description": "Report",
"row_id": 1399539,
"text": "Pmicu Nursing Progress Note:\n\nNeuro: increased alertness, w/ periods of somnulance. Orientated to self and family. Unable to state place or date. Attempted to get OOB x 3. Wrist restraints placed.\n\nCV/Pulm: dilt gtt cont at 15mg/h w/ goal to keep hr <100. Cont in afib, no ectopy noted. SBP 133-110. cont NC 3l w/ O2 sats >95%. LS clear w/ faint wheeze RUL.\n\nGI/GU: TF^ to 50cc/h goal 65cc/h. FSBS >350. Rectal tube patent - draining sm amts of brown liquid stool. HCT remains stable at 32.5. U/O 50-80cc/h.\n\nAccess/Integ: open areas on buttocks, cleaned -OTA.\n\nSocial: family called x 1, asking appropriate questions.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-25 00:00:00.000",
"description": "Report",
"row_id": 1399536,
"text": "MICU A NPN 7-11pm\nCardiac-\n1730--- HR increased to 124-156 Afib w/VEA > 10/min and increase in SBP 140-160 despite increase Lopressor to 75 qid. HO notified, and assessed pt. Lopressor 5mg IVP and increased to 100mg po QID --both given at w/ good response of 95-110 Afib w/ slight decrease of VEA, and SBP decrease 110-116/50.\n\nREsp-\nDuring above ^ HR and SBP, ^RRto 26-30, with O2sat of 92-94. BS=minimal to no wheezes but ronchi upper ant. yankauer sx for moderate tan thick secretions in oropharynx--gag minimal. After Lopressor IV and PO/NG, w/ HR and SBP, (and sx) pt RR -20 and sat ^95-96%.\n\nI/O- Volume\nIV lasix 20mg IVP given at 1600 w/ good response 180 cc over 1-2 hours. U/O 20-30/hour -2300. IV= KVO at 10 cc/hr. Mod amount liq stool out (rectal tube in place now) w/ additional incont volume.\n\nInf Dis\nT max 100.4 at . On Levoquin qd (d#) for LLL infiltrate and atelectasis. Tylenol 650mg per NG given.\n\nMental \nPt visably uncomfortable w/ ^HR/ SBP. Once controlled, looking much more comfortable. Still minimal response to voice, more to painful stimuli, but moving limbs more spont over the course of evening.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-26 00:00:00.000",
"description": "Report",
"row_id": 1399537,
"text": "Pmicu nsg progress note\n Pt moving about in bed at times moaning but unable to follow commands. No further sedation.\nCardiac- Cont in af with rate 80-110 on increased does of lopressor. No further iv lopressor. Bp stable with adwquate uo\nGi- Recieving tube feeds at 20/hr. Passing mod amts liquid brown stool via rectal tube. Cont on ss insulin with fs on 200's. No s/s bleeding\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-22 00:00:00.000",
"description": "Report",
"row_id": 1399527,
"text": "PMICU Nuring Progress Note\nReview Of Systems-allergies PCN, full code\n\n Pt in Afibrillation, frequent PVC's, HR 90-100 w/ bursts 120-130's. Highest HR (150's) occurred after pt's sedation was dc'd and recieved MOM enema; team notified, 5 mg IV lopressor given w/ good effect. Arterial BP's monitored ranged from 120-140's/60-70's, short period of hypertension associated w/ tachycardia.\n\nResp-Pt remains intubated, placed on weaning trials after rounds-CPCPA. PS 10, PEEP 5, TV's 300-400's, RR in the 20's. After period of inc. HR and BP and low grade temp apnea alarm triggered several times. Team and RT noted, vent changes made (please refer to RT note); SIMV, 600x10, PS 10. LS coarse throughout. Pt required infrequent suctioning for thick, whitish sputum.\n\nNeuro- Ativan sedation dc'd. Pt still not awake; w/draws to painful stimuli, does not follow commands. Grimaces in response to pain and has non-purposeful movements.\n\nGU- U/O 60-70 cc/hr, clr yellow urine.\n\nGI- TPN infusing. Hyperactive BS, abd. soft, distended. Rectal bag changed. One MOM enema given-moderate amt. of loose brown stool resulted, no clots seen.\n\nHeme/endocrine- HCT 30.8, hemodynamically stable. BG ranged from 222-318, recieved insulin per sliding scale orders. Dietary notified about insulin reqirements, discussed adding insulin to TPN.\n\nID- Max temp 101.1, given PO tylenol. No growth in all cultures done to date.\n\nPlan: Continue to treat constipation w/ enemas as ordered. Team discussed KUB for tomorrow am. Monitor resp and CV status closely. Allow pt to rest overnight and begin resp. trials again tomorrow morning. Monitor neuro status-if pt becomes extremely agitated, sedate w/ ativan-otherwise try to avoid.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-23 00:00:00.000",
"description": "Report",
"row_id": 1399528,
"text": "Pmicu Nursing Progress Note:\n\nCV/neuro: HR 95-115, afib w/ frequent PVC's: runs into 130-140's. SBP 160-180's. MD's made aware. PO lopressor increased. Rec'd iv lopressor 5mg x 2. Lopressor 25mg po x 1 given. Ativan 2mg given w/ little effect. Placed on propofol gtt to decrease agitation/HR. Propofol slow to reach sedation level, but now w/ excellent sedating effect at 10.58mcg/kg/min.\n\nPulm: Vent changed-> simv 550 x 10 fio2 40%-> abg 101/43/7.43. Sx x 3 for thick wht secretions. LS coarse throughout.\n\nGI/GU: abd soft, hyperactive BS. Rectal bag replaced, drng brown g+ stool. Stool total for shift ~300cc. TPN cont's. U/O 60-75cc/h.\n\nID/Labs: Tmax 100.1 ax. Started on po levoquin yesterday. Hct 30.4, INR 1.2.\n\nAccess/Skin: aline dampened and occassionally difficult to draw from. sm skin tear on coccyx-tegaderm place prior to rectal bag placemt.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-18 00:00:00.000",
"description": "Report",
"row_id": 1399508,
"text": "PMICU NURSING PROGRESS NOTE:\n\n77 YO woman was in USOH until 4 wks ago when she reports starting to have painful bm's and passing lg clots several times/day. Presented to ew on where she passed 900cc of BRBPR. Hct 38, INR 5.8(on coumadin at home for A-fib). Was admitted to medical floor. On continued to pass large clots per rectum, HCT fell to 30, with runs of afib to 160's. Transferred to Pmicu for further management.\n\nPMHx: CAD, Afib, s/p avr w/ valve, HTN, DM, COPD, CHF, diverticulitis , h/o LGIB, ^chol.\n\nAllergies: PCN\n\nGI/Heme: Rec'd 2u FFP on admission to micu. Intial HCT holding at 30. Later passed very large amt of BRBPR, w/lg clots(~1000cc). Midnight HCT now 28.4, INR 1.6. Denies nausea, cramps or dizziness. Ordered for 2u PRBC's, 1st now hanging. Pre-medicated for transfusion. Pt had tagged RBC scan today which was negative. Rec-ing IVF at 150cc/h. Colonoscopy possible on Fri. Cont to monitor FS.\n\nCV/Pulm: Afib, rate 90-135.HR coming down w/ hydration, and blood products. Cont on lopressor, coumadin on hold. Cont digoxin. Upon arrival showed no sx of supposed reaction to iv vit K, no rash, airway difficulty, or itchiness. Arrived on RA w/ O2 sat 90-92%. Placed on NC 3L w/ O2 sat >95%.\n\nGU/Integ: + foley. u/o sufficient. Bruises visible over whole body.\n\nNeuro: A&O x3, cooperative.\n\nSocial: dtr very involved - called to check in.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-18 00:00:00.000",
"description": "Report",
"row_id": 1399509,
"text": "nsg progress note\n8 am hct 31.6, 1 pm hct 30.6. denies abd pain. small ooze x2 dark bloody drg. tol clears. heparin gtt started this am 2nd afib. started at 750u/hr. bilat insp/exp wheeze- albuterol/atrovent nebs x2 w/o releif. lasix 20 x1. sats 95-98 with 4l nasal . a+o. c/o only mild lower back pain- rx with tylenol. plan scope pr md. to remain in micu overnoc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-18 00:00:00.000",
"description": "Report",
"row_id": 1399510,
"text": "7P-11 npn\nPTT 40.8 Heparin gtt increased to 800 u/hr Hct 30.8 K~3.6 pt to receive 40 meq po x1. pt to have colonoscopy in am - to drink 4l go-lytely prep tonight. VSS afebrile, BP 122/57 HR 85 AF sats 98% on 4 l n/p pt c/o back pain~med w/ 650 mg Tylenol (pt stated she fell @ home a few weeks ago - HO aware)\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-19 00:00:00.000",
"description": "Report",
"row_id": 1399511,
"text": "PMICU Nursing Progress Note:\n\nPt started go-lightly prep at ~8:30pm. Was able to drink approx over next 3hrs. Started c/o of cramps: go lightly d/c'd. Also started to have intermittent runs of ST to 130-140's. Cont'd to c/o of cramps and abd pain, felt like she had to have BM but was unable. Still had no rslts from the go lightly prep. Runs to 160's and runs of ST became more frequent. Lopressor iv 5mg given x 2-> w/ min reslts. At approx 11:45pm started shouting out that she couldnt breath. Was given 2mg ativan, neb tx, 1mg MSO4, lasix w/ no relief or improvement. Additional piv placed, abg stick attempted w/o success. Anesthesia called, pt intubated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-19 00:00:00.000",
"description": "Report",
"row_id": 1399512,
"text": "Respiratory Care:\n\nPatient intubated for increased resp distress. 7.0 ETT taped at 20 cm. Vent settings Vt 600, A/C 12, Fio2 40%, and Peep 5. PAP/Plateau 25/18. A/C rate weaned to 8 with peep increased to 7.5. PaO2 improved. Bs clear bilaterally. Combivent MDI given Q6hr. Serevent ordered . No further changes made. See Carevue for Abg's. Continue with mechanical support and wean to Psv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-19 00:00:00.000",
"description": "Report",
"row_id": 1399513,
"text": "MICU Nsg progress note\nCV: Pt started on Dilt gtt at 5mg/hr and titrated up to 10mg/hr with HR gradually down from 160s to 70s Afib. Occational PVC noted. K+ 4.0\nBP 140-180s initially after intubation but then dropped to 90-low 100s after pt started and Dilt gtt and sedated with Ativan and Fentanyl. Over past hr BP down to 80-90s. Dilt decreased back to 5mg/hr and sedation decreased. HR up to 80s but BP remained low. Pt presently receiving 500cc NS bolus. Pt cont on Heparin gtt. PTT 49.1 on 800u/hr and was increased to 850u/hr. Pt needs repeat PTT at 10am. Pt to be r/o for MI. 1st CK 43.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-19 00:00:00.000",
"description": "Report",
"row_id": 1399514,
"text": "MICU nsg progress note\nRespiratory:Pt vented initially on AC 14 TV 600 FIO2 40% with ABG 66/35/7.47 PEEP increased to 7.5 and rate decreased to 12 with ABG 77/35/7.52. Rate decreased to 8 with ABG 94/45/7.42. Lungs sounds- I/E wheezes prior to intubation. Pt receiving nebs overnight. LS now clear - upper airways, crackles at bases.\n\nGI: Abdomen soft very distended at 12mn, +BS. NGT placed - large amt air + approx 100cc golytly aspirated from NGT with abdomen less distended. No stool overnight. HCT 30.9.\n\nEndo: BS up to 350 - covered with regular insulin per s/s. BS down to 210 this morning.\n\nNeuro: Pt agitated after intubation. Initially sedated with MSO4 3mg/h and Ativan 3mg/hr with pt adequately sedated but arousable to stimuli. With drop in BP sedation decreased - pt now on only 1mg/h Ativan.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-19 00:00:00.000",
"description": "Report",
"row_id": 1399515,
"text": "s/p lower gi bleed\nD: PT REMAINS INTUBATED AND ATIVAN GTT WAS D/C'D AT 0900 AND PT HAS REQUIRED NO FURTHER SEDATION. SHE IS LIGHTER BUT DOES NOT FOLLOW SIMPLE COMMANDS AND HAS NOT BEEN RESTLESS OR OPENED HER EYES TO HER NAME BEING CALLED. DILTIAZEM GTT INCREASED OT 10MG/HR BECAUSE HR CLIMBED TO 100'S AND REMAINED IN AFIB. SBP >97. DIFFICULTY WITH DRAWING BLOODS OFF THE ALINE AND THE RESULTS OF ALL THE LABS HAVE BEEN SLIGHTLY MEDICAL TEAM AWARE. VENT MODE OF VENTILATION CHANGED TO 40% CAP WITH 5 OF PEEP AND IPS OF 10 WITH O2 SATS>98% AND RR 16-22. SUCTIONED ETT BUT NO SPUTUM OBTAINED. PLAN IS TO EXTUBATE WHEN PT AWAKENS. NGT IN PLACE BUT REMAINS CLAMPED. KUB THIS AM REVEALED THAT PT WAS FULL OF STOOL. A TOTAL OF 8 TAP WATER ENEMAS GIVEN AND INITALLY BRB PER FIB BUT HTEN CLEARED AND IS NOW BROWN BUT POS GUAIC. FIB CHANGED TO MUSHROOM CATH AFTER FIB NOTED TO BE LEAKING. HCT STABLE 28.9-29 BUT AFTER PT IS FULLY CULTURED WILL TRANSFUSE WITH 1 ADDITIONAL U PRBC. UO HAS BEEN BORDERLINE BUT HAS NOT RESPONDED TO 2 BOLUSES OF 250CC'S NS. GI TEAM BY TO SE PT AND NO INTERVENTION TO BE DONE AT PRESENT. WILL FOLLOW HCTS AS ORDERED. FOLLOW AND PT BE EXTUBATED IN THE AM IF SHE WAKES UP AND IF KUB IMPROVES TOMORROW. PT'S DAUGHTE IN TO VISIT WITH PT AND AHS BEEN UPDATED BY NURSING AND MD. PT REMAINS A FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-11-19 00:00:00.000",
"description": "Report",
"row_id": 1399516,
"text": "resp. care note\nremains intubated and vented. changed to ps 10/5 with good vols. and rate. no abg at this point. still rather sleepy. ets thick tan secretions. mdi's given. cont. support and extubate when awake.\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 745250,
"text": " 12:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 77yo woman extub yest w/ decr BS LLL, exp wheezes. Eval for\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with COPD, CAD, CHF undergoing bowel prep for colonoscopy\n s/p code, s/p NG tube placement\n REASON FOR THIS EXAMINATION:\n 77yo woman extub yest w/ decr BS LLL, exp wheezes. Eval for PNA progression,\n CHF.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Decreased breath sounds left lower lobe and expiratory wheezes.\n\n Portable upright AP chest radiograph dated is compared to portable AP\n supine radiograph dated . There is an enlarged cardiac silhouette with\n a tortuous calcified aorta. Sternal wires are seen. An NG tube is seen to\n course below the diaphragm but the tip is not included on the film. A right\n internal jugular venous catheter is in place with the tip in the mid superior\n vena cava. There is collapse of the left lower lobe and a left sided pleural\n effusion cannot be excluded. There is mild blunting of the right costophrenic\n angle probably representing a small effusion. There is chronic upper zone\n redistribution of the pulmonary vascularity. There is no pneumothorax.\n Overall, there is minimal change compared to the prior study.\n\n IMPRESSION: Left lower lobe atelectasis.. This is new compared to prior\n study. Remainder of the lung parenchyma is essentially unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-17 00:00:00.000",
"description": "GI BLEEDING STUDY",
"row_id": 744738,
"text": "GI BLEEDING STUDY Clip # \n Reason: DIVERTICULOSIS. ON COUMADIN. ACTIVE GI BLEED ? SOURCE.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diverticulosis on Coumadin. Active GI bleed ? source.\n\n INTERPRETATION: Following intravenous injection of autologous red blood cells\n labeled with Tc-m, blood flow and delayed images of the abdomen for 90 minutes\n were obtained.\n\n Blood flow images show no active bleed.\n\n Delayed blood pool images also show no abnormal tracer activity to suggest an\n active GI bleed.\n\n IMPRESSION: No evidence of active GI bleed. /nkg\n\n\n , M.D.\n , M.D. Approved: WED 5:27 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 744849,
"text": " 12:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f appropriate ETT placement, e/f free air, any air/fluid l\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with COPD, CAD, CHF undergoing bowel prep for colonoscopy\n s/p code\n REASON FOR THIS EXAMINATION:\n e/f appropriate ETT placement\n e/f free air, any air/fluid levels\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ETT placed. COPD. CAD, CHF.\n\n FRONTAL CHEST: Comparison with is made. The heart remains enlarged.\n Exam is degraded by respiratory motion and evaluation of cardiopulmonary\n status is limited. There appear to be areas of bibasilar atelectasis. No\n pleural effusions are identified. ETT in good position.\n\n IMPRESSION: Satisfactory positioning of ETT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-20 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 744932,
"text": " 8:29 AM\n PORTABLE ABDOMEN Clip # \n Reason: 78yo woman w/ incr abd distension. Moved bowels yest, nothi\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with lower GI bleed\n with inability to pass stool, no flatus, increasing abd pain.\n REASON FOR THIS EXAMINATION:\n 78yo woman w/ incr abd distension. Moved bowels yest, nothing o/n. Concerned\n for obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE VIEW\n\n HISTORY: History of increasing abdominal pain and distention in patient with\n lower GI bleed. Evaluate for obstruction.\n\n NG tube is in body of stomach. Gas and fecal residue are present throughout\n the colon and there is no evidence of intestinal obstruction. There is a\n calcified gallstone. Previously noted focal calcifications in left mid zone\n overlying the left renal region are again demonstrated. The cecum is\n difficult to measure but not acutely dilated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-21 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 744966,
"text": " 6:09 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval persistent abd distention and attempts to decompress\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with lower GI bleed\n with inability to pass stool, no flatus, increasing abd pain.\n REASON FOR THIS EXAMINATION:\n eval persistent abd distention and attempts to decompress\n ______________________________________________________________________________\n FINAL REPORT\n History of persistent abdominal distention with absence of bowel movement and\n flatus and inability to decompress.\n\n NG tube is in stomach. Distribution of bowel gas is unremarkable and there is\n no evidence for intestinal obstruction. There is an opacity in the left lung\n base consistent with consolidation/effusion. Status post sternotomy. Calcific\n densities overlie the left renal outline.PRESSION: No evidence for intestinal\n obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 744957,
"text": " 5:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PLEASE CHECK LINE PLACEMENT AND R/O PNEUMOTHORAX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with GIBLEED, ABD DISTENSION\n REASON FOR THIS EXAMINATION:\n PLEASE CHECK LINE PLACEMENT AND R/O PNEUMOTHORAX\n ______________________________________________________________________________\n FINAL REPORT\n Chest single film.\n\n History of GI bleed with abdominal distention and line placement.\n\n Endotracheal tube is 6 cm above carina. CV line introduced via right jugular\n vein is in proximal SVC. NG tube extends below diaphragm. Status post CABG.\n No pneumothorax. There is cardiomegaly with slight upper zone redistribution\n but no overt pulmonary edema. There could be some atelectasis in the left\n lower lobe with slight elevation of the left hemidiaphragm. Overall\n appearance is unchanged since the previous film of . No focal\n opacities noted in the right apical region on this film.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-20 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 744960,
"text": " 5:16 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: 77yo woman w/ LGIB thought diverticulosis given prep for col\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with DM, ischemic CM EF 35-40%, afib, COPD, AVR, CAD,\n hyperchol, s/p appy + partial thyroidectomy + oopherectomy.\n REASON FOR THIS EXAMINATION:\n 77yo woman w/ LGIB thought diverticulosis given prep for colonoscopy and ceased\n stool outpt. Abd\n pain, cramping, distention, dilated loops on KUB film, likey ileus. Assess for\n causes of ileus-- obstruction, diverticulitis, etc.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Abdominal distention and no bowel movement despite bowel preparation\n for colonoscopy.\n\n TECHNIQUE: Images of the abdomen and pelvis were obtained with oral and\n intravenous contrast enhancement. Reconstructions were also performed.\n\n CT ABDOMEN WITH CONTRAST: There are moderate pleural effusions bilaterally,\n with adjacent atelectasis. A large lamellated gallstone is noted. There is\n no gall bladder wall thickening or pericholecystic fluid. The liver, spleen,\n pancreas and right adrenal gland are normal. There is calcification in the\n left adrenal gland, likely due to distant hemorrhage or infection. There are\n areas of cortical scarring in both kidneys, greater on the left. There is\n extensive calcification of the aorta and its major branches, without\n aneurysmal dilatation.\n\n The stomach and small bowel are normal in caliber. The ascending and\n transverse colon is distended with fluid and gas; fluid is mixed with stool in\n the descending colon.\n\n CT PELVIS WITH CONTRAST: Multiple sigmoid diverticula are noted. The rectum\n is distended with stool. There is no evidence of an obstructing lesion. The\n urinary bladder is collapsed by a Foley catheter. The uterus is atrophic.\n There is a small amount of free fluid in the pelvis.\n\n Bone windows demonstrate generalized demineralization. Degenerative changes\n are present in the lumbar spine.\n\n IMPRESSION:\n 1) Small pleural effusions bilaterally and small amount of pelvic free fluid.\n 2) Rectal distention with stool.\n\n\n (Over)\n\n 5:16 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: 77yo woman w/ LGIB thought diverticulosis given prep for col\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-24 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 745158,
"text": " 8:58 AM\n PORTABLE ABDOMEN Clip # \n Reason: 77yo woman w/ decr abd distention. Eval for interval change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with lower GI bleed with inability to pass stool, no flatus,\n increasing abd pain.\n REASON FOR THIS EXAMINATION:\n 77yo woman w/ decr abd distention. Eval for interval change in loops of bowel\n and content of colon.\n ______________________________________________________________________________\n FINAL REPORT\n\n ABDOMEN, SINGLE FILM.\n\n HISTORY: GI bleed with abdominal distension and absence of bowel movements.\n\n NG tube is in stomach. Distribution of bowel gas is unremarkable with gas\n present throughout the colon and no evidence for ileus or intestinal\n obstruction. Large calcified gallstone in right upper quadrant and multiple\n calcific densities overlie left kidney, as previously demonstrated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-30 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 745531,
"text": " 11:09 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: Please eval for aspiration.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with recent intubation in MICU, extubated several days ago\n but appears to be having difficulty swalling.\n REASON FOR THIS EXAMINATION:\n Please eval for aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77 YEAR OLD WOMAN WITH RECENT INTUBATION. APPEARS TO HAVE\n DIFFICULTY SWALLOWING AFTER EXTUBATION.\n\n FINDINGS:\n\n Video fluoroscopic evaluation was performed after oral administration of\n varying consistencies of radiopaque material. This ranged from thin barium\n liquid to barium coated cookie. Deep laryngeal penetration was identified\n with thin liquids. No aspiration was identified. Bolus formation was slow,\n but otherwise normal. Mildly enlarged cricopharyngeus is seen.\n\n IMPRESSION: Deep laryngeal penetration with thin liquid. Otherwise normal\n exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-19 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 744858,
"text": " 8:11 AM\n PORTABLE ABDOMEN Clip # \n Reason: e/f air/fluid levels, stool in vault, please also e/f approp\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with lower GI bleed undergoing bowel prep for colonoscopy\n with inability to pass stool, no flatus, increasing abd pain\n s/p OG tube placement\n REASON FOR THIS EXAMINATION:\n e/f air/fluid levels, stool in vault\n please also e/f appropriate placement of OG tube\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN, SINGLE FILM:\n\n History of increasing abdominal pain and OG tube placement.\n\n OG tube is in antrum of stomach. The distribution of bowel gas is\n unremarkable and there is no evidence for intestinal obstruction. A\n collection of focal radiodensities is noted in the left mid abdomen, n.\n overlying left renal outline consistent with calculi.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-22 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 745015,
"text": " 8:27 AM\n PORTABLE ABDOMEN Clip # \n Reason: e/f persistent stool, any air/fluid levels\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with lower GI bleed\n with inability to pass stool, no flatus, increasing abd pain.\n REASON FOR THIS EXAMINATION:\n e/f persistent stool, any air/fluid levels\n ______________________________________________________________________________\n FINAL REPORT\n\n ABDOMEN, SINGLE FILM.\n\n HISTORY: Abdominal pain with inability to pass tube and absence of flatus.\n\n A supine chest film is provided demonstrating sternotomy wires. ET tube is 4\n cm above carina. NG tube extends below diaphragm. CV line introduced via\n right jugular vein is in mid-SVC. No pneumothorax. There is cardiomegaly\n with small bilateral pleural effusions and slight upper zone redistribution,\n consistent with CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-22 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 745058,
"text": " 4:37 PM\n PORTABLE ABDOMEN Clip # \n Reason: decreased stool output\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with lower GI bleed with inability to pass stool, no flatus,\n increasing abd pain.\n REASON FOR THIS EXAMINATION:\n decreased stool output\n ______________________________________________________________________________\n FINAL REPORT\n\n ABDOMEN, SINGLE FILM.\n\n HISTORY: Abdominal pain with lower GI bleed and absence of bowel movements.\n\n NG tube is in proximal antrum of stomach. Gas is present throughout the colon\n and there is no evidence for intestinal obstruction. No soft tissue masses or\n radiopaque calculi.\n\n IMPRESSION: No evidence for intestinal obstruction. The cecum is not unduly\n dilated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 744860,
"text": " 8:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please e/f appropriate NG tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with COPD, CAD, CHF undergoing bowel prep for colonoscopy\n s/p code, s/p NG tube placement\n REASON FOR THIS EXAMINATION:\n please e/f appropriate NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: NG tube placement.\n\n A nasogastric tube is in place, and terminates within the stomach. An\n endotracheal tube is in satisfactory position. The heart remains enlarged.\n The pulmonary vascularity is within normal limits, portable technique. There\n remains an area of increased opacity at the right apex centrally, near the\n right clavicle. The lungs otherwise reveal no focal areas of opacification.\n There is probably a small right pleural effusion.\n\n IMPRESSION:\n\n 1. Nasogastric tube terminates below the diaphragm.\n\n 2. Asymmetric focal opacity in right apex, possible due to somation of\n structures on this portable radiograph. Recommended dedicated PA and lateral\n chest radiograph prior to discharge to differentiate somation of structures\n from a discrete lung nodule.\n\n 3. Cardiac enlargement.\n\n 4. Probable small right pleural effusion.\n\n"
}
] |
|
7,651 | 190,580 | The patient was admitted to where she underwent an aorto-bifemoral bypass on . Details of this procedure are dictated in a separate operative note. On the way to surgery she had become lightheaded and had a pre-syncopal episode, was initially taken to the Emergency Room prior to admission. This was felt to be secondary to mild hypovolemia and hypokalemia. She subsequently was taken to the pre-op holding area where she was hydrated adequately and her electrolytes were repleted. She felt better, back to her baseline and it was decided they would continue with surgery. Postoperatively she did quite well and was transferred up to the Vascular Intensive Care Unit. She was monitored with a Swann-Ganz catheter for any fluid shifts as well as cardiac events. Initially postoperatively she was maintained on renal dose Dopamine as well as Neo-Synephrine for a low blood pressure and low SVR and low urine output. She subsequently improved with two units of packed red blood cells and some mild gentle hydration. On postoperative day one she was subsequently weaned off of both medications and had adequate urine output. She continued to do well and was maintained on NPO until her bowel function returned. Her electrolytes were repleted adequately and she continued to progress well without any hemodynamically significant events. On postop day four her Swann-Ganz catheter was removed and she was now making good urine, passing flatus and was having a clear lung exam. She was gotten out of bed and evaluated by physical therapy. They felt she would need several days of acute rehabilitation while in hospital and would benefit from another two days. Currently she is doing quite well and she is tolerating an oral diet without any difficulty. She is afebrile with vital signs stable. She has been restarted on all of her usual medications. Her physical examination at this time reveals a well developed female appearing older than her standard age of 64. Her neck is supple without evidence of jugular venous distention and there is a left carotid bruits. Her heart is regular rate and rhythm. Lungs are clear to auscultation bilaterally without wheezes, rales or rhonchi. Abdomen is soft, nontender, nondistended with positive bowel sounds present. Her incisions are clean, dry and intact with staples present in the midline and in both groins. There is no drainage from these incisions or erythema noted. Her pulse exam is remarkable for palpable femoral pulses bilaterally as well as posterior tibial pulses bilaterally. Her disposition at this time is stable, progressing well. She will be discharged when she is cleared by physical therapy and wishes to be discharged home to go to a rehabilitation facility. Her staples are to remain in until she follows up with Dr. in approximately 10 days to two weeks. A nurse will be arranged for routine vitals and monitoring. At this point home physical therapy is not necessary. | resolved with diuresis. db+c.gi: ngt dc'd. CV=HEMODY STABLE. F0LLOW UO-?ATTEMPT TO DIURESE. NIPRIDE WEANED & DCED. TOLERATING EXTUBATION. improved w/diuresis. PM LASIX DOSE HELD. Interstitial edema. Resolving CHF. This has fluid attenuation that probably represents a postop seroma. There is perihilar haze. PCA PUMP INFUSING AS ORDER.A:HEMODY STABLE. There is interval placement of endotracheal tube and NG tube. please eval for chf. please eval for chf. CCU NSG PROGRESS NOTE-SICU BORDER.O:CV=HEMODY STABLE. R/O pneumothorax. WO FLATUS. WO FLATUS. Ascites. CV=VARIABLE BP-ON NIPRIDE & NTG W GD CONTROL. ntg and nipride weaning for sbp<130. CK AM LABS-REPLACE S INDICATED. replete lytes. There is interval placement of an NG tube, that is in the appropriate position. TOLERATING CAPTO, HYDRAL, & LOPRESSOR. The right IJ catheter tip is located in the mid SVC. ACCESS-RIL MLC & LRAD ALINE. There is a hypodensity within left mid pole that probably represents a simple cyst. "O: For complete VS see CCU flow sheet.ID: PT afebrile. CONTIN DECREASED UO.P:ENCOURAGE DB & IS. enc i/s. OP SITE=DSG D&I. Q-T interval prolongation. added captopril. CVP was . First degree A-V block. ET tube and NG tube removed. MAINT ADEQ UO. LABS=K & CALCIUM-REPLACED. There is interval improvement in aeration, consistent with resolving CHF. There is pericholecystic fluid. Sinus bradycardia with first degree A-V block. IMPRESSION: 1) CHF with interstitial edema, slightly improved. on ampi for uti. The cardiomediastinal silhouette is within normal limits. ?CALL-OUT. ABG X2 W GD #'S-SEE FLOW SHEET. There is a small pericardial effusion. bp 120-180/50-60 via l rad aline. There is vascular calcification consistent with atherosclerotic disease. There is diffuse subcutaneous edema. Again noted is slight cardiomegaly. MAINT BP 120'S. OP SITE-WO CHG. LABS=AM SENT.A:STABLE. ?DC ALINE. GU=DECREASED UO. oob to ch with 2 assist. IMPRESSION: Interval placement of ETT, NGT and right IJ central venous catheter, which are in appropriate position. Sinus bradycardia. Underlying right bundle-branchblock. Q-T interval prolongation isless.TRACING #2 There is evidence of ET tube, PA line and NG tube in place. The SGC has been replaced with a right IJ catheter, which has its tip in the SVC. IMPRESSION: 1. IMPRESSION: 1. BOLUSED W LR 500ML X1 WO SIGNIF IMPROVEMENT. There is calcification and tortuosity of the aorta. Mild congestive failure. htn improving.p: pulm toilet. scatt coarse and occ exp wheeze. IMPRESSION: Right-sided Swan-Ganz catheter probably within the RV outflow tract and suggest advancement. Bilateral pleural effusion with associated subsegmental atelectasis. started sips of clears. Contact pt. WO CO SOB/DYSPNEA. There is a right IJ Swan-Ganz catheter, with the tip overlying region of the RV outflow tract. COMPARISON: . There is prompt excretion of contrast. Two hypodensities, first at the dome of the diaphragm (series 2, image 7) and the second on (image 3). The ET tube and NG tube have been removed. CCU NSG PROGRESS NOTE-SICU BORDER.O:PULM=BREATH SOUNDS=CLEAR. There is bilateral apical pleural thickening, unchanged from the last examination. IMPRESSION: 1) PA line in place, with tip in the right pulmonary artery. ENCOURAGE PO FL. FOLLOW ABG. Prolonged Q-Tc interval. Page w/ questions/results. FINAL REPORT INDICATION: Placement of PA line. rr 14-20. diffuse crackles this am. STRESS IMPROVEMENT & PROGRESS. A-V junctional rhythm. LABS=AM SENT. There are tiny bilateral pleural effusions. She conts on ABX.CV: HR ranges between high 70s to low 100s. Right IJ tip in SVC; no pneumothorax. Evaluate for pneumothorax. Please eval for abscess, obstruction. wean iv drugs as tol. The heart is within normal limits. There remains upper zone redistribution and mild interstitial pulmonary edema, with slight improvement from . follow response to lasix. FINAL REPORT INDICATION: PA catheter placement, evaluate for CHF. pca with good pain control.id: afeb. New, sizeable bilateral pleural effusions. denies flatus. There is a small amount of perihepatic fluid collection. NTG WEANED TO 60MCG. CHEST AP: FINDINGS: Comparison is made to the prior film dated . To evaluate for obstruction. CT ABDOMEN WITH CONTRAST: There is bilateral small pleural effusion associated with atelectasis (right greater than left). The tip of the PA line has been repositioned and now is in the right pulmonary artery, with satisfactory position. The tip of the NG tube is in the mid stomach. There is evidence of cholestasis with sludge formation. The ET tube is in proper position. 3. 3. PORTABLE AP CHEST: The right internal jugular Swan-Ganz catheter has been withdrawn with tip now in the proximal right atrium. There is mild prominence of the biliary ducts. CCU NSG PROGRESS NOTE-SICU BORDER.O:PULM=DEMINISHED BREATH SOUNDS THROUGHOUT-WO AUDIBLE CRACKLES. 4. 4. DIURESING.P:CONTIN PRESENT MEDICAL PLAN. NTG GTT @ 60MCG. 2. 2. 2. SUPPORT. The enhancing pattern suggest active extravasation at the site of proximal anastomosis. IMPRESSION: (Over) 5:47 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: 64yoF POD#6 s/p aortobifem w/ acute onset LLQ abd pain. GU=DIURESED W LASIX @ 0600 & 0400 W EXCELLENT RESPONSE. 1:40 AM CHEST (PORTABLE AP) Clip # Reason: s/p aortobifem. Ple Field of view: 36 Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) 1. | 18 | [
{
"category": "Nursing/other",
"chartdate": "2143-12-22 00:00:00.000",
"description": "Report",
"row_id": 1364852,
"text": "CCU NSG NOTE: S/P SURGERY\nS: \"This has been so long and so painful. \"\nO: For complete VS see CCU flow sheet.\nID: PT afebrile. She conts on ABX.\nCV: HR ranges between high 70s to low 100s. Higher number are near when her lopressor 15mg iv is due. BP is also labile, but more in control as day went on. Earlier in the day she ranges 145-170/50s on 60mg iv nitro. Captopril was increased to 50mg po and hydralazine was increased to 20mg IV. BP has been in 1o0-130s/50s later in the day. CVP was . She received 2 gm MgSo4 for Mg of 1.4.\nRESP: Pt has bronchial breath sound bilaterally and is very decreased at L base. On 4L NP she is sating 94-95% when lying down in bed, and uup to 96-97% when in the chair. RR 12-22.\nGI: Suture lines dry and intact. DSD placed over groin incisions. She has decreased bowel sounds and has not passed gas. She is taking sips and has no nausea.\nGU: Foley draining clear urine. She did not receive afternoon lasix as she is over 2 liters negative for the day.\nCOMFORT: Pt is now comfortable at rest. She does require pre-medication with pca mso4 with activity and had a total of 4mg today for washing and getting up to chair. She also received xanax po which she will take at home when she feel anxious.\nACTIVITY: Pt Assisted to cardiac chair. She was able to weight bare with minimal assist and seemed stable on her feet. PT consult tomorrow might help with increasing her activity.\nA: BP better controlled/ diuresis continues\nP: Continue assisting pt with position changes. Attempt to increase activity. Encourage pt to use pca prior to activity. Contact pt. Monitor for change.\n"
},
{
"category": "Nursing/other",
"chartdate": "2143-12-23 00:00:00.000",
"description": "Report",
"row_id": 1364853,
"text": "CCU NSG PROGRESS NOTE-SICU BORDER.\nO:CV=HEMODY STABLE. TOLERATING CAPTO, HYDRAL, & LOPRESSOR. NTG GTT @ 60MCG. ACCESS-RIL MLC & LRAD ALINE.\n GI=MINIMAL PO INTAKE-JUST SIPS. WO FLATUS.\n GU=>2L NEG @ 2300. PM LASIX DOSE HELD.\n =CONCERNED ABOUT PROGRESS-THINKS SHE'S NOT DOING WELL-MORE AWARE OF ALL HER ACHES & PAINS---REMAINS ON MSO4 PCA & STARTED ON XANAX & AMITRIPTYLINE. OP SITE-WO CHG.\n LABS=AM SENT.\nA:STABLE. MOBILIZING THIRD SPACE FLUID.\nP:CONTIN CARDIAC MEDS-?START TO CONVERT TO PO MEDS. ?DC ALINE. ENCOURAGE PO FL. MAINT ADEQ UO. STRESS IMPROVEMENT & PROGRESS. SUPPORT PT/FAMILY AS NEEDED. ?CALL-OUT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2143-12-20 00:00:00.000",
"description": "Report",
"row_id": 1364848,
"text": "npn admit to ccu from pacu\n64 yo women s/p aorto-bifem bpg c/b para-aortic hematoma with extravasation on pod #6 taken back to or for exp lap/exac of hematoma\npmhx-htn, ^chol, severe pvd, hypothyroid, pyelo, anxiety, bladder suspension, tah, thyroidectomy, nkda\n\nmanaged in pacu with nipride/ntg/lopressor/hydarlazine for goal sbp<130\narrived to ccu thisafternoon\nn-intact\nr-open face tent with good oxygenation/ventialtion, abg wnl\ncv-nsr 80's, bp quite variable 166-175-ntg at 267mcg's/min, nipride at .6mcg's/kg/min, ^'ing lopressor to 15mgs q 4hr, ^hydralazine to 20mgs q 8 with goal to wean nipride off and transfer to vicu, r ij 3 l cvl, l rad aline both intact, admission weight 54kgs now 84kgs-very fluid volume overloaded in third space-total body edema very taunt cvp only 13, in pacu were manageing low urine output state with multiple fluid volume boluses but this has not improved urine output, bilat fem sites wnl, abdominal dsg cdi\ngi-taunt distended abdomen\ngu-foley marginal uo\nafebrile\na/p-optimise hemodynamics, assess fluid volume balance, tranfer ti vicu when stable\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2143-12-21 00:00:00.000",
"description": "Report",
"row_id": 1364849,
"text": "CCU NSG PROGRESS NOTE-SICU BORDER.\nO:PULM=DEMINISHED BREATH SOUNDS THROUGHOUT-WO AUDIBLE CRACKLES. CONGESTED COUGH-PRODUCTIVE OF THICK GRAYISH SECRETIONS. SATS MID 90'S ON 4LNC & .5 CN. ABG X2 W GD #'S-SEE FLOW SHEET.\n CV=VARIABLE BP-ON NIPRIDE & NTG W GD CONTROL. W ANXIETY INCREASE IN BP.\n GU=DECREASED UO. BOLUSED W LR 500ML X1 WO SIGNIF IMPROVEMENT.\n LABS=AM SENT.\n OP SITE=DSG D&I. SPLINTING W COUGHING. PCA PUMP INFUSING AS ORDER.\nA:HEMODY STABLE. TOLERATING EXTUBATION. CONTIN DECREASED UO.\nP:ENCOURAGE DB & IS. MAINT SATS MID 90'S. FOLLOW ABG. MAINT BP 120'S. F0LLOW UO-?ATTEMPT TO DIURESE. CK AM LABS-REPLACE S INDICATED. SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2143-12-21 00:00:00.000",
"description": "Report",
"row_id": 1364850,
"text": "ccu nursing progress note\ns: my breathing feels heavy\no: pls see carevue flowsheet for complete vs/data/events\ncv: no cp but c/o sob. no acute distress. resolved with diuresis. bp 120-180/50-60 via l rad aline. added captopril. ntg and nipride weaning for sbp<130. k, mg, ca being repleted.\nresp: weaned to 5lnc. rr 14-20. diffuse crackles this am. scatt coarse and occ exp wheeze. improved w/diuresis. sats>96%. prod cough of yellow thick sputum. enc i/s. db+c.\ngi: ngt dc'd. no c/o n/v. denies flatus. started sips of clears. abd distended, hypoactive bs.\ngu: last lasix at 6pm. cr stable.\nms: more alert this afternoon. oob to ch with 2 assist. pca with good pain control.\nid: afeb. on ampi for uti. repeat ua sent.\nsocial: husband visited, he took her belongings home.\na: chf d/t volume overload. htn improving.\np: pulm toilet. replete lytes. wean iv drugs as tol. follow response to lasix.\n"
},
{
"category": "Nursing/other",
"chartdate": "2143-12-22 00:00:00.000",
"description": "Report",
"row_id": 1364851,
"text": "CCU NSG PROGRESS NOTE-SICU BORDER.\nO:PULM=BREATH SOUNDS=CLEAR. WO CO SOB/DYSPNEA.\n CV=HEMODY STABLE. TOLERATING CARDIAC MEDS. NIPRIDE WEANED & DCED. NTG WEANED TO 60MCG.\n GI=TAKING SIPS CLEAR LIQUIDS. WO FLATUS.\n GU=DIURESED W LASIX @ 0600 & 0400 W EXCELLENT RESPONSE.\n LABS=K & CALCIUM-REPLACED.\n SOCIALLY=STATES THAT SHE FEELS LOST-FORGOTEN ABOUT. CONCERNED W LENGTH OF HOSPITAL STAY & ABOUT HER HUSBAND. HOPING THAT NOTHING ELSE HAPPENS THAT WOULD LENGTHEN HER STAY IN THE HOSPITAL EVEN LONGER.\nA:STABLE. DIURESING.\nP:CONTIN PRESENT MEDICAL PLAN.\n"
},
{
"category": "ECG",
"chartdate": "2143-12-12 00:00:00.000",
"description": "Report",
"row_id": 152564,
"text": "Sinus bradycardia. First degree A-V block. Underlying right bundle-branch\nblock. Q-T interval prolongation. Compared to the previous tracing of \nthe right bundle-branch block is new. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2143-12-12 00:00:00.000",
"description": "Report",
"row_id": 152813,
"text": "Sinus bradycardia with first degree A-V block. Since earlier this date sinus\nmechanism has resumed, but the rate is unchanged. Q-T interval prolongation is\nless.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2143-12-12 00:00:00.000",
"description": "Report",
"row_id": 152814,
"text": "A-V junctional rhythm. Prolonged Q-Tc interval. No previous tracing available\nfor comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 746459,
"text": " 12:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/om PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p PA pacement\n REASON FOR THIS EXAMINATION:\n r/om PTX\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Check placement of Swan-Ganz catheter.\n\n Single portable AP chest radiograph is compared to a prior study dated\n . There is interval placement of an NG tube, that is in the\n appropriate position. There is a right IJ Swan-Ganz catheter, with the tip\n overlying region of the RV outflow tract. There is calcification and\n tortuosity of the aorta. The heart is within normal limits. There is\n prominence of the interstitium with no focal consolidations. The osseous\n structures are unremarkable.\n\n IMPRESSION: Right-sided Swan-Ganz catheter probably within the RV outflow\n tract and suggest advancement.\n\n Interstitial edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-12-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 746943,
"text": " 1:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p R cordis placement\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Status post right cortise placement. R/O pneumothorax.\n\n Single frontal view of the chest was compared to film obtained 9 hours ago.\n There is interval placement of endotracheal tube and NG tube. The tip of the\n endotracheal tube is 4.5 cm above the carina. The tip of the NG tube is in\n the mid stomach. There is also interval placement of the right jugular\n central venous catheter with its tip in the distal right jugular vein. The\n cardiomediastinal silhouette is within normal limits. There is bilateral\n apical pleural thickening, unchanged from the last examination. There is\n vascular congestion, associated with mild diffuse bilateral ground glass\n opacities, consistent with pulmonary edema. No pleural effusion or\n pneumothorax is seen. The visualized bony and soft tissue structures are\n unremarkable.\n\n IMPRESSION:\n\n Interval placement of ETT, NGT and right IJ central venous catheter, which are\n in appropriate position. Vascular congestion and mild diffuse bilateral\n pulmonary edema, suggestive of CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-12-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 746969,
"text": " 9:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p line placament\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p R cordis placement\n REASON FOR THIS EXAMINATION:\n s/p line placament\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post central venous catheter placement. Evaluate for\n pneumothorax.\n\n Supine AP radiograph dated at 21:35 is compared with the supine\n radiograph dated at 13:31.\n\n The heart size is normal. There is perihilar haze. There is worsening\n increased opacity in the retrocardiac space, an infectious process cannot be\n excluded. There are no pleural effusions.\n\n The right IJ catheter tip is located in the mid SVC. The ET tube is in\n proper position. There is no pneumothorax.\n\n IMPRESSION:\n 1. Increased opacity in the retrocardiac space which may represent atelectasis\n or pneumonia; follow-up radiographs may be helpful.\n 2. Mild congestive failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-12-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 746917,
"text": " 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P PA PACE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p PA pacement\n REASON FOR THIS EXAMINATION:\n r/o free air\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATIONS: Rule out free air.\n\n Single, frontal view of the chest demonstrates the cardiomediastinal\n silhouette within normal limits. Plate like atelectasis are seen in both lung\n bases. There is no pneumoperitoneum. The visualized bony and soft tissue\n structures are unremarkable.\n\n IMPRESSION: No pneumoperitoneum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-12-19 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 746918,
"text": " 4:47 AM\n PORTABLE ABDOMEN Clip # \n Reason: abd pain, eval for obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with\n REASON FOR THIS EXAMINATION:\n abd pain, eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE VIEW\n\n HISTORY: Abdominal pain. To evaluate for obstruction.\n\n Distribution of bowel gas is unremarkable with gas and fecal residue\n throughout the colon and no evidence for intestinal obstruction.\n\n IMPRESSION No diagnostic abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-12-19 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 746919,
"text": " 5:47 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: 64yoF POD#6 s/p aortobifem w/ acute onset LLQ abd pain. Ple\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with\n REASON FOR THIS EXAMINATION:\n 64yoF POD#6 s/p aortobifem w/ acute onset LLQ abd pain. Please eval for\n abscess, obstruction. Page w/ questions/results.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute onset of left lower quadrant abdominal pain.\n\n CT ABDOMEN AND PELVIS WITH CONTRAST:\n\n TECHNIQUE: Contiguous axial images were obtained from the lung base to the\n pubic symphysis. No oral contrast was given as per request. 150cc Optiray\n were given at patient's request. No procedural complications. There are no\n prior studies.\n\n CT ABDOMEN WITH CONTRAST: There is bilateral small pleural effusion associated\n with atelectasis (right greater than left). The anterior lung zones are\n clear. The heart is normal. There is vascular calcification consistent with\n atherosclerotic disease. There is a small pericardial effusion. Two\n hypodensities, first at the dome of the diaphragm (series 2, image 7) and the\n second on (image 3). These are too small to adequately characterize. The\n remaining liver is unremarkable. There is mild prominence of the biliary\n ducts. The gallbladder is mildly thickened with a fluid/fluid level\n suggesting sludge. There is pericholecystic fluid. There is a small amount of\n perihepatic fluid collection. There are no radiopaque gallstones. The\n pancreas, spleen and adrenal glands are normal. There is prompt excretion of\n contrast. There is no hydronephrosis. There is a hypodensity within left mid\n pole that probably represents a simple cyst. The patient is postop day 6, s/p\n aortic bifem. There is a large heterogeneous enhancing collection starting at\n the level of the renal artery extending to 2cm below the bifurcation. This\n measures 6.9 x 4.5cm in its largest dimension and probably represents postop\n hematoma. The enhancing pattern suggest active extravasation at the site of\n proximal anastomosis. There is a small amount of fluid adjacent to the\n spleen.\n\n CT PELVIS WITH CONTRAST: There is a fluid collection anterior to the left\n psoas muscle just lateral to the iliac vessel that measured 50 x 18mm. This\n has fluid attenuation that probably represents a postop seroma. The bladder is\n intact with no intraluminal filling defects. There is fluid within the cul-de-\n sac in the dependent portions. No oral contrast was given, so a suboptimal\n evaluation of the small and large bowel but are grossly unremarkable.\n\n The osseous structures are unremarkable. There is diffuse subcutaneous edema.\n\n IMPRESSION:\n\n (Over)\n\n 5:47 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: 64yoF POD#6 s/p aortobifem w/ acute onset LLQ abd pain. Ple\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Large paraortic hematoma, with active extravasation.\n 2. A fluid collection anterior to the left psoas muscle, probably representing\n a postop seroma.\n 3. Ascites.\n 4. Slight prominence of the gallbladder with pericholecystic fluid, in this\n setting of ascites, cholecystitis is difficult to adequately assess. There is\n evidence of cholestasis with sludge formation.\n 5. Bilateral pleural effusion with associated subsegmental atelectasis.\n\n The findings were discussed with Dr. at the time of the study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-12-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 747086,
"text": " 2:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p R cordis placement\n REASON FOR THIS EXAMINATION:\n eval CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right IJ placement.\n PORTABLE CHEST: Comparison is made to film from two days earlier. The ET tube\n and NG tube have been removed. The SGC has been replaced with a right IJ\n catheter, which has its tip in the SVC. There is no evidence of pneumothorax.\n There is interval improvement in aeration, consistent with resolving CHF.\n There are new, sizeable areas of hazy increased density in both lung bases,\n compatible with bilateral pleural effusions.\n\n IMPRESSION:\n 1. ET tube and NG tube removed.\n\n 2. Right IJ tip in SVC; no pneumothorax.\n\n 3. Resolving CHF.\n\n 4. New, sizeable bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 746476,
"text": " 2:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p PA line repositioning.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p PA pacement\n REASON FOR THIS EXAMINATION:\n s/p PA line repositioning.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Placement of PA line.\n\n CHEST AP:\n\n FINDINGS: Comparison is made to the prior film dated . There is\n evidence of ET tube, PA line and NG tube in place. The tip of the PA line has\n been repositioned and now is in the right pulmonary artery, with satisfactory\n position. Again noted is slight cardiomegaly. Upper zone redistribution and\n pulmonary kerley B lines are noted, suggestive of mild heart failure. No\n evidence of pulmonary consolidation. Osseous structures are unremarkable.\n\n IMPRESSION: 1) PA line in place, with tip in the right pulmonary artery.\n\n 2) Persistent mild heart failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-12-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 746701,
"text": " 1:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p aortobifem. please eval for chf.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p PA pacement\n REASON FOR THIS EXAMINATION:\n s/p aortobifem. please eval for chf.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PA catheter placement, evaluate for CHF.\n\n COMPARISON: .\n\n PORTABLE AP CHEST: The right internal jugular Swan-Ganz catheter has been\n withdrawn with tip now in the proximal right atrium. There remains upper zone\n redistribution and mild interstitial pulmonary edema, with slight improvement\n from . There are tiny bilateral pleural effusions. There are\n worsened bibasilar opacities, likely representing atelectasis but cannot\n exclude pneumonia. No pneumothorax.\n\n IMPRESSION:\n 1) CHF with interstitial edema, slightly improved.\n 2) Worsened bibasilar opacities, likely atelectasis, but cannot exclude\n pneumonia.\n\n"
}
] |
59,225 | 123,146 | Patient is a 53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary hypertension, a. fib, admitted for R-heart cath for demonstration of pulmonary and ventricular filling pressures and optimization in consideration for liver transplantation. Mr. cardiac catheterization revealed resting hemodynamics with elevated right and left sided filling pressures (RVEDP 22 mm Hg, PCWP mean 25 mm Hg). There was moderate to severe pulmonary arterial hypertension (PASP 68 mm Hg). revealed normal systolic function and diastolic dysfunction. Because liver transplantation is generally contraindicated with mean PA pressures of greater than 35mm Hg, a swan ganz catheter was placed and he was admitted to the cardiac ICU for careful monitoring and diuresis. He was started on amlodipine & lisinopril and diuresed over 10 liters (with IV lasix drip + bolus, & fluid restriction). He was cardioverted out of atrial fibrillation into normal sinus rhythm. After 9 days in the CCU, his mean PA pressure improved to 31-34 consistently for about 24 hours (eg PA 50/23, mean PA 33). His dry weight should be considered 177.5lbs. He was transitioned to bumex 2mg daily with stable weights. He should be followed carefully for weight gain and diuresed as appropriate. Mr. was kept on his home regimen of lactulos & rifaxamin for his ESLD without any evidence of encephalopathy. He was kept on coumadin for h/o DVT/PE and for atrial fib. This can likely be discontinued in 1 month b/c his history of DVT/PE was over 1 year ago. Dr. of hematology has evaluated him in the past and recommended anticoagulation only for atrial fibrillation. | ECG w/ atrial fib but otherwise w/o e/o ischemia. ECG w/ atrial fib but otherwise w/o e/o ischemia. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. ALLERGIES: Sulfa/cardizem . ALLERGIES: Sulfa/cardizem . #DVT/PE - INR therapeutic -cont coumadin . #DVT/PE - INR therapeutic -cont coumadin . #DVT/PE - INR therapeutic -cont coumadin . #DVT/PE - INR therapeutic -cont coumadin . #DVT/PE - INR therapeutic -cont coumadin . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . PPx: PPI, bowel regimen, systemic AC . PPx: PPI, bowel regimen, systemic AC . PPx: PPI, bowel regimen, systemic AC . #DVT/PE -resume heparin for subtherapeutic INR -cont coumadin goal INR . Action: Lactulose Q4H given and rifaxamin given. Continue to f/u with LFTs, ammonia levels, mental status. #DVT/PE: INR 2.3 this am -cont coumadin (goal INR ) . #CRI Cr stable -cont monitor while diuresing . #DVT/PE -resume heparin for subtherapeutic INR -cont coumadin goal INR . #DVT/PE -resume heparin for subtherapeutic INR -cont coumadin goal INR . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . Action: Lactulose Q4H given and rifaxamin given. #CRI Cr stable -cont monitor while diuresing . #Cirrhosis stable; awaiting transplant -continue rifaxamin, lactulose -Rx comorbidities as above . Continue to f/u with LFTs, ammonia levels, mental status. Continue to f/u with LFTs, ammonia levels, mental status. Continue to f/u with LFTs, ammonia levels, mental status. Continue to f/u with LFTs, ammonia levels, mental status. #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . Action: Lactulose Q4H , miralax , senna and rifaxamin given. #Cirrhosis stable; awaiting transplant -continue rifaxamin, lactulose . #DVT/PE - INR therapeutic -cont coumadin . #DVT/PE - INR therapeutic -cont coumadin . #DVT/PE - INR therapeutic -cont coumadin . #DVT/PE - INR therapeutic -cont coumadin . #DVT/PE - INR therapeutic -cont coumadin . #DVT/PE - INR therapeutic -cont coumadin . #Cirrhosis stable; awaiting transplant -continue rifaxamin, lactulose -Rx comorbidities as above . #Cirrhosis stable; awaiting transplant -continue rifaxamin, lactulose -Rx comorbidities as above . #Cirrhosis stable; awaiting transplant -continue rifaxamin, lactulose -Rx comorbidities as above . #Cirrhosis stable; awaiting transplant -continue rifaxamin, lactulose -Rx comorbidities as above . #Cirrhosis stable; awaiting transplant -continue rifaxamin, lactulose -Rx comorbidities as above . #Cirrhosis stable; awaiting transplant -continue rifaxamin, lactulose -Rx comorbidities as above . #DVT/PE - INR 3.0 this am -hold coumadin dose today . #Cirrhosis stable w/o evidence of decompensation; awaiting transplant -continue rifaxamin, lactulose . #Cirrhosis stable w/o evidence of decompensation; awaiting transplant -continue rifaxamin, lactulose . #Cirrhosis stable w/o evidence of decompensation; awaiting transplant -continue rifaxamin, lactulose . The cath revealed acute and chronic diastolic CHF.and pulm HTN. #Cirrhosis stable; awaiting transplant -continue rifaxamin, lactulose -Rx comorbidities as above . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #DVT/PE: INR 3.0 this am -hold coumadin dose today . #DVT/PE: INR 3.0 this am -hold coumadin dose today . #DVT/PE: INR 3.0 this am -hold coumadin dose today . #CRI Cr stable -cont monitor while diuresing . #CRI Cr stable -cont monitor while diuresing . #CRI Cr stable -cont monitor while diuresing . Action: Lactulose Q4H given and rifaxamin given. #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #PPx: PPI, bowel regimen, systemic AC . #Cirrhosis stable w/o evidence of decompensation; awaiting transplant -continue rifaxamin, lactulose . The cath revealed acute and chronic diastolic CHF.and pulm HTN, pt swaned and diuresed aggressively w/ improvement in PADs.. pt in a fib when admitted and cardioverted to sinus rhythm . The cath revealed acute and chronic diastolic CHF.and pulm HTN, pt swaned and diuresed aggressively w/ improvement in PADs.. pt in a fib when admitted and cardioverted to sinus rhythm . #Cirrhosis stable; awaiting transplant -continue rifaxamin, lactulose . #Cirrhosis stable; awaiting transplant -continue rifaxamin, lactulose . | 178 | [
{
"category": "Physician ",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 572116,
"text": "Chief Complaint:\n 24 Hour Events:\n PA CATHETER - STOP 05:28 PM\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.6\nC (97.8\n HR: 57 (50 - 69) bpm\n BP: 109/75(83) {83/49(57) - 128/90(96)} mmHg\n RR: 17 (13 - 45) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 1 (1 - 8)mmHg\n PAP: (44 mmHg) / (16 mmHg)\n PCWP: 7 (7 - 9.) mmHg\n Total In:\n 1,202 mL\n 80 mL\n PO:\n 380 mL\n TF:\n IVF:\n 822 mL\n 80 mL\n Blood products:\n Total out:\n 1,750 mL\n 550 mL\n Urine:\n 1,500 mL\n 400 mL\n NG:\n 250 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -548 mL\n -470 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 172 K/uL\n 15.0 g/dL\n 104 mg/dL\n 2.3 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 42 mg/dL\n 98 mEq/L\n 135 mEq/L\n 44.0 %\n 9.5 K/uL\n [image002.jpg]\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n 01:32 PM\n 02:59 AM\n WBC\n 12.5\n 8.4\n 9.5\n 8.7\n 9.4\n 9.5\n Hct\n 42.2\n 44.1\n 43.7\n 47.2\n 45.6\n 44.0\n Plt\n 100\n 116\n 123\n 136\n 163\n 172\n Cr\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n 2.4\n 2.3\n Glucose\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n 125\n 104\n Other labs: PT / PTT / INR:29.2/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -10L LOS;\n Cr/HCO3 indicating that likely has reached dry weight\n -stop lasix gtt\n -determine PO lasix dose needed to keep even\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n -check BNP to establish dry weight value\n -check PCWP at dry weight prior to d/c swan\n .\n #Pulm HTN\n pulm pressures improving with most reflecting\n pre-transplant target of mPAP 35 mmHg; likely has element of\n irreversible pulm HTN given h/o PE, possible portopulmonary syndrome\n (as suggested by absence of response to inhaled NO at cath )\n -will discuss progress/outpt mgmt with transplant team\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr rising in the setting of aggressive diuresis\n - lytes, Cr\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -decr. lopressor given bradycardia since now s/p cardioversion and\n doesn\nt need rate control\n -continue CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place then call\n out to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section------\n Entered in error. MD\n ------ Protected Section Error Entered By: , MD\n on: 08:04 ------\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 572118,
"text": "Chief Complaint:\n 24 Hour Events:\n -Cr 2.4 PCWP 9, gave 250 cc NS bolus; repeat PCWP 7\n -d/c'd lasix gtt @ 1030\n -d/c'd swan/cordis (has PIV)\n -decr. lopressor 25 mg to 12.5 mg bradycardia\n -ordered lasix 80 mg PO daily to start AM \n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.6\nC (97.8\n HR: 57 (50 - 69) bpm\n BP: 109/75(83) {83/49(57) - 128/90(96)} mmHg\n RR: 17 (13 - 45) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 1 (1 - 8)mmHg\n PAP: (44 mmHg) / (16 mmHg)\n PCWP: 7 (7 - 9.) mmHg\n Total In:\n 1,202 mL\n 83 mL\n PO:\n 380 mL\n TF:\n IVF:\n 822 mL\n 83 mL\n Blood products:\n Total out:\n 1,750 mL\n 550 mL\n Urine:\n 1,500 mL\n 400 mL\n NG:\n 250 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -548 mL\n -467 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 172 K/uL\n 15.0 g/dL\n 104 mg/dL\n 2.3 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 42 mg/dL\n 98 mEq/L\n 135 mEq/L\n 44.0 %\n 9.5 K/uL\n [image002.jpg]\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n 01:32 PM\n 02:59 AM\n WBC\n 12.5\n 8.4\n 9.5\n 8.7\n 9.4\n 9.5\n Hct\n 42.2\n 44.1\n 43.7\n 47.2\n 45.6\n 44.0\n Plt\n 100\n 116\n 123\n 136\n 163\n 172\n Cr\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n 2.4\n 2.3\n Glucose\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n 125\n 104\n Other labs: PT / PTT / INR:29.2/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -10L LOS;\n Cr/HCO3 indicating that likely has reached dry weight\n -stop lasix gtt\n -determine PO lasix dose needed to keep even\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n -check BNP to establish dry weight value\n -check PCWP at dry weight prior to d/c swan\n .\n #Pulm HTN\n pulm pressures improving with most reflecting\n pre-transplant target of mPAP 35 mmHg; likely has element of\n irreversible pulm HTN given h/o PE, possible portopulmonary syndrome\n (as suggested by absence of response to inhaled NO at cath )\n -will discuss progress/outpt mgmt with transplant team\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr rising in the setting of aggressive diuresis\n - lytes, Cr\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -decr. lopressor given bradycardia since now s/p cardioversion and\n doesn\nt need rate control\n -continue CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place then call\n out to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570367,
"text": "Chief Complaint:\n 24 Hour Events:\n PA CATHETER - START 10:30 AM\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:35 AM\n Other medications:\n Changes to medical and family history: N/a\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 76 (54 - 76) bpm\n BP: 113/82(88) {99/55(64) - 127/94(110)} mmHg\n RR: 35 (13 - 35) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 8 (8 - 30)mmHg\n PAP: (48 mmHg) / (27 mmHg)\n PCWP: 23 (23 - 25) mmHg\n CO/CI (Fick): (4.1 L/min) / (1.9 L/min/m2)\n Mixed Venous O2% Sat: 63 - 68\n Total In:\n 309 mL\n 456 mL\n PO:\n 200 mL\n TF:\n IVF:\n 309 mL\n 256 mL\n Blood products:\n Total out:\n 1,650 mL\n 900 mL\n Urine:\n 1,650 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,341 mL\n -444 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 180 K/uL\n 14.2 g/dL\n 97 mg/dL\n 1.5 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 22 mg/dL\n 103 mEq/L\n 139 mEq/L\n 44\n 6.8 K/uL\n [image002.jpg]\n 10:56 AM\n 03:50 AM\n 04:14 AM\n WBC\n 7.7\n 6.8\n Hct\n 42.6\n 42.5\n 44\n Plt\n 197\n 180\n Cr\n 1.7\n 1.5\n Glucose\n 99\n 97\n Other labs: PT / PTT / INR:20.9/38.4/2.0, Differential-Neuts:58.3 %,\n Lymph:30.8 %, Mono:7.5 %, Eos:2.5 %, Ca++:9.2 mg/dL, Mg++:1.7 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n CIRRHOSIS OF LIVER, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 11:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570543,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n Rec\nd 20 mg lasix x 3 with 2800 cc UOP (-800 @ MN)\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:50 PM\n Other medications:\n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 73 (64 - 83) bpm\n BP: 108/72(81) {94/56(67) - 137/99(109)} mmHg\n RR: 15 (12 - 26) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 8 (5 - 12)mmHg\n PAP: (51 mmHg) / (28 mmHg)\n CO/CI (Fick): (5 L/min) / (2.4 L/min/m2)\n Mixed Venous O2% Sat: 69 (66\n 69)\n SVR 968\n Total In:\n 2,005 mL\n 363 mL\n PO:\n 1,400 mL\n 180 mL\n TF:\n IVF:\n 605 mL\n 183 mL\n Blood products:\n Total out:\n 2,825 mL\n 650 mL\n Urine:\n 2,825 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -820 mL\n -287 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath site c/d/i\n CV: irreg irreg no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 162 K/uL\n 15.7\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 19 mg/dL\n 98 mEq/L\n 133 mEq/L\n 47\n 8.1 K/uL\n [image002.jpg]\n 10:56 AM\n 03:50 AM\n 04:14 AM\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n WBC\n 7.7\n 6.8\n 8.1\n Hct\n 42.6\n 42.5\n 44\n 45\n 44\n 44.8\n 47\n Plt\n 197\n 180\n 162\n Cr\n 1.7\n 1.5\n 1.6\n 1.5\n Glucose\n 99\n 97\n 107\n 119\n Other labs: PT / PTT / INR:19.8/38.4/1.8, Differential-Neuts:58.3 %,\n Lymph:30.8 %, Mono:7.5 %, Eos:2.5 %, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, PE and Afib on coumadin admitted\n for elective RHC demonstrating acute on chronic LV diastolic CHF and\n pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: negative 2.4L LOS; PAD improving with\n diuresis and afterload reduction but not yet optimal; borderline low CI\n and elev. SVR may suggest need for further afterload reduction\n -cont diuresis to goal PAD 21-23 mmHg (PCWP 16-18 mmHg)\n -goal -1 L today\n -incr. captopril prn for improved afterload reduction\n .\n #Pulm HTN\n PAD remain elevated due to left-sided CHF; not\n NO-responsive per cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator responsive\n -treat left-sided CHF, as above\n .\n #DVT/PE\n -resume heparin for subtherapeutic INR\n -cont coumadin goal INR \n .\n #Afib\n rate well-controlled\n -cont heparin/coumadin\n -cont lopressor\n .\n #Cirrhosis - awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; consider d/c;ing Swan and treating acute CHF clinically\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #. Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring until swan comes out\n ICU Care\n Nutrition: low Na diet\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 11:00 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Communication: sister \n status: FULL\n Disposition: CCU for hemodynamic monitoring until swan comes out\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571930,
"text": "Chief Complaint: acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n - 1L negative at 7pm, Cr 2.0->2.6, remained -800 cc at MN\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies dizziness, lightheadedness, CP, palp, SOB,\n abd pain, N/V/D\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 54 (46 - 66) bpm\n BP: 93/47(59) {87/47(59) - 131/101(109)} mmHg\n RR: 21 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 5 (1 - 9)mmHg\n PAP: 47/21 mmHg\n (37-57/21-32)\n mPAP 31 mmHg (30-41)\n Total In:\n 1,416 mL\n 166 mL\n PO:\n 840 mL\n TF:\n IVF:\n 576 mL\n 166 mL\n Blood products:\n Total out:\n 2,250 mL\n 400 mL\n Urine:\n 2,250 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -834 mL\n -234 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 136 K/uL\n 15.5 g/dL\n 85 mg/dL\n 2.4 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 96 mEq/L\n 138 mEq/L\n 47.2 %\n 8.7 K/uL\n [image002.jpg]\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n WBC\n 11.1\n 12.5\n 8.4\n 9.5\n 8.7\n Hct\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n 47.2\n Plt\n 128\n 100\n 116\n 123\n 136\n Cr\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n Glucose\n 89\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n Other labs: PT / PTT / INR:26.4/36.3/2.6, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -10L LOS;\n Cr/HCO3 indicating that likely has reached dry weight\n -stop lasix gtt\n -determine PO lasix dose needed to keep even\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n -check BNP to establish dry weight value\n -check PCWP at dry weight prior to d/c swan\n .\n #Pulm HTN\n pulm pressures improving with most reflecting\n pre-transplant target of mPAP 35 mmHg; likely has element of\n irreversible pulm HTN given h/o PE, possible portopulmonary syndrome\n (as suggested by absence of response to inhaled NO at cath )\n -will discuss progress/outpt mgmt with transplant team\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr rising in the setting of aggressive diuresis\n - lytes, Cr\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -decr. lopressor given bradycardia since now s/p cardioversion and\n doesn\nt need rate control\n -continue CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place then call\n out to floor\n ICU Care\n Nutrition: low Na diet, 1 L fluid restriction\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Code status: FULL\n Disposition: CCU for hemodynamic monitoring while swan in place then\n call out to floor\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 572087,
"text": "Chief Complaint:\n 24 Hour Events:\n -Cr 2.4 PCWP 9, gave 250 cc NS bolus; repeat PCWP 7\n -d/c'd lasix gtt @ 1030\n -d/c'd swan/cordis (has PIV)\n -decr. lopressor 25 mg to 12.5 mg bradycardia\n -ordered lasix 80 mg PO daily to start AM \n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.6\nC (97.8\n HR: 57 (50 - 69) bpm\n BP: 109/75(83) {83/49(57) - 128/90(96)} mmHg\n RR: 17 (13 - 45) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 1 (1 - 8)mmHg\n PAP: (44 mmHg) / (16 mmHg)\n PCWP: 7 (7 - 9.) mmHg\n Total In:\n 1,202 mL\n 73 mL\n PO:\n 380 mL\n TF:\n IVF:\n 822 mL\n 73 mL\n Blood products:\n Total out:\n 1,750 mL\n 550 mL\n Urine:\n 1,500 mL\n 400 mL\n NG:\n 250 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -548 mL\n -477 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 172 K/uL\n 15.0 g/dL\n 104 mg/dL\n 2.3 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 42 mg/dL\n 98 mEq/L\n 135 mEq/L\n 44.0 %\n 9.5 K/uL\n [image002.jpg]\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n 01:32 PM\n 02:59 AM\n WBC\n 12.5\n 8.4\n 9.5\n 8.7\n 9.4\n 9.5\n Hct\n 42.2\n 44.1\n 43.7\n 47.2\n 45.6\n 44.0\n Plt\n 100\n 116\n 123\n 136\n 163\n 172\n Cr\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n 2.4\n 2.3\n Glucose\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n 125\n 104\n Other labs: PT / PTT / INR:29.2/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -10L LOS;\n Cr/HCO3 indicating that likely has reached dry weight\n -stop lasix gtt\n -determine PO lasix dose needed to keep even\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n -check BNP to establish dry weight value\n -check PCWP at dry weight prior to d/c swan\n .\n #Pulm HTN\n pulm pressures improving with most reflecting\n pre-transplant target of mPAP 35 mmHg; likely has element of\n irreversible pulm HTN given h/o PE, possible portopulmonary syndrome\n (as suggested by absence of response to inhaled NO at cath )\n -will discuss progress/outpt mgmt with transplant team\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr rising in the setting of aggressive diuresis\n - lytes, Cr\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -decr. lopressor given bradycardia since now s/p cardioversion and\n doesn\nt need rate control\n -continue CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place then call\n out to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 572091,
"text": "Chief Complaint:\n 24 Hour Events:\n -Cr 2.4 PCWP 9, gave 250 cc NS bolus; repeat PCWP 7\n -d/c'd lasix gtt @ 1030\n -d/c'd swan/cordis (has PIV)\n -decr. lopressor 25 mg to 12.5 mg bradycardia\n -ordered lasix 80 mg PO daily to start AM \n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications: Lasix 80mg PO daily, Lopressor 12.5mg PO BID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.6\nC (97.8\n HR: 57 (50 - 69) bpm\n BP: 109/75(83) {83/49(57) - 128/90(96)} mmHg\n RR: 17 (13 - 45) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 1 (1 - 8)mmHg\n PAP: (44 mmHg) / (16 mmHg)\n PCWP: 7 (7 - 9.) mmHg\n Total In:\n 1,202 mL\n 73 mL\n PO:\n 380 mL\n TF:\n IVF:\n 822 mL\n 73 mL\n Blood products:\n Total out:\n 1,750 mL\n 550 mL\n Urine:\n 1,500 mL\n 400 mL\n NG:\n 250 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -548 mL\n -477 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 172 K/uL\n 15.0 g/dL\n 104 mg/dL\n 2.3 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 42 mg/dL\n 98 mEq/L\n 135 mEq/L\n 44.0 %\n 9.5 K/uL\n [image002.jpg]\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n 01:32 PM\n 02:59 AM\n WBC\n 12.5\n 8.4\n 9.5\n 8.7\n 9.4\n 9.5\n Hct\n 42.2\n 44.1\n 43.7\n 47.2\n 45.6\n 44.0\n Plt\n 100\n 116\n 123\n 136\n 163\n 172\n Cr\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n 2.4\n 2.3\n Glucose\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n 125\n 104\n Other labs: PT / PTT / INR:29.2/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -10L LOS;\n Cr/HCO3 indicating that likely has reached dry weight\n -stop lasix gtt\n -determine PO lasix dose needed to keep even\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n -check BNP to establish dry weight value\n -check PCWP at dry weight prior to d/c swan\n .\n #Pulm HTN\n pulm pressures improving with most reflecting\n pre-transplant target of mPAP 35 mmHg; likely has element of\n irreversible pulm HTN given h/o PE, possible portopulmonary syndrome\n (as suggested by absence of response to inhaled NO at cath )\n -will discuss progress/outpt mgmt with transplant team\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr rising in the setting of aggressive diuresis\n - lytes, Cr\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -decr. lopressor given bradycardia since now s/p cardioversion and\n doesn\nt need rate control\n -continue CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place then call\n out to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 07:10 ------\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1076212,
"text": " 8:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval line placement.\n Admitting Diagnosis: PULMONARY HYPERTENSION\\RIGHT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with PAH and swan ganz cath in place\n REASON FOR THIS EXAMINATION:\n eval line placement.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 10:03 AM\n Swan-Ganz in unchanged position, at the inferior aspect of the right hilum,\n could be pulled back several centimeters for optimal placement. No other\n change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: Pulmonary hypertension and Swan-Ganz, evaluate placement.\n\n Since , Swan-Ganz catheter still ends in unchanged position,\n with its tip overlying the inferior aspect of the right hilum, likely in the\n right lower lobe artery, should be pulled back 3.5 cm for optimal placement.\n Marked enlargement of central pulmonary arteries is unchanged, due to\n pulmonary hypertension. Mild cardiomegaly is stable. Old rib fractures are\n unchanged. Incidentally, a large gallstone is present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1077023,
"text": " 7:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lines and tubes.\n Admitting Diagnosis: PULMONARY HYPERTENSION\\RIGHT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with chf with swan cath in place\n REASON FOR THIS EXAMINATION:\n eval lines and tubes.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CHF with Swan-Ganz catheter in place, to evaluate for change.\n\n FINDINGS: In comparison with the study of , there is little change.\n Swan-Ganz catheter tip again extends well into the right pulmonary artery\n system, several cm outside of the mediastinum. Striking prominence of both\n hila is again seen suggesting pulmonary hypertension. No evidence of acute\n focal pneumonia or vascular congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1076213,
"text": ", H. 8:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval line placement.\n Admitting Diagnosis: PULMONARY HYPERTENSION\\RIGHT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with PAH and swan ganz cath in place\n REASON FOR THIS EXAMINATION:\n eval line placement.\n ______________________________________________________________________________\n PFI REPORT\n Swan-Ganz in unchanged position, at the inferior aspect of the right hilum,\n could be pulled back several centimeters for optimal placement. No other\n change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1076453,
"text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement\n Admitting Diagnosis: PULMONARY HYPERTENSION\\RIGHT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with CHF with swan ganz in place\n REASON FOR THIS EXAMINATION:\n eval placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CHF, Swan-Ganz in place.\n\n CHEST, SINGLE AP VIEW.\n\n The lungs are hyperinflated, suggesting COPD. Heart size is borderline or\n slightly enlarged. There is marked prominence of both hila as well as\n suggested prominence of the main pulmonary artery. Again seen is a right IJ\n Swan-Ganz catheter. The tip lies relatively distal in the right pulmonary\n artery. The aorta is mildly unfolded. There is slight upper zone\n redistribution, but no other evidence for CHF. No focal infiltrate or\n effusion is identified. Old healed right-sided rib fractures noted.\n\n IMPRESSION:\n\n 1. Right IJ Swan-Ganz catheter tip relatively distal in relation to the right\n pulmonary artery -- clinical correlation concerning possible retraction of\n the cathetere is requested.\n\n 2. Stable cardiomegaly.\n\n 3. Stable enlargement of the right and left pulmonary arteries. This most\n likely reflects severe pulmonary hypertension, though, based on this film\n alone, pulmonary lymphadenopathy cannot be excluded.\n\n 4. No acute pulmonary process detected.\n\n 5. 18-mm calcification in the right upper quadrant consistent with large\n gallstone.\n\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570328,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 28-30. Pt denies SOB, CP LS CTA. Hr 60\ns afib with rare to\n occasional PVC\ns, pt noted for rare to occasional second pauses\n while sleeping. SBP 99-120\n Action:\n 20 mg IVP lasix given. Heparin gtt increased to 750 units/hr for\n subtherapeutic PTT at 2200. Captopril 6.25 mg given. Coumadin resumed\n as MD\ns. CHF teaching/discussion with pt.\n Response:\n PADs 28->26. AM cardiac numbers Pt voiding via urinal. Hemodynamically\n stable. PTT at 0400 was Pt verbalized understanding and knowledge r/t\n disease management.\n Plan:\n Continue to monitor hemodynamics, cardiac numbers. Continue to titrate\n meds as tolerated and ordered. Continue with teaching/encourage\n knowledge as indicated.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Pt with moderate to severe pulmonary HTN as per cath reports .\n LS CTA. Pt denies SOB.\n Action:\n Pt monitored. Pt ordered for norvasc in am.\n Response:\n No c/o SOB, O2 sats >94% on room air.\n Plan:\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant.\n Reportedly pt had 2 BM\ns yesterday. Pt A&Ox3. Talkative with RN and\n asking appropriate questions/appropriate statements about POC and\n disease.\n Action:\n Lactulose 60 cc\ns and rifaximin 200 mg PO given.\n Response:\n Awaiting BM.\n Plan:\n Continue with lactulose for BM daily. Continue to f/u with LFT\n ammonia levels, mental status.\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-18 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 570266,
"text": "Chief Complaint: OUTPATIENT CARDIOLOGIST: , \n .\n PCP: , \n .\n Chief Complaint: admit to CCU for heart cath\n HPI:\n 53 y/o male with history of HTN, atrial fibrillation, possible\n diastolic dysfunction, DVT, PE and cryptogenic cirrhosis from childhood\n complicated by portal HTN\n and variceal hemorrhages. Patient is currently being worked-up to be\n placed on the liver transplant list.\n .\n On , the patient underwent a right heart catheterization to\n assess for pulmonary hypertension that was noted on echocardiogram.\n Found to have elevated right and left sided filling pressures (RVEDP 16\n mmHG, PCWP mean 21 mmHG), Moderate to severe pulmonary artery\n hypertension with a PASP of 72 mmHG. Cardiac index reduced at 1.74\n l/min/m2. Pulmonary vascular resistance markedly elevated at 670\n dynes-sec/cm5. Pulmonary hypertension was not responsive to vasodilator\n therapy, although it did decrease to 533 from 594 dynes/cm5.\n .\n Patient was seen by pulmonary as an outpatient who felt that the\n primary cause for his pulmonary hypertension was likely to be left\n heart failure with possibly a secondary superimposed primary pulmonary\n process either due to chronic PE, or liver disease.\n .\n Patient was in his usual state of health until over the weekend the\n patient was admitted to a local hospital with hypotension (80/57) and\n bradycardia (HR 47). Apparently had become encephalopathic at home,\n and vomitted and was brought to OSH ED. Discharged to home with\n discontinuation of Verapamil. He is now being readmitted to for\n repeat RHC and likely admission to CCU for titration of medications,\n hemodynamic monitoring.\n .\n Patient reports that at home that he was feeling well. He reports\n stable 2 pillow orthopnea, no PND, no weight gain, increased LE edema,\n or exertional chest pain. He states that he has in fact lost 10 lbs in\n the last 3-4 months.\n .\n In the Cath lab patient had a Swan placed. PCWP of 25 (mean), PA\n pressure 68/30 (mean 51), RV 64/15 (mean 22), RA 16-19. CI 2.5.\n Impression was for severe LV diastolic dysfunction, pulmonary\n hypertension. Patient was admitted to the ICU for tailored diuresis.\n .\n Cardiac review of systems notable for stable dyspnea on exertion at\n about 20-30 feet. Is able to climb 10 steps without difficulty,\n however.\n Patient admitted from: OR / PACU\n History obtained from Patient, Family / Medical records\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - cryptogenic cirrhosis c/b portal HTN and variceal bleeding\n - s/p splenorenal shunt and splenectomy with splenic vein anastamosed\n to left renal vein\n - UGIB portacaval shunt\n - s/p end vena cava o superior mesenteric vein anastamosis\n - hepatic encephalopathy w/ mult admits\n - DVT\n - pulmonary emboli 2-3 years ago\n - atrial fib\n - htn\n - pvd?\n - GERD\n - HOH(?)\n .\n ALLERGIES: Sulfa/cardizem\n .\n CURRENT MEDICATIONS:\n (on admission)\n -lactulose 60cc TID/QID\n -metoprolol 25mg PO BID\n -polyethylene glycol 17gram\n -Rifaxamin 200 TID\n -Omeprazole 20mg daily\n -Calcium 600mg \n -MVI daily\n -Coumadin as directed\n He is adopted and family history is unknown. His adopted father was a\n long term cigarette smoker, and thus he was exposed to secondhand smoke\n as a child.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Mr. currently lives with his brother-in-law, , and\n sister . They have three cats and one dog. He is currently\n disabled and previously worked in a shoe factory and at Victory\n Market. He does not drink alcoholic beverages and has never smoked\n cigarettes. He is originally from . While\n working in the shoe factory he was exposed to latex and acetone.\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, Weight loss, 10lbs over \n months\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Constipation\n Flowsheet Data as of 01:26 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 70 (70 - 73) bpm\n BP: 117/82(90) {117/69(81) - 127/94(99)} mmHg\n RR: 15 (15 - 18) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 30 (21 - 30)mmHg\n PAP: (60 mmHg) / (32 mmHg)\n Total In:\n 32 mL\n PO:\n TF:\n IVF:\n 32 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 32 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Anxious,\n No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) NG tube, No(t) OG tube\n Cardiovascular: (S1: Normal), (S2: Loud), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, multiple soft tissue prominences\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 197 K/uL\n 14.2 g/dL\n 99 mg/dL\n 1.7 mg/dL\n 23 mg/dL\n 26 mEq/L\n 107 mEq/L\n 4.4 mEq/L\n 140 mEq/L\n 42.6 %\n 7.7 K/uL\n [image002.jpg]\n \n 2:33 A4/27/ 10:56 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.7\n Hct\n 42.6\n Plt\n 197\n Cr\n 1.7\n Glucose\n 99\n Other labs: Differential-Neuts:58.3 %, Lymph:30.8 %, Mono:7.5 %,\n Eos:2.5 %, Ca++:9.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.5 mg/dL\n Imaging: 2D-ECHOCARDIOGRAM performed on demonstrated:\n The left atrium is moderately dilated. The right atrium is moderately\n dilated. No atrial septal defect is seen by 2D or color Doppler. There\n is mild symmetric left ventricular hypertrophy with normal cavity size\n and regional/global systolic function (LVEF>55%). There is no\n ventricular septal defect. The right ventricular cavity is mildly\n dilated with normal free wall contractility. The aortic root is mildly\n dilated at the sinus level. The ascending aorta is mildly dilated. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n appears structurally normal with trivial mitral regurgitation. The\n tricuspid valve leaflets are mildly thickened. There is mild pulmonary\n artery systolic hypertension. There is a small pericardial effusion.\n There are no echocardiographic signs of tamponade.\n .\n CARDIAC CATH performed on demonstrated:\n COMMENTS:\n 1. Resting hemodynamics demonstrated elevated right and left sided\n filling pressures (RVEDP 16 mm Hg, PCWP mean 21 mm Hg). There was\n moderate to severe pulmonary arterial hypertension (PASP 72 mm Hg). The\n cardiac index was moderately reduced at 1.74 l/min/m2. The pulmonary\n vascular resistance was markedly elevated (670 dynes-sec/cm5). There\n was severe systemic arterial hypertension (SBP 180 mm Hg).\n 2. Administrated of 100% inhaled FiO2 resulted in a decrease in\n pulmonary vascular resistance (594 dynes-sec/cm5) but an increase in\n PCWP (mean 29 mm Hg) and no significant change in pulmonary arterial\n hypertension (PASP 76 mm Hg).\n 3. Administration of inhaled nitric oxide + 100% FiO2 resulted in a\n further decrease of pulmonary vascular resistance (533 dynes-sec/cm5).\n There was no change in the elevated left sided filling pressure (PCWP\n mean 31 mm Hg) or pulmonary arterial hypertension (PASP 75 mm Hg).\n .\n FINAL DIAGNOSIS:\n 1. Moderate to severe pulmonary hypertension.\n 2. Pulmonary hypertension not vasodilator responsive.\n 3. Biventricular diastolic dysfunction.\n A six-minute walk test was performed and Mr. was\n able to ambulate approximately 1300 feet. His resting oxygen\n saturation on room air was 99%. When ambulating his oxygen\n saturation decreased to 97%.\n Microbiology: none\n ECG: EKG demonstrated atrial fibrillation.\n Assessment and Plan\n Patient is a 53 y/o M w/ h/o cryptogenic cirrhosis, portal\n hypertension, pulmonary hypertension, a. fib, admitted for R-heart cath\n w/ e/o diastolic LH failure as well as pulmonary hypertension.\n .\n # Heart Failure: By symptoms would be class II-III heart failure.\n R-Heart cath suggests component of left heart failure. No focal wall\n motion by echo to suggest CAD or prior infarct. ECG w/ atrial fib but\n otherwise w/o e/o ischemia. Is diastolic dysfunction given nml ef and\n echo findings.\n - follow swann numbers and diurese as tolerated with goal PCWP 16-18.\n - consider repeat echo\n - check TSH, lipid panel\n - uptitrate beta-blocker as tolerated\n - consider ACE/ although no mortality benefit in diastolic HF\n - consider cardioversion, obtain outpatient INR record\n - contact family regarding h/o sulfa allergy and consider\n .\n #. Cirrhosis: On transplant list. Completing transplant w/u\n - continue rifaxamin, lactulose\n .\n #. Afib: Continue coumadin. continue coumadin.\n - heparin gtt for INR < 1.9\n .\n #. HTN: Continue beta-blocker\n .\n #. DVT/PE: Continue coumadin. Heparin gtt for INR < 1.9\n .\n #. FEN: Replete lytes prn\n .\n #. Access: PIV, swann -> will need to pull back based on CXR findings,\n tracings and fact distal port is not drawing.\n .\n #. PPx: bowel regimen, heparin\n .\n #. Emergency contact: sister \n .\n #. Code: full\n .\n #. Dispo: Pending resolution of above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:00 AM\n Multi Lumen - 11:45 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Chart reviewed. Patient interviewed and examined. I agree with Dr.\n \ns H+P, A+P. 60 minutes spent on patient critical care. ICU\n level care due to severe heart failure requiring PA monitoring.\n ------ Protected Section Addendum Entered By: , MD\n on: 15:04 ------\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570324,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 28-30. Pt denies SOB, CP LS CTA. Hr 60\ns afib. SBP 99-120\n Action:\n 20 mg IVP lasix given.\n Response:\n Pt voiding via urinal. Hemodynamically stable.\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570538,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:50 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 73 (64 - 83) bpm\n BP: 108/72(81) {94/56(67) - 137/99(109)} mmHg\n RR: 15 (12 - 26) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 8 (5 - 12)mmHg\n PAP: (51 mmHg) / (28 mmHg)\n CO/CI (Fick): (5 L/min) / (2.4 L/min/m2)\n Mixed Venous O2% Sat: 66 - 69\n Total In:\n 2,005 mL\n 363 mL\n PO:\n 1,400 mL\n 180 mL\n TF:\n IVF:\n 605 mL\n 183 mL\n Blood products:\n Total out:\n 2,825 mL\n 650 mL\n Urine:\n 2,825 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -820 mL\n -287 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 162 K/uL\n 15.7\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 19 mg/dL\n 98 mEq/L\n 133 mEq/L\n 47\n 8.1 K/uL\n [image002.jpg]\n 10:56 AM\n 03:50 AM\n 04:14 AM\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n WBC\n 7.7\n 6.8\n 8.1\n Hct\n 42.6\n 42.5\n 44\n 45\n 44\n 44.8\n 47\n Plt\n 197\n 180\n 162\n Cr\n 1.7\n 1.5\n 1.6\n 1.5\n Glucose\n 99\n 97\n 107\n 119\n Other labs: PT / PTT / INR:19.8/38.4/1.8, Differential-Neuts:58.3 %,\n Lymph:30.8 %, Mono:7.5 %, Eos:2.5 %, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n CIRRHOSIS OF LIVER, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 11:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570540,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n Rec\nd 20 mg lasix x 3 with 2800 cc UOP (-800 @ MN)\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:50 PM\n Other medications:\n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 73 (64 - 83) bpm\n BP: 108/72(81) {94/56(67) - 137/99(109)} mmHg\n RR: 15 (12 - 26) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 8 (5 - 12)mmHg\n PAP: (51 mmHg) / (28 mmHg)\n CO/CI (Fick): (5 L/min) / (2.4 L/min/m2)\n Mixed Venous O2% Sat: 69 (66 - 690\n SVR 968\n Total In:\n 2,005 mL\n 363 mL\n PO:\n 1,400 mL\n 180 mL\n TF:\n IVF:\n 605 mL\n 183 mL\n Blood products:\n Total out:\n 2,825 mL\n 650 mL\n Urine:\n 2,825 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -820 mL\n -287 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 162 K/uL\n 15.7\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 19 mg/dL\n 98 mEq/L\n 133 mEq/L\n 47\n 8.1 K/uL\n [image002.jpg]\n 10:56 AM\n 03:50 AM\n 04:14 AM\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n WBC\n 7.7\n 6.8\n 8.1\n Hct\n 42.6\n 42.5\n 44\n 45\n 44\n 44.8\n 47\n Plt\n 197\n 180\n 162\n Cr\n 1.7\n 1.5\n 1.6\n 1.5\n Glucose\n 99\n 97\n 107\n 119\n Other labs: PT / PTT / INR:19.8/38.4/1.8, Differential-Neuts:58.3 %,\n Lymph:30.8 %, Mono:7.5 %, Eos:2.5 %, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal\n hypertension, pulmonary hypertension, chronic diastolic CHF, PE and\n Afib on coumadin admitted for elective RHC demonstrating acute on\n chronic LV diastolic dysfunction and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: PAD not optimal due to inadequate\n diuresis; low CI and elev. SVR suggest need for incr. afterload\n reduction; likely longstanding HTN, no focal WMA by echo to suggest\n CAD or prior infarct, ECG w/o evidence of ischemia\n -cont diuresis to goal PAD 21-23 mmHg (PCWP 16-18 mmHg)\n -goal -2 L today\n -incr. captopril for better afterload reduction\n .\n #Pulm HTN\n PAD remain elevated due to left-sided CHF; not vasodilator\n responsive per cath \n -cont amlodipine although not likely to produce substantial response\n -treat left-sided CHF, as above\n .\n #Cirrhosis - awaiting transplant\n -continue rifaxamin, lactulose\n .\n #. Afib\n rate well-controlled\n -cont coumadin goal INR \n -cont metoprolol\n -consider cardioversion if OSH records confirm recent therapeutic INR\n -d/c heparin drip today\n .\n #. HTN: well-controlled\n -continue BB, CCB\n .\n #. DVT/PE: Continue coumadin. INR therapeutic today.\n .\n #. FEN: Replete lytes prn\n .\n #. Access: PIV, swann -> tip placement reviewed and felt to be in good\n place after adjusting last night despite radiology read.\n .\n #. PPx: PPI, bowel regimen, systemic AC\n .\n #. Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 11:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570304,
"text": "Patient is a 53 y/o M w/ h/o cryptogenic cirrhosis, portal\n hypertension, pulmonary hypertension, a. fib, admitted for R-heart cath\n w/ e/o diastolic LH failure as well as pulmonary hypertension.\n .\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PA line in R IJ-> filling pressures elevated- in chronic afib on tele\n Action:\n Lasix 20mg IV given- started on heparin gtt @ 600u/hr @ 1400- Captopril\n .625mg started TID\n Response:\n Hemodynamically stable- Diuresing well.\n Plan:\n Follow hemodynamics- monitor output- monitor lytes and replete as\n needed.\n Cirrhosis of liver, other\n Assessment:\n H/O cryptogenic cirrhosis as child.\n Action:\n Lactulose 60cc QID titrate to BM\ns/day (given @ 1230 & 1800-\n rifaximin 200mg TID.\n Response:\n Had 2 BM\ns prior to admission to CCU only.\n Plan:\n Con\nt present management- follow LFT\ns and ammonia levels.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Mod to severe pulmonary HTN\n PAS >55- lung sounds clear.\n Action:\n On norvasc 10mg qd.\n Response:\n No resp distress- SpO2 >95% on room air.\n Plan:\n Monitor closely.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570306,
"text": "Patient is a 53 y/o M w/ h/o cryptogenic cirrhosis, portal\n hypertension, pulmonary hypertension, a. fib, admitted for R-heart cath\n w/ e/o diastolic LH failure as well as pulmonary hypertension.\n .\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PA line in R IJ-> filling pressures elevated- in chronic afib on tele\n Action:\n Lasix 20mg IV given- started on heparin gtt @ 600u/hr @ 1400- Captopril\n .625mg started TID\n Response:\n Hemodynamically stable- Diuresing well.\n Plan:\n Follow hemodynamics- monitor output- monitor lytes and replete as\n needed.\n Cirrhosis of liver, other\n Assessment:\n H/O cryptogenic cirrhosis as child.\n Action:\n Lactulose 60cc QID titrate to BM\ns/day (given @ 1230 & 1800-\n rifaximin 200mg TID.\n Response:\n Had 2 BM\ns prior to admission to CCU only.\n Plan:\n Con\nt present management- follow LFT\ns and ammonia levels.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Mod to severe pulmonary HTN on last cath \n PAS >55- lung sounds\n clear.\n Action:\n On norvasc 10mg qd.\n Response:\n No resp distress- SpO2 >95% on room air.\n Plan:\n Monitor closely.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570349,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 28-30. Pt denies SOB, CP LS CTA. Hr 60\ns afib with rare to\n occasional PVC\ns, pt noted for rare to occasional second pauses\n while sleeping. SBP 99-120\n Action:\n 20 mg IVP lasix given. Heparin gtt increased to 750 units/hr for\n subtherapeutic (59.5) PTT at 2200 with no bolus as per Dr. .\n Captopril 6.25 mg given. Coumadin resumed as MD\ns. CHF\n teaching/discussion with pt.\n Response:\n PADs 28->26. AM cardiac numbers-> CO 4.1/CI 1.9/SVR1445->Dr. \n aware. Pt voiding via urinal, -1.3L at midnoc. Hemodynamically\n stable. PTT drawn at 0400 (heparin noted to not be connected to pt ?\n for approximately an hour as pt turns self side to side in bed). Dr.\n aware, INR 2.0 so heparin gtt continued at 750 units/hr. Pt\n verbalized understanding and knowledge r/t disease management.\n Plan:\n Continue to monitor hemodynamics, cardiac numbers. Obtain PTT. Continue\n to titrate meds as tolerated and ordered. Continue with\n teaching/encourage knowledge as indicated.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Pt with moderate to severe pulmonary HTN as per cath reports .\n LS CTA. Pt denies SOB.\n Action:\n Pt monitored. Pt ordered for norvasc in am.\n Response:\n Pt frequently changing position/turning self in bed with no c/o SOB, O2\n sats >94% on room air.\n Plan:\n Continue to monitor resp status and hemodynamics.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant.\n Reportedly pt had 2 BM\ns yesterday. Pt A&Ox3. Talkative with RN and\n asking appropriate questions/appropriate statements about POC and\n disease.\n Action:\n Lactulose 60 cc\ns given x2 and rifaximin 200 mg PO given.\n Response:\n Awaiting BM.\n Plan:\n Continue with lactulose for BM daily. Continue to f/u with LFT\n ammonia levels, mental status.\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-18 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 570262,
"text": "Chief Complaint: OUTPATIENT CARDIOLOGIST: , \n .\n PCP: , \n .\n Chief Complaint: admit to CCU for heart cath\n HPI:\n 53 y/o male with history of HTN, atrial fibrillation, possible\n diastolic dysfunction, DVT, PE and cryptogenic cirrhosis from childhood\n complicated by portal HTN\n and variceal hemorrhages. Patient is currently being worked-up to be\n placed on the liver transplant list.\n .\n On , the patient underwent a right heart catheterization to\n assess for pulmonary hypertension that was noted on echocardiogram.\n Found to have elevated right and left sided filling pressures (RVEDP 16\n mmHG, PCWP mean 21 mmHG), Moderate to severe pulmonary artery\n hypertension with a PASP of 72 mmHG. Cardiac index reduced at 1.74\n l/min/m2. Pulmonary vascular resistance markedly elevated at 670\n dynes-sec/cm5. Pulmonary hypertension was not responsive to vasodilator\n therapy, although it did decrease to 533 from 594 dynes/cm5.\n .\n Patient was seen by pulmonary as an outpatient who felt that the\n primary cause for his pulmonary hypertension was likely to be left\n heart failure with possibly a secondary superimposed primary pulmonary\n process either due to chronic PE, or liver disease.\n .\n Patient was in his usual state of health until over the weekend the\n patient was admitted to a local hospital with hypotension (80/57) and\n bradycardia (HR 47). Apparently had become encephalopathic at home,\n and vomitted and was brought to OSH ED. Discharged to home with\n discontinuation of Verapamil. He is now being readmitted to for\n repeat RHC and likely admission to CCU for titration of medications,\n hemodynamic monitoring.\n .\n Patient reports that at home that he was feeling well. He reports\n stable 2 pillow orthopnea, no PND, no weight gain, increased LE edema,\n or exertional chest pain. He states that he has in fact lost 10 lbs in\n the last 3-4 months.\n .\n In the Cath lab patient had a Swan placed. PCWP of 25 (mean), PA\n pressure 68/30 (mean 51), RV 64/15 (mean 22), RA 16-19. CI 2.5.\n Impression was for severe LV diastolic dysfunction, pulmonary\n hypertension. Patient was admitted to the ICU for tailored diuresis.\n .\n Cardiac review of systems notable for stable dyspnea on exertion at\n about 20-30 feet. Is able to climb 10 steps without difficulty,\n however.\n Patient admitted from: OR / PACU\n History obtained from Patient, Family / Medical records\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - cryptogenic cirrhosis c/b portal HTN and variceal bleeding\n - s/p splenorenal shunt and splenectomy with splenic vein anastamosed\n to left renal vein\n - UGIB portacaval shunt\n - s/p end vena cava o superior mesenteric vein anastamosis\n - hepatic encephalopathy w/ mult admits\n - DVT\n - pulmonary emboli 2-3 years ago\n - atrial fib\n - htn\n - pvd?\n - GERD\n - HOH(?)\n .\n ALLERGIES: Sulfa/cardizem\n .\n CURRENT MEDICATIONS:\n (on admission)\n -lactulose 60cc TID/QID\n -metoprolol 25mg PO BID\n -polyethylene glycol 17gram\n -Rifaxamin 200 TID\n -Omeprazole 20mg daily\n -Calcium 600mg \n -MVI daily\n -Coumadin as directed\n He is adopted and family history is unknown. His adopted father was a\n long term cigarette smoker, and thus he was exposed to secondhand smoke\n as a child.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Mr. currently lives with his brother-in-law, , and\n sister . They have three cats and one dog. He is currently\n disabled and previously worked in a shoe factory and at Victory\n Market. He does not drink alcoholic beverages and has never smoked\n cigarettes. He is originally from . While\n working in the shoe factory he was exposed to latex and acetone.\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, Weight loss, 10lbs over \n months\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Constipation\n Flowsheet Data as of 01:26 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 70 (70 - 73) bpm\n BP: 117/82(90) {117/69(81) - 127/94(99)} mmHg\n RR: 15 (15 - 18) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 30 (21 - 30)mmHg\n PAP: (60 mmHg) / (32 mmHg)\n Total In:\n 32 mL\n PO:\n TF:\n IVF:\n 32 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 32 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Anxious,\n No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) NG tube, No(t) OG tube\n Cardiovascular: (S1: Normal), (S2: Loud), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, multiple soft tissue prominences\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 197 K/uL\n 14.2 g/dL\n 99 mg/dL\n 1.7 mg/dL\n 23 mg/dL\n 26 mEq/L\n 107 mEq/L\n 4.4 mEq/L\n 140 mEq/L\n 42.6 %\n 7.7 K/uL\n [image002.jpg]\n \n 2:33 A4/27/ 10:56 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 7.7\n Hct\n 42.6\n Plt\n 197\n Cr\n 1.7\n Glucose\n 99\n Other labs: Differential-Neuts:58.3 %, Lymph:30.8 %, Mono:7.5 %,\n Eos:2.5 %, Ca++:9.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.5 mg/dL\n Imaging: 2D-ECHOCARDIOGRAM performed on demonstrated:\n The left atrium is moderately dilated. The right atrium is moderately\n dilated. No atrial septal defect is seen by 2D or color Doppler. There\n is mild symmetric left ventricular hypertrophy with normal cavity size\n and regional/global systolic function (LVEF>55%). There is no\n ventricular septal defect. The right ventricular cavity is mildly\n dilated with normal free wall contractility. The aortic root is mildly\n dilated at the sinus level. The ascending aorta is mildly dilated. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n appears structurally normal with trivial mitral regurgitation. The\n tricuspid valve leaflets are mildly thickened. There is mild pulmonary\n artery systolic hypertension. There is a small pericardial effusion.\n There are no echocardiographic signs of tamponade.\n .\n CARDIAC CATH performed on demonstrated:\n COMMENTS:\n 1. Resting hemodynamics demonstrated elevated right and left sided\n filling pressures (RVEDP 16 mm Hg, PCWP mean 21 mm Hg). There was\n moderate to severe pulmonary arterial hypertension (PASP 72 mm Hg). The\n cardiac index was moderately reduced at 1.74 l/min/m2. The pulmonary\n vascular resistance was markedly elevated (670 dynes-sec/cm5). There\n was severe systemic arterial hypertension (SBP 180 mm Hg).\n 2. Administrated of 100% inhaled FiO2 resulted in a decrease in\n pulmonary vascular resistance (594 dynes-sec/cm5) but an increase in\n PCWP (mean 29 mm Hg) and no significant change in pulmonary arterial\n hypertension (PASP 76 mm Hg).\n 3. Administration of inhaled nitric oxide + 100% FiO2 resulted in a\n further decrease of pulmonary vascular resistance (533 dynes-sec/cm5).\n There was no change in the elevated left sided filling pressure (PCWP\n mean 31 mm Hg) or pulmonary arterial hypertension (PASP 75 mm Hg).\n .\n FINAL DIAGNOSIS:\n 1. Moderate to severe pulmonary hypertension.\n 2. Pulmonary hypertension not vasodilator responsive.\n 3. Biventricular diastolic dysfunction.\n A six-minute walk test was performed and Mr. was\n able to ambulate approximately 1300 feet. His resting oxygen\n saturation on room air was 99%. When ambulating his oxygen\n saturation decreased to 97%.\n Microbiology: none\n ECG: EKG demonstrated atrial fibrillation.\n Assessment and Plan\n Patient is a 53 y/o M w/ h/o cryptogenic cirrhosis, portal\n hypertension, pulmonary hypertension, a. fib, admitted for R-heart cath\n w/ e/o diastolic LH failure as well as pulmonary hypertension.\n .\n # Heart Failure: By symptoms would be class II-III heart failure.\n R-Heart cath suggests component of left heart failure. No focal wall\n motion by echo to suggest CAD or prior infarct. ECG w/ atrial fib but\n otherwise w/o e/o ischemia. Is diastolic dysfunction given nml ef and\n echo findings.\n - follow swann numbers and diurese as tolerated with goal PCWP 16-18.\n - consider repeat echo\n - check TSH, lipid panel\n - uptitrate beta-blocker as tolerated\n - consider ACE/ although no mortality benefit in diastolic HF\n - consider cardioversion, obtain outpatient INR record\n - contact family regarding h/o sulfa allergy and consider\n .\n #. Cirrhosis: On transplant list. Completing transplant w/u\n - continue rifaxamin, lactulose\n .\n #. Afib: Continue coumadin. continue coumadin.\n - heparin gtt for INR < 1.9\n .\n #. HTN: Continue beta-blocker\n .\n #. DVT/PE: Continue coumadin. Heparin gtt for INR < 1.9\n .\n #. FEN: Replete lytes prn\n .\n #. Access: PIV, swann -> will need to pull back based on CXR findings,\n tracings and fact distal port is not drawing.\n .\n #. PPx: bowel regimen, heparin\n .\n #. Emergency contact: sister \n .\n #. Code: full\n .\n #. Dispo: Pending resolution of above\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:00 AM\n Multi Lumen - 11:45 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570315,
"text": "Patient is a 53 y/o M w/ h/o cryptogenic cirrhosis, portal\n hypertension, pulmonary hypertension, a. fib, admitted for R-heart cath\n w/ e/o diastolic LH failure as well as pulmonary hypertension.\n .\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PA line in R IJ-> filling pressures elevated- in chronic afib on tele\n Action:\n Lasix 20mg IV given- started on heparin gtt @ 600u/hr @ 1400- Captopril\n .625mg started TID\n Response:\n Hemodynamically stable- Diuresing well.\n Plan:\n Follow hemodynamics- monitor output- monitor lytes and replete as\n needed.\n Cirrhosis of liver, other\n Assessment:\n H/O cryptogenic cirrhosis as child.\n Action:\n Lactulose 60cc QID titrate to BM\ns/day (given @ 1230 & 1800-\n rifaximin 200mg TID.\n Response:\n Had 2 BM\ns prior to admission to CCU only.\n Plan:\n Con\nt present management- follow LFT\ns and ammonia levels.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Mod to severe pulmonary HTN on last cath \n PAS >55- lung sounds\n clear.\n Action:\n On norvasc 10mg qd.\n Response:\n No resp distress- SpO2 >95% on room air.\n Plan:\n Monitor closely.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570270,
"text": "Patient is a 53 y/o M w/ h/o cryptogenic cirrhosis, portal\n hypertension, pulmonary hypertension, a. fib, admitted for R-heart cath\n w/ e/o diastolic LH failure as well as pulmonary hypertension.\n .\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PA line in R IJ-> filling pressures elevated- in chronic afib on tele\n Action:\n Lasix 20mg IV given- started on heparin gtt @ 600u/hr @ 1400.\n Response:\n Hemodynamically stable.\n Plan:\n Cirrhosis of liver, other\n Assessment:\n h/o cryptogenic cirrhosis as child.\n Action:\n Lactulose 60cc TID\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570420,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulmonary HTN\n 24 Hour Events:\n -RHC showed PCWP of 25 (mean), PA pressure 68/30 (mean 51), RV 64/15\n (mean 22), RA 16-19. CI 2.5 (severe LV diastolic dysfxn, pulm HTN)\n -put out 750 cc to lasix 20 mg IV, PAP 50-60/20-30\n -gave another lasix 20 mg IV @ 2100\n -started heparin/coumadin for PE/AFib\n -added captopril 6.25 TID for afterload reduction\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:35 AM\n Other medications:\n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 76 (54 - 76) bpm\n BP: 113/82(88) {99/55(64) - 127/94(110)} mmHg\n RR: 35 (13 - 35) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 8 (8 - 30)mmHg\n PAP: (48 mmHg) / (27 mmHg)\n PCWP: 23 (23 - 25) mmHg\n CO/CI (Fick): (4.1 L/min) / (1.9 L/min/m2)\n Mixed Venous O2% Sat: 63 - 68\n SVR 1445dynes/sec x cm^-5\n Total In:\n 309 mL\n 456 mL\n PO:\n 200 mL\n TF:\n IVF:\n 309 mL\n 256 mL\n Blood products:\n Total out:\n 1,650 mL\n 900 mL\n Urine:\n 1,650 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,341 mL\n -444 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: irreg irreg no m/r/g\n PULM: scattered end-exp wheezes bilat no rales/rhonchi\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 180 K/uL\n 14.2 g/dL\n 97 mg/dL\n 1.5 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 22 mg/dL\n 103 mEq/L\n 139 mEq/L\n 44\n 6.8 K/uL\n [image002.jpg]\n 10:56 AM\n 03:50 AM\n 04:14 AM\n WBC\n 7.7\n 6.8\n Hct\n 42.6\n 42.5\n 44\n Plt\n 197\n 180\n Cr\n 1.7\n 1.5\n Glucose\n 99\n 97\n Other labs: PT / PTT / INR:20.9/38.4/2.0, Differential-Neuts:58.3 %,\n Lymph:30.8 %, Mono:7.5 %, Eos:2.5 %, Ca++:9.2 mg/dL, Mg++:1.7 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal\n hypertension, pulmonary hypertension, chronic diastolic CHF, PE and\n Afib on coumadin admitted for elective RHC demonstrating acute on\n chronic LV diastolic dysfunction and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: PAD not optimal due to inadequate\n diuresis; low CI and elev. SVR suggest need for incr. afterload\n reduction; likely longstanding HTN, no focal WMA by echo to suggest\n CAD or prior infarct, ECG w/o evidence of ischemia\n -cont diuresis to goal PAD 21-23 mmHg (PCWP 16-18 mmHg)\n -goal -2 L today\n -incr. captopril for better afterload reduction\n .\n #Pulm HTN\n PAD remain elevated due to left-sided CHF; not vasodilator\n responsive per cath \n -cont amlodipine although not likely to produce substantial response\n -treat left-sided CHF, as above\n .\n #Cirrhosis - awaiting transplant\n -continue rifaxamin, lactulose\n .\n #. Afib\n rate well-controlled\n -cont coumadin goal INR \n -cont metoprolol\n -consider cardioversion if OSH records confirm recent therapeutic INR\n -d/c heparin drip today\n .\n #. HTN: well-controlled\n -continue BB, CCB\n .\n #. DVT/PE: Continue coumadin. INR therapeutic today.\n .\n #. FEN: Replete lytes prn\n .\n #. Access: PIV, swann -> tip placement reviewed and felt to be in good\n place after adjusting last night despite radiology read.\n .\n #. PPx: PPI, bowel regimen, systemic AC\n .\n #. Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring\n ICU Care\n Nutrition: low sodium diet\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 11:00 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n VAP:\n Code status: FULL\n Disposition: CCU for hemodynamic monitoring\n ------ Protected Section ------\n Chart reviewed. Patient interviewed and examined. I agree with Dr.\n \ns H+P, A+P. ICU level care secondary to indwelling PA line.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:34 ------\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570556,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n Rec\nd 20 mg lasix x 3 with 2800 cc UOP (-800 @ MN)\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:50 PM\n Other medications:\n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 73 (64 - 83) bpm\n BP: 108/72(81) {94/56(67) - 137/99(109)} mmHg\n RR: 15 (12 - 26) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 8 (5 - 12)mmHg\n PAP: (51 mmHg) / (28 mmHg)\n CO/CI (Fick): (5 L/min) / (2.4 L/min/m2)\n Mixed Venous O2% Sat: 69 (66\n 69)\n SVR 968\n Total In:\n 2,005 mL\n 363 mL\n PO:\n 1,400 mL\n 180 mL\n TF:\n IVF:\n 605 mL\n 183 mL\n Blood products:\n Total out:\n 2,825 mL\n 650 mL\n Urine:\n 2,825 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -820 mL\n -287 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath site c/d/i\n CV: irreg irreg no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 162 K/uL\n 15.7\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 19 mg/dL\n 98 mEq/L\n 133 mEq/L\n 47\n 8.1 K/uL\n [image002.jpg]\n 10:56 AM\n 03:50 AM\n 04:14 AM\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n WBC\n 7.7\n 6.8\n 8.1\n Hct\n 42.6\n 42.5\n 44\n 45\n 44\n 44.8\n 47\n Plt\n 197\n 180\n 162\n Cr\n 1.7\n 1.5\n 1.6\n 1.5\n Glucose\n 99\n 97\n 107\n 119\n Other labs: PT / PTT / INR:19.8/38.4/1.8, Differential-Neuts:58.3 %,\n Lymph:30.8 %, Mono:7.5 %, Eos:2.5 %, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, PE and Afib on coumadin admitted\n for elective RHC demonstrating acute on chronic LV diastolic CHF and\n pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: negative 2.4L LOS; PAD improving with\n diuresis and afterload reduction but not yet optimal; borderline low CI\n and elev. SVR may suggest need for further afterload reduction\n -cont diuresis to goal PAD 21-23 mmHg (PCWP 16-18 mmHg)\n -assess wedge today\n -goal -1 L today\n -incr. captopril prn for improved afterload reduction\n .\n #Pulm HTN\n PAD remain elevated due to left-sided CHF; not\n NO-responsive per cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator responsive\n -treat left-sided CHF, as above\n .\n #DVT/PE\n -resume heparin for subtherapeutic INR\n -cont coumadin goal INR \n .\n #Afib\n rate well-controlled, however he would benefit from being in\n NSR with improved cardiac filling from atrial kick\n -obtain OSH information re:duration of afib and anti-coagulation\n -cont heparin/coumadin\n -cont lopressor\n .\n #Cirrhosis - awaiting transplant. Will discuss with transplant team\n re:appropriate parameters that would be acceptable for surgical\n intervention\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #. Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition: low Na diet\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 11:00 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Communication: sister \n status: FULL\n Disposition: CCU for hemodynamic monitoring while swan in place\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570358,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 28-30. Pt denies SOB, CP LS CTA. Hr 60\ns afib with rare to\n occasional PVC\ns, pt noted for rare to occasional second pauses\n while sleeping. SBP 99-120\n Action:\n 20 mg IVP lasix given. Heparin gtt increased to 750 units/hr for\n subtherapeutic (59.5) PTT at 2200 with no bolus as per Dr. .\n Captopril 6.25 mg given. Coumadin resumed as MD\ns. CHF\n teaching/discussion with pt.\n Response:\n PADs 28->26. AM cardiac numbers-> CO 4.1/CI 1.9/SVR1445->Dr. \n aware. Pt voiding via urinal, -1.3L at midnoc. Hemodynamically\n stable. PTT drawn at 0400 (heparin noted to not be connected to pt ?\n for approximately an hour as pt turns self side to side in bed). Dr.\n aware, INR 2.0 so heparin gtt continued at 750 units/hr. Pt\n verbalized understanding and knowledge r/t disease management.\n Plan:\n Continue to monitor hemodynamics, cardiac numbers. Obtain PTT. Continue\n to titrate meds as tolerated and ordered. Continue with\n teaching/encourage knowledge as indicated.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Pt with moderate to severe pulmonary HTN as per cath reports .\n LS CTA. Pt denies SOB.\n Action:\n Pt monitored. Pt ordered for norvasc in am.\n Response:\n Pt frequently changing position/turning self in bed with no c/o SOB, O2\n sats >94% on room air.\n Plan:\n Continue to monitor resp status and hemodynamics.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant.\n Reportedly pt had 2 BM\ns yesterday. Pt A&Ox3. Talkative with RN and\n asking appropriate questions/appropriate statements about POC and\n disease.\n Action:\n Lactulose 60 cc\ns given x2 and rifaximin 200 mg PO given.\n Response:\n Awaiting BM.\n Plan:\n Continue with lactulose for BM daily. Continue to f/u with LFT\n ammonia levels, mental status.\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570376,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulmonary HTN\n 24 Hour Events:\n -RHC showed PCWP of 25 (mean), PA pressure 68/30 (mean 51), RV 64/15\n (mean 22), RA 16-19. CI 2.5 (severe LV diastolic dysfxn, pulm HTN)\n -put out 750 cc to lasix 20 mg IV, PAP 50-60/20-30\n -gave another lasix 20 mg IV @ 2100\n -started heparin/coumadin for PE/AFib\n -added captopril 6.25 TID for afterload reduction\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:35 AM\n Other medications:\n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 76 (54 - 76) bpm\n BP: 113/82(88) {99/55(64) - 127/94(110)} mmHg\n RR: 35 (13 - 35) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 8 (8 - 30)mmHg\n PAP: (48 mmHg) / (27 mmHg)\n PCWP: 23 (23 - 25) mmHg\n CO/CI (Fick): (4.1 L/min) / (1.9 L/min/m2)\n Mixed Venous O2% Sat: 63 - 68\n SVR 1445dynes/sec x cm^-5\n Total In:\n 309 mL\n 456 mL\n PO:\n 200 mL\n TF:\n IVF:\n 309 mL\n 256 mL\n Blood products:\n Total out:\n 1,650 mL\n 900 mL\n Urine:\n 1,650 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,341 mL\n -444 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: irreg irreg no m/r/g\n PULM: scattered end-exp wheezes bilat no rales/rhonchi\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 180 K/uL\n 14.2 g/dL\n 97 mg/dL\n 1.5 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 22 mg/dL\n 103 mEq/L\n 139 mEq/L\n 44\n 6.8 K/uL\n [image002.jpg]\n 10:56 AM\n 03:50 AM\n 04:14 AM\n WBC\n 7.7\n 6.8\n Hct\n 42.6\n 42.5\n 44\n Plt\n 197\n 180\n Cr\n 1.7\n 1.5\n Glucose\n 99\n 97\n Other labs: PT / PTT / INR:20.9/38.4/2.0, Differential-Neuts:58.3 %,\n Lymph:30.8 %, Mono:7.5 %, Eos:2.5 %, Ca++:9.2 mg/dL, Mg++:1.7 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal\n hypertension, pulmonary hypertension, chronic diastolic CHF, PE and\n Afib on coumadin admitted for elective RHC demonstrating acute on\n chronic LV diastolic dysfunction and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: PAD not optimal due to inadequate\n diuresis; low CI and elev. SVR suggest need for incr. afterload\n reduction; likely longstanding HTN, no focal WMA by echo to suggest\n CAD or prior infarct, ECG w/o evidence of ischemia\n -cont diuresis to goal PAD 21-23 mmHg (PCWP 16-18 mmHg)\n -incr. captopril for better afterload reduction\n .\n #Pulm HTN\n PAD remain elevated due to left-sided CHF; not vasodilator\n responsive per cath \n -cont amlodipine although not likely to produce substantial response\n -treat left-sided CHF, as above\n .\n #Cirrhosis - awaiting transplant\n -continue rifaxamin, lactulose\n .\n #. Afib\n rate well-controlled\n -cont coumadin goal INR \n -cont metoprolol\n -consider cardioversion if OSH records confirm recent therapeutic INR\n -heparin gtt for INR < 1.9\n .\n #. HTN: well-controlled\n -continue BB, CCB\n .\n #. DVT/PE: Continue coumadin. Heparin gtt for INR < 1.9\n .\n #. FEN: Replete lytes prn\n .\n #. Access: PIV, swann -> will need to pull back based on CXR findings,\n tracings and fact distal port is not drawing.\n .\n #. PPx: PPI, bowel regimen, systemic AC\n .\n #. Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring\n ICU Care\n Nutrition: low sodium diet\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 11:00 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n VAP:\n Code status: FULL\n Disposition: CCU for hemodynamic monitoring\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570391,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulmonary HTN\n 24 Hour Events:\n -RHC showed PCWP of 25 (mean), PA pressure 68/30 (mean 51), RV 64/15\n (mean 22), RA 16-19. CI 2.5 (severe LV diastolic dysfxn, pulm HTN)\n -put out 750 cc to lasix 20 mg IV, PAP 50-60/20-30\n -gave another lasix 20 mg IV @ 2100\n -started heparin/coumadin for PE/AFib\n -added captopril 6.25 TID for afterload reduction\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:35 AM\n Other medications:\n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 76 (54 - 76) bpm\n BP: 113/82(88) {99/55(64) - 127/94(110)} mmHg\n RR: 35 (13 - 35) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 8 (8 - 30)mmHg\n PAP: (48 mmHg) / (27 mmHg)\n PCWP: 23 (23 - 25) mmHg\n CO/CI (Fick): (4.1 L/min) / (1.9 L/min/m2)\n Mixed Venous O2% Sat: 63 - 68\n SVR 1445dynes/sec x cm^-5\n Total In:\n 309 mL\n 456 mL\n PO:\n 200 mL\n TF:\n IVF:\n 309 mL\n 256 mL\n Blood products:\n Total out:\n 1,650 mL\n 900 mL\n Urine:\n 1,650 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,341 mL\n -444 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: irreg irreg no m/r/g\n PULM: scattered end-exp wheezes bilat no rales/rhonchi\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 180 K/uL\n 14.2 g/dL\n 97 mg/dL\n 1.5 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 22 mg/dL\n 103 mEq/L\n 139 mEq/L\n 44\n 6.8 K/uL\n [image002.jpg]\n 10:56 AM\n 03:50 AM\n 04:14 AM\n WBC\n 7.7\n 6.8\n Hct\n 42.6\n 42.5\n 44\n Plt\n 197\n 180\n Cr\n 1.7\n 1.5\n Glucose\n 99\n 97\n Other labs: PT / PTT / INR:20.9/38.4/2.0, Differential-Neuts:58.3 %,\n Lymph:30.8 %, Mono:7.5 %, Eos:2.5 %, Ca++:9.2 mg/dL, Mg++:1.7 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal\n hypertension, pulmonary hypertension, chronic diastolic CHF, PE and\n Afib on coumadin admitted for elective RHC demonstrating acute on\n chronic LV diastolic dysfunction and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: PAD not optimal due to inadequate\n diuresis; low CI and elev. SVR suggest need for incr. afterload\n reduction; likely longstanding HTN, no focal WMA by echo to suggest\n CAD or prior infarct, ECG w/o evidence of ischemia\n -cont diuresis to goal PAD 21-23 mmHg (PCWP 16-18 mmHg)\n -goal -2 L today\n -incr. captopril for better afterload reduction\n .\n #Pulm HTN\n PAD remain elevated due to left-sided CHF; not vasodilator\n responsive per cath \n -cont amlodipine although not likely to produce substantial response\n -treat left-sided CHF, as above\n .\n #Cirrhosis - awaiting transplant\n -continue rifaxamin, lactulose\n .\n #. Afib\n rate well-controlled\n -cont coumadin goal INR \n -cont metoprolol\n -consider cardioversion if OSH records confirm recent therapeutic INR\n -d/c heparin drip today\n .\n #. HTN: well-controlled\n -continue BB, CCB\n .\n #. DVT/PE: Continue coumadin. INR therapeutic today.\n .\n #. FEN: Replete lytes prn\n .\n #. Access: PIV, swann -> tip placement reviewed and felt to be in good\n place after adjusting last night despite radiology read.\n .\n #. PPx: PPI, bowel regimen, systemic AC\n .\n #. Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring\n ICU Care\n Nutrition: low sodium diet\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 11:00 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n VAP:\n Code status: FULL\n Disposition: CCU for hemodynamic monitoring\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570321,
"text": "Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570322,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted for R-heart cath w/ e/o diastolic LH\n failure as well as pulmonary hypertension.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570323,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570467,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns continue elevated 26-30. Pt LS CTA. Pt denies SOB/CP. O2 sats\n >95% on room air.\n Action:\n 20 mg IVP lasix given. Captopril 12.5 mg given.\n Response:\n CO 4.5/CI 2.1/SVR 1425 with MVO2 66%. PADs 24-28. Pt continues to deny\n SOB/CP, LS CTA. Pt -\n :\n Continue to follow hemodynamics, PAD\ns. Cont to monitor resp status.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant.\n Reportedly pt with no BM\ns today. Pt A&Ox3. Talkative with RN and\n asking appropriate questions/appropriate statements about POC and\n disease.\n Action:\n Lactulose and rifaxamin given.\n Response:\n Plan:\n Continue with lactulose for BM daily. Continue to f/u with LFT\n ammonia levels, mental status.\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570874,
"text": "Chief Complaint:\n 24 Hour Events:\n -d/c'd heparin gtt given therapeutic INR\n -DC cardioversion -> SR\n -lasix 40 mg IV x 2\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 04:25 PM\n Other medications: metoprolol tartrate 25mg , miralax, calcium\n carbonate 1000mg , MVI, omeprazole 20mg daily, amlodipine 10mg PO\n daily, coumadin 5mg daily, lactulose 60mL PO q4h, captopril 12.5mg PO\n TID, rifaximin 400mg PO TID, senna 2tabs PO BID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: Reports mild nausea yesterday relieved by zofran,\n vomiting x1. Denies chest pain, SOB\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.2\nC (99\n HR: 52 (47 - 80) bpm\n BP: 98/57(67) {95/50(62) - 129/97(110)} mmHg\n RR: 17 (14 - 26) insp/min\n SpO2: 91%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 3 (-4 - 10)mmHg\n PAP: (60 mmHg) / (25 mmHg)\n PA (mean): 37\n CO/CI (Fick): (4.9 L/min) / (2.3 L/min/m2)\n Mixed Venous O2% Sat: 63 - 63\n Total In:\n 1,185 mL\n 70 mL\n PO:\n 780 mL\n TF:\n IVF:\n 405 mL\n 70 mL\n Blood products:\n Total out:\n 1,835 mL\n 0 mL\n Urine:\n 1,835 mL\n NG:\n Stool:\n Drains:\n Balance:\n -650 mL\n 70 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 91%\n ABG: ///30/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: RRR nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 116 K/uL\n 14.4 g/dL\n 94 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 102 mEq/L\n 139 mEq/L\n 43.4 %\n 10.5 K/uL\n [image002.jpg]\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n WBC\n 8.1\n 11.6\n 10.5\n Hct\n 45\n 44\n 44.8\n 47\n 43.7\n 40\n 43.4\n Plt\n 162\n 156\n 116\n Cr\n 1.6\n 1.5\n 1.6\n 1.6\n 1.7\n 1.5\n Glucose\n 107\n 119\n 128\n 97\n 111\n 94\n Other labs: PT / PTT / INR:24.0/39.0/2.3, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.8 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -4.5L LOS. In\n order to meet transplant requirements, mean PA pressures need to be\n less than 35\n -cont diuresis to goal -2 L today\n -lasix 80mg IV this am then prn\n -eval wedge this afternoon\n - lytes\n -incr. captopril prn as tolerated for improved afterload reduction\n -consider d/c Swan when hemodynamics improved\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with element of\n irreversible pulm HTN, also suggested by absence of response to inhaled\n NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE: INR 2.3 this am\n -cont coumadin (goal INR )\n .\n #Afib\n s/p successful cardioversion yesterday and remains in NSR\n -cont lopressor for rate-control\n -continue coumadin to maintain INR 2.0-3.0\n .\n #CRI\n Cr stable\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n Prophylaxis:\n DVT: therapeutic on coumadin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570499,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns continue elevated 26-30. Pt LS CTA. Pt denies SOB/CP. O2 sats\n >95% on room air.\n Action:\n 20 mg IVP lasix given. Captopril 12.5 mg given.\n Response:\n Cardiac numbers improved-> CO 5/CI 2.4/SVR 968. Pt continues to deny\n SOB/CP, LS CTA. Pt negative approx 800 cc\ns at midnoc. Voiding via\n urinal.\n Plan:\n Continue to follow hemodynamics, PAD\ns. Cont to monitor resp status.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant.\n Reportedly pt with 1 BM today. Pt A&Ox3. Talkative with RN and asking\n appropriate questions/appropriate statements about POC and disease.\n Action:\n Lactulose Q4H given and rifaxamin given.\n Response:\n Awaiting BM.\n Plan:\n Continue with lactulose for BM daily, f/ with MD\ns re. increasing\n bowel regimen to meet goal BM\ns. Continue to f/u with LFT\ns, ammonia\n levels, mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570453,
"text": "Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570455,
"text": "Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570458,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis on with RIJ PA line in place.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAP\ns remain high but improving w/Lasix 20mg iv boluses; CO/CI\n improving, K= 3.8\n Action:\n Lasix 20mg iv x1 at 1230pm, Kcl 40meq given x 1; captopril increased to\n 12.5 mg three times daily\n Response:\n Approximate 700cc diuresis\n voiding well in urinal, no c/o SOB, lungs\n clear on room air, BP tolerating increased meds\n Plan:\n Continue follow PAP\ns, hemodynamics per team, Replace lytes as\n needed, diurese as ordered.\n Knowledge Deficit\n Assessment:\n Pt asking question about his meds\n has some basic understanding of at\n home meds but needs reinforcement\n Question of capacity to understand med regimen in depth\n Action:\n Pt given simple explanations of meds given; spoke with sister whom he\n lives with\n sister takes care of med administration at home\n Response:\n Continues to ask appropriate questions\n am I getting my coumadin here?\n Plan:\n Cont offer information to pt and reinforce med teaching w/sister and\n family prior to discharge.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570459,
"text": "Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570460,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570461,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant.\n Reportedly pt with no BM\ns today. Pt A&Ox3. Talkative with RN and\n asking appropriate questions/appropriate statements about POC and\n disease.\n Action:\n Lactulose and rifaxamin given.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570462,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant.\n Reportedly pt with no BM\ns today. Pt A&Ox3. Talkative with RN and\n asking appropriate questions/appropriate statements about POC and\n disease.\n Action:\n Lactulose and rifaxamin given.\n Response:\n Plan:\n Continue with lactulose for BM daily. Continue to f/u with LFT\n ammonia levels, mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570463,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns continue elevated 26-30. Pt LS CTA. Pt denies SOB/CP. O2 sats\n >95% on room air.\n Action:\n 20 mg IVP lasix given. Captopril 12.5 mg given.\n Response:\n Plan:\n Continue to follow hemodynamics, PAD\ns. Cont to monitor resp status.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant.\n Reportedly pt with no BM\ns today. Pt A&Ox3. Talkative with RN and\n asking appropriate questions/appropriate statements about POC and\n disease.\n Action:\n Lactulose and rifaxamin given.\n Response:\n Plan:\n Continue with lactulose for BM daily. Continue to f/u with LFT\n ammonia levels, mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570468,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns continue elevated 26-30. Pt LS CTA. Pt denies SOB/CP. O2 sats\n >95% on room air.\n Action:\n 20 mg IVP lasix given. Captopril 12.5 mg given.\n Response:\n CO 4.5/CI 2.1/SVR 1425 with MVO2 66%. PADs 24-28. Pt continues to deny\n SOB/CP, LS CTA. Pt negative approx 800 cc\ns at midnoc. Voiding via\n urinal.\n Plan:\n Continue to follow hemodynamics, PAD\ns. Cont to monitor resp status.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant.\n Reportedly pt with no BM\ns today. Pt A&Ox3. Talkative with RN and\n asking appropriate questions/appropriate statements about POC and\n disease.\n Action:\n Lactulose and rifaxamin given.\n Response:\n Awaiting BM.\n Plan:\n Continue with lactulose for BM daily. Continue to f/u with LFT\n ammonia levels, mental status.\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570745,
"text": "Chief Complaint: acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n -records from PCP reflect therapeutic INR while on coumadin for PE;\n however Afib reportedly new\n -goal pre-transplant mean PAP < 35 mmHg per Dr. \n lasix 20/40/40 IV with 2850 cc UOP (-1800 cc balance)\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Other medications: coumadin\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: c/o nausea, 2 episodes brown, non-bloody emesis O/N\n attributed to dinner\nnot agreeing with me;\n now feels fine; no f/c,\n abd pain, diarrhea, melena, hematochezia\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 76 (69 - 90) bpm\n BP: 112/74(83) {96/63(75) - 132/85(119)} mmHg\n RR: 20 (16 - 27) insp/min\n SpO2: 91%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 8 (7 - 16)mmHg\n PAP: 62/31 mmHg\n (43-73/24-43 mgHg)\n mPAP 46 mmHg\n (29-57 mmgHg)\n CO/CI (Fick): (6.2 L/min) / (2.9 L/min/m2)\n Mixed Venous O2% Sat: 71 - 71\n Total In:\n 1,732 mL\n 178 mL\n PO:\n 900 mL\n TF:\n IVF:\n 832 mL\n 178 mL\n Blood products:\n Total out:\n 3,350 mL\n 340 mL\n Urine:\n 2,850 mL\n 340 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n -1,618 mL\n -162 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 91% (88-97%)\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath site c/d/i\n CV: irreg irreg no m/r/g\n PULM: scattered bilat end-exp wheezes no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 156 K/uL\n 14.5 g/dL\n 97 mg/dL\n 1.6 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 18 mg/dL\n 103 mEq/L\n 141 mEq/L\n 40\n 11.6 K/uL\n [image002.jpg]\n 03:50 AM\n 04:14 AM\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n WBC\n 6.8\n 8.1\n 11.6\n Hct\n 42.5\n 44\n 45\n 44\n 44.8\n 47\n 43.7\n 40\n Plt\n 180\n 162\n 156\n Cr\n 1.5\n 1.6\n 1.5\n 1.6\n 1.6\n Glucose\n 97\n 107\n 119\n 128\n 97\n Other labs: PT / PTT / INR:23.7/150.0/2.3, Differential-Neuts:58.3 %,\n Lymph:30.8 %, Mono:7.5 %, Eos:2.5 %, Ca++:7.4 mg/dL, Mg++:1.7 mg/dL,\n PO4:2.6 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: improving, -4L diuresis to goal -2 L today\n -eval wedge this afternoon\n - lytes\n -incr. captopril prn for improved afterload reduction\n -consider d/c Swan pending evaluation\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with\n elementirreversible pulm HTN, also suggested by absence of response to\n inhaled NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE\n -cont coumadin (goal INR )\n -d/c heparin given that his INR 2.3\n .\n #Afib\n rate well-controlled, however would benefit from conversion to\n sinus given comorbid diastolic CHF\n -plan is for cardioversion today\n -cont lopressor for rate-control\n -continue coumadin to maintain INR 2.0-3.0\n .\n #CRI\n Cr stable\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition: low Na diet\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 11:00 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Communication: sister \n status: FULL\n Disposition: CCU for hemodynamic monitoring while swan in place\n ------ Protected Section ------\n Chart reviewed. Patient interviewed and examined. I agree with Dr.\n \ns H+P, A+P. I have personally reviewed her INRs over the past\n several weeks, and timing of IV heparin initiation. Given the ongoing\n atrial fibrillation, we will cardiovert to SR. There is no indication\n for TEE prior to cardioversion at this time. Will continue to update\n the liver tx team on the progress.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:46 ------\n"
},
{
"category": "General",
"chartdate": "2139-05-21 00:00:00.000",
"description": "ICU Event Note",
"row_id": 570749,
"text": "Clinician: Resident\n Procedure: DC Cardioversion\n Indication: Atrial fibrillation\n Patient therapeutically anticoagulated. Consented by medical and\n anesthesia teams. DC cardioversion performed by delivery of 200 J shock\n under conscious sedation with restoration of sinus rhythm.\n No complications.\n Attending physician . present for entire procedure.\n Total time spent: 15 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570500,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns continue elevated 26-30. Pt LS CTA. Pt denies SOB/CP. O2 sats\n >95% on room air.\n Action:\n 20 mg IVP lasix given. Captopril 12.5 mg given. CHF teaching/discussion\n with pt.\n Response:\n Cardiac numbers improved-> CO 5/CI 2.4/SVR 968. Pt continues to deny\n SOB/CP, LS CTA. Pt negative approx 800 cc\ns at midnoc. Voiding via\n urinal.\n Plan:\n Continue to follow hemodynamics, PAD\ns. Cont to monitor resp status.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant.\n Reportedly pt with 1 BM today. Pt A&Ox3. Talkative with RN and asking\n appropriate questions/appropriate statements about POC and disease.\n Action:\n Lactulose Q4H given and rifaxamin given.\n Response:\n Awaiting BM.\n Plan:\n Continue with lactulose for BM daily, f/ with MD\ns re. increasing\n bowel regimen to meet goal BM\ns. Continue to f/u with LFT\ns, ammonia\n levels, mental status.\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570601,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n Rec\nd 20 mg lasix x 3 with 2800 cc UOP (-800 @ MN)\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:50 PM\n Other medications:\n Changes to medical and family history: N/A\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 73 (64 - 83) bpm\n BP: 108/72(81) {94/56(67) - 137/99(109)} mmHg\n RR: 15 (12 - 26) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 8 (5 - 12)mmHg\n PAP: (51 mmHg) / (28 mmHg)\n CO/CI (Fick): (5 L/min) / (2.4 L/min/m2)\n Mixed Venous O2% Sat: 69 (66\n 69)\n SVR 968\n Total In:\n 2,005 mL\n 363 mL\n PO:\n 1,400 mL\n 180 mL\n TF:\n IVF:\n 605 mL\n 183 mL\n Blood products:\n Total out:\n 2,825 mL\n 650 mL\n Urine:\n 2,825 mL\n 650 mL\n NG:\n Stool:\n Drains:\n Balance:\n -820 mL\n -287 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath site c/d/i\n CV: irreg irreg no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 162 K/uL\n 15.7\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 3.3 mEq/L\n 19 mg/dL\n 98 mEq/L\n 133 mEq/L\n 47\n 8.1 K/uL\n [image002.jpg]\n 10:56 AM\n 03:50 AM\n 04:14 AM\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n WBC\n 7.7\n 6.8\n 8.1\n Hct\n 42.6\n 42.5\n 44\n 45\n 44\n 44.8\n 47\n Plt\n 197\n 180\n 162\n Cr\n 1.7\n 1.5\n 1.6\n 1.5\n Glucose\n 99\n 97\n 107\n 119\n Other labs: PT / PTT / INR:19.8/38.4/1.8, Differential-Neuts:58.3 %,\n Lymph:30.8 %, Mono:7.5 %, Eos:2.5 %, Ca++:9.1 mg/dL, Mg++:1.7 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, PE and Afib on coumadin admitted\n for elective RHC demonstrating acute on chronic LV diastolic CHF and\n pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: negative 2.4L LOS; PAD improving with\n diuresis and afterload reduction but not yet optimal; borderline low CI\n and elev. SVR may suggest need for further afterload reduction\n -cont diuresis to goal PAD 21-23 mmHg (PCWP 16-18 mmHg)\n -assess wedge today\n -goal -1 L today\n -incr. captopril prn for improved afterload reduction\n .\n #Pulm HTN\n PAD remain elevated due to left-sided CHF; not\n NO-responsive per cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator responsive\n -treat left-sided CHF, as above\n .\n #DVT/PE\n -resume heparin for subtherapeutic INR\n -cont coumadin goal INR \n .\n #Afib\n rate well-controlled, however he would benefit from being in\n NSR with improved cardiac filling from atrial kick\n -obtain OSH information re:duration of afib and anti-coagulation\n -cont heparin/coumadin\n -cont lopressor\n .\n #Cirrhosis - awaiting transplant. Will discuss with transplant team\n re:appropriate parameters that would be acceptable for surgical\n intervention\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #. Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition: low Na diet\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 11:00 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Communication: sister \n status: FULL\n Disposition: CCU for hemodynamic monitoring while swan in place\n ------ Protected Section ------\n Chart reviewed. Patient interviewed and examined. I agree with Dr.\n \ns H+P, A+P.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:11 ------\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570501,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns continue elevated 26-30. Pt LS CTA. Pt denies SOB/CP. O2 sats\n >95% on room air.\n Action:\n 20 mg IVP lasix given. Captopril 12.5 mg given. CHF teaching/discussion\n with pt.\n Response:\n Cardiac numbers improved-> CO 5/CI 2.4/SVR 968. Pt continues to deny\n SOB/CP, LS CTA. Pt negative approx 800 cc\ns at midnoc. Voiding via\n urinal.\n Plan:\n Continue to follow hemodynamics, PAD\ns. Cont to monitor resp status.\n Continue with teaching/encourage knowledge as indicated.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant.\n Reportedly pt with 1 BM today. Pt A&Ox3. Talkative with RN and asking\n appropriate questions/appropriate statements about POC and disease.\n Action:\n Lactulose Q4H given and rifaxamin given.\n Response:\n Awaiting BM.\n Plan:\n Continue with lactulose for BM daily, f/ with MD\ns re. increasing\n bowel regimen to meet goal BM\ns. Continue to f/u with LFT\ns, ammonia\n levels, mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570504,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns continue elevated 26-30. Pt LS CTA. Pt denies SOB/CP. O2 sats\n >95% on room air.\n Action:\n 20 mg IVP lasix given. Captopril 12.5 mg given. CHF teaching/discussion\n with pt.\n Response:\n Cardiac numbers improved-> CO 5/CI 2.4/SVR 968. Pt continues to deny\n SOB/CP, frequently turning/changing position independently without\n complaint, LS CTA. Pt negative approx 800 cc\ns at midnoc. Voiding via\n urinal.\n Plan:\n Continue to follow hemodynamics, PAD\ns. Cont to monitor resp status.\n Continue with teaching/encourage knowledge as indicated.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant.\n Reportedly pt with 1 BM today. Pt A&Ox3. Talkative with RN and asking\n appropriate questions/appropriate statements about POC and disease.\n Action:\n Lactulose Q4H given and rifaxamin given.\n Response:\n Awaiting BM.\n Plan:\n Continue with lactulose for BM daily, f/ with MD\ns re. increasing\n bowel regimen to meet goal BM\ns. Continue to f/u with LFT\ns, ammonia\n levels, mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570621,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns trending slowly down to 25-29. Pt LS CTA. Pt denies SOB/CP. O2\n sats >95% on room air.\n Action:\n 20 mg IVP lasix given. w/ 150cc response, 40 mg given at 1400\n .Captopril 12.5 mg given.\n Response:\n Poor response to initial 20 mg lasix,450cc out over 2 hrs after 40 mg\n lasix given. Pt continues to deny SOB/CP, frequently turning/changing\n position independently without complaint, LS CTA. Voiding via urinal.\n Cr 1.6 this afternoon up from 1.5 this am. K 4.0 at 1500.\n Plan:\n Continue to diurese, follow PAD\ns.No co.ci per resident. Cont to\n monitor resp status. Continue with teaching/encourage knowledge as\n indicated.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant..pt\n with 1 BM today. Pt A&Ox3. Talkative with RN and asking appropriate\n questions/appropriate statements about POC and disease.\n Action:\n Lactulose Q4H given and rifaxamin given.\n Response:\n Awaiting BM.\n Plan:\n Continue with lactulose for BM daily, f/ with MD\ns re. increasing\n bowel regimen to meet goal BM\ns. Continue to f/u with LFT\ns, ammonia\n levels, mental status.\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570699,
"text": "Chief Complaint: acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n -records from PCP reflect therapeutic INR while on coumadin for PE;\n however Afib reportedly new\n -goal pre-transplant mean PAP < 35 mmHg per Dr. \n lasix 20/40/40 IV with 2850 cc UOP (-1800 cc balance)\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: c/o nausea, 2 episodes brown, non-bloody emesis O/N\n attributed to dinner\nnot agreeing with me;\n now feels fine; no f/c,\n abd pain, diarrhea, melena, hematochezia\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 76 (69 - 90) bpm\n BP: 112/74(83) {96/63(75) - 132/85(119)} mmHg\n RR: 20 (16 - 27) insp/min\n SpO2: 91%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 8 (-5 - 16)mmHg\n PAP: (62 mmHg) / (31 mmHg)\n CO/CI (Fick): (6.2 L/min) / (2.9 L/min/m2)\n Mixed Venous O2% Sat: 71 - 71\n Total In:\n 1,732 mL\n 178 mL\n PO:\n 900 mL\n TF:\n IVF:\n 832 mL\n 178 mL\n Blood products:\n Total out:\n 3,350 mL\n 340 mL\n Urine:\n 2,850 mL\n 340 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n -1,618 mL\n -162 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 91%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 156 K/uL\n 14.5 g/dL\n 97 mg/dL\n 1.6 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 18 mg/dL\n 103 mEq/L\n 141 mEq/L\n 40\n 11.6 K/uL\n [image002.jpg]\n 03:50 AM\n 04:14 AM\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n WBC\n 6.8\n 8.1\n 11.6\n Hct\n 42.5\n 44\n 45\n 44\n 44.8\n 47\n 43.7\n 40\n Plt\n 180\n 162\n 156\n Cr\n 1.5\n 1.6\n 1.5\n 1.6\n 1.6\n Glucose\n 97\n 107\n 119\n 128\n 97\n Other labs: PT / PTT / INR:23.7/150.0/2.3, Differential-Neuts:58.3 %,\n Lymph:30.8 %, Mono:7.5 %, Eos:2.5 %, Ca++:7.4 mg/dL, Mg++:1.7 mg/dL,\n PO4:2.6 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, PE and Afib on coumadin admitted\n for elective RHC demonstrating acute on chronic LV diastolic CHF and\n pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: negative 2.4L LOS; PAD improving with\n diuresis and afterload reduction but not yet optimal; borderline low CI\n and elev. SVR may suggest need for further afterload reduction\n -cont diuresis to goal PAD 21-23 mmHg (PCWP 16-18 mmHg)\n -assess wedge today\n -goal -1 L today\n -incr. captopril prn for improved afterload reduction\n .\n #Pulm HTN\n PAD remain elevated due to left-sided CHF; not\n NO-responsive per cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator responsive\n -treat left-sided CHF, as above\n .\n #DVT/PE\n -resume heparin for subtherapeutic INR\n -cont coumadin goal INR \n .\n #Afib\n rate well-controlled, however he would benefit from being in\n NSR with improved cardiac filling from atrial kick\n -obtain OSH information re:duration of afib and anti-coagulation\n -cont heparin/coumadin\n -cont lopressor\n .\n #Cirrhosis - awaiting transplant. Will discuss with transplant team\n re:appropriate parameters that would be acceptable for surgical\n intervention\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #. Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition: low Na diet\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 11:00 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Communication: sister \n status: FULL\n Disposition: CCU for hemodynamic monitoring while swan in place\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570707,
"text": "Chief Complaint: acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n -records from PCP reflect therapeutic INR while on coumadin for PE;\n however Afib reportedly new\n -goal pre-transplant mean PAP < 35 mmHg per Dr. \n lasix 20/40/40 IV with 2850 cc UOP (-1800 cc balance)\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: c/o nausea, 2 episodes brown, non-bloody emesis O/N\n attributed to dinner\nnot agreeing with me;\n now feels fine; no f/c,\n abd pain, diarrhea, melena, hematochezia\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 76 (69 - 90) bpm\n BP: 112/74(83) {96/63(75) - 132/85(119)} mmHg\n RR: 20 (16 - 27) insp/min\n SpO2: 91%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 8 (7 - 16)mmHg\n PAP: 62/31 mmHg\n (43-73/24-43 mgHg)\n mPAP 46 mmHg\n (29-57 mmgHg)\n CO/CI (Fick): (6.2 L/min) / (2.9 L/min/m2)\n Mixed Venous O2% Sat: 71 - 71\n Total In:\n 1,732 mL\n 178 mL\n PO:\n 900 mL\n TF:\n IVF:\n 832 mL\n 178 mL\n Blood products:\n Total out:\n 3,350 mL\n 340 mL\n Urine:\n 2,850 mL\n 340 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n -1,618 mL\n -162 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 91% (88-97%)\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath site c/d/i\n CV: irreg irreg no m/r/g\n PULM: scattered bilat end-exp wheezes no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 156 K/uL\n 14.5 g/dL\n 97 mg/dL\n 1.6 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 18 mg/dL\n 103 mEq/L\n 141 mEq/L\n 40\n 11.6 K/uL\n [image002.jpg]\n 03:50 AM\n 04:14 AM\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n WBC\n 6.8\n 8.1\n 11.6\n Hct\n 42.5\n 44\n 45\n 44\n 44.8\n 47\n 43.7\n 40\n Plt\n 180\n 162\n 156\n Cr\n 1.5\n 1.6\n 1.5\n 1.6\n 1.6\n Glucose\n 97\n 107\n 119\n 128\n 97\n Other labs: PT / PTT / INR:23.7/150.0/2.3, Differential-Neuts:58.3 %,\n Lymph:30.8 %, Mono:7.5 %, Eos:2.5 %, Ca++:7.4 mg/dL, Mg++:1.7 mg/dL,\n PO4:2.6 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: improving, -4L diuresis to goal PAD 21-23 mmHg (proxy for PCWP 16-18 mmHg)\n -volume goal -2 L today\n - lytes\n -incr. captopril prn for improved afterload reduction\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with\n elementirreversible pulm HTN, also suggested by absence of response to\n inhaled NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator responsive\n -treat left-sided CHF, as above\n .\n #DVT/PE\n -cont coumadin (goal INR )\n -heparin for INR<1.9\n .\n #Afib\n rate well-controlled, however would benefit from conversion to\n sinus given comorbid diastolic CHF\n -consider cardioversion\n -cont lopressor for rate-control\n .\n #CRI\n Cr stable\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition: low Na diet\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 11:00 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Communication: sister \n status: FULL\n Disposition: CCU for hemodynamic monitoring while swan in place\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570852,
"text": "Chief Complaint:\n 24 Hour Events:\n \n -d/c'd heparin gtt given therapeutic INR\n -DC cardioversion -> SR\n -lasix 40 mg IV x 2\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 04:25 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.2\nC (99\n HR: 52 (47 - 80) bpm\n BP: 98/57(67) {95/50(62) - 129/97(110)} mmHg\n RR: 17 (14 - 26) insp/min\n SpO2: 91%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 3 (-4 - 10)mmHg\n PAP: (60 mmHg) / (25 mmHg)\n CO/CI (Fick): (4.9 L/min) / (2.3 L/min/m2)\n Mixed Venous O2% Sat: 63 - 63\n Total In:\n 1,185 mL\n 70 mL\n PO:\n 780 mL\n TF:\n IVF:\n 405 mL\n 70 mL\n Blood products:\n Total out:\n 1,835 mL\n 0 mL\n Urine:\n 1,835 mL\n NG:\n Stool:\n Drains:\n Balance:\n -650 mL\n 70 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 91%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 14.4 g/dL\n 94 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 102 mEq/L\n 139 mEq/L\n 43.4 %\n 10.5 K/uL\n [image002.jpg]\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n WBC\n 8.1\n 11.6\n 10.5\n Hct\n 45\n 44\n 44.8\n 47\n 43.7\n 40\n 43.4\n Plt\n 162\n 156\n 116\n Cr\n 1.6\n 1.5\n 1.6\n 1.6\n 1.7\n 1.5\n Glucose\n 107\n 119\n 128\n 97\n 111\n 94\n Other labs: PT / PTT / INR:24.0/39.0/2.3, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.8 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n CIRRHOSIS OF LIVER, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570853,
"text": "Chief Complaint:\n 24 Hour Events:\n \n -d/c'd heparin gtt given therapeutic INR\n -DC cardioversion -> SR\n -lasix 40 mg IV x 2\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 04:25 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.2\nC (99\n HR: 52 (47 - 80) bpm\n BP: 98/57(67) {95/50(62) - 129/97(110)} mmHg\n RR: 17 (14 - 26) insp/min\n SpO2: 91%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 3 (-4 - 10)mmHg\n PAP: (60 mmHg) / (25 mmHg)\n CO/CI (Fick): (4.9 L/min) / (2.3 L/min/m2)\n Mixed Venous O2% Sat: 63 - 63\n Total In:\n 1,185 mL\n 70 mL\n PO:\n 780 mL\n TF:\n IVF:\n 405 mL\n 70 mL\n Blood products:\n Total out:\n 1,835 mL\n 0 mL\n Urine:\n 1,835 mL\n NG:\n Stool:\n Drains:\n Balance:\n -650 mL\n 70 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 91%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 14.4 g/dL\n 94 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 102 mEq/L\n 139 mEq/L\n 43.4 %\n 10.5 K/uL\n [image002.jpg]\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n WBC\n 8.1\n 11.6\n 10.5\n Hct\n 45\n 44\n 44.8\n 47\n 43.7\n 40\n 43.4\n Plt\n 162\n 156\n 116\n Cr\n 1.6\n 1.5\n 1.6\n 1.6\n 1.7\n 1.5\n Glucose\n 107\n 119\n 128\n 97\n 111\n 94\n Other labs: PT / PTT / INR:24.0/39.0/2.3, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.8 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: improving, -4L diuresis to goal -2 L today\n -eval wedge this afternoon\n - lytes\n -incr. captopril prn for improved afterload reduction\n -consider d/c Swan pending evaluation\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with\n elementirreversible pulm HTN, also suggested by absence of response to\n inhaled NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE\n -cont coumadin (goal INR )\n -d/c heparin given that his INR 2.3\n .\n #Afib\n rate well-controlled, however would benefit from conversion to\n sinus given comorbid diastolic CHF\n -plan is for cardioversion today\n -cont lopressor for rate-control\n -continue coumadin to maintain INR 2.0-3.0\n .\n #CRI\n Cr stable\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570854,
"text": "Chief Complaint:\n 24 Hour Events:\n -d/c'd heparin gtt given therapeutic INR\n -DC cardioversion -> SR\n -lasix 40 mg IV x 2\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 04:25 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.2\nC (99\n HR: 52 (47 - 80) bpm\n BP: 98/57(67) {95/50(62) - 129/97(110)} mmHg\n RR: 17 (14 - 26) insp/min\n SpO2: 91%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 3 (-4 - 10)mmHg\n PAP: (60 mmHg) / (25 mmHg)\n PA (mean): 37\n CO/CI (Fick): (4.9 L/min) / (2.3 L/min/m2)\n Mixed Venous O2% Sat: 63 - 63\n Total In:\n 1,185 mL\n 70 mL\n PO:\n 780 mL\n TF:\n IVF:\n 405 mL\n 70 mL\n Blood products:\n Total out:\n 1,835 mL\n 0 mL\n Urine:\n 1,835 mL\n NG:\n Stool:\n Drains:\n Balance:\n -650 mL\n 70 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 91%\n ABG: ///30/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: irreg irreg no m/r/g\n PULM: scattered end-exp wheezes bilat no rales/rhonchi\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 116 K/uL\n 14.4 g/dL\n 94 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 102 mEq/L\n 139 mEq/L\n 43.4 %\n 10.5 K/uL\n [image002.jpg]\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n WBC\n 8.1\n 11.6\n 10.5\n Hct\n 45\n 44\n 44.8\n 47\n 43.7\n 40\n 43.4\n Plt\n 162\n 156\n 116\n Cr\n 1.6\n 1.5\n 1.6\n 1.6\n 1.7\n 1.5\n Glucose\n 107\n 119\n 128\n 97\n 111\n 94\n Other labs: PT / PTT / INR:24.0/39.0/2.3, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.8 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: improving, -4L diuresis to goal -2 L today\n -eval wedge this afternoon\n - lytes\n -incr. captopril prn for improved afterload reduction\n -consider d/c Swan pending evaluation\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with\n elementirreversible pulm HTN, also suggested by absence of response to\n inhaled NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE\n -cont coumadin (goal INR )\n -d/c heparin given that his INR 2.3\n .\n #Afib\n rate well-controlled, however would benefit from conversion to\n sinus given comorbid diastolic CHF\n -plan is for cardioversion today\n -cont lopressor for rate-control\n -continue coumadin to maintain INR 2.0-3.0\n .\n #CRI\n Cr stable\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570964,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis & w/u for liver transplant.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 25-27- denies SOB/CP- LS clear- O2 sats >92% on room air-\n remained in SR/SB since cardioversion yesterday. Coumadin w/ INR 2.3\n Action:\n 80 mg IV lasix given X2\n repeat labs drawn @ 1600- K 3.7 KCL 40meq\n given.\n Response:\n good response to lasix, ~ 800cc neg @ 1700- BUN/Crea trending up BUN\n 22 Crea 1.9 ( 21/1.5 this am) - continues to deny SOB, frequently\n turning/changing position independently- voiding in urinal.\n Plan:\n Continue to diurese- follow PAD\ns- monitor resp status- monitor\n rhythm.-follow labs.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child- being w/u for liver transplant-\n A&Ox3- talkative with RN and asking appropriate questions- c/o N/V\n overnight requiring zofran- no N/V this shift.\n Action:\n Lactulose Q4H, senna, polyethylene glycol and rifaxamin given.\n Response:\n BM X2 (lg amts) today.\n Plan:\n Continue with lactulose for goal of BM\ns/day. Continue to follow\n LFT\ns, ammonia levels and mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570679,
"text": "Knowledge Deficit\n Assessment:\n Pt asking questions why he has to be npo, asking questions about meds\n Action:\n Rn explained to pt that he may have his swan removed and he cannot eat\n until it is removed, also rn gave pt zofran for nausea and vomiting\n overnight pt wanted to know what the med was because he felt much\n better.\n Response:\n Pt appears to understand he cannot eat or drink until he is cleared\n Plan:\n Continue to teach pt about his meds and health\n Cirrhosis of liver, other\n Assessment:\n h/o cirrhosis as a child\n Action:\n Lactulose 60cc QID, rifaxamin\n Response:\n Pt had one large bm\n Plan:\n Continue c lactulose for BM daily, continue to follow mental\n status, labs\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD59/30(43), continues in afib\n Action:\n Lasix 40mg ivp, heparin gtt on hold r/t ptt >150\n Response:\n Hemodynamically stable, responding to lasix\n Plan:\n Continue to monitor lytes and hemodynamics\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570695,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 76 (69 - 90) bpm\n BP: 112/74(83) {96/63(75) - 132/85(119)} mmHg\n RR: 20 (16 - 27) insp/min\n SpO2: 91%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 8 (-5 - 16)mmHg\n PAP: (62 mmHg) / (31 mmHg)\n CO/CI (Fick): (6.2 L/min) / (2.9 L/min/m2)\n Mixed Venous O2% Sat: 71 - 71\n Total In:\n 1,732 mL\n 178 mL\n PO:\n 900 mL\n TF:\n IVF:\n 832 mL\n 178 mL\n Blood products:\n Total out:\n 3,350 mL\n 340 mL\n Urine:\n 2,850 mL\n 340 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n -1,618 mL\n -162 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 91%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 156 K/uL\n 14.5 g/dL\n 97 mg/dL\n 1.6 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 18 mg/dL\n 103 mEq/L\n 141 mEq/L\n 40\n 11.6 K/uL\n [image002.jpg]\n 03:50 AM\n 04:14 AM\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n WBC\n 6.8\n 8.1\n 11.6\n Hct\n 42.5\n 44\n 45\n 44\n 44.8\n 47\n 43.7\n 40\n Plt\n 180\n 162\n 156\n Cr\n 1.5\n 1.6\n 1.5\n 1.6\n 1.6\n Glucose\n 97\n 107\n 119\n 128\n 97\n Other labs: PT / PTT / INR:23.7/150.0/2.3, Differential-Neuts:58.3 %,\n Lymph:30.8 %, Mono:7.5 %, Eos:2.5 %, Ca++:7.4 mg/dL, Mg++:1.7 mg/dL,\n PO4:2.6 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n CIRRHOSIS OF LIVER, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 11:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570727,
"text": "Chief Complaint: acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n -records from PCP reflect therapeutic INR while on coumadin for PE;\n however Afib reportedly new\n -goal pre-transplant mean PAP < 35 mmHg per Dr. \n lasix 20/40/40 IV with 2850 cc UOP (-1800 cc balance)\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 PM\n Other medications: coumadin\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: c/o nausea, 2 episodes brown, non-bloody emesis O/N\n attributed to dinner\nnot agreeing with me;\n now feels fine; no f/c,\n abd pain, diarrhea, melena, hematochezia\n Flowsheet Data as of 07:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 76 (69 - 90) bpm\n BP: 112/74(83) {96/63(75) - 132/85(119)} mmHg\n RR: 20 (16 - 27) insp/min\n SpO2: 91%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 75 Inch\n CVP: 8 (7 - 16)mmHg\n PAP: 62/31 mmHg\n (43-73/24-43 mgHg)\n mPAP 46 mmHg\n (29-57 mmgHg)\n CO/CI (Fick): (6.2 L/min) / (2.9 L/min/m2)\n Mixed Venous O2% Sat: 71 - 71\n Total In:\n 1,732 mL\n 178 mL\n PO:\n 900 mL\n TF:\n IVF:\n 832 mL\n 178 mL\n Blood products:\n Total out:\n 3,350 mL\n 340 mL\n Urine:\n 2,850 mL\n 340 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n -1,618 mL\n -162 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 91% (88-97%)\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath site c/d/i\n CV: irreg irreg no m/r/g\n PULM: scattered bilat end-exp wheezes no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 156 K/uL\n 14.5 g/dL\n 97 mg/dL\n 1.6 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 18 mg/dL\n 103 mEq/L\n 141 mEq/L\n 40\n 11.6 K/uL\n [image002.jpg]\n 03:50 AM\n 04:14 AM\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n WBC\n 6.8\n 8.1\n 11.6\n Hct\n 42.5\n 44\n 45\n 44\n 44.8\n 47\n 43.7\n 40\n Plt\n 180\n 162\n 156\n Cr\n 1.5\n 1.6\n 1.5\n 1.6\n 1.6\n Glucose\n 97\n 107\n 119\n 128\n 97\n Other labs: PT / PTT / INR:23.7/150.0/2.3, Differential-Neuts:58.3 %,\n Lymph:30.8 %, Mono:7.5 %, Eos:2.5 %, Ca++:7.4 mg/dL, Mg++:1.7 mg/dL,\n PO4:2.6 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: improving, -4L diuresis to goal -2 L today\n -eval wedge this afternoon\n - lytes\n -incr. captopril prn for improved afterload reduction\n -consider d/c Swan pending evaluation\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with\n elementirreversible pulm HTN, also suggested by absence of response to\n inhaled NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE\n -cont coumadin (goal INR )\n -d/c heparin given that his INR 2.3\n .\n #Afib\n rate well-controlled, however would benefit from conversion to\n sinus given comorbid diastolic CHF\n -plan is for cardioversion today\n -cont lopressor for rate-control\n -continue coumadin to maintain INR 2.0-3.0\n .\n #CRI\n Cr stable\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition: low Na diet\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 11:00 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Communication: sister \n status: FULL\n Disposition: CCU for hemodynamic monitoring while swan in place\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570849,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 20-30. Pt denies SOB/CP. LS clear. O2 sats >95% on room air. Has\n remained in NSR/SB since cardioversion yesterday. Coumadin w/ INR 2.4\n Action:\n 40 mg IV lasix given. X2 yesterday, last at 1630..\n Response:\n Good response to lasix, ~1L neg at mn.. Pt continues to deny SOB,\n frequently turning/changing position independently, Voiding via urinal.\n Plan:\n Continue to diurese, follow PAD\ns. Cont to monitor resp status.\n Monitor rhythm. Continue with teaching/encourage knowledge as\n indicated. DC swan this am?\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant, pt had\n lg BM overnight. Pt A&Ox3. Talkative with RN and asking appropriate\n questions/appropriate statements about POC and disease. N/V at 0330\n Action:\n Lactulose Q4H, senna and rifaxamin given. Given Zofran 4mg x1 for N/V,\n held 4am lactulose\n Response:\n Lg BM overnight, held 4am lactulose d/t N/V\n Plan:\n Continue with lactulose for goal of BM\ns/day. Continue to f/u with\n LFT\ns, ammonia levels, mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570954,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis & w/u for liver transplant.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 25-27- denies SOB/CP- LS clear- O2 sats >92% on room air-\n remained in NSR/SB since cardioversion yesterday. Coumadin w/ INR 2.3\n Action:\n 80 mg IV lasix given X2\n repeat labs drawn this afternoon and pending.\n Response:\n good response to lasix, ~ 800cc neg @ 1700- continues to deny SOB,\n frequently turning/changing position independently- voiding in urinal.\n Plan:\n Continue to diurese, follow PAD\ns. Cont to monitor resp status.\n Monitor rhythm. Follow labs.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child- being w/u for liver transplant-\n A&Ox3- talkative with RN and asking appropriate questions- c/o N/V\n overnight requiring zofran- no N/V this shift.\n Action:\n Lactulose Q4H, senna, polyethylene glycol and rifaxamin given.\n Response:\n BM X2 (lg amts) today.\n Plan:\n Continue with lactulose for goal of BM\ns/day. Continue to f/u with\n LFT\ns, ammonia levels- monitor mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570778,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns trending slowly down to 20-30 Pt LS CTA. Pt denies SOB/CP. O2\n sats >95% on room air. Mg 1.6, Cr 1.7 this afternoon from 1.6 this am.\n A fib on heparin and coumadin w/ INR 2.3\n Action:\n 40 mg IV lasix given. X2 , last at 1630.. Cardioverted w/ 200j at 1330\n to sb rate 52. Heparin d/c.\n Response:\n Good response to lasix, ~ 600cc neg since mn.. Pt continues to deny\n SOB, frequently turning/changing position independently, LS CTA.\n Voiding via urinal. Sinus rhythm.\n Plan:\n Continue to diurese, follow PAD\ns.No co.ci per resident. Cont to\n monitor resp status. Monitor rhythm. Continue with teaching/encourage\n knowledge as indicated.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant..pt\n with no BM today. Pt A&Ox3. Talkative with RN and asking appropriate\n questions/appropriate statements about POC and disease.\n Action:\n Lactulose Q4H , miralax , senna and rifaxamin given.\n Response:\n Awaiting BM.\n Plan:\n Continue with lactulose for BM daily, f/ with MD\ns re. increasing\n bowel regimen to meet goal BM\ns. Continue to f/u with LFT\ns, ammonia\n levels, mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570956,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis & w/u for liver transplant.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 25-27- denies SOB/CP- LS clear- O2 sats >92% on room air-\n remained in SR/SB since cardioversion yesterday. Coumadin w/ INR 2.3\n Action:\n 80 mg IV lasix given X2\n repeat labs drawn this afternoon and pending.\n Response:\n good response to lasix, ~ 800cc neg @ 1700- continues to deny SOB,\n frequently turning/changing position independently- voiding in urinal.\n Plan:\n Continue to diurese- follow PAD\ns- monitor resp status- monitor\n rhythm.-follow labs.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child- being w/u for liver transplant-\n A&Ox3- talkative with RN and asking appropriate questions- c/o N/V\n overnight requiring zofran- no N/V this shift.\n Action:\n Lactulose Q4H, senna, polyethylene glycol and rifaxamin given.\n Response:\n BM X2 (lg amts) today.\n Plan:\n Continue with lactulose for goal of BM\ns/day. Continue to follow\n LFT\ns, ammonia levels and mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570944,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis & w/u for liver transplant.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 25-27- Pt denies SOB/CP. LS clear. O2 sats >92% on room air. Has\n remained in NSR/SB since cardioversion yesterday. Coumadin w/ INR 2.4\n Action:\n 80 mg IV lasix given X2\n Response:\n Good response to lasix, ~1L neg at mn.. Pt continues to deny SOB,\n frequently turning/changing position independently, Voiding via urinal.\n Plan:\n Continue to diurese, follow PAD\ns. Cont to monitor resp status.\n Monitor rhythm. Continue with teaching/encourage knowledge as\n indicated.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant-\n A&Ox3. Talkative with RN and asking appropriate questions/appropriate\n statements about POC and disease. N/V overnight- no C/O N/V this shift.\n Action:\n Lactulose Q4H, senna, polyethylene glycol and rifaxamin given.\n Response:\n BM X2 (lg amts) today.\n Plan:\n Continue with lactulose for goal of BM\ns/day. Continue to f/u with\n LFT\ns, ammonia levels, mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570945,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis & w/u for liver transplant.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 25-27- Pt denies SOB/CP. LS clear. O2 sats >92% on room air. Has\n remained in NSR/SB since cardioversion yesterday. Coumadin w/ INR 2.3\n Action:\n 80 mg IV lasix given X2\n Response:\n fair response to lasix, ~ 600cc neg @ 1600- continues to deny SOB,\n frequently turning/changing position independently- voiding in urinal.\n Plan:\n Continue to diurese, follow PAD\ns. Cont to monitor resp status.\n Monitor rhythm. Follow labs.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant-\n A&Ox3. Talkative with RN and asking appropriate questions/appropriate\n statements about POC and disease. N/V overnight- no C/O N/V this shift.\n Action:\n Lactulose Q4H, senna, polyethylene glycol and rifaxamin given.\n Response:\n BM X2 (lg amts) today.\n Plan:\n Continue with lactulose for goal of BM\ns/day. Continue to f/u with\n LFT\ns, ammonia levels, mental status.\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570934,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n -d/c'd heparin gtt given therapeutic INR\n -DC cardioversion -> SR\n -lasix 40 mg IV x 2\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 04:25 PM\n Other medications: metoprolol tartrate 25mg , miralax, calcium\n carbonate 1000mg , MVI, omeprazole 20mg daily, amlodipine 10mg PO\n daily, coumadin 5mg daily, lactulose 60mL PO q4h, captopril 12.5mg PO\n TID, rifaximin 400mg PO TID, senna 2tabs PO BID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: Reports mild nausea yesterday relieved by zofran,\n vomiting x1. Denies chest pain, SOB\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.2\nC (99\n HR: 52 (47 - 80) bpm\n BP: 98/57(67) {95/50(62) - 129/97(110)} mmHg\n RR: 17 (14 - 26) insp/min\n SpO2: 91%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 3 (-4 - 10)mmHg\n PAP: (60 mmHg) / (25 mmHg)\n PA (mean): 37\n CO/CI (Fick): (4.9 L/min) / (2.3 L/min/m2)\n Mixed Venous O2% Sat: 63 - 63\n Total In:\n 1,185 mL\n 70 mL\n PO:\n 780 mL\n TF:\n IVF:\n 405 mL\n 70 mL\n Blood products:\n Total out:\n 1,835 mL\n 0 mL\n Urine:\n 1,835 mL\n NG:\n Stool:\n Drains:\n Balance:\n -650 mL\n 70 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 91%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 116 K/uL\n 14.4 g/dL\n 94 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 102 mEq/L\n 139 mEq/L\n 43.4 %\n 10.5 K/uL\n [image002.jpg]\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n WBC\n 8.1\n 11.6\n 10.5\n Hct\n 45\n 44\n 44.8\n 47\n 43.7\n 40\n 43.4\n Plt\n 162\n 156\n 116\n Cr\n 1.6\n 1.5\n 1.6\n 1.6\n 1.7\n 1.5\n Glucose\n 107\n 119\n 128\n 97\n 111\n 94\n Other labs: PT / PTT / INR:24.0/39.0/2.3, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.8 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -4.5L LOS. In\n order to meet transplant requirements, mean PA pressures need to be\n less than 35; using PA diastolic pressures as a proxy for PCWP\n -cont diuresis to goal 1-2 L neg today or until Cr bumps\n -lasix 80mg IV this am then prn\n - lytes\n -incr. captopril prn as tolerated for improved afterload reduction\n -d/c swan when documented consistent mPAP <35\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with element of\n irreversible pulm HTN, also suggested by absence of response to inhaled\n NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE: INR 2.3 this am\n -cont coumadin (goal INR )\n .\n #Afib\n s/p successful cardioversion yesterday and remains in NSR\n -cont lopressor for rate-control\n -continue coumadin to maintain INR 2.0-3.0\n .\n #CRI\n Cr stable\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition: low Na diet\n Lines:\n PA Catheter - 10:30 AM\n Prophylaxis:\n DVT: therapeutic on coumadin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: CCU\n ------ Protected Section ------\n Chart reviewed. Patient interviewed and examined. I agree with Dr.\n \ns H+P, A+P. We will continue to diurese in an effort to get PA\n pressures down. Maintaining SR. Continue with anticoagulation.\n ------ Protected Section Addendum Entered By: , MD\n on: 15:24 ------\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570943,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis. Awaiting liver transplant.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 25-27- Pt denies SOB/CP. LS clear. O2 sats >92% on room air. Has\n remained in NSR/SB since cardioversion yesterday. Coumadin w/ INR 2.4\n Action:\n 80 mg IV lasix given X2\n Response:\n Good response to lasix, ~1L neg at mn.. Pt continues to deny SOB,\n frequently turning/changing position independently, Voiding via urinal.\n Plan:\n Continue to diurese, follow PAD\ns. Cont to monitor resp status.\n Monitor rhythm. Continue with teaching/encourage knowledge as\n indicated.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant-\n A&Ox3. Talkative with RN and asking appropriate questions/appropriate\n statements about POC and disease. N/V overnight- no C/O N/V this shift.\n Action:\n Lactulose Q4H, senna, polyethylene glycol and rifaxamin given.\n Response:\n BM X2 (lg amts) today.\n Plan:\n Continue with lactulose for goal of BM\ns/day. Continue to f/u with\n LFT\ns, ammonia levels, mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570947,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis & w/u for liver transplant.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 25-27- denies SOB/CP. LS clear. O2 sats >92% on room air. Has\n remained in NSR/SB since cardioversion yesterday. Coumadin w/ INR 2.3\n Action:\n 80 mg IV lasix given X2\n Response:\n fair response to lasix, ~ 600cc neg @ 1600- continues to deny SOB,\n frequently turning/changing position independently- voiding in urinal.\n Plan:\n Continue to diurese, follow PAD\ns. Cont to monitor resp status.\n Monitor rhythm. Follow labs.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant-\n A&Ox3. Talkative with RN and asking appropriate questions/appropriate\n statements about POC and disease. N/V overnight- no C/O N/V this shift.\n Action:\n Lactulose Q4H, senna, polyethylene glycol and rifaxamin given.\n Response:\n BM X2 (lg amts) today.\n Plan:\n Continue with lactulose for goal of BM\ns/day. Continue to f/u with\n LFT\ns, ammonia levels- monitor mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570987,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis & w/u for liver transplant.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 25-27- denies SOB/CP- LS clear- O2 sats >92% on room air-\n remained in SR/SB since cardioversion yesterday. Coumadin w/ INR 2.3\n Action:\n 80 mg IV lasix given X2\n repeat labs drawn @ 1600- K 3.7 KCL 40meq\n given.\n Response:\n good response to lasix, ~ 800cc neg @ 1700- BUN/Crea trending up BUN\n 22 Crea 1.9 ( 21/1.5 this am) - continues to deny SOB, frequently\n turning/changing position independently- voiding in urinal.\n Plan:\n Continue to diurese- follow PAD\ns- monitor resp status- monitor\n rhythm.-follow labs.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child- being w/u for liver transplant-\n A&Ox3- talkative with RN and asking appropriate questions- c/o N/V\n overnight requiring zofran- no N/V this shift.\n Action:\n Lactulose Q4H, senna, polyethylene glycol and rifaxamin given.\n Response:\n BM X2 (lg amts) today.\n Plan:\n Continue with lactulose for goal of BM\ns/day. Continue to follow\n LFT\ns, ammonia levels and mental status.\n"
},
{
"category": "ECG",
"chartdate": "2139-05-31 00:00:00.000",
"description": "Report",
"row_id": 223846,
"text": "Sinus bradycardia. Left atrial abnormality. Rightward axis. Borderline\nprolonged QTc interval. Modest ST-T wave changes. Findings are non-specific\nbut clinical correlation is suggested for possible drug/electrolyte/metabolic\neffect. Since the previous tracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Report",
"row_id": 223847,
"text": "Sinus bradycardia. The Q-T interval is prolonged. Right axis deviation.\nNon-specific ST-T wave changes. Compared to the previous tracing atrial\nectopy is no longer present. The Q-T interval is slightly longer and\nright axis deviation is now present.\n\n"
},
{
"category": "ECG",
"chartdate": "2139-05-21 00:00:00.000",
"description": "Report",
"row_id": 223848,
"text": "Sinus bradycardia with atrial premature complexes\nConsider left atrial abnormality\nRightward axis\nBorderline prolonged/upper limits of normal Q-Tc interval\nST-T wave changes\nThese findings are nonspecific but clinical correlation is suggested\nSince previous tracing of , atrial fibrillation absent, axis less\nrightward, Q-Tc interval appears longer and further ST-T wave changes seen\n\n\n"
},
{
"category": "ECG",
"chartdate": "2139-05-18 00:00:00.000",
"description": "Report",
"row_id": 223849,
"text": "TRACING SUBMMITTED LATE AND OUT OF SEQUENCE. Atrial fibrillation with\ncontrolled ventricular response. Right axis deviation. Q-T interval\nprolongation. Compared to the subsequent tracing of no diagnostic\ninterim change. Clinical correlation of the right axis deviation is\nsuggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2139-05-18 00:00:00.000",
"description": "Report",
"row_id": 223850,
"text": "Atrial fibrillation. Rightward axis. Non-specific ST-T wave changes in\nleads II, III and aVF. Compared to the previous tracing of no\ndiagnostic interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-18 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1075446,
"text": " 2:11 PM\n CHEST (SINGLE VIEW); -76 BY SAME PHYSICIAN # \n Reason: PORTABLE SWAN GANZ CATHETER ADJUSTMENT IN ICU\n Admitting Diagnosis: PULMONARY HYPERTENSION\\RIGHT HEART CATH\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with adjustment of the\n portable Swan-Ganz catheter in the ICU unit.\n\n Single view was brought to our review, but note is made that the radiologist\n was not attending the procedure. The current limited view demonstrates the\n tip of the Swan-Ganz catheter projecting over the level of the interlobar\n right pulmonary artery or right lower lobe pulmonary artery. For precise\n details, please review the procedure report.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1075543,
"text": ", H. 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PULMONARY HYPERTENSION\\RIGHT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pulm HTN s/p swan, CHF\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n PFI REPORT\n Swan-Ganz ends in the right lower lobe artery. No other change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1075395,
"text": " 10:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate PA catheter placement\n Admitting Diagnosis: PULMONARY HYPERTENSION\\RIGHT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pulmonary hypertension s/p PA catheter placement\n REASON FOR THIS EXAMINATION:\n please evaluate PA catheter placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MBue MON 8:58 PM\n Stable cardiomegaly with interval placement of right Swan-Ganz catheter\n terminating in the right lower lobe pulmonary artery.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY DATED \n\n HISTORY: 53-year-old male with pulmonary hypertension status post PA catheter\n placement.\n\n COMPARISON: .\n\n FINDINGS: A single AP semi-upright view of the chest was obtained. The heart\n is stably enlarged. There has been interval placement of a Swan-Ganz catheter\n which terminates within the right lower lobe pulmonary artery. The pulmonary\n arteries are stably enlarged bilaterally. The lungs are clear bilaterally.\n There are no pleural effusions or pneumothorax. The osseous structures are\n intact.\n\n IMPRESSION:\n\n Stable cardiomegaly with interval placement of right Swan-Ganz catheter\n terminating in the right lower lobe pulmonary artery.\n\n These findings were communicated to Dr. on at 2:30 p.m.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1075396,
"text": ", H. 10:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate PA catheter placement\n Admitting Diagnosis: PULMONARY HYPERTENSION\\RIGHT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pulmonary hypertension s/p PA catheter placement\n REASON FOR THIS EXAMINATION:\n please evaluate PA catheter placement\n ______________________________________________________________________________\n PFI REPORT\n Stable cardiomegaly with interval placement of right Swan-Ganz catheter\n terminating in the right lower lobe pulmonary artery.\n\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571424,
"text": "Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571425,
"text": "52 yo male with a history of HTN, atrial fibrillation, DVT, PE and\n cryptogenic cirrhosis since childhood complicated by portal\n hypertension and variceal hemorrhages He comes to for right\n heart catheterization as part of liver transplant work up. Patient\n reports sob (with mild activity) relieved with rest for about a year.\n He was recently admitted in for hepatic encephalopathy. This has\n been controlled with lactulose. Echo done EF > 55% mildly\n dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic root\n at the sinus level and mildly dilated ascending aorta. Mild pulm artery\n systolic HTN A heart cath done showed severe LV diastolic\n dysfunction and pulm htn. He had a Swan placed at that time which\n showed PCWP 25 PA pressure 68/30 mean 51, RV 64/15 mean 22, RA 16-19 He\n has been given lasix goal of pa mean pressures of <35 A DC\n cardioversion preformed Atrial fibrillation on \n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Pt w/ chronic pulm HTN.\n Action:\n Diuresis\n Response:\n Good response to diuresis.\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Cirrhosis since childhood\n Action:\n Lactulose as ordered\n Response:\n BM after lactulose\n Plan:\n Optimize hemodynamic function for liver transplant list.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Lungs clr and slightly diminished at bases. Central numbers continue to\n remain high PCWP 31. CO/CI 5.6/2.7.\n Action:\n Lasix 120mg iv\n Response:\n Plan:\n Goal to reduce PCWP before transplant.\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571620,
"text": "Chief Complaint:\n 24 Hour Events:\n -lasix 80 mg IV @ 0900 -> 1L out, -430 @ 1430, lasix 120 mg IV @ 1900\n -put on 1L fluid restriction\n -changed captopril to lisinopril\n -held coumadin for INR 3.0\n -plts stable, held off on ordering HIT/starting fondaparinux per\n heme-onc c/s\n -PCWP 25 mmHg, mPAP 45 mmHg\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications: coumadin 5mg PO daily, omeprazole 20mg daily, MVI,\n Calcium 1000mg PO BID, miralax, metoprolol 25mg PO BID, amlodipine 10mg\n PO daily, lactulose 60mL PO q6h, rifaximin 400mg PO TID, senna 2 tab PO\n BID, lisinopril 5mg PO daily\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: No complaints. Denies nausea, vomiting or abdominal\n pain. Eating well. +Bm\ns daily. No SOB or chest pain\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 54 (50 - 74) bpm\n BP: 99/85(88) {99/50(62) - 127/87(97)} mmHg\n RR: 25 (12 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 12 (-3 - 12)mmHg\n PAP: (59 mmHg) / (27 mmHg)\n PCWP: 27 (25 - 31) mmHg\n CO/CI (Fick): (5.6 L/min) / (2.7 L/min/m2)\n SvO2: 72%\n Mixed Venous O2% Sat: 72 - 72\n Total In:\n 2,005 mL\n 66 mL\n PO:\n 1,000 mL\n TF:\n IVF:\n 1,005 mL\n 66 mL\n Blood products:\n Total out:\n 2,300 mL\n 1,100 mL\n Urine:\n 2,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -295 mL\n -1,034 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 123 K/uL\n 14.8 g/dL\n 89 mg/dL\n 1.8 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 27 mg/dL\n 98 mEq/L\n 137 mEq/L\n 43.7 %\n 9.5 K/uL\n [image002.jpg]\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n WBC\n 10.5\n 11.1\n 12.5\n 8.4\n 9.5\n Hct\n 40\n 43.4\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n Plt\n 116\n 128\n 100\n 116\n 123\n Cr\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n Glucose\n 111\n 94\n 125\n 89\n 131\n 100\n 128\n 89\n Other labs: PT / PTT / INR:28.5/38.9/2.9, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -7.9L LOS; Cr\n has remained relatively stable despite diuresis\n -cont diuresis to goal 2-3 L neg today\n -will start lasix gtt\n - lytes\n -continue lisinopril 5 mg po daily\n .\n #Pulm HTN\n pulm pressures improving but not at preoperative target of\n mPAP 35 mmHg, consistent with element of irreversible pulm HTN, also\n suggested by absence of response to inhaled NO at cath . Based\n on wedge however, he has not been completely diuresed\n -cont amlodipine\n -treat left-sided CHF, as above\n .\n # Thrombocytopenia\n platelets decreased to 100 from 200 on admission,\n low pre-test prob for HIT. Recovering with no intervention\n -check platelets daily\n .\n #DVT/PE - INR 2.9 this am\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -cont lopressor for rate-control\n .\n #CKD\n Cr remains stable at 1.8-2.0 despite aggressive diuresis\n -cont to monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n -Rx comorbidities as above\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; fluid restrict to 1L; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ------ Protected Section ------\n I have reviewed the above progress note on at 07:49 AM by\n Dr. . I have personally reviewed the history with the patient, and\n the physical examination noted above is consistent with my own today.\n I concur with the assessment and treatment plan as outline above. Mr.\n presented with a acute on chronic diastolic left and right\n ventricular failure and was admitted for tailor therapy in the CCU with\n invasive monitoring. He was diuresed an excess of 7 liters of fluid\n and his mean PA pressure in now 35 mmHg, but has not changed\n significantly in the past 24 hours. Our plan is outlined above and\n involves more aggressive treatment of his acute on chronic diastolic\n heart failure with intravenous diuretics. This plan was communicated\n with the patient and all questions were addressed.\n , MD Cell \n ------ Protected Section Addendum Entered By: , MD\n on: 20:43 ------\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571189,
"text": "Knowledge Deficit\n Assessment:\n Pt asking why swan line has to continue to stay in and how could he\n possibly have more fluid to remove\n Action:\n Rn explained to pt how the swan works and how it is helping us\n determine how much fluid he still has on board\n Response:\n Pt stated that he understood rn but every few hours he would ask again\n Plan:\n Continue to reinforce and educate pt about procedures and plan of care\n Cirrhosis of liver, other\n Assessment:\n H/O cryptogenic cirrhosis as a child being w/u for liver transplant\n Action:\n Lactulose Q4hrs, senna, mirilax, rifamin given as ordered, third c-diff\n specimen sent\n Response:\n BM x 4 goal is 5 bm\n Plan:\n Continue c current bowel regimen for goal bm a day, continue to\n follow LFT\ns and mental status\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PADs 35-45 swan line dampened cvp 5, LS clear, o2 sats do drop 92%\n when pt naps , remains in NSR/SB\n Action:\n 80mg iv lasix x2\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571191,
"text": "Knowledge Deficit\n Assessment:\n Pt asking why swan line has to continue to stay in and how could he\n possibly have more fluid to remove\n Action:\n Rn explained to pt how the swan works and how it is helping us\n determine how much fluid he still has on board\n Response:\n Pt stated that he understood rn but every few hours he would ask again\n Plan:\n Continue to reinforce and educate pt about procedures and plan of care,\n emotional support\n Cirrhosis of liver, other\n Assessment:\n H/O cryptogenic cirrhosis as a child being w/u for liver transplant\n Action:\n Lactulose Q4hrs, senna, mirilax, rifamin given as ordered, third c-diff\n specimen sent\n Response:\n BM x 4 goal is 5 bm\n Plan:\n Continue c current bowel regimen for goal bm a day, continue to\n follow LFT\ns and mental status\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAPm 35-45 swan line dampened cvp 5 CO 8.5, CI 4 SVR 690, LS clear, o2\n sats do drop 92% when pt naps , remains in NSR/SB,\n Action:\n 80mg iv lasix x2\n Response:\n Good response to second dose of lasix\n Plan:\n Continue to diurese, follow hemodynamics, resp status\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571735,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n -not meeting diuresis goals with bolus lasix therefore was started on\n lsix gtt with 120mg IV lasix bolus\n -INR 1.9 therefore coumadin restarted\n -I/O check @ 1400 - 900cc negative, inc lasix gtt from 10 to 20mg/hr\n -I/O check @ 1900 - 1600cc negative; re-bolused with lasix 120mg IV @\n , however had minimal response\n -bolused 500cc diuril @2300\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies CP, palp, cough, SOB, abd pain, N/V\n Flowsheet Data as of 05:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.1\nC (97\n HR: 51 (48 - 69) bpm\n BP: 99/62(71) {93/56(67) - 132/85(95)} mmHg\n RR: 23 (12 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 5 (3 - 12)mmHg\n PAP: (45 mmHg) / (20 mmHg)\n PCWP: 27 (27 - 27) mmHg\n Total In:\n 1,236 mL\n 135 mL\n PO:\n 780 mL\n TF:\n IVF:\n 456 mL\n 135 mL\n Blood products:\n Total out:\n 2,950 mL\n 725 mL\n Urine:\n 2,950 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,714 mL\n -590 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///36/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 123 K/uL\n 14.8 g/dL\n 89 mg/dL\n 1.9 mg/dL\n 36 mEq/L\n 3.6 mEq/L\n 28 mg/dL\n 97 mEq/L\n 139 mEq/L\n 43.7 %\n 9.5 K/uL\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n WBC\n 10.5\n 11.1\n 12.5\n 8.4\n 9.5\n Hct\n 43.4\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n Plt\n 116\n 128\n 100\n 116\n 123\n Cr\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n Glucose\n 111\n 94\n 125\n 89\n 131\n 100\n 128\n 89\n 89\n Other labs: PT / PTT / INR:28.5/38.9/2.9, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -9.5L LOS; Cr\n has remained relatively stable despite diuresis\n -cont lasix gtt with diuril/metolazone prn to achieve volume balance\n negative 2-3 L\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n .\n #Pulm HTN\n pulm pressures improving but not consistently at\n pre-transplant target of mPAP 35 mmHg, consistent with inadequate\n diuresis, as well as element of irreversible pulm HTN (as suggested by\n absence of response to inhaled NO at cath )\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n # Thrombocytopenia\n stable\n -cont monitor daily\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr remains stable at 1.8-2.0 despite aggressive diuresis\n -cont to monitor while diuresing\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition: low Na diet, 1 L fluid restriction\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Communication: patient; sister \n status: FULL\n Disposition: CCU for hemodynamic monitoring while swan in place\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571738,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n -not meeting diuresis goals with bolus lasix therefore was started on\n lsix gtt with 120mg IV lasix bolus\n -INR 1.9 therefore coumadin restarted\n -I/O check @ 1400 - 900cc negative, inc lasix gtt from 10 to 20mg/hr\n -I/O check @ 1900 - 1600cc negative; re-bolused with lasix 120mg IV @\n , however had minimal response\n -bolused 500cc diuril @2300\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies CP, palp, cough, SOB, abd pain, N/V\n Flowsheet Data as of 05:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.1\nC (97\n HR: 51 (48 - 69) bpm\n BP: 99/62(71) {93/56(67) - 132/85(95)} mmHg\n RR: 23 (12 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 5 (3 - 12)mmHg\n PAP: (45 mmHg) / (20 mmHg)\n PCWP: 27 (27 - 27) mmHg\n Total In:\n 1,236 mL\n 135 mL\n PO:\n 780 mL\n TF:\n IVF:\n 456 mL\n 135 mL\n Blood products:\n Total out:\n 2,950 mL\n 725 mL\n Urine:\n 2,950 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,714 mL\n -590 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///36/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 123 K/uL\n 14.8 g/dL\n 89 mg/dL\n 1.9 mg/dL\n 36 mEq/L\n 3.6 mEq/L\n 28 mg/dL\n 97 mEq/L\n 139 mEq/L\n 43.7 %\n 9.5 K/uL\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n WBC\n 10.5\n 11.1\n 12.5\n 8.4\n 9.5\n Hct\n 43.4\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n Plt\n 116\n 128\n 100\n 116\n 123\n Cr\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n Glucose\n 111\n 94\n 125\n 89\n 131\n 100\n 128\n 89\n 89\n Other labs: PT / PTT / INR:28.5/38.9/2.9, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -9.5L LOS; Cr\n has remained relatively stable despite diuresis\n -cont lasix gtt with diuril/metolazone prn to achieve volume balance\n negative 2-3 L\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n .\n #Pulm HTN\n pulm pressures improving but not consistently at\n pre-transplant target of mPAP 35 mmHg, consistent with inadequate\n diuresis, as well as element of irreversible pulm HTN (as suggested by\n absence of response to inhaled NO at cath )\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n # Thrombocytopenia\n stable\n -cont monitor daily\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr remains stable at 1.8-2.0 despite aggressive diuresis\n -cont to monitor while diuresing\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition: low Na diet, 1 L fluid restriction\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Communication: patient; sister \n status: FULL\n Disposition: CCU for hemodynamic monitoring while swan in place\n ------ Protected Section ------\n Agree with excellent PGY1 note. Patient was weighed when mean PA\n pressures were sustained below < 35mmHg and after 8.5L of diuresis.\n His weight was 78kg. At this point, plan is for more diuresis until\n dry weight is reached.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:34 ------\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571829,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Patient reports sob (with mild activity) relieved with rest for about a\n year. He was recently admitted in for hepatic encephalopathy.\n This has been controlled with lactulose. Echo done EF > 55%\n mildly dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic\n root at the sinus level and mildly dilated ascending aorta. Mild pulm\n artery systolic HTN\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571833,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Patient reports sob (with mild activity) relieved with rest for about a\n year. He was recently admitted in for hepatic encephalopathy.\n This has been controlled with lactulose. Echo done EF > 55%\n mildly dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic\n root at the sinus level and mildly dilated ascending aorta. Mild pulm\n artery systolic HTN\n Cath : mod. To severe Pulm. HTN. Negative response to inhaled\n NO at that time.\n Started heparin for afib on admit. Goal mPAP <35 diuresing with prn\n lasix for goal net neg. 1-2L /day.\n : CDV (200jx1) to NSR. Heparin d/c\n : Captopril changed to lisinopril. Contin. with prn lasix with\n decreasing results.\n : Lasix gtt was started with additional lasix bolus. Titrated up\n to 20mg/hr. INR 1.9-> coumadin restarted.\n Diurel 500mg x1 for additional diuresis.\n mPAP\ns overnight 29-35. neg. 9.5L LOS\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n LS clear. No SOB. Laying flat comfortably.\n HR 50\ns SB. BP 90\ns-110/\n Contin. lasix gtt at 20mg/hr. no further boluses elevated\n Creatinine.\n Action:\n Lasix gtt 20mg/hr.\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Sats 92-99% on RA.\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n On transplant list .\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 570907,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n -d/c'd heparin gtt given therapeutic INR\n -DC cardioversion -> SR\n -lasix 40 mg IV x 2\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 04:25 PM\n Other medications: metoprolol tartrate 25mg , miralax, calcium\n carbonate 1000mg , MVI, omeprazole 20mg daily, amlodipine 10mg PO\n daily, coumadin 5mg daily, lactulose 60mL PO q4h, captopril 12.5mg PO\n TID, rifaximin 400mg PO TID, senna 2tabs PO BID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: Reports mild nausea yesterday relieved by zofran,\n vomiting x1. Denies chest pain, SOB\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.2\nC (99\n HR: 52 (47 - 80) bpm\n BP: 98/57(67) {95/50(62) - 129/97(110)} mmHg\n RR: 17 (14 - 26) insp/min\n SpO2: 91%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 3 (-4 - 10)mmHg\n PAP: (60 mmHg) / (25 mmHg)\n PA (mean): 37\n CO/CI (Fick): (4.9 L/min) / (2.3 L/min/m2)\n Mixed Venous O2% Sat: 63 - 63\n Total In:\n 1,185 mL\n 70 mL\n PO:\n 780 mL\n TF:\n IVF:\n 405 mL\n 70 mL\n Blood products:\n Total out:\n 1,835 mL\n 0 mL\n Urine:\n 1,835 mL\n NG:\n Stool:\n Drains:\n Balance:\n -650 mL\n 70 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 91%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 116 K/uL\n 14.4 g/dL\n 94 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 102 mEq/L\n 139 mEq/L\n 43.4 %\n 10.5 K/uL\n [image002.jpg]\n 11:49 AM\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n WBC\n 8.1\n 11.6\n 10.5\n Hct\n 45\n 44\n 44.8\n 47\n 43.7\n 40\n 43.4\n Plt\n 162\n 156\n 116\n Cr\n 1.6\n 1.5\n 1.6\n 1.6\n 1.7\n 1.5\n Glucose\n 107\n 119\n 128\n 97\n 111\n 94\n Other labs: PT / PTT / INR:24.0/39.0/2.3, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.8 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -4.5L LOS. In\n order to meet transplant requirements, mean PA pressures need to be\n less than 35; using PA diastolic pressures as a proxy for PCWP\n -cont diuresis to goal 1-2 L neg today or until Cr bumps\n -lasix 80mg IV this am then prn\n - lytes\n -incr. captopril prn as tolerated for improved afterload reduction\n -d/c swan when documented consistent mPAP <35\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with element of\n irreversible pulm HTN, also suggested by absence of response to inhaled\n NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE: INR 2.3 this am\n -cont coumadin (goal INR )\n .\n #Afib\n s/p successful cardioversion yesterday and remains in NSR\n -cont lopressor for rate-control\n -continue coumadin to maintain INR 2.0-3.0\n .\n #CRI\n Cr stable\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition: low Na diet\n Lines:\n PA Catheter - 10:30 AM\n Prophylaxis:\n DVT: therapeutic on coumadin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: FULL\n Disposition: CCU\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571361,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n Rec\nd lasix 80 mg IV x 2 -> 1550 out\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 03:00 PM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies fever, chills, CP, palp, cough, orthopnea,\n dyspnea\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.8\nC (98.2\n HR: 55 (52 - 81) bpm\n BP: 99/50(62) {80/30(48) - 131/89(119)} mmHg\n RR: 17 (14 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: -3 (-3 - 17)mmHg\n PAP: (42 mmHg) / (13 mmHg)\n CO/CI (Fick): (7.2 L/min) / (3.4 L/min/m2)\n Mixed Venous O2% Sat: 76 - 76\n Total In:\n 549 mL\n 94 mL\n PO:\n 280 mL\n TF:\n IVF:\n 269 mL\n 94 mL\n Blood products:\n Total out:\n 1,550 mL\n 300 mL\n Urine:\n 1,550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,001 mL\n -206 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 100 K/uL\n 14.5 g/dL\n 100 mg/dL\n 1.8 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 27 mg/dL\n 98 mEq/L\n 135 mEq/L\n 42.2 %\n 12.5 K/uL\n [image002.jpg]\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n WBC\n 11.6\n 10.5\n 11.1\n 12.5\n Hct\n 43.7\n 40\n 43.4\n 44.0\n 44.0\n 42.2\n Plt\n 156\n 116\n 128\n 100\n Cr\n 1.6\n 1.6\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n Glucose\n 128\n 97\n 111\n 94\n 125\n 89\n 131\n 100\n Other labs: PT / PTT / INR:29.5/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -6.8L LOS; Cr\n has remained relatively stable despite diuresis\n -cont diuresis to goal 1 L neg today\n - lytes\n -switch captopril to lisinopril 5 mg po daily\n -will attempt to wedge swan to see if mPAP correlate with PCWP\n .\n #Pulm HTN\n pulm pressures improving but not at preoperative target of\n mPAP 35 mmHg, consistent with element of irreversible pulm HTN, also\n suggested by absence of response to inhaled NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n # Thrombocytopenia\n platelets decreased to 100 from 200 on admission,\n intermediate pre-test prob for HIT\n -recheck in PM\n -send heparin Ab\n .\n #DVT/PE - INR 3.0 this am\n -hold coumadin dose today\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -cont lopressor for rate-control\n -continue anticoagulation\n .\n #CKD\n Cr increased slightly but not in ARF range\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n -Rx comorbidities as above\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ------ Protected Section ------\n I have reviewed the above progress note on at 12:47 PM by\n Dr. and have reviewed the history with the patient, and was\n present during the physical examination noted above. I concur with the\n assessment and treatment plan as outline above. Mr. presented\n with a acute on chronic diastolic left and right ventricular failure\n and was admitted for tailor therapy in the CCU with invasive\n monitoring. He was diuresed an excess of 7 liters of fluid and his\n mean PA pressure in now 35 mmHg. He has developed some degree of\n thrombocytopenia and we will evaluate its etiology. He is currently\n tolerating his dose of lopressor, Captopril, and Novasc in addition to\n his diuretics. Our plan is outlined above and involves continued\n treatment of his acute on chronic diastolic heart failure. This plan\n was communicated with the patient and all questions were addressed.\n , MD Cell \n ------ Protected Section Addendum Entered By: , MD\n on: 16:13 ------\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571507,
"text": "Chief Complaint:\n 24 Hour Events:\n -lasix 80 mg IV @ 0900 -> 1L out, -430 @ 1430, lasix 120 mg IV @ 1900\n -put on 1L fluid restriction\n -changed captopril to lisinopril\n -held coumadin for INR 3.0\n -plts stable, held off on ordering HIT/starting fondaparinux per\n heme-onc c/s\n -PCWP 25 mmHg, mPAP 45 mmHg\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications: coumadin 5mg PO daily, omeprazole 20mg daily, MVI,\n Calcium 1000mg PO BID, miralax, metoprolol 25mg PO BID, amlodipine 10mg\n PO daily, lactulose 60mL PO q6h, rifaximin 400mg PO TID, senna 2 tab PO\n BID, lisinopril 5mg PO daily\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: No complaints. Denies nausea, vomiting or abdominal\n pain. Eating well. +Bm\ns daily. No SOB or chest pain\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 54 (50 - 74) bpm\n BP: 99/85(88) {99/50(62) - 127/87(97)} mmHg\n RR: 25 (12 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 12 (-3 - 12)mmHg\n PAP: (59 mmHg) / (27 mmHg)\n PCWP: 27 (25 - 31) mmHg\n CO/CI (Fick): (5.6 L/min) / (2.7 L/min/m2)\n SvO2: 72%\n Mixed Venous O2% Sat: 72 - 72\n Total In:\n 2,005 mL\n 66 mL\n PO:\n 1,000 mL\n TF:\n IVF:\n 1,005 mL\n 66 mL\n Blood products:\n Total out:\n 2,300 mL\n 1,100 mL\n Urine:\n 2,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -295 mL\n -1,034 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 123 K/uL\n 14.8 g/dL\n 89 mg/dL\n 1.8 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 27 mg/dL\n 98 mEq/L\n 137 mEq/L\n 43.7 %\n 9.5 K/uL\n [image002.jpg]\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n WBC\n 10.5\n 11.1\n 12.5\n 8.4\n 9.5\n Hct\n 40\n 43.4\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n Plt\n 116\n 128\n 100\n 116\n 123\n Cr\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n Glucose\n 111\n 94\n 125\n 89\n 131\n 100\n 128\n 89\n Other labs: PT / PTT / INR:28.5/38.9/2.9, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -7.9L LOS; Cr\n has remained relatively stable despite diuresis\n -cont diuresis to goal 2-3 L neg today\n -will start lasix gtt\n - lytes\n -continue lisinopril 5 mg po daily\n .\n #Pulm HTN\n pulm pressures improving but not at preoperative target of\n mPAP 35 mmHg, consistent with element of irreversible pulm HTN, also\n suggested by absence of response to inhaled NO at cath . Based\n on wedge however, he has not been completely diuresed\n -cont amlodipine\n -treat left-sided CHF, as above\n .\n # Thrombocytopenia\n platelets decreased to 100 from 200 on admission,\n low pre-test prob for HIT. Recovering with no intervention\n -check platelets daily\n .\n #DVT/PE - INR 2.9 this am\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -cont lopressor for rate-control\n .\n #CKD\n Cr remains stable at 1.8-2.0 despite aggressive diuresis\n -cont to monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n -Rx comorbidities as above\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; fluid restrict to 1L; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571611,
"text": "52 yo male with a history of HTN, atrial fibrillation, DVT, PE and\n cryptogenic cirrhosis since childhood complicated by portal\n hypertension and variceal hemorrhages He comes to for right\n heart catheterization as part of liver transplant work up. Patient\n reports sob (with mild activity) relieved with rest for about a year.\n He was recently admitted in for hepatic encephalopathy. This has\n been controlled with lactulose. Echo done EF > 55% mildly\n dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic root\n at the sinus level and mildly dilated ascending aorta. Mild pulm artery\n systolic HTN A heart cath done showed severe LV diastolic\n dysfunction and pulm htn. He had a Swan placed at that time which\n showed PCWP 25 PA pressure 68/30 mean 51, RV 64/15 mean 22, RA 16-19 He\n has been given lasix goal of pa mean pressures of <35 A DC\n cardioversion preformed Atrial fibrillation on \n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Chronic pulmonary HTN- no resp distress\n Action:\n Following PA numbers-> PAS 57-62 PAD 27-28 Mean 37-42- lasix given\n followed by gtt.- CI 2.7\n Response:\n Mean remains > 35\n Plan:\n Con\nt present management.\n Cirrhosis of liver, other\n Assessment:\n Cirrhosis since childhoold.\n Action:\n Lactulose, rifaximin, senna & polyethylene glycol given as ordered.\n Response:\n 2 large soft/loose stools today.\n Plan:\n Optimize hemodynamic status for possible liver transplant.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Lung sounds clear- SpO2 94-98% on room air.\n Action:\n Lasix 120mg IV this am followed by a lasix gtt @ 10mg/hr.\n Response:\n Diuresed 900cc by 1330- goal is 2-3 L today- lasix gtt increased 20mg @\n 1330- (-) 1500cc @ present.\n Plan:\n Con\nt t to aggressively diurese.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571826,
"text": "Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571827,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571929,
"text": "Chief Complaint: acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n - 1L negative at 7pm, Cr 2.0->2.6, remained -800 cc at MN\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies dizziness, lightheadedness, CP, palp, SOB,\n abd pain, N/V/D\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 54 (46 - 66) bpm\n BP: 93/47(59) {87/47(59) - 131/101(109)} mmHg\n RR: 21 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 5 (1 - 9)mmHg\n PAP: 47/21 mmHg\n (37-57/21-32)\n mPAP 31 mmHg (30-41)\n Total In:\n 1,416 mL\n 166 mL\n PO:\n 840 mL\n TF:\n IVF:\n 576 mL\n 166 mL\n Blood products:\n Total out:\n 2,250 mL\n 400 mL\n Urine:\n 2,250 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -834 mL\n -234 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 136 K/uL\n 15.5 g/dL\n 85 mg/dL\n 2.4 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 96 mEq/L\n 138 mEq/L\n 47.2 %\n 8.7 K/uL\n [image002.jpg]\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n WBC\n 11.1\n 12.5\n 8.4\n 9.5\n 8.7\n Hct\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n 47.2\n Plt\n 128\n 100\n 116\n 123\n 136\n Cr\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n Glucose\n 89\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n Other labs: PT / PTT / INR:26.4/36.3/2.6, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -10L LOS;\n Cr/HCO3 indicating that likely has reached dry weight\n -stop lasix gtt\n -determine PO lasix dose needed to keep even\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n -check BNP to establish dry weight value\n -d/c swan\n .\n #Pulm HTN\n pulm pressures improving with most reflecting\n pre-transplant target of mPAP 35 mmHg; likely has element of\n irreversible pulm HTN given h/o PE, possible portopulmonary syndrome\n (as suggested by absence of response to inhaled NO at cath )\n -will discuss progress/outpt mgmt with transplant team\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr rising in the setting of aggressive diuresis\n - lytes, Cr\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -decr. lopressor given bradycardia since now s/p cardioversion and\n doesn\nt need rate control\n -continue CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place then call\n out to floor\n ICU Care\n Nutrition: low Na diet, 1 L fluid restriction\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Code status: FULL\n Disposition: CCU for hemodynamic monitoring while swan in place then\n call out to floor\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571960,
"text": "Chief Complaint: acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n - 1L negative at 7pm, Cr 2.0->2.6, remained -800 cc at MN\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies dizziness, lightheadedness, CP, palp, SOB,\n abd pain, N/V/D\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 54 (46 - 66) bpm\n BP: 93/47(59) {87/47(59) - 131/101(109)} mmHg\n RR: 21 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 5 (1 - 9)mmHg\n PAP: 47/21 mmHg\n (37-57/21-32)\n mPAP 31 mmHg (30-41)\n Total In:\n 1,416 mL\n 166 mL\n PO:\n 840 mL\n TF:\n IVF:\n 576 mL\n 166 mL\n Blood products:\n Total out:\n 2,250 mL\n 400 mL\n Urine:\n 2,250 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -834 mL\n -234 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 136 K/uL\n 15.5 g/dL\n 85 mg/dL\n 2.4 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 96 mEq/L\n 138 mEq/L\n 47.2 %\n 8.7 K/uL\n [image002.jpg]\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n WBC\n 11.1\n 12.5\n 8.4\n 9.5\n 8.7\n Hct\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n 47.2\n Plt\n 128\n 100\n 116\n 123\n 136\n Cr\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n Glucose\n 89\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n Other labs: PT / PTT / INR:26.4/36.3/2.6, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -10L LOS;\n Cr/HCO3 indicating that likely has reached dry weight\n -stop lasix gtt\n -determine PO lasix dose needed to keep even\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n -check BNP to establish dry weight value\n -check PCWP at dry weight prior to d/c swan\n .\n #Pulm HTN\n pulm pressures improving with most reflecting\n pre-transplant target of mPAP 35 mmHg; likely has element of\n irreversible pulm HTN given h/o PE, possible portopulmonary syndrome\n (as suggested by absence of response to inhaled NO at cath )\n -will discuss progress/outpt mgmt with transplant team\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr rising in the setting of aggressive diuresis\n - lytes, Cr\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -decr. lopressor given bradycardia since now s/p cardioversion and\n doesn\nt need rate control\n -continue CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place then call\n out to floor\n ICU Care\n Nutrition: low Na diet, 1 L fluid restriction\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Code status: FULL\n Disposition: CCU for hemodynamic monitoring while swan in place then\n call out to floor\n ------ Protected Section ------\n I have reviewed the above progress note and addendum on by\n Dr. . I have personally reviewed the history with the patient, and\n the physical examination noted above is consistent with my own today.\n I concur with the assessment and treatment plan as outline above. Mr.\n is reaching maximum diuresis with a PCWP of 9 mmHg and if this\n remains stable this afternoon, we will remove the PA catheter line\n later today.\n , MD Cell \n ------ Protected Section Addendum Entered By: , MD\n on: 15:09 ------\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 572110,
"text": "Chief Complaint:\n 24 Hour Events:\n PA CATHETER - STOP 05:28 PM\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.6\nC (97.8\n HR: 57 (50 - 69) bpm\n BP: 109/75(83) {83/49(57) - 128/90(96)} mmHg\n RR: 17 (13 - 45) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 1 (1 - 8)mmHg\n PAP: (44 mmHg) / (16 mmHg)\n PCWP: 7 (7 - 9.) mmHg\n Total In:\n 1,202 mL\n 80 mL\n PO:\n 380 mL\n TF:\n IVF:\n 822 mL\n 80 mL\n Blood products:\n Total out:\n 1,750 mL\n 550 mL\n Urine:\n 1,500 mL\n 400 mL\n NG:\n 250 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -548 mL\n -470 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 172 K/uL\n 15.0 g/dL\n 104 mg/dL\n 2.3 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 42 mg/dL\n 98 mEq/L\n 135 mEq/L\n 44.0 %\n 9.5 K/uL\n [image002.jpg]\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n 01:32 PM\n 02:59 AM\n WBC\n 12.5\n 8.4\n 9.5\n 8.7\n 9.4\n 9.5\n Hct\n 42.2\n 44.1\n 43.7\n 47.2\n 45.6\n 44.0\n Plt\n 100\n 116\n 123\n 136\n 163\n 172\n Cr\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n 2.4\n 2.3\n Glucose\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n 125\n 104\n Other labs: PT / PTT / INR:29.2/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION\n INEFFECTIVE COPING\n KNOWLEDGE DEFICIT\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n CIRRHOSIS OF LIVER, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 572111,
"text": "Chief Complaint:\n 24 Hour Events:\n PA CATHETER - STOP 05:28 PM\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.6\nC (97.8\n HR: 57 (50 - 69) bpm\n BP: 109/75(83) {83/49(57) - 128/90(96)} mmHg\n RR: 17 (13 - 45) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 1 (1 - 8)mmHg\n PAP: (44 mmHg) / (16 mmHg)\n PCWP: 7 (7 - 9.) mmHg\n Total In:\n 1,202 mL\n 80 mL\n PO:\n 380 mL\n TF:\n IVF:\n 822 mL\n 80 mL\n Blood products:\n Total out:\n 1,750 mL\n 550 mL\n Urine:\n 1,500 mL\n 400 mL\n NG:\n 250 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -548 mL\n -470 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 172 K/uL\n 15.0 g/dL\n 104 mg/dL\n 2.3 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 42 mg/dL\n 98 mEq/L\n 135 mEq/L\n 44.0 %\n 9.5 K/uL\n [image002.jpg]\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n 01:32 PM\n 02:59 AM\n WBC\n 12.5\n 8.4\n 9.5\n 8.7\n 9.4\n 9.5\n Hct\n 42.2\n 44.1\n 43.7\n 47.2\n 45.6\n 44.0\n Plt\n 100\n 116\n 123\n 136\n 163\n 172\n Cr\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n 2.4\n 2.3\n Glucose\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n 125\n 104\n Other labs: PT / PTT / INR:29.2/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -10L LOS;\n Cr/HCO3 indicating that likely has reached dry weight\n -stop lasix gtt\n -determine PO lasix dose needed to keep even\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n -check BNP to establish dry weight value\n -check PCWP at dry weight prior to d/c swan\n .\n #Pulm HTN\n pulm pressures improving with most reflecting\n pre-transplant target of mPAP 35 mmHg; likely has element of\n irreversible pulm HTN given h/o PE, possible portopulmonary syndrome\n (as suggested by absence of response to inhaled NO at cath )\n -will discuss progress/outpt mgmt with transplant team\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr rising in the setting of aggressive diuresis\n - lytes, Cr\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -decr. lopressor given bradycardia since now s/p cardioversion and\n doesn\nt need rate control\n -continue CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place then call\n out to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 572115,
"text": "Chief Complaint:\n 24 Hour Events:\n -Cr 2.4 PCWP 9, gave 250 cc NS bolus; repeat PCWP 7\n -d/c'd lasix gtt @ 1030\n -d/c'd swan/cordis (has PIV)\n -decr. lopressor 25 mg to 12.5 mg bradycardia\n -ordered lasix 80 mg PO daily to start AM \n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.6\nC (97.8\n HR: 57 (50 - 69) bpm\n BP: 109/75(83) {83/49(57) - 128/90(96)} mmHg\n RR: 17 (13 - 45) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 1 (1 - 8)mmHg\n PAP: (44 mmHg) / (16 mmHg)\n PCWP: 7 (7 - 9.) mmHg\n Total In:\n 1,202 mL\n 83 mL\n PO:\n 380 mL\n TF:\n IVF:\n 822 mL\n 83 mL\n Blood products:\n Total out:\n 1,750 mL\n 550 mL\n Urine:\n 1,500 mL\n 400 mL\n NG:\n 250 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -548 mL\n -467 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 172 K/uL\n 15.0 g/dL\n 104 mg/dL\n 2.3 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 42 mg/dL\n 98 mEq/L\n 135 mEq/L\n 44.0 %\n 9.5 K/uL\n [image002.jpg]\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n 01:32 PM\n 02:59 AM\n WBC\n 12.5\n 8.4\n 9.5\n 8.7\n 9.4\n 9.5\n Hct\n 42.2\n 44.1\n 43.7\n 47.2\n 45.6\n 44.0\n Plt\n 100\n 116\n 123\n 136\n 163\n 172\n Cr\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n 2.4\n 2.3\n Glucose\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n 125\n 104\n Other labs: PT / PTT / INR:29.2/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION\n INEFFECTIVE COPING\n KNOWLEDGE DEFICIT\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n CIRRHOSIS OF LIVER, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 572117,
"text": "Chief Complaint:\n 24 Hour Events:\n -Cr 2.4 PCWP 9, gave 250 cc NS bolus; repeat PCWP 7\n -d/c'd lasix gtt @ 1030\n -d/c'd swan/cordis (has PIV)\n -decr. lopressor 25 mg to 12.5 mg bradycardia\n -ordered lasix 80 mg PO daily to start AM \n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.6\nC (97.8\n HR: 57 (50 - 69) bpm\n BP: 109/75(83) {83/49(57) - 128/90(96)} mmHg\n RR: 17 (13 - 45) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 1 (1 - 8)mmHg\n PAP: (44 mmHg) / (16 mmHg)\n PCWP: 7 (7 - 9.) mmHg\n Total In:\n 1,202 mL\n 83 mL\n PO:\n 380 mL\n TF:\n IVF:\n 822 mL\n 83 mL\n Blood products:\n Total out:\n 1,750 mL\n 550 mL\n Urine:\n 1,500 mL\n 400 mL\n NG:\n 250 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -548 mL\n -467 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 172 K/uL\n 15.0 g/dL\n 104 mg/dL\n 2.3 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 42 mg/dL\n 98 mEq/L\n 135 mEq/L\n 44.0 %\n 9.5 K/uL\n [image002.jpg]\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n 01:32 PM\n 02:59 AM\n WBC\n 12.5\n 8.4\n 9.5\n 8.7\n 9.4\n 9.5\n Hct\n 42.2\n 44.1\n 43.7\n 47.2\n 45.6\n 44.0\n Plt\n 100\n 116\n 123\n 136\n 163\n 172\n Cr\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n 2.4\n 2.3\n Glucose\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n 125\n 104\n Other labs: PT / PTT / INR:29.2/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -10L LOS;\n Cr/HCO3 indicating that likely has reached dry weight\n -stop lasix gtt\n -determine PO lasix dose needed to keep even\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n -check BNP to establish dry weight value\n -check PCWP at dry weight prior to d/c swan\n .\n #Pulm HTN\n pulm pressures improving with most reflecting\n pre-transplant target of mPAP 35 mmHg; likely has element of\n irreversible pulm HTN given h/o PE, possible portopulmonary syndrome\n (as suggested by absence of response to inhaled NO at cath )\n -will discuss progress/outpt mgmt with transplant team\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr rising in the setting of aggressive diuresis\n - lytes, Cr\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -decr. lopressor given bradycardia since now s/p cardioversion and\n doesn\nt need rate control\n -continue CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place then call\n out to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 570913,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n 53 year old male admitted on for R-heart cath. In cath lab\n patient had a Swan placed, pt remains in the CCU for tailored\n diuresis. Pt screened today per ICU protocol, pt currently tol diet\n without any problem, pt eating everything on his tray, will cont to f/u\n re intakes. \n"
},
{
"category": "Physician ",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571340,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n Rec\nd lasix 80 mg IV x 2 -> 1550 out\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 03:00 PM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies fever, chills, CP, palp, cough, orthopnea,\n dyspnea\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.8\nC (98.2\n HR: 55 (52 - 81) bpm\n BP: 99/50(62) {80/30(48) - 131/89(119)} mmHg\n RR: 17 (14 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: -3 (-3 - 17)mmHg\n PAP: (42 mmHg) / (13 mmHg)\n CO/CI (Fick): (7.2 L/min) / (3.4 L/min/m2)\n Mixed Venous O2% Sat: 76 - 76\n Total In:\n 549 mL\n 94 mL\n PO:\n 280 mL\n TF:\n IVF:\n 269 mL\n 94 mL\n Blood products:\n Total out:\n 1,550 mL\n 300 mL\n Urine:\n 1,550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,001 mL\n -206 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 100 K/uL\n 14.5 g/dL\n 100 mg/dL\n 1.8 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 27 mg/dL\n 98 mEq/L\n 135 mEq/L\n 42.2 %\n 12.5 K/uL\n [image002.jpg]\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n WBC\n 11.6\n 10.5\n 11.1\n 12.5\n Hct\n 43.7\n 40\n 43.4\n 44.0\n 44.0\n 42.2\n Plt\n 156\n 116\n 128\n 100\n Cr\n 1.6\n 1.6\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n Glucose\n 128\n 97\n 111\n 94\n 125\n 89\n 131\n 100\n Other labs: PT / PTT / INR:29.5/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -6.8L LOS; Cr\n has remained relatively stable despite diuresis\n -cont diuresis to goal 1 L neg today\n - lytes\n -switch captopril to lisinopril 5 mg po daily\n -will attempt to wedge swan to see if mPAP correlate with PCWP\n .\n #Pulm HTN\n pulm pressures improving but not at preoperative target of\n mPAP 35 mmHg, consistent with element of irreversible pulm HTN, also\n suggested by absence of response to inhaled NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n # Thrombocytopenia\n platelets decreased to 100 from 200 on admission,\n intermediate pre-test prob for HIT\n -recheck in PM\n -send heparin Ab\n .\n #DVT/PE - INR 3.0 this am\n -hold coumadin dose today\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -cont lopressor for rate-control\n -continue anticoagulation\n .\n #CKD\n Cr increased slightly but not in ARF range\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n -Rx comorbidities as above\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571697,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n -not meeting diuresis goals with bolus lasix therefore was started on\n lsix gtt with 120mg IV lasix bolus\n -INR 1.9 therefore coumadin restarted\n -I/O check @ 1400 - 900cc negative, inc lasix gtt from 10 to 20mg/hr\n -I/O check @ 1900 - 1600cc negative; re-bolused with lasix 120mg IV @\n , however had minimal response\n -bolused 500cc diuril @2300\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies CP, palp, cough, SOB, abd pain, N/V\n Flowsheet Data as of 05:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.1\nC (97\n HR: 51 (48 - 69) bpm\n BP: 99/62(71) {93/56(67) - 132/85(95)} mmHg\n RR: 23 (12 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 5 (3 - 12)mmHg\n PAP: (45 mmHg) / (20 mmHg)\n PCWP: 27 (27 - 27) mmHg\n Total In:\n 1,236 mL\n 135 mL\n PO:\n 780 mL\n TF:\n IVF:\n 456 mL\n 135 mL\n Blood products:\n Total out:\n 2,950 mL\n 725 mL\n Urine:\n 2,950 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,714 mL\n -590 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///36/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 123 K/uL\n 14.8 g/dL\n 89 mg/dL\n 1.9 mg/dL\n 36 mEq/L\n 3.6 mEq/L\n 28 mg/dL\n 97 mEq/L\n 139 mEq/L\n 43.7 %\n 9.5 K/uL\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n WBC\n 10.5\n 11.1\n 12.5\n 8.4\n 9.5\n Hct\n 43.4\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n Plt\n 116\n 128\n 100\n 116\n 123\n Cr\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n Glucose\n 111\n 94\n 125\n 89\n 131\n 100\n 128\n 89\n 89\n Other labs: PT / PTT / INR:28.5/38.9/2.9, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -9.5L LOS; Cr\n has remained relatively stable despite diuresis\n -cont lasix gtt with diuril/metolazone to achieve volume balance\n negative 2-3 L\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n .\n #Pulm HTN\n pulm pressures improving but not consistently at\n pre-transplant target of mPAP 35 mmHg, consistent with inadequate\n diuresis, as well as element of irreversible pulm HTN (as suggested by\n absence of response to inhaled NO at cath )\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n # Thrombocytopenia\n stable\n -cont monitor daily\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr remains stable at 1.8-2.0 despite aggressive diuresis\n -cont to monitor while diuresing\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition: low Na diet, 1 L fluid restriction\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Communication: patient; sister \n status: FULL\n Disposition: CCU for hemodynamic monitoring while swan in place\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571886,
"text": "Chief Complaint: acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n - 1L negative at 7pm, Cr 2.0->2.6, remained -800 cc at MN\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 54 (46 - 66) bpm\n BP: 93/47(59) {87/47(59) - 131/101(109)} mmHg\n RR: 21 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 5 (1 - 9)mmHg\n PAP: (47 mmHg) / (21 mmHg)\n mPAP 31 mmHg\n Total In:\n 1,416 mL\n 166 mL\n PO:\n 840 mL\n TF:\n IVF:\n 576 mL\n 166 mL\n Blood products:\n Total out:\n 2,250 mL\n 400 mL\n Urine:\n 2,250 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -834 mL\n -234 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 136 K/uL\n 15.5 g/dL\n 85 mg/dL\n 2.4 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 96 mEq/L\n 138 mEq/L\n 47.2 %\n 8.7 K/uL\n [image002.jpg]\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n WBC\n 11.1\n 12.5\n 8.4\n 9.5\n 8.7\n Hct\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n 47.2\n Plt\n 128\n 100\n 116\n 123\n 136\n Cr\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n Glucose\n 89\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n Other labs: PT / PTT / INR:26.4/36.3/2.6, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571887,
"text": "Chief Complaint: acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n - 1L negative at 7pm, Cr 2.0->2.6, remained -800 cc at MN\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 54 (46 - 66) bpm\n BP: 93/47(59) {87/47(59) - 131/101(109)} mmHg\n RR: 21 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 5 (1 - 9)mmHg\n PAP: 47/21 mmHg\n (37-57/21-32)\n mPAP 31 mmHg (30-41)\n Total In:\n 1,416 mL\n 166 mL\n PO:\n 840 mL\n TF:\n IVF:\n 576 mL\n 166 mL\n Blood products:\n Total out:\n 2,250 mL\n 400 mL\n Urine:\n 2,250 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -834 mL\n -234 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 136 K/uL\n 15.5 g/dL\n 85 mg/dL\n 2.4 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 96 mEq/L\n 138 mEq/L\n 47.2 %\n 8.7 K/uL\n [image002.jpg]\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n WBC\n 11.1\n 12.5\n 8.4\n 9.5\n 8.7\n Hct\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n 47.2\n Plt\n 128\n 100\n 116\n 123\n 136\n Cr\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n Glucose\n 89\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n Other labs: PT / PTT / INR:26.4/36.3/2.6, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571889,
"text": "Chief Complaint: acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n - 1L negative at 7pm, Cr 2.0->2.6, remained -800 cc at MN\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 54 (46 - 66) bpm\n BP: 93/47(59) {87/47(59) - 131/101(109)} mmHg\n RR: 21 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 5 (1 - 9)mmHg\n PAP: 47/21 mmHg\n (37-57/21-32)\n mPAP 31 mmHg (30-41)\n Total In:\n 1,416 mL\n 166 mL\n PO:\n 840 mL\n TF:\n IVF:\n 576 mL\n 166 mL\n Blood products:\n Total out:\n 2,250 mL\n 400 mL\n Urine:\n 2,250 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -834 mL\n -234 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 136 K/uL\n 15.5 g/dL\n 85 mg/dL\n 2.4 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 96 mEq/L\n 138 mEq/L\n 47.2 %\n 8.7 K/uL\n [image002.jpg]\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n WBC\n 11.1\n 12.5\n 8.4\n 9.5\n 8.7\n Hct\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n 47.2\n Plt\n 128\n 100\n 116\n 123\n 136\n Cr\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n Glucose\n 89\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n Other labs: PT / PTT / INR:26.4/36.3/2.6, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571890,
"text": "Chief Complaint: acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n - 1L negative at 7pm, Cr 2.0->2.6, remained -800 cc at MN\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 54 (46 - 66) bpm\n BP: 93/47(59) {87/47(59) - 131/101(109)} mmHg\n RR: 21 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 5 (1 - 9)mmHg\n PAP: 47/21 mmHg\n (37-57/21-32)\n mPAP 31 mmHg (30-41)\n Total In:\n 1,416 mL\n 166 mL\n PO:\n 840 mL\n TF:\n IVF:\n 576 mL\n 166 mL\n Blood products:\n Total out:\n 2,250 mL\n 400 mL\n Urine:\n 2,250 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -834 mL\n -234 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 136 K/uL\n 15.5 g/dL\n 85 mg/dL\n 2.4 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 96 mEq/L\n 138 mEq/L\n 47.2 %\n 8.7 K/uL\n [image002.jpg]\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n WBC\n 11.1\n 12.5\n 8.4\n 9.5\n 8.7\n Hct\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n 47.2\n Plt\n 128\n 100\n 116\n 123\n 136\n Cr\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n Glucose\n 89\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n Other labs: PT / PTT / INR:26.4/36.3/2.6, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -9.5L LOS; Cr\n has remained relatively stable despite diuresis\n -cont lasix gtt with diuril/metolazone prn to achieve volume balance\n negative 2-3 L\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n .\n #Pulm HTN\n pulm pressures improving but not consistently at\n pre-transplant target of mPAP 35 mmHg, consistent with inadequate\n diuresis, as well as element of irreversible pulm HTN (as suggested by\n absence of response to inhaled NO at cath )\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n # Thrombocytopenia\n stable\n -cont monitor daily\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr remains stable at 1.8-2.0 despite aggressive diuresis\n -cont to monitor while diuresing\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571914,
"text": "Chief Complaint: acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n - 1L negative at 7pm, Cr 2.0->2.6, remained -800 cc at MN\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies dizziness, lightheadedness, CP, palp, SOB,\n abd pain, N/V/D\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 54 (46 - 66) bpm\n BP: 93/47(59) {87/47(59) - 131/101(109)} mmHg\n RR: 21 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 5 (1 - 9)mmHg\n PAP: 47/21 mmHg\n (37-57/21-32)\n mPAP 31 mmHg (30-41)\n Total In:\n 1,416 mL\n 166 mL\n PO:\n 840 mL\n TF:\n IVF:\n 576 mL\n 166 mL\n Blood products:\n Total out:\n 2,250 mL\n 400 mL\n Urine:\n 2,250 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -834 mL\n -234 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 136 K/uL\n 15.5 g/dL\n 85 mg/dL\n 2.4 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 96 mEq/L\n 138 mEq/L\n 47.2 %\n 8.7 K/uL\n [image002.jpg]\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n WBC\n 11.1\n 12.5\n 8.4\n 9.5\n 8.7\n Hct\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n 47.2\n Plt\n 128\n 100\n 116\n 123\n 136\n Cr\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n Glucose\n 89\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n Other labs: PT / PTT / INR:26.4/36.3/2.6, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -10L LOS;\n Cr/HCO3 indicating that likely has reached dry weight\n -stop lasix gtt\n -determine PO lasix dose needed to keep even\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n -check BNP to establish dry weight value\n .\n #Pulm HTN\n pulm pressures improving with most reflecting\n pre-transplant target of mPAP 35 mmHg; likely has element of\n irreversible pulm HTN given h/o PE, possible portopulmonary syndrome\n (as suggested by absence of response to inhaled NO at cath )\n -will discuss progress/outpt mgmt with transplant team\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr rising in the setting of aggressive diuresis\n - lytes, Cr\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -decr. lopressor given bradycardia since now s/p cardioversion and\n doesn\nt need rate control\n -continue CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571915,
"text": "Chief Complaint: acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n - 1L negative at 7pm, Cr 2.0->2.6, remained -800 cc at MN\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies dizziness, lightheadedness, CP, palp, SOB,\n abd pain, N/V/D\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 54 (46 - 66) bpm\n BP: 93/47(59) {87/47(59) - 131/101(109)} mmHg\n RR: 21 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 5 (1 - 9)mmHg\n PAP: 47/21 mmHg\n (37-57/21-32)\n mPAP 31 mmHg (30-41)\n Total In:\n 1,416 mL\n 166 mL\n PO:\n 840 mL\n TF:\n IVF:\n 576 mL\n 166 mL\n Blood products:\n Total out:\n 2,250 mL\n 400 mL\n Urine:\n 2,250 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -834 mL\n -234 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 136 K/uL\n 15.5 g/dL\n 85 mg/dL\n 2.4 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 96 mEq/L\n 138 mEq/L\n 47.2 %\n 8.7 K/uL\n [image002.jpg]\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n WBC\n 11.1\n 12.5\n 8.4\n 9.5\n 8.7\n Hct\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n 47.2\n Plt\n 128\n 100\n 116\n 123\n 136\n Cr\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n Glucose\n 89\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n Other labs: PT / PTT / INR:26.4/36.3/2.6, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -10L LOS;\n Cr/HCO3 indicating that likely has reached dry weight\n -stop lasix gtt\n -determine PO lasix dose needed to keep even\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n -check BNP to establish dry weight value\n -d/c swan\n .\n #Pulm HTN\n pulm pressures improving with most reflecting\n pre-transplant target of mPAP 35 mmHg; likely has element of\n irreversible pulm HTN given h/o PE, possible portopulmonary syndrome\n (as suggested by absence of response to inhaled NO at cath )\n -will discuss progress/outpt mgmt with transplant team\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr rising in the setting of aggressive diuresis\n - lytes, Cr\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -decr. lopressor given bradycardia since now s/p cardioversion and\n doesn\nt need rate control\n -continue CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place then call\n out to floor\n ICU Care\n Nutrition: low Na diet, 1 L fluid restriction\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Code status: FULL\n Disposition: CCU for hemodynamic monitoring while swan in place then\n call out to floor\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572026,
"text": "52 yo male with history of HTN, atrial fibrillation, DVT, PE and\n cryptogenic cirrhosis since childhood which has been complicated by\n portal hypertension and variceal hemorrhages was referred for right\n heart cath as part of a liver transplant work up The cath revealed\n elevated right and left sided, moderate to severe pulmonary\n hypertension He has had a number of episodes of hepatic encephalopathy\n requiring hospitalizations. He is on lactulose.\n Ineffective Coping\n Assessment:\n Patient appearing more comfortable with PA line removed. Talking about\n going to regular floor. Resting comfortably\n Action:\n discussed plan of care with patient\n Response:\n Appears to be coping effectively\n Plan:\n Continue to discuss plan of care with patient, answer all his questions\n Cirrhosis of liver, other\n Assessment:\n Long standing\n Action:\n Lactulose, rifaximin, senna and polyethylene glycol given as ordered\n Response:\n Had a large BM\n Plan:\n Optimize hemodynamics for possible liver transplant, cont diuresis,\n lasix po, monitor I+O\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 572085,
"text": "Chief Complaint:\n 24 Hour Events:\n -Cr 2.4 PCWP 9, gave 250 cc NS bolus; repeat PCWP 7\n -d/c'd lasix gtt @ 1030\n -d/c'd swan/cordis (has PIV)\n -decr. lopressor 25 mg to 12.5 mg bradycardia\n -ordered lasix 80 mg PO daily to start AM \n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.6\nC (97.8\n HR: 57 (50 - 69) bpm\n BP: 109/75(83) {83/49(57) - 128/90(96)} mmHg\n RR: 17 (13 - 45) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 1 (1 - 8)mmHg\n PAP: (44 mmHg) / (16 mmHg)\n PCWP: 7 (7 - 9.) mmHg\n Total In:\n 1,202 mL\n 73 mL\n PO:\n 380 mL\n TF:\n IVF:\n 822 mL\n 73 mL\n Blood products:\n Total out:\n 1,750 mL\n 550 mL\n Urine:\n 1,500 mL\n 400 mL\n NG:\n 250 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -548 mL\n -477 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 172 K/uL\n 15.0 g/dL\n 104 mg/dL\n 2.3 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 42 mg/dL\n 98 mEq/L\n 135 mEq/L\n 44.0 %\n 9.5 K/uL\n [image002.jpg]\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n 01:32 PM\n 02:59 AM\n WBC\n 12.5\n 8.4\n 9.5\n 8.7\n 9.4\n 9.5\n Hct\n 42.2\n 44.1\n 43.7\n 47.2\n 45.6\n 44.0\n Plt\n 100\n 116\n 123\n 136\n 163\n 172\n Cr\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n 2.4\n 2.3\n Glucose\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n 125\n 104\n Other labs: PT / PTT / INR:29.2/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION\n INEFFECTIVE COPING\n KNOWLEDGE DEFICIT\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n CIRRHOSIS OF LIVER, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 572090,
"text": "Chief Complaint:\n 24 Hour Events:\n -Cr 2.4 PCWP 9, gave 250 cc NS bolus; repeat PCWP 7\n -d/c'd lasix gtt @ 1030\n -d/c'd swan/cordis (has PIV)\n -decr. lopressor 25 mg to 12.5 mg bradycardia\n -ordered lasix 80 mg PO daily to start AM \n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications: Lasix 80mg PO daily, Lopressor 12.5mg PO BID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.6\nC (97.8\n HR: 57 (50 - 69) bpm\n BP: 109/75(83) {83/49(57) - 128/90(96)} mmHg\n RR: 17 (13 - 45) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 1 (1 - 8)mmHg\n PAP: (44 mmHg) / (16 mmHg)\n PCWP: 7 (7 - 9.) mmHg\n Total In:\n 1,202 mL\n 73 mL\n PO:\n 380 mL\n TF:\n IVF:\n 822 mL\n 73 mL\n Blood products:\n Total out:\n 1,750 mL\n 550 mL\n Urine:\n 1,500 mL\n 400 mL\n NG:\n 250 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -548 mL\n -477 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 172 K/uL\n 15.0 g/dL\n 104 mg/dL\n 2.3 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 42 mg/dL\n 98 mEq/L\n 135 mEq/L\n 44.0 %\n 9.5 K/uL\n [image002.jpg]\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n 01:32 PM\n 02:59 AM\n WBC\n 12.5\n 8.4\n 9.5\n 8.7\n 9.4\n 9.5\n Hct\n 42.2\n 44.1\n 43.7\n 47.2\n 45.6\n 44.0\n Plt\n 100\n 116\n 123\n 136\n 163\n 172\n Cr\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n 2.4\n 2.3\n Glucose\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n 125\n 104\n Other labs: PT / PTT / INR:29.2/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -10L LOS;\n Cr/HCO3 indicating that likely has reached dry weight\n -stop lasix gtt\n -determine PO lasix dose needed to keep even\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n -check BNP to establish dry weight value\n -check PCWP at dry weight prior to d/c swan\n .\n #Pulm HTN\n pulm pressures improving with most reflecting\n pre-transplant target of mPAP 35 mmHg; likely has element of\n irreversible pulm HTN given h/o PE, possible portopulmonary syndrome\n (as suggested by absence of response to inhaled NO at cath )\n -will discuss progress/outpt mgmt with transplant team\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr rising in the setting of aggressive diuresis\n - lytes, Cr\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -decr. lopressor given bradycardia since now s/p cardioversion and\n doesn\nt need rate control\n -continue CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place then call\n out to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571476,
"text": "Chief Complaint:\n 24 Hour Events:\n -lasix 80 mg IV @ 0900 -> 1L out, -430 @ 1430\n -changed captopril to lisinopril\n -held coumadin for INR 3.0\n -plts stable, held off on ordering HIT/starting fondaparinux per\n heme-onc c/s\n -PCWP 25 mmHg, mPAP 45 mmHg\n -put on 1L fluid restriction\n -lasix 120 mg IV @ 1900\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 54 (50 - 74) bpm\n BP: 99/85(88) {99/50(62) - 127/87(97)} mmHg\n RR: 25 (12 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 12 (-3 - 12)mmHg\n PAP: (59 mmHg) / (27 mmHg)\n PCWP: 27 (25 - 31) mmHg\n CO/CI (Fick): (5.6 L/min) / (2.7 L/min/m2)\n SvO2: 72%\n Mixed Venous O2% Sat: 72 - 72\n Total In:\n 2,005 mL\n 66 mL\n PO:\n 1,000 mL\n TF:\n IVF:\n 1,005 mL\n 66 mL\n Blood products:\n Total out:\n 2,300 mL\n 1,100 mL\n Urine:\n 2,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -295 mL\n -1,034 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 123 K/uL\n 14.8 g/dL\n 89 mg/dL\n 1.8 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 27 mg/dL\n 98 mEq/L\n 137 mEq/L\n 43.7 %\n 9.5 K/uL\n [image002.jpg]\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n WBC\n 10.5\n 11.1\n 12.5\n 8.4\n 9.5\n Hct\n 40\n 43.4\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n Plt\n 116\n 128\n 100\n 116\n 123\n Cr\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n Glucose\n 111\n 94\n 125\n 89\n 131\n 100\n 128\n 89\n Other labs: PT / PTT / INR:28.5/38.9/2.9, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n CIRRHOSIS OF LIVER, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571478,
"text": "Chief Complaint:\n 24 Hour Events:\n -lasix 80 mg IV @ 0900 -> 1L out, -430 @ 1430\n -changed captopril to lisinopril\n -held coumadin for INR 3.0\n -plts stable, held off on ordering HIT/starting fondaparinux per\n heme-onc c/s\n -PCWP 25 mmHg, mPAP 45 mmHg\n -put on 1L fluid restriction\n -lasix 120 mg IV @ 1900\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 54 (50 - 74) bpm\n BP: 99/85(88) {99/50(62) - 127/87(97)} mmHg\n RR: 25 (12 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 12 (-3 - 12)mmHg\n PAP: (59 mmHg) / (27 mmHg)\n PCWP: 27 (25 - 31) mmHg\n CO/CI (Fick): (5.6 L/min) / (2.7 L/min/m2)\n SvO2: 72%\n Mixed Venous O2% Sat: 72 - 72\n Total In:\n 2,005 mL\n 66 mL\n PO:\n 1,000 mL\n TF:\n IVF:\n 1,005 mL\n 66 mL\n Blood products:\n Total out:\n 2,300 mL\n 1,100 mL\n Urine:\n 2,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -295 mL\n -1,034 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 123 K/uL\n 14.8 g/dL\n 89 mg/dL\n 1.8 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 27 mg/dL\n 98 mEq/L\n 137 mEq/L\n 43.7 %\n 9.5 K/uL\n [image002.jpg]\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n WBC\n 10.5\n 11.1\n 12.5\n 8.4\n 9.5\n Hct\n 40\n 43.4\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n Plt\n 116\n 128\n 100\n 116\n 123\n Cr\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n Glucose\n 111\n 94\n 125\n 89\n 131\n 100\n 128\n 89\n Other labs: PT / PTT / INR:28.5/38.9/2.9, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -6.8L LOS; Cr\n has remained relatively stable despite diuresis\n -cont diuresis to goal 1 L neg today\n - lytes\n -switch captopril to lisinopril 5 mg po daily\n -will attempt to wedge swan to see if mPAP correlate with PCWP\n .\n #Pulm HTN\n pulm pressures improving but not at preoperative target of\n mPAP 35 mmHg, consistent with element of irreversible pulm HTN, also\n suggested by absence of response to inhaled NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n # Thrombocytopenia\n platelets decreased to 100 from 200 on admission,\n intermediate pre-test prob for HIT\n -recheck in PM\n -send heparin Ab\n .\n #DVT/PE - INR 3.0 this am\n -hold coumadin dose today\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -cont lopressor for rate-control\n -continue anticoagulation\n .\n #CKD\n Cr increased slightly but not in ARF range\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n -Rx comorbidities as above\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571491,
"text": "Chief Complaint:\n 24 Hour Events:\n -lasix 80 mg IV @ 0900 -> 1L out, -430 @ 1430, lasix 120 mg IV @ 1900\n -put on 1L fluid restriction\n -changed captopril to lisinopril\n -held coumadin for INR 3.0\n -plts stable, held off on ordering HIT/starting fondaparinux per\n heme-onc c/s\n -PCWP 25 mmHg, mPAP 45 mmHg\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications: coumadin 5mg PO daily, omeprazole 20mg daily, MVI,\n Calcium 1000mg PO BID, miralax, metoprolol 25mg PO BID, amlodipine 10mg\n PO daily, lactulose 60mL PO q6h, rifaximin 400mg PO TID, senna 2 tab PO\n BID, lisinopril 5mg PO daily\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: No complaints. Denies nausea, vomiting or abdominal\n pain. Eating well. +Bm\ns daily. No SOB or chest pain\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 54 (50 - 74) bpm\n BP: 99/85(88) {99/50(62) - 127/87(97)} mmHg\n RR: 25 (12 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 12 (-3 - 12)mmHg\n PAP: (59 mmHg) / (27 mmHg)\n PCWP: 27 (25 - 31) mmHg\n CO/CI (Fick): (5.6 L/min) / (2.7 L/min/m2)\n SvO2: 72%\n Mixed Venous O2% Sat: 72 - 72\n Total In:\n 2,005 mL\n 66 mL\n PO:\n 1,000 mL\n TF:\n IVF:\n 1,005 mL\n 66 mL\n Blood products:\n Total out:\n 2,300 mL\n 1,100 mL\n Urine:\n 2,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -295 mL\n -1,034 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 123 K/uL\n 14.8 g/dL\n 89 mg/dL\n 1.8 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 27 mg/dL\n 98 mEq/L\n 137 mEq/L\n 43.7 %\n 9.5 K/uL\n [image002.jpg]\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n WBC\n 10.5\n 11.1\n 12.5\n 8.4\n 9.5\n Hct\n 40\n 43.4\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n Plt\n 116\n 128\n 100\n 116\n 123\n Cr\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n Glucose\n 111\n 94\n 125\n 89\n 131\n 100\n 128\n 89\n Other labs: PT / PTT / INR:28.5/38.9/2.9, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -6.8L LOS; Cr\n has remained relatively stable despite diuresis\n -cont diuresis to goal 1-2 L neg today\n - lytes\n -continue lisinopril 5 mg po daily\n .\n #Pulm HTN\n pulm pressures improving but not at preoperative target of\n mPAP 35 mmHg, consistent with element of irreversible pulm HTN, also\n suggested by absence of response to inhaled NO at cath . Based\n on wedge however, he has not been completely diuresed\n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n # Thrombocytopenia\n platelets decreased to 100 from 200 on admission,\n intermediate pre-test prob for HIT. Recovering with no intervention\n -cont to trend daily\n .\n #DVT/PE - INR 2.9 this am\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -cont lopressor for rate-control\n .\n #CKD\n Cr remains stable at 1.8-2.0 despite aggressive diuresis\n -cont to monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n -Rx comorbidities as above\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; fluid restrict to 1L; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571805,
"text": "53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n HR 49-57- MAPs 66-76- PA mean 32-35- K 3.6- KCL 60meq given\n Action:\n Con\nt on lasix gtt @ 20mg/hr & lopressor, lisinopril, amlodipine &\n coumadin.\n Response:\n Hemodynamically stable- (-) 800cc today- U/O trending down this\n afternoon- BUN/Crea trending up 37/2.6- repeat K 3.8- INR 2.6\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571810,
"text": "53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n HR 49-57- MAPs 66-76- PA mean 32-35- K 3.6- KCL 60meq given\n Action:\n Con\nt on lasix gtt @ 20mg/hr & lopressor, lisinopril, amlodipine &\n coumadin.\n Response:\n Hemodynamically stable- (-) 800cc today- U/O trending down this\n afternoon- BUN/Crea trending up 37/2.6- repeat K 3.8- INR 2.6\n Plan:\n Con\nt lasix gtt & present medicat management.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572013,
"text": "Ineffective Coping\n Assessment:\n PT ASKING SAME QUESTIONS OVER AND OVER AGAIN ABOUT HIS ILLNESS/PLAN OF\n CARE, NOTED TO BE ANXIOUS REGARDING CENTRALL LINE/SWAN GANZ CATH & WHEN\n HE WIL BE GOING HOME\n Action:\n PT\nS QUESTIONS ANSWERED, PT REASSURED, SWAN GANZ/CENTRALL LINE DC\n 1700, TEACHING TOWARDS DISEASE PROCESS/PLAN OF CARE GIVEN TO PT &\n FAMILY\n Response:\n PT LESS ANXIOUS ONCE CENTRAL LINE OUT & ONCE TOLD WILL BE TRANSFERED TO\n FLOOR IN AM\n Plan:\n CONTINUE TO ASSESS COPING, SUPPORT PT/FAMILY, SEE NURSING CARE PLAN\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 572129,
"text": "Chief Complaint:\n 24 Hour Events:\n -Cr 2.4 PCWP 9, gave 250 cc NS bolus; repeat PCWP 7\n -d/c'd lasix gtt @ 1030\n -d/c'd swan/cordis (has PIV)\n -decr. lopressor 25 mg to 12.5 mg bradycardia\n -ordered lasix 80 mg PO daily to start AM \n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.6\nC (97.8\n HR: 57 (50 - 69) bpm\n BP: 109/75(83) {83/49(57) - 128/90(96)} mmHg\n RR: 17 (13 - 45) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 1 (1 - 8)mmHg\n PAP: (44 mmHg) / (16 mmHg)\n PCWP: 7 (7 - 9.) mmHg\n Total In:\n 1,202 mL\n 83 mL\n PO:\n 380 mL\n TF:\n IVF:\n 822 mL\n 83 mL\n Blood products:\n Total out:\n 1,750 mL\n 550 mL\n Urine:\n 1,500 mL\n 400 mL\n NG:\n 250 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -548 mL\n -467 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 172 K/uL\n 15.0 g/dL\n 104 mg/dL\n 2.3 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 42 mg/dL\n 98 mEq/L\n 135 mEq/L\n 44.0 %\n 9.5 K/uL\n [image002.jpg]\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n 01:32 PM\n 02:59 AM\n WBC\n 12.5\n 8.4\n 9.5\n 8.7\n 9.4\n 9.5\n Hct\n 42.2\n 44.1\n 43.7\n 47.2\n 45.6\n 44.0\n Plt\n 100\n 116\n 123\n 136\n 163\n 172\n Cr\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n 2.4\n 2.3\n Glucose\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n 125\n 104\n Other labs: PT / PTT / INR:29.2/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -10L LOS;\n Cr/HCO3 indicating that likely has reached dry weight\n -start lasix 80 PO dose needed to keep even\n -daily weights; strict I/Os.\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n -check BNP to establish dry weight value\n .\n #Pulm HTN\n pulm pressures improving with most reflecting\n pre-transplant target of mPAP 35 mmHg; likely has element of\n irreversible pulm HTN given h/o PE, possible portopulmonary syndrome\n (as suggested by absence of response to inhaled NO at cath )\n -will discuss progress/outpt mgmt with transplant team\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n #DVT/PE - INR therapeutic\n -decrease coumadin dose to 4mg Qhs\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr rising in the setting of aggressive diuresis\n - lytes, Cr\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -decr. lopressor given bradycardia since now s/p cardioversion and\n doesn\nt need rate control\n -continue CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: call out to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571228,
"text": "52 yo male with a history of HTN, atrial fibrillation, DVT, PE and\n cryptogenic cirrhosis since childhood complicatied by portal\n hypertension and variceal hemorrhages He comes to for right\n heart catheterization as part of liver transplant work up. Patient\n reports sob with mild activity relieved with rest for about a year. He\n was recently admitted in for hepatic encephalopathy . This has\n been controlled with lactulose. Echo done EF > 55% mildly\n dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic root\n at the sinus level and mildly dilated ascending aorta. Mild pulm artery\n systolic HTN A heart cath done showed severe LV diastolic\n dysfunction and pulm htn. He had a Swan placed at that time which\n showed PCWP 25 PA pressure 68/30 mean 51, RV 64/15 mean 22, RA 16-19 He\n has been given lasix goal of pa mean pressures of <35 A DC\n cardioversion preformed Atrial fibrillation on \n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n CVP 5 CO fick 7.2 CI 3.4 PA 60/35-55/27 means 38-45 mixed venous o2\n sat 72%. Lungs clear LOS output neg 6 liters output yesterday neg 1\n liter\n Action:\n Given lasix yesterday 20mg \n Response:\n 1 liter neg\n Plan:\n Lasix prn, Captopril to be increased prn for improved Afterload\n reduction, goal PA mean <35\n Cirrhosis of liver, other\n Assessment:\n w/u for liver transplant in progress, PA mean pressures continue to be\n high 38-45 patient anxious to have PA line removed. A/O x3 lactulose\n given\n Action:\n Lactulose q 4hr for BM qd, follow LFT, ammonia levels and mental\n status\n Response:\n 3 large BM\ns \n Plan:\n Follow LFTs, ammonia levels and mental status\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571398,
"text": "52 yo male with a history of HTN, atrial fibrillation, DVT, PE and\n cryptogenic cirrhosis since childhood complicated by portal\n hypertension and variceal hemorrhages He comes to for right\n heart catheterization as part of liver transplant work up. Patient\n reports sob (with mild activity) relieved with rest for about a year.\n He was recently admitted in for hepatic encephalopathy. This has\n been controlled with lactulose. Echo done EF > 55% mildly\n dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic root\n at the sinus level and mildly dilated ascending aorta. Mild pulm artery\n systolic HTN A heart cath done showed severe LV diastolic\n dysfunction and pulm htn. He had a Swan placed at that time which\n showed PCWP 25 PA pressure 68/30 mean 51, RV 64/15 mean 22, RA 16-19 He\n has been given lasix goal of pa mean pressures of <35 A DC\n cardioversion preformed Atrial fibrillation on \n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PCWP 25, PAP 70/27 mean 45, BP 104/85(89), hr nsr 64\n Action:\n Captopril changed to Lisinopril, 80mg lasix x1, k of 3.3 repleated c\n 6+0meq of potassium, coumadin held, swan advanced by cardiac fellow\n able to pcwp now, amlodipine\n Response:\n Bun 26, cr 1.9, pt -6L since length of stay, pt met goal of -500cc\n today\n Plan:\n In order for pt to reach transplant requirements his mean PAP need to\n be less than35 pt needs to be Diuresed as much as tolerated by pt. \n lytes,\n Cirrhosis of liver, other\n Assessment:\n h/o cirrhosis since childhood, waiting to get on transplant list for\n liver\n Action:\n Lactulose, rifaxamin, oob to commode c supervision\n Response:\n Bm x 4 today met goal\n Plan:\n Continue to follow mental status, lfts\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571480,
"text": "Chief Complaint:\n 24 Hour Events:\n -lasix 80 mg IV @ 0900 -> 1L out, -430 @ 1430, lasix 120 mg IV @ 1900\n -put on 1L fluid restriction\n -changed captopril to lisinopril\n -held coumadin for INR 3.0\n -plts stable, held off on ordering HIT/starting fondaparinux per\n heme-onc c/s\n -PCWP 25 mmHg, mPAP 45 mmHg\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications: coumadin 5mg PO daily, omeprazole 20mg daily, MVI,\n Calcium 1000mg PO BID< miralax, metoprolol 25mg Po BID, amlodipine 10mg\n PO daily, lactulose 60mL PO q6h, rifaximin 400mg PO TID, senna 2tab PO\n BID,lisinopril5mg PO daily,\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (97\n HR: 54 (50 - 74) bpm\n BP: 99/85(88) {99/50(62) - 127/87(97)} mmHg\n RR: 25 (12 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 12 (-3 - 12)mmHg\n PAP: (59 mmHg) / (27 mmHg)\n PCWP: 27 (25 - 31) mmHg\n CO/CI (Fick): (5.6 L/min) / (2.7 L/min/m2)\n SvO2: 72%\n Mixed Venous O2% Sat: 72 - 72\n Total In:\n 2,005 mL\n 66 mL\n PO:\n 1,000 mL\n TF:\n IVF:\n 1,005 mL\n 66 mL\n Blood products:\n Total out:\n 2,300 mL\n 1,100 mL\n Urine:\n 2,300 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -295 mL\n -1,034 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 123 K/uL\n 14.8 g/dL\n 89 mg/dL\n 1.8 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 27 mg/dL\n 98 mEq/L\n 137 mEq/L\n 43.7 %\n 9.5 K/uL\n [image002.jpg]\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n WBC\n 10.5\n 11.1\n 12.5\n 8.4\n 9.5\n Hct\n 40\n 43.4\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n Plt\n 116\n 128\n 100\n 116\n 123\n Cr\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n Glucose\n 111\n 94\n 125\n 89\n 131\n 100\n 128\n 89\n Other labs: PT / PTT / INR:28.5/38.9/2.9, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -6.8L LOS; Cr\n has remained relatively stable despite diuresis\n -cont diuresis to goal 1-2 L neg today\n - lytes\n -continue lisinopril 5 mg po daily\n .\n #Pulm HTN\n pulm pressures improving but not at preoperative target of\n mPAP 35 mmHg, consistent with element of irreversible pulm HTN, also\n suggested by absence of response to inhaled NO at cath . Based\n on wedge however, he has not been completely diuresed\n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n # Thrombocytopenia\n platelets decreased to 100 from 200 on admission,\n intermediate pre-test prob for HIT. Recovering with no intervention\n -cont to trend daily\n .\n #DVT/PE - INR 2.9 this am\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -cont lopressor for rate-control\n .\n #CKD\n Cr remains stable at 1.8-2.0 despite aggressive diuresis\n -cont to monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n -Rx comorbidities as above\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; fluid restrict to 1L; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571486,
"text": "52 yo male with a history of HTN, atrial fibrillation, DVT, PE and\n cryptogenic cirrhosis since childhood complicated by portal\n hypertension and variceal hemorrhages He comes to for right\n heart catheterization as part of liver transplant work up. Patient\n reports sob (with mild activity) relieved with rest for about a year.\n He was recently admitted in for hepatic encephalopathy. This has\n been controlled with lactulose. Echo done EF > 55% mildly\n dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic root\n at the sinus level and mildly dilated ascending aorta. Mild pulm artery\n systolic HTN A heart cath done showed severe LV diastolic\n dysfunction and pulm htn. He had a Swan placed at that time which\n showed PCWP 25 PA pressure 68/30 mean 51, RV 64/15 mean 22, RA 16-19 He\n has been given lasix goal of pa mean pressures of <35 A DC\n cardioversion preformed Atrial fibrillation on \n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Pt w/ chronic pulm HTN.\n Action:\n Diuresis\n Response:\n Good response to diuresis.\n Plan:\n Fluid restriction. Goal is mean PAP =35\n Cirrhosis of liver, other\n Assessment:\n Cirrhosis since childhood\n Action:\n Lactulose as ordered\n Response:\n BM after lactulose\n Plan:\n Optimize hemodynamic function for liver transplant list.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Lungs clr and slightly diminished at bases. Central numbers continue to\n remain high PCWP 31. CO/CI 5.6/2.7.\n Action:\n Lasix 120mg iv\n Response:\n Good response to lasix. PCWP 27 this am. swan tracing dampened w/\n square wave test performed.\n Plan:\n Goal to reduce PCWP before transplant.\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571687,
"text": "Chief Complaint:\n 24 Hour Events:\n -not meeting diuresis goals with bolus lasix therefore was started on\n lsix gtt with 120mg IV lasix bolus\n -INR 1.9 therefore coumadin restarted\n -I/O check @ 1400 - 900cc negative, inc lasix gtt from 10 to 20mg/hr\n -I/O check @ 1900 - 1600cc negative; re-bolused with lasix 120mg IV @\n , however had minimal response\n -bolused 500cc diuril @2300\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies CP, palp, cough, SOB, abd pain, N/V\n Flowsheet Data as of 05:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.1\nC (97\n HR: 51 (48 - 69) bpm\n BP: 99/62(71) {93/56(67) - 132/85(95)} mmHg\n RR: 23 (12 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 5 (3 - 12)mmHg\n PAP: (45 mmHg) / (20 mmHg)\n PCWP: 27 (27 - 27) mmHg\n Total In:\n 1,236 mL\n 135 mL\n PO:\n 780 mL\n TF:\n IVF:\n 456 mL\n 135 mL\n Blood products:\n Total out:\n 2,950 mL\n 725 mL\n Urine:\n 2,950 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,714 mL\n -590 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///36/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 123 K/uL\n 14.8 g/dL\n 89 mg/dL\n 1.9 mg/dL\n 36 mEq/L\n 3.6 mEq/L\n 28 mg/dL\n 97 mEq/L\n 139 mEq/L\n 43.7 %\n 9.5 K/uL\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n WBC\n 10.5\n 11.1\n 12.5\n 8.4\n 9.5\n Hct\n 43.4\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n Plt\n 116\n 128\n 100\n 116\n 123\n Cr\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n Glucose\n 111\n 94\n 125\n 89\n 131\n 100\n 128\n 89\n 89\n Other labs: PT / PTT / INR:28.5/38.9/2.9, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -7.9L LOS; Cr\n has remained relatively stable despite diuresis\n -cont diuresis to goal 2-3 L neg today\n -will start lasix gtt\n - lytes\n -continue lisinopril 5 mg po daily\n .\n #Pulm HTN\n pulm pressures improving but not at preoperative target of\n mPAP 35 mmHg, consistent with element of irreversible pulm HTN, also\n suggested by absence of response to inhaled NO at cath . Based\n on wedge however, he has not been completely diuresed\n -cont amlodipine\n -treat left-sided CHF, as above\n .\n # Thrombocytopenia\n platelets decreased to 100 from 200 on admission,\n low pre-test prob for HIT. Recovering with no intervention\n -check platelets daily\n .\n #DVT/PE - INR 2.9 this am\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -cont lopressor for rate-control\n .\n #CKD\n Cr remains stable at 1.8-2.0 despite aggressive diuresis\n -cont to monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n -Rx comorbidities as above\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; fluid restrict to 1L; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571877,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Patient reports sob (with mild activity) relieved with rest for about a\n year. He was recently admitted in for hepatic encephalopathy.\n This has been controlled with lactulose. Echo done EF > 55%\n mildly dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic\n root at the sinus level and mildly dilated ascending aorta. Mild pulm\n artery systolic HTN\n Cath : mod. To severe Pulm. HTN. Negative response to inhaled\n NO at that time.\n Started heparin for afib on admit. Goal mPAP <35 diuresing with prn\n lasix for goal net neg. 1-2L /day.\n : CDV (200jx1) to NSR. Heparin d/c\n : Captopril changed to lisinopril. Contin. with prn lasix with\n decreasing results.\n : Lasix gtt was started with additional lasix bolus. Titrated up\n to 20mg/hr. INR 1.9-> coumadin restarted.\n Diurel 500mg x1 for additional diuresis.\n mPAP\ns overnight 29-35. neg. 9.5L LOS\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n LS clear. No SOB. Laying flat comfortably.\n HR 50\ns SB. BP 90\ns/ 60\n Contin. lasix gtt at 20mg/hr. no further boluses elevated\n Creatinine.\n Action:\n Lasix gtt 20mg/hr.\n Response:\n PAP\ns 50\ns/23-32. Mean 30-37. (goal <35).\n Neg. 800cc for . neg. 250cc since MN> neg. 9.6L LOS\n Plan:\n ? d/c\n swan today. Follow plan for lasix gtt. Contin. lopressor,\n lisinopril, amlodipine.\n Coumadin for afib.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Sats 92-99% on RA. LS clear. Denies SOB.\n Action:\n Response:\n No distress. Slept comfortably.\n Plan:\n Follow plan with team\n Cirrhosis of liver, other\n Assessment:\n Transplant w/u in progress. hx encephalopathy rx with lactulose\n Action:\n Lactulose for goal 3-4bms/day.\n Response:\n Had 4 bms . lactulose held overnight for sleep.\n Plan:\n Contin. meds as ordered. Fluid restriction.\n Pt. was talking about feeling optimistic about transplant hopes and\n going home soon.\n No c/o pain/nausea.\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571883,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.7\nC (98\n HR: 54 (46 - 66) bpm\n BP: 93/47(59) {87/47(59) - 131/101(109)} mmHg\n RR: 21 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 5 (1 - 9)mmHg\n PAP: (47 mmHg) / (21 mmHg)\n Total In:\n 1,416 mL\n 166 mL\n PO:\n 840 mL\n TF:\n IVF:\n 576 mL\n 166 mL\n Blood products:\n Total out:\n 2,250 mL\n 400 mL\n Urine:\n 2,250 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -834 mL\n -234 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///34/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 136 K/uL\n 15.5 g/dL\n 85 mg/dL\n 2.4 mg/dL\n 34 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 96 mEq/L\n 138 mEq/L\n 47.2 %\n 8.7 K/uL\n [image002.jpg]\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n WBC\n 11.1\n 12.5\n 8.4\n 9.5\n 8.7\n Hct\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n 47.2\n Plt\n 128\n 100\n 116\n 123\n 136\n Cr\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n Glucose\n 89\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n Other labs: PT / PTT / INR:26.4/36.3/2.6, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572203,
"text": "52 yo male with history of cryptogenic cirrhosis which he has had since\n childhood is referred for a right heart cath as part of the liver\n transplant work up. He had been experiencing dyspnea with mild activity\n relieved with rest. for about a year. His cirrohosis has been\n complicated by portal hypertension and variceal hemorrhages, as well as\n hepatic encephalopathy requiring hospitalizations. The cath revealed\n acute and chronic diastolic CHF.and pulm HTN, pt swaned and diuresed\n aggressively w/ improvement in PAD\ns.. pt in a fib when admitted and\n cardioverted to sinus rhythm .\n Ineffective Coping\n Assessment:\n Patient appearing more comfortable with PA line removed. Talking\n about going to regular floor. Resting comfortably\n Action:\n discussed plan of care with patient\n Response:\n Appears to be coping effectively\n Plan:\n Continue to discuss plan of care with patient, answer all his questions\n Cirrhosis of liver, other\n Assessment:\n Long standing. Vomited several times clear fluid, c/o nausea abdomen\n soft nontender BS+\n Action:\n Given 8 mg zofran,Lactulose, rifaximin, senna and polyethylene glycol\n given as ordered. INR 3.0\n Response:\n Had a large BM\n Plan:\n Optimize hemodynamics for possible liver transplant, cont diuresis,\n lasix po, monitor I+O continue lactulose rifaximin, senna and\n polyethylene glycol.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Cr 2.3 bun 42, 24 hr output neg 500 cc\n Action:\n On lasix 40mg qd,\n Response:\n Urine output slowing down ? dry\n Plan:\n Follow hemodynamics, monitor output, cr and bun, monitor lytes treat as\n needed\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571308,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n Rec\nd lasix 80 mg IV x 2\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 03:00 PM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies fever, chills, CP, palp, cough, orthopnea,\n dyspnea\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.8\nC (98.2\n HR: 55 (52 - 81) bpm\n BP: 99/50(62) {80/30(48) - 131/89(119)} mmHg\n RR: 17 (14 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: -3 (-3 - 17)mmHg\n PAP: (42 mmHg) / (13 mmHg)\n CO/CI (Fick): (7.2 L/min) / (3.4 L/min/m2)\n Mixed Venous O2% Sat: 76 - 76\n Total In:\n 549 mL\n 94 mL\n PO:\n 280 mL\n TF:\n IVF:\n 269 mL\n 94 mL\n Blood products:\n Total out:\n 1,550 mL\n 300 mL\n Urine:\n 1,550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,001 mL\n -206 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 100 K/uL\n 14.5 g/dL\n 100 mg/dL\n 1.8 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 27 mg/dL\n 98 mEq/L\n 135 mEq/L\n 42.2 %\n 12.5 K/uL\n [image002.jpg]\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n WBC\n 11.6\n 10.5\n 11.1\n 12.5\n Hct\n 43.7\n 40\n 43.4\n 44.0\n 44.0\n 42.2\n Plt\n 156\n 116\n 128\n 100\n Cr\n 1.6\n 1.6\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n Glucose\n 128\n 97\n 111\n 94\n 125\n 89\n 131\n 100\n Other labs: PT / PTT / INR:29.5/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -6.8L LOS; Cr\n has remained stable despite diuresis\n -cont diuresis to goal 1-2 L neg today\n - lytes\n -cont. captopril\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with element of\n irreversible pulm HTN, also suggested by absence of response to inhaled\n NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE: INR 3.0 this am\n -hold coumadin dose today\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -cont lopressor for rate-control\n -continue anticoagulation\n .\n #CRI\n Cr increased\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571314,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n Rec\nd lasix 80 mg IV x 2\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 03:00 PM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies fever, chills, CP, palp, cough, orthopnea,\n dyspnea\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.8\nC (98.2\n HR: 55 (52 - 81) bpm\n BP: 99/50(62) {80/30(48) - 131/89(119)} mmHg\n RR: 17 (14 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: -3 (-3 - 17)mmHg\n PAP: (42 mmHg) / (13 mmHg)\n CO/CI (Fick): (7.2 L/min) / (3.4 L/min/m2)\n Mixed Venous O2% Sat: 76 - 76\n Total In:\n 549 mL\n 94 mL\n PO:\n 280 mL\n TF:\n IVF:\n 269 mL\n 94 mL\n Blood products:\n Total out:\n 1,550 mL\n 300 mL\n Urine:\n 1,550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,001 mL\n -206 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 100 K/uL\n 14.5 g/dL\n 100 mg/dL\n 1.8 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 27 mg/dL\n 98 mEq/L\n 135 mEq/L\n 42.2 %\n 12.5 K/uL\n [image002.jpg]\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n WBC\n 11.6\n 10.5\n 11.1\n 12.5\n Hct\n 43.7\n 40\n 43.4\n 44.0\n 44.0\n 42.2\n Plt\n 156\n 116\n 128\n 100\n Cr\n 1.6\n 1.6\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n Glucose\n 128\n 97\n 111\n 94\n 125\n 89\n 131\n 100\n Other labs: PT / PTT / INR:29.5/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -6.8L LOS; Cr\n has remained stable despite diuresis\n -cont diuresis to goal 1 L neg today\n - lytes\n -cont. captopril\n -will attempt to wedge swan to see if PAP correlate with PCWP.\n .\n #Pulm HTN\n pulm pressures improving but not at preoperative target of\n mPAP 35 mmHg, consistent with element of irreversible pulm HTN, also\n suggested by absence of response to inhaled NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE: INR 3.0 this am\n -hold coumadin dose today\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -cont lopressor for rate-control\n -continue anticoagulation\n .\n #CRI\n Cr increased\n -cont monitor while diuresing\n .\n # Thrombocytopenia\n platelets decreased to 100. low prob for HIT.\n - will check pm plts.\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n -will discuss endpoints with transplant team.\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571337,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n Rec\nd lasix 80 mg IV x 2\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 03:00 PM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies fever, chills, CP, palp, cough, orthopnea,\n dyspnea\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.8\nC (98.2\n HR: 55 (52 - 81) bpm\n BP: 99/50(62) {80/30(48) - 131/89(119)} mmHg\n RR: 17 (14 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: -3 (-3 - 17)mmHg\n PAP: (42 mmHg) / (13 mmHg)\n CO/CI (Fick): (7.2 L/min) / (3.4 L/min/m2)\n Mixed Venous O2% Sat: 76 - 76\n Total In:\n 549 mL\n 94 mL\n PO:\n 280 mL\n TF:\n IVF:\n 269 mL\n 94 mL\n Blood products:\n Total out:\n 1,550 mL\n 300 mL\n Urine:\n 1,550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,001 mL\n -206 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 100 K/uL\n 14.5 g/dL\n 100 mg/dL\n 1.8 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 27 mg/dL\n 98 mEq/L\n 135 mEq/L\n 42.2 %\n 12.5 K/uL\n [image002.jpg]\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n WBC\n 11.6\n 10.5\n 11.1\n 12.5\n Hct\n 43.7\n 40\n 43.4\n 44.0\n 44.0\n 42.2\n Plt\n 156\n 116\n 128\n 100\n Cr\n 1.6\n 1.6\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n Glucose\n 128\n 97\n 111\n 94\n 125\n 89\n 131\n 100\n Other labs: PT / PTT / INR:29.5/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -6.8L LOS; Cr\n has remained stable despite diuresis\n -cont diuresis to goal 1 L neg today\n - lytes\n -switch captopril to lisinopril 5 mg po daily\n -will attempt to wedge swan to see if PAP correlate with PCWP.\n .\n #Pulm HTN\n pulm pressures improving but not at preoperative target of\n mPAP 35 mmHg, consistent with element of irreversible pulm HTN, also\n suggested by absence of response to inhaled NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE: INR 3.0 this am\n -hold coumadin dose today\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -cont lopressor for rate-control\n -continue anticoagulation\n .\n #Acute on Chronic kidney injury\n Cr increased slightly in the setting\n of diuresis.\n -cont monitor while diuresing\n .\n # Thrombocytopenia\n platelets decreased to 100. intermediate prob for\n HIT. Possibly cirrhosis\n - will check pm plts.\n - will check heparin Ab.\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n -will discuss endpoints with transplant team.\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571592,
"text": "52 yo male with a history of HTN, atrial fibrillation, DVT, PE and\n cryptogenic cirrhosis since childhood complicated by portal\n hypertension and variceal hemorrhages He comes to for right\n heart catheterization as part of liver transplant work up. Patient\n reports sob (with mild activity) relieved with rest for about a year.\n He was recently admitted in for hepatic encephalopathy. This has\n been controlled with lactulose. Echo done EF > 55% mildly\n dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic root\n at the sinus level and mildly dilated ascending aorta. Mild pulm artery\n systolic HTN A heart cath done showed severe LV diastolic\n dysfunction and pulm htn. He had a Swan placed at that time which\n showed PCWP 25 PA pressure 68/30 mean 51, RV 64/15 mean 22, RA 16-19 He\n has been given lasix goal of pa mean pressures of <35 A DC\n cardioversion preformed Atrial fibrillation on \n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Chronic pulmonary HTN- no resp distress\n Action:\n Following PA numbers-> PAS 57-62 PAD 27-28 Mean 37-42- lasix given\n followed by gtt.- CI 2.7\n Response:\n Mean remains > 35\n Plan:\n Con\nt present management.\n Cirrhosis of liver, other\n Assessment:\n Cirrhosis since childhoold.\n Action:\n Lactulose, rifaximin, senna & polyethylene glycol given as ordered.\n Response:\n 2 large soft/loose stools today.\n Plan:\n Optimize hemodynamic status for possible liver transplant.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Lung sounds clear- SpO2 94-98% on room air.\n Action:\n Lasix 120mg IV this am followed by a lasix gtt @ 10mg/hr.\n Response:\n Diuresed 900cc by 1330- goal is 2-3 L today- lasix gtt increased 20mg @\n 1330- (-) 1500cc @ present.\n Plan:\n Con\nt t to aggressively diurese.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 572200,
"text": "52 yo male with history of cryptogenic cirrhosis which he has had since\n childhood is referred for a right heart cath as part of the liver\n transplant work up. He had been experiencing dyspnea with mild activity\n relieved with rest. for about a year. His cirrohosis has been\n complicated by portal hypertension and variceal hemorrhages, as well as\n hepatic encephalopathy requiring hospitalizations. The cath revealed\n acute and chronic diastolic CHF.and pulm HTN, pt swaned and diuresed\n aggressively w/ improvement in PAD\ns.. pt in a fib when admitted and\n cardioverted to sinus rhythm .\n Ineffective Coping\n Assessment:\n Patient appearing more comfortable with PA line removed. Talking\n about going to regular floor. Resting comfortably\n Action:\n discussed plan of care with patient\n Response:\n Appears to be coping effectively\n Plan:\n Continue to discuss plan of care with patient, answer all his questions\n Cirrhosis of liver, other\n Assessment:\n Long standing. Vomited several times clear fluid, c/o nausea abdomen\n soft nontender BS+\n Action:\n Given 8 mg zofran,Lactulose, rifaximin, senna and polyethylene glycol\n given as ordered. INR 3.0\n Response:\n Had a large BM\n Plan:\n Optimize hemodynamics for possible liver transplant, cont diuresis,\n lasix po, monitor I+O continue lactulose rifaximin, senna and\n polyethylene glycol.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Cr 2.3 bun 42, 24 hr output neg 500 cc\n Action:\n On lasix 40mg qd,\n Response:\n Urine output slowing down ? dry\n Plan:\n Follow hemodynamics, monitor output, cr and bun, monitor lytes treat as\n needed\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571226,
"text": "52 yo male with a history of HTN, atrial fibrillation, DVT, PE and\n cryptogenic cirrhosis since childhood complicatied by portal\n hypertension and variceal hemorrhages He comes to for right\n heart catheterization as part of liver transplant work up. Patient\n reports sob with mild activity relieved with rest for about a year. He\n was recently admitted in for hepatic encephalopathy . This has\n been controlled with lactulose. Echo done EF > 55% mildly\n dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic root\n at the sinus level and mildly dilated ascending aorta. Mild pulm artery\n systolic HTN A heart cath done showed severe LV diastolic\n dysfunction and pulm htn. He had a Swan placed at that time which\n showed PCWP 25 PA pressure 68/30 mean 51, RV 64/15 mean 22, RA 16-19 He\n has been given lasix goal of pa mean pressures of <35 A DC\n cardioversion preformed Atrial fibrillation on \n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n CVP 5 CO fick 7.2 CI 3.4 PA 60/35-55/27 mixed venous o2 sat 72%.\n Lungs clear LOS output neg 6 liters\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571317,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n Rec\nd lasix 80 mg IV x 2\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 03:00 PM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies fever, chills, CP, palp, cough, orthopnea,\n dyspnea\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.8\nC (98.2\n HR: 55 (52 - 81) bpm\n BP: 99/50(62) {80/30(48) - 131/89(119)} mmHg\n RR: 17 (14 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: -3 (-3 - 17)mmHg\n PAP: (42 mmHg) / (13 mmHg)\n CO/CI (Fick): (7.2 L/min) / (3.4 L/min/m2)\n Mixed Venous O2% Sat: 76 - 76\n Total In:\n 549 mL\n 94 mL\n PO:\n 280 mL\n TF:\n IVF:\n 269 mL\n 94 mL\n Blood products:\n Total out:\n 1,550 mL\n 300 mL\n Urine:\n 1,550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,001 mL\n -206 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 100 K/uL\n 14.5 g/dL\n 100 mg/dL\n 1.8 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 27 mg/dL\n 98 mEq/L\n 135 mEq/L\n 42.2 %\n 12.5 K/uL\n [image002.jpg]\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n WBC\n 11.6\n 10.5\n 11.1\n 12.5\n Hct\n 43.7\n 40\n 43.4\n 44.0\n 44.0\n 42.2\n Plt\n 156\n 116\n 128\n 100\n Cr\n 1.6\n 1.6\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n Glucose\n 128\n 97\n 111\n 94\n 125\n 89\n 131\n 100\n Other labs: PT / PTT / INR:29.5/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -6.8L LOS; Cr\n has remained stable despite diuresis\n -cont diuresis to goal 1 L neg today\n - lytes\n -switch captopril to lisinopril 5 mg po daily\n -will attempt to wedge swan to see if PAP correlate with PCWP.\n .\n #Pulm HTN\n pulm pressures improving but not at preoperative target of\n mPAP 35 mmHg, consistent with element of irreversible pulm HTN, also\n suggested by absence of response to inhaled NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE: INR 3.0 this am\n -hold coumadin dose today\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -cont lopressor for rate-control\n -continue anticoagulation\n .\n #Acute on Chronic kidney injury\n Cr increased slightly in the setting\n of diuresis.\n -cont monitor while diuresing\n .\n # Thrombocytopenia\n platelets decreased to 100. intermediate prob for\n HIT. Possibly cirrhosis\n - will check pm plts.\n - will check heparin Ab.\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n -will discuss endpoints with transplant team.\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571394,
"text": "52 yo male with a history of HTN, atrial fibrillation, DVT, PE and\n cryptogenic cirrhosis since childhood complicatied by portal\n hypertension and variceal hemorrhages He comes to for right\n heart catheterization as part of liver transplant work up. Patient\n reports sob with mild activity relieved with rest for about a year. He\n was recently admitted in for hepatic encephalopathy . This has\n been controlled with lactulose. Echo done EF > 55% mildly\n dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic root\n at the sinus level and mildly dilated ascending aorta. Mild pulm artery\n systolic HTN A heart cath done showed severe LV diastolic\n dysfunction and pulm htn. He had a Swan placed at that time which\n showed PCWP 25 PA pressure 68/30 mean 51, RV 64/15 mean 22, RA 16-19 He\n has been given lasix goal of pa mean pressures of <35 A DC\n cardioversion preformed Atrial fibrillation on \n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PCWP 25, PAP 70/27 mean 45, bp 104/85(89), hr nsr 64\n Action:\n Captopril changed to lisinopril, 80mg lasix x1, k of 3.3 repleated c\n 6+0meq of potassium, coumadin held, swan advanced by cardiac fellow\n able to pcwp now, amlodipine\n Response:\n Bun 26, cr 1.9, pt -6L since lenghth of stay, pt met goal of -500cc\n today\n Plan:\n In order for pt to reach transplant requirments his mean PAP need to\n be less than35 pt needs to be diuresed as much as tolerated by pt. \n lytes,\n Cirrhosis of liver, other\n Assessment:\n h/o cirrosis since childhood, waiting to get on transplant list for\n liver\n Action:\n Lactulose, rifaxamin\n Response:\n Bm x 4 today met goal\n Plan:\n Continue to folloe mental status, lfts\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571673,
"text": "53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n HR 50\ns SB. s/p successful cardioversion from Afib on admission. on\n lopressor for rate control.\n BP 93/63-119/76. PAP 50\ns/30->20 with mean 41-> dropping to 29-35 when\n asleep.\n Poor response to Lasix 120mg bolus at .\n Action:\n Med with diurel 500mg IV x1 at midnight. Lasix gtt continues at\n 20mg/min.\n Response:\n 600cc u/o response to diurel. PAD\ns decreased to 20\ns. mean to\n 29-30\ns (goal <35).\n RA sat 99% when awake\n.91-95% when asleep. LS clear.\n Slept through night. Wakes easily. Extremeties warm, no edema. No\n c/o.\n Plan:\n Monitor PAP\ns, u/o. contininue Lasix gtt per plan.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571801,
"text": "53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n HR 49-57- MAPs 66-76- PA mean 32-35\n Action:\n Con\nt on lasix gtt @ 20mg/hr & lopressor, lisinopril, amlodipine &\n coumadin.\n Response:\n Hemodynamically stable- (-) 800cc today- U/O trending down this\n afternoon-\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571802,
"text": "53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n HR 49-57- MAPs 66-76- PA mean 32-35\n Action:\n Con\nt on lasix gtt @ 20mg/hr & lopressor, lisinopril, amlodipine &\n coumadin.\n Response:\n Hemodynamically stable- (-) 800cc today- U/O trending down this\n afternoon-\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571803,
"text": "53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n HR 49-57- MAPs 66-76- PA mean 32-35- K 3.6- KCL 60meq given\n Action:\n Con\nt on lasix gtt @ 20mg/hr & lopressor, lisinopril, amlodipine &\n coumadin.\n Response:\n Hemodynamically stable- (-) 800cc today- U/O trending down this\n afternoon- BUN/Crea trending up 37/2.6- repeat K\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572064,
"text": "52 yo male with history of cryptogenic cirrhosis which he has had since\n childhood is referred for a right heart cath as part of the liver\n transplant work up. He had been experiencing dyspnea with mild activity\n relieved with rest. for about a year. His cirrohosis has been\n complicated by portal hypertension and variceal hemorrhages, as well as\n hepatic encephalopathy requiring hospitalizations. The cath revealed\n acute and chronic diastolic CHF.and pulm HTN. PMH includes HTN, atrial\n fibrillation, DVT, PE. He is on coumadin.\n Ineffective Coping\n Assessment:\n Patient appearing more comfortable with PA line removed. Talking about\n going to regular floor. Resting comfortably\n Action:\n discussed plan of care with patient\n Response:\n Appears to be coping effectively\n Plan:\n Continue to discuss plan of care with patient, answer all his questions\n Cirrhosis of liver, other\n Assessment:\n Long standing. Vomited several times clear fluid, denied nausea abdomen\n soft nontender BS+\n Action:\n Lactulose, rifaximin, senna and polyethylene glycol given as ordered.\n INR 3.0\n Response:\n Had a large BM\n Plan:\n Optimize hemodynamics for possible liver transplant, cont diuresis,\n lasix po, monitor I+O continue lactulose rifaximin, senna and\n polyethylene glycol. ?hold coumadin\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Cr 2.3 bun 42, 24 hr output neg 500 cc given 40meq kcl po and 2gm of\n mag sulfate IV\n Action:\n On lasix 40mg qd, K+4.2 mag 2.4\n Response:\n Urine output slowing down ? dry\n Plan:\n Follow hemodynamics, monitor output, cr and bun, monitor lytes treat as\n needed\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571282,
"text": "52 yo male with a history of HTN, atrial fibrillation, DVT, PE and\n cryptogenic cirrhosis since childhood complicatied by portal\n hypertension and variceal hemorrhages He comes to for right\n heart catheterization as part of liver transplant work up. Patient\n reports sob with mild activity relieved with rest for about a year. He\n was recently admitted in for hepatic encephalopathy . This has\n been controlled with lactulose. Echo done EF > 55% mildly\n dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic root\n at the sinus level and mildly dilated ascending aorta. Mild pulm artery\n systolic HTN A heart cath done showed severe LV diastolic\n dysfunction and pulm htn. He had a Swan placed at that time which\n showed PCWP 25 PA pressure 68/30 mean 51, RV 64/15 mean 22, RA 16-19 He\n has been given lasix goal of pa mean pressures of <35 A DC\n cardioversion preformed Atrial fibrillation on \n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n CVP 5 CO fick 7.2 CI 3.4 PA 60/35-55/27 means 38-45 mixed venous o2\n sat 72%. Lungs clear LOS output neg 6 liters output yesterday neg 1\n liter\n Action:\n Given lasix yesterday 20mg \n Response:\n 1 liter neg\n Plan:\n Lasix prn, Captopril to be increased prn for improved Afterload\n reduction, goal PA mean <35\n Cirrhosis of liver, other\n Assessment:\n w/u for liver transplant in progress, PA mean pressures continue to be\n high 38-45 patient anxious to have PA line removed. A/O x3 lactulose\n given\n Action:\n Lactulose q 4hr for BM qd, follow LFT, ammonia levels and mental\n status\n Response:\n 3 large BM\ns \n Plan:\n Follow LFTs, ammonia levels and mental status\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571291,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 03:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.8\nC (98.2\n HR: 55 (52 - 81) bpm\n BP: 99/50(62) {80/30(48) - 131/89(119)} mmHg\n RR: 17 (14 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: -3 (-3 - 17)mmHg\n PAP: (42 mmHg) / (13 mmHg)\n CO/CI (Fick): (7.2 L/min) / (3.4 L/min/m2)\n Mixed Venous O2% Sat: 76 - 76\n Total In:\n 549 mL\n 94 mL\n PO:\n 280 mL\n TF:\n IVF:\n 269 mL\n 94 mL\n Blood products:\n Total out:\n 1,550 mL\n 300 mL\n Urine:\n 1,550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,001 mL\n -206 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 100 K/uL\n 14.5 g/dL\n 100 mg/dL\n 1.8 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 27 mg/dL\n 98 mEq/L\n 135 mEq/L\n 42.2 %\n 12.5 K/uL\n [image002.jpg]\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n WBC\n 11.6\n 10.5\n 11.1\n 12.5\n Hct\n 43.7\n 40\n 43.4\n 44.0\n 44.0\n 42.2\n Plt\n 156\n 116\n 128\n 100\n Cr\n 1.6\n 1.6\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n Glucose\n 128\n 97\n 111\n 94\n 125\n 89\n 131\n 100\n Other labs: PT / PTT / INR:29.5/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n CIRRHOSIS OF LIVER, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571292,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n Rec\nd lasix 80 mg IV x 2\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 03:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 36.8\nC (98.2\n HR: 55 (52 - 81) bpm\n BP: 99/50(62) {80/30(48) - 131/89(119)} mmHg\n RR: 17 (14 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: -3 (-3 - 17)mmHg\n PAP: (42 mmHg) / (13 mmHg)\n CO/CI (Fick): (7.2 L/min) / (3.4 L/min/m2)\n Mixed Venous O2% Sat: 76 - 76\n Total In:\n 549 mL\n 94 mL\n PO:\n 280 mL\n TF:\n IVF:\n 269 mL\n 94 mL\n Blood products:\n Total out:\n 1,550 mL\n 300 mL\n Urine:\n 1,550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,001 mL\n -206 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 100 K/uL\n 14.5 g/dL\n 100 mg/dL\n 1.8 mg/dL\n 29 mEq/L\n 4.2 mEq/L\n 27 mg/dL\n 98 mEq/L\n 135 mEq/L\n 42.2 %\n 12.5 K/uL\n [image002.jpg]\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n WBC\n 11.6\n 10.5\n 11.1\n 12.5\n Hct\n 43.7\n 40\n 43.4\n 44.0\n 44.0\n 42.2\n Plt\n 156\n 116\n 128\n 100\n Cr\n 1.6\n 1.6\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n Glucose\n 128\n 97\n 111\n 94\n 125\n 89\n 131\n 100\n Other labs: PT / PTT / INR:29.5/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.6 mg/dL,\n Mg++:2.3 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -6.8L LOS. In\n order to meet transplant requirements, mean PA pressures need to be\n less than 35. mPAP at 40 this am. Pt is getting close to dry volume\n status by exam and labs.\n -cont diuresis to goal 500cc-1 L neg today, creatinine likely to rise\n with this diuresis\n -lasix 80mg IV this am then prn\n - lytes\n -cont. captopril prn\n -cont swan\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with element of\n irreversible pulm HTN, also suggested by absence of response to inhaled\n NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE: INR 2.7 this am\n -cont coumadin (goal INR )\n .\n #Afib\n s/p successful cardioversion and remains in NSR\n -cont lopressor for rate-control\n -continue coumadin to maintain INR 2.0-3.0\n .\n #CRI\n Cr increased\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571796,
"text": "53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571799,
"text": "53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n HR 49-57- MAPs 66-76-\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571098,
"text": "Chief Complaint:\n 24 Hour Events:\n -continued diuresis with IV lasix; increased bolus dose from 40mg to\n 80mg IV - got IV lasix x3\n -remained in NSR\n - mean PAP 35-37\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.5\n HR: 51 (51 - 68) bpm\n BP: 108/61(72) {96/53(64) - 126/92(96)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: -1 (-1 - 5)mmHg\n PAP: (35 mmHg) / (19 mmHg)\n Total In:\n 1,030 mL\n 184 mL\n PO:\n 790 mL\n 120 mL\n TF:\n IVF:\n 240 mL\n 64 mL\n Blood products:\n Total out:\n 2,225 mL\n 300 mL\n Urine:\n 1,825 mL\n 300 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -1,195 mL\n -117 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 116 K/uL\n 14.4 g/dL\n 125 mg/dL\n 1.9 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 97 mEq/L\n 139 mEq/L\n 43.4 %\n 10.5 K/uL\n [image002.jpg]\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n WBC\n 8.1\n 11.6\n 10.5\n Hct\n 44\n 44.8\n 47\n 43.7\n 40\n 43.4\n Plt\n 162\n 156\n 116\n Cr\n 1.6\n 1.5\n 1.6\n 1.6\n 1.7\n 1.5\n 1.9\n Glucose\n 107\n 119\n 128\n 97\n 111\n 94\n 125\n Other labs: PT / PTT / INR:24.0/39.0/2.3,\n Ca++:8.8 mg/dL, Mg++:1.8 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -4.5L LOS. In\n order to meet transplant requirements, mean PA pressures need to be\n less than 35; using PA diastolic pressures as a proxy for PCWP\n -cont diuresis to goal 1-2 L neg today or until Cr bumps\n -lasix 80mg IV this am then prn\n - lytes\n -incr. captopril prn as tolerated for improved afterload reduction\n -d/c swan when documented consistent mPAP <35\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with element of\n irreversible pulm HTN, also suggested by absence of response to inhaled\n NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE: INR 2.3 this am\n -cont coumadin (goal INR )\n .\n #Afib\n s/p successful cardioversion yesterday and remains in NSR\n -cont lopressor for rate-control\n -continue coumadin to maintain INR 2.0-3.0\n .\n #CRI\n Cr stable\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571659,
"text": "Chief Complaint:\n 24 Hour Events:\n -not meeting diuresis goals with bolus lasix therefore was started on\n lsix gtt with 120mg IV lasix bolus\n -INR 1.9 therefore coumadin restarted\n -I/O check @ 1400 - 900cc negative, inc lasix gtt from 10 to 20mg/hr\n -I/O check @ 1900 - 1600cc negative; re-bolused with lasix 120mg IV @\n , however had minimal response\n -bolused 500cc diuril @2300\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.1\nC (97\n HR: 51 (48 - 69) bpm\n BP: 99/62(71) {93/56(67) - 132/85(95)} mmHg\n RR: 23 (12 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 5 (3 - 12)mmHg\n PAP: (45 mmHg) / (20 mmHg)\n PCWP: 27 (27 - 27) mmHg\n Total In:\n 1,236 mL\n 135 mL\n PO:\n 780 mL\n TF:\n IVF:\n 456 mL\n 135 mL\n Blood products:\n Total out:\n 2,950 mL\n 725 mL\n Urine:\n 2,950 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,714 mL\n -590 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///36/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 123 K/uL\n 14.8 g/dL\n 89 mg/dL\n 1.9 mg/dL\n 36 mEq/L\n 3.6 mEq/L\n 28 mg/dL\n 97 mEq/L\n 139 mEq/L\n 43.7 %\n 9.5 K/uL\n [image002.jpg]\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n WBC\n 10.5\n 11.1\n 12.5\n 8.4\n 9.5\n Hct\n 43.4\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n Plt\n 116\n 128\n 100\n 116\n 123\n Cr\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n Glucose\n 111\n 94\n 125\n 89\n 131\n 100\n 128\n 89\n 89\n Other labs: PT / PTT / INR:28.5/38.9/2.9, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n CIRRHOSIS OF LIVER, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571660,
"text": "Chief Complaint:\n 24 Hour Events:\n -not meeting diuresis goals with bolus lasix therefore was started on\n lsix gtt with 120mg IV lasix bolus\n -INR 1.9 therefore coumadin restarted\n -I/O check @ 1400 - 900cc negative, inc lasix gtt from 10 to 20mg/hr\n -I/O check @ 1900 - 1600cc negative; re-bolused with lasix 120mg IV @\n , however had minimal response\n -bolused 500cc diuril @2300\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.1\nC (97\n HR: 51 (48 - 69) bpm\n BP: 99/62(71) {93/56(67) - 132/85(95)} mmHg\n RR: 23 (12 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 5 (3 - 12)mmHg\n PAP: (45 mmHg) / (20 mmHg)\n PCWP: 27 (27 - 27) mmHg\n Total In:\n 1,236 mL\n 135 mL\n PO:\n 780 mL\n TF:\n IVF:\n 456 mL\n 135 mL\n Blood products:\n Total out:\n 2,950 mL\n 725 mL\n Urine:\n 2,950 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,714 mL\n -590 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///36/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 123 K/uL\n 14.8 g/dL\n 89 mg/dL\n 1.9 mg/dL\n 36 mEq/L\n 3.6 mEq/L\n 28 mg/dL\n 97 mEq/L\n 139 mEq/L\n 43.7 %\n 9.5 K/uL\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n WBC\n 10.5\n 11.1\n 12.5\n 8.4\n 9.5\n Hct\n 43.4\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n Plt\n 116\n 128\n 100\n 116\n 123\n Cr\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n Glucose\n 111\n 94\n 125\n 89\n 131\n 100\n 128\n 89\n 89\n Other labs: PT / PTT / INR:28.5/38.9/2.9, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n KNOWLEDGE DEFICIT\n HEART FAILURE (CHF), DIASTOLIC, ACUTE ON CHRONIC\n PULMONARY HYPERTENSION (PULM HTN, PHTN)\n CIRRHOSIS OF LIVER, OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571661,
"text": "Chief Complaint:\n 24 Hour Events:\n -not meeting diuresis goals with bolus lasix therefore was started on\n lsix gtt with 120mg IV lasix bolus\n -INR 1.9 therefore coumadin restarted\n -I/O check @ 1400 - 900cc negative, inc lasix gtt from 10 to 20mg/hr\n -I/O check @ 1900 - 1600cc negative; re-bolused with lasix 120mg IV @\n , however had minimal response\n -bolused 500cc diuril @2300\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.1\nC (97\n HR: 51 (48 - 69) bpm\n BP: 99/62(71) {93/56(67) - 132/85(95)} mmHg\n RR: 23 (12 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 5 (3 - 12)mmHg\n PAP: (45 mmHg) / (20 mmHg)\n PCWP: 27 (27 - 27) mmHg\n Total In:\n 1,236 mL\n 135 mL\n PO:\n 780 mL\n TF:\n IVF:\n 456 mL\n 135 mL\n Blood products:\n Total out:\n 2,950 mL\n 725 mL\n Urine:\n 2,950 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,714 mL\n -590 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///36/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 123 K/uL\n 14.8 g/dL\n 89 mg/dL\n 1.9 mg/dL\n 36 mEq/L\n 3.6 mEq/L\n 28 mg/dL\n 97 mEq/L\n 139 mEq/L\n 43.7 %\n 9.5 K/uL\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n WBC\n 10.5\n 11.1\n 12.5\n 8.4\n 9.5\n Hct\n 43.4\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n Plt\n 116\n 128\n 100\n 116\n 123\n Cr\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n Glucose\n 111\n 94\n 125\n 89\n 131\n 100\n 128\n 89\n 89\n Other labs: PT / PTT / INR:28.5/38.9/2.9, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -7.9L LOS; Cr\n has remained relatively stable despite diuresis\n -cont diuresis to goal 2-3 L neg today\n -will start lasix gtt\n - lytes\n -continue lisinopril 5 mg po daily\n .\n #Pulm HTN\n pulm pressures improving but not at preoperative target of\n mPAP 35 mmHg, consistent with element of irreversible pulm HTN, also\n suggested by absence of response to inhaled NO at cath . Based\n on wedge however, he has not been completely diuresed\n -cont amlodipine\n -treat left-sided CHF, as above\n .\n # Thrombocytopenia\n platelets decreased to 100 from 200 on admission,\n low pre-test prob for HIT. Recovering with no intervention\n -check platelets daily\n .\n #DVT/PE - INR 2.9 this am\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -cont lopressor for rate-control\n .\n #CKD\n Cr remains stable at 1.8-2.0 despite aggressive diuresis\n -cont to monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n -Rx comorbidities as above\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; fluid restrict to 1L; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571120,
"text": "Chief Complaint:\n 24 Hour Events:\n -continued diuresis with IV lasix; increased bolus dose from 40mg to\n 80mg IV - got IV lasix x3\n -remained in NSR\n - mean PAP 35-37\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.5\n HR: 51 (51 - 68) bpm\n BP: 108/61(72) {96/53(64) - 126/92(96)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: -1 (-1 - 5)mmHg\n PAP: (35 mmHg) / (19 mmHg)\n Total In:\n 1,030 mL\n 184 mL\n PO:\n 790 mL\n 120 mL\n TF:\n IVF:\n 240 mL\n 64 mL\n Blood products:\n Total out:\n 2,225 mL\n 300 mL\n Urine:\n 1,825 mL\n 300 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -1,195 mL\n -117 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 116 K/uL\n 14.4 g/dL\n 125 mg/dL\n 1.9 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 97 mEq/L\n 139 mEq/L\n 43.4 %\n 10.5 K/uL\n [image002.jpg]\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n WBC\n 8.1\n 11.6\n 10.5\n Hct\n 44\n 44.8\n 47\n 43.7\n 40\n 43.4\n Plt\n 162\n 156\n 116\n Cr\n 1.6\n 1.5\n 1.6\n 1.6\n 1.7\n 1.5\n 1.9\n Glucose\n 107\n 119\n 128\n 97\n 111\n 94\n 125\n Other labs: PT / PTT / INR:24.0/39.0/2.3,\n Ca++:8.8 mg/dL, Mg++:1.8 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -4.5L LOS. In\n order to meet transplant requirements, mean PA pressures need to be\n less than 35; using PA diastolic pressures as a proxy for PCWP\n -cont diuresis to goal 500cc-1 L neg today, creatinine likely to rise\n with this diuresis\n -lasix 80mg IV this am then prn\n - lytes\n -incr. captopril prn as tolerated for improved afterload reduction\n -d/c swan when documented consistent mPAP <35\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with element of\n irreversible pulm HTN, also suggested by absence of response to inhaled\n NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE: INR 2.7 this am\n -cont coumadin (goal INR )\n .\n #Afib\n s/p successful cardioversion and remains in NSR\n -cont lopressor for rate-control\n -continue coumadin to maintain INR 2.0-3.0\n .\n #CRI\n Cr increased\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570345,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 28-30. Pt denies SOB, CP LS CTA. Hr 60\ns afib with rare to\n occasional PVC\ns, pt noted for rare to occasional second pauses\n while sleeping. SBP 99-120\n Action:\n 20 mg IVP lasix given. Heparin gtt increased to 750 units/hr for\n subtherapeutic (59.5) PTT at 2200 with no bolus as per Dr. .\n Captopril 6.25 mg given. Coumadin resumed as MD\ns. CHF\n teaching/discussion with pt.\n Response:\n PADs 28->26. AM cardiac numbers-> CO 4.1/CI 1.9/SVR1445->Dr. \n aware. Pt voiding via urinal, -1.3L at midnoc. Hemodynamically\n stable. PTT drawn at 0400 (heparin noted to not be connected to pt ?\n for approximately an hour as pt turns self side to side in bed). Dr.\n aware, INR 2.0 so heparin gtt continued at 750 units/hr. Pt\n verbalized understanding and knowledge r/t disease management.\n Plan:\n Continue to monitor hemodynamics, cardiac numbers. Obtain PTT. Continue\n to titrate meds as tolerated and ordered. Continue with\n teaching/encourage knowledge as indicated.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Pt with moderate to severe pulmonary HTN as per cath reports .\n LS CTA. Pt denies SOB.\n Action:\n Pt monitored. Pt ordered for norvasc in am.\n Response:\n No c/o SOB, O2 sats >94% on room air.\n Plan:\n Continue to monitor resp status and hemodynamics.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant.\n Reportedly pt had 2 BM\ns yesterday. Pt A&Ox3. Talkative with RN and\n asking appropriate questions/appropriate statements about POC and\n disease.\n Action:\n Lactulose 60 cc\ns given x2 and rifaximin 200 mg PO given.\n Response:\n Awaiting BM.\n Plan:\n Continue with lactulose for BM daily. Continue to f/u with LFT\n ammonia levels, mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570301,
"text": "Patient is a 53 y/o M w/ h/o cryptogenic cirrhosis, portal\n hypertension, pulmonary hypertension, a. fib, admitted for R-heart cath\n w/ e/o diastolic LH failure as well as pulmonary hypertension.\n .\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PA line in R IJ-> filling pressures elevated- in chronic afib on tele\n Action:\n Lasix 20mg IV given- started on heparin gtt @ 600u/hr @ 1400- Captopril\n .625mg started TID\n Response:\n Hemodynamically stable- Diuresing well.\n Plan:\n Follow hemodynamics- monitor output- monitor lytes and replete as\n needed.\n Cirrhosis of liver, other\n Assessment:\n H/O cryptogenic cirrhosis as child.\n Action:\n Lactulose 60cc QID titrate to BM\ns/day (given @ 1230 & 1800-\n rifaximin 200mg TID.\n Response:\n Had 2 BM\ns prior to admission to CCU only.\n Plan:\n Con\nt present management- follow LFT\ns and ammonia levels.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570342,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 28-30. Pt denies SOB, CP LS CTA. Hr 60\ns afib with rare to\n occasional PVC\ns, pt noted for rare to occasional second pauses\n while sleeping. SBP 99-120\n Action:\n 20 mg IVP lasix given. Heparin gtt increased to 750 units/hr for\n subtherapeutic (59.5) PTT at 2200 with no bolus as per Dr. .\n Captopril 6.25 mg given. Coumadin resumed as MD\ns. CHF\n teaching/discussion with pt.\n Response:\n PADs 28->26. AM cardiac numbers Pt voiding via urinal. Hemodynamically\n stable. PTT drawn at 0400 (heparin noted to not be connected to pt ?\n for approximately an hour as pt turns self side to side in bed). Dr.\n aware, INR 2.0 so heparin gtt continued at 750 units/hr. Pt\n verbalized understanding and knowledge r/t disease management.\n Plan:\n Continue to monitor hemodynamics, cardiac numbers. Continue to titrate\n meds as tolerated and ordered. Continue with teaching/encourage\n knowledge as indicated.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Pt with moderate to severe pulmonary HTN as per cath reports .\n LS CTA. Pt denies SOB.\n Action:\n Pt monitored. Pt ordered for norvasc in am.\n Response:\n No c/o SOB, O2 sats >94% on room air.\n Plan:\n Continue to monitor resp status and hemodynamics.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant.\n Reportedly pt had 2 BM\ns yesterday. Pt A&Ox3. Talkative with RN and\n asking appropriate questions/appropriate statements about POC and\n disease.\n Action:\n Lactulose 60 cc\ns given x2 and rifaximin 200 mg PO given.\n Response:\n Awaiting BM.\n Plan:\n Continue with lactulose for BM daily. Continue to f/u with LFT\n ammonia levels, mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571650,
"text": "53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n HR 50\ns SB. s/p successful cardioversion from Afib on admission. on\n lopressor for rate control.\n BP 93/63-119/76. PAP 50\ns/30->20 with mean 41-> dropping to 29-35 when\n asleep.\n Poor response to Lasix 120mg bolus at .\n Action:\n Med with diurel 500mg IV x1 at midnight. Lasix gtt continues at\n 20mg/min.\n Response:\n 600cc u/o response to diurel. PAD\ns decreased to 20\ns. mean to\n 29-30\ns (goal <35).\n RA sat 99% when awake\n.91-95% when asleep. LS clear.\n Slept through night. Wakes easily. Extremeties warm, no edema. No\n c/o.\n Plan:\n Monitor PAP\ns, u/o. contininue Lasix gtt per plan.\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 572174,
"text": "Chief Complaint:\n 24 Hour Events:\n -Cr 2.4 PCWP 9, gave 250 cc NS bolus; repeat PCWP 7\n -d/c'd lasix gtt @ 1030\n -d/c'd swan/cordis (has PIV)\n -decr. lopressor 25 mg to 12.5 mg bradycardia\n -ordered lasix 80 mg PO daily to start AM \n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.6\nC (97.8\n HR: 57 (50 - 69) bpm\n BP: 109/75(83) {83/49(57) - 128/90(96)} mmHg\n RR: 17 (13 - 45) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 78 kg (admission): 83.3 kg\n Height: 75 Inch\n CVP: 1 (1 - 8)mmHg\n PAP: (44 mmHg) / (16 mmHg)\n PCWP: 7 (7 - 9.) mmHg\n Total In:\n 1,202 mL\n 83 mL\n PO:\n 380 mL\n TF:\n IVF:\n 822 mL\n 83 mL\n Blood products:\n Total out:\n 1,750 mL\n 550 mL\n Urine:\n 1,500 mL\n 400 mL\n NG:\n 250 mL\n 150 mL\n Stool:\n Drains:\n Balance:\n -548 mL\n -467 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 172 K/uL\n 15.0 g/dL\n 104 mg/dL\n 2.3 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 42 mg/dL\n 98 mEq/L\n 135 mEq/L\n 44.0 %\n 9.5 K/uL\n [image002.jpg]\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n 05:41 AM\n 04:19 PM\n 05:53 AM\n 01:32 PM\n 02:59 AM\n WBC\n 12.5\n 8.4\n 9.5\n 8.7\n 9.4\n 9.5\n Hct\n 42.2\n 44.1\n 43.7\n 47.2\n 45.6\n 44.0\n Plt\n 100\n 116\n 123\n 136\n 163\n 172\n Cr\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n 2.0\n 2.6\n 2.4\n 2.4\n 2.3\n Glucose\n 131\n 100\n 128\n 89\n 89\n 93\n 63\n 85\n 125\n 104\n Other labs: PT / PTT / INR:29.2/39.0/3.0, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.9 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -10L LOS;\n Cr/HCO3 indicating that likely has reached dry weight\n -start lasix 80 PO dose needed to keep even\n -daily weights; strict I/Os.\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n -check BNP to establish dry weight value\n .\n #Pulm HTN\n pulm pressures improving with most reflecting\n pre-transplant target of mPAP 35 mmHg; likely has element of\n irreversible pulm HTN given h/o PE, possible portopulmonary syndrome\n (as suggested by absence of response to inhaled NO at cath )\n -will discuss progress/outpt mgmt with transplant team\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n #DVT/PE - INR therapeutic\n -decrease coumadin dose to 4mg Qhs\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr rising in the setting of aggressive diuresis\n - lytes, Cr\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -decr. lopressor given bradycardia since now s/p cardioversion and\n doesn\nt need rate control\n -continue CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: call out to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:02 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n I have reviewed the above progress note and addendum on by\n Dr. . I have reviewed the history and physical and I was present\n due the clinical aspects of the examination today. I concur with the\n assessment and treatment plan as outline above. Mr. has\n reached a stable fluid status and a mPAP < 35 mmHg. We will remove the\n PA catheter and transfer to the to continued monitoring of his\n fluid status.\n , MD Cell \n ------ Protected Section Addendum Entered By: , MD\n on: 14:36 ------\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571071,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis & w/u for liver transplant.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Lungs clear, denies c/o chest pain. Oob to commode without sob\n hemodynamics pad 25-35, cvp 1-4 unable to wedge pa line o2 sat down to\n 86% on RA\n Action:\n Lasix 80 mg ivp, placed on 2l nc repleted K+\n Response:\n Diuresing fair from lasix, PA line dampened, difficult to flush\n Plan:\n Monitor response to lasix, follow i/o, goal to keep PA mean < 35\n Cirrhosis of liver, other\n Assessment:\n HX of cryptogenic cirrhosis since age 8, alert and oriented x3,\n sleeping in short naps, answering questions appropriately, following\n all commands, oob to commode with min assistance\n Action:\n Cont lactulose q 4 hrs until BM\ns/day\n Response:\n 5 liquid bm\ns yest. Guiac neg.\n Plan:\n Cont lactulose as ordered, follow lft, lytes, I/O\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571852,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Patient reports sob (with mild activity) relieved with rest for about a\n year. He was recently admitted in for hepatic encephalopathy.\n This has been controlled with lactulose. Echo done EF > 55%\n mildly dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic\n root at the sinus level and mildly dilated ascending aorta. Mild pulm\n artery systolic HTN\n Cath : mod. To severe Pulm. HTN. Negative response to inhaled\n NO at that time.\n Started heparin for afib on admit. Goal mPAP <35 diuresing with prn\n lasix for goal net neg. 1-2L /day.\n : CDV (200jx1) to NSR. Heparin d/c\n : Captopril changed to lisinopril. Contin. with prn lasix with\n decreasing results.\n : Lasix gtt was started with additional lasix bolus. Titrated up\n to 20mg/hr. INR 1.9-> coumadin restarted.\n Diurel 500mg x1 for additional diuresis.\n mPAP\ns overnight 29-35. neg. 9.5L LOS\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n LS clear. No SOB. Laying flat comfortably.\n HR 50\ns SB. BP 90\ns/ 60\n Contin. lasix gtt at 20mg/hr. no further boluses elevated\n Creatinine.\n Action:\n Lasix gtt 20mg/hr.\n Response:\n PAP\ns 50\ns/23-32. Mean 30-37. (goal <35).\n Neg. 800cc for . neg. 250cc since MN> neg. 9.6L LOS\n Plan:\n ? d/c\n swan today. Follow plan for lasix gtt. Contin. lopressor,\n lisinopril, amlodipine.\n Coumadin for afib.\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Sats 92-99% on RA. LS clear. Denies SOB.\n Action:\n Response:\n No distress. Slept comfortably.\n Plan:\n Follow plan with team\n Cirrhosis of liver, other\n Assessment:\n Transplant w/u in progress. hx encephalopathy rx with lactulose\n Action:\n Lactulose for goal 3-4bms/day.\n Response:\n Had 4 bms . lactulose held overnight for sleep.\n Plan:\n Contin. meds as ordered. Fluid restriction.\n Pt. was talking about feeling optimistic about transplant hopes and\n going home soon.\n No c/o pain/nausea.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572039,
"text": "52 yo male with history of cryptogenic cirrhosis which he has had since\n childhood is referred for a right heart cath as part of the liver\n transplant work up. He had been experiencing dyspnea with mild activity\n relieved with rest. for about a year. His cirrohosis has been\n complicated by portal hypertension and variceal hemorrhages, as well as\n hepatic encephalopathy requiring hospitalizations. The cath revealed\n acute and chronic diastolic CHF.and pulm HTN. PMH includes HTN, atrial\n fibrillation, DVT, PE. He is on coumadin.\n Ineffective Coping\n Assessment:\n Patient appearing more comfortable with PA line removed. Talking about\n going to regular floor. Resting comfortably\n Action:\n discussed plan of care with patient\n Response:\n Appears to be coping effectively\n Plan:\n Continue to discuss plan of care with patient, answer all his questions\n Cirrhosis of liver, other\n Assessment:\n Long standing\n Action:\n Lactulose, rifaximin, senna and polyethylene glycol given as ordered\n Response:\n Had a large BM\n Plan:\n Optimize hemodynamics for possible liver transplant, cont diuresis,\n lasix po, monitor I+O continue lactulose rifaximin, senna and\n polyethylene glycol\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Cr 2.3 bun 42, 24 hr output neg 500 cc given 40meq kcl po and 2gm of\n mag sulfate IV\n Action:\n On lasix 40mg qd, K+4.2 mag 2.4\n Response:\n Urine output slowing down ? dry\n Plan:\n Follow hemodynamics, monitor output, cr and bun, monitor lytes treat as\n needed\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571061,
"text": "Chief Complaint:\n 24 Hour Events:\n -continued diuresis with IV lasix; increased bolus dose from 40mg to\n 80mg IV - got IV lasix x3\n -remained in NSR\n - mean PAP 35-37\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.5\n HR: 51 (51 - 68) bpm\n BP: 108/61(72) {96/53(64) - 126/92(96)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: -1 (-1 - 5)mmHg\n PAP: (35 mmHg) / (19 mmHg)\n Total In:\n 1,030 mL\n 184 mL\n PO:\n 790 mL\n 120 mL\n TF:\n IVF:\n 240 mL\n 64 mL\n Blood products:\n Total out:\n 2,225 mL\n 300 mL\n Urine:\n 1,825 mL\n 300 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -1,195 mL\n -117 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 14.4 g/dL\n 125 mg/dL\n 1.9 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 97 mEq/L\n 139 mEq/L\n 43.4 %\n 10.5 K/uL\n [image002.jpg]\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n WBC\n 8.1\n 11.6\n 10.5\n Hct\n 44\n 44.8\n 47\n 43.7\n 40\n 43.4\n Plt\n 162\n 156\n 116\n Cr\n 1.6\n 1.5\n 1.6\n 1.6\n 1.7\n 1.5\n 1.9\n Glucose\n 107\n 119\n 128\n 97\n 111\n 94\n 125\n Other labs: PT / PTT / INR:24.0/39.0/2.3, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.8 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -4.5L LOS. In\n order to meet transplant requirements, mean PA pressures need to be\n less than 35; using PA diastolic pressures as a proxy for PCWP\n -cont diuresis to goal 1-2 L neg today or until Cr bumps\n -lasix 80mg IV this am then prn\n - lytes\n -incr. captopril prn as tolerated for improved afterload reduction\n -d/c swan when documented consistent mPAP <35\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with element of\n irreversible pulm HTN, also suggested by absence of response to inhaled\n NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE: INR 2.3 this am\n -cont coumadin (goal INR )\n .\n #Afib\n s/p successful cardioversion yesterday and remains in NSR\n -cont lopressor for rate-control\n -continue coumadin to maintain INR 2.0-3.0\n .\n #CRI\n Cr stable\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571062,
"text": "Chief Complaint:\n 24 Hour Events:\n -continued diuresis with IV lasix; increased bolus dose from 40mg to\n 80mg IV - got IV lasix x3\n -remained in NSR\n - mean PAP 35-37\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.5\n HR: 51 (51 - 68) bpm\n BP: 108/61(72) {96/53(64) - 126/92(96)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: -1 (-1 - 5)mmHg\n PAP: (35 mmHg) / (19 mmHg)\n Total In:\n 1,030 mL\n 184 mL\n PO:\n 790 mL\n 120 mL\n TF:\n IVF:\n 240 mL\n 64 mL\n Blood products:\n Total out:\n 2,225 mL\n 300 mL\n Urine:\n 1,825 mL\n 300 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -1,195 mL\n -117 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 116 K/uL\n 14.4 g/dL\n 125 mg/dL\n 1.9 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 97 mEq/L\n 139 mEq/L\n 43.4 %\n 10.5 K/uL\n [image002.jpg]\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n WBC\n 8.1\n 11.6\n 10.5\n Hct\n 44\n 44.8\n 47\n 43.7\n 40\n 43.4\n Plt\n 162\n 156\n 116\n Cr\n 1.6\n 1.5\n 1.6\n 1.6\n 1.7\n 1.5\n 1.9\n Glucose\n 107\n 119\n 128\n 97\n 111\n 94\n 125\n Other labs: PT / PTT / INR:24.0/39.0/2.3, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.8 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -4.5L LOS. In\n order to meet transplant requirements, mean PA pressures need to be\n less than 35; using PA diastolic pressures as a proxy for PCWP\n -cont diuresis to goal 1-2 L neg today or until Cr bumps\n -lasix 80mg IV this am then prn\n - lytes\n -incr. captopril prn as tolerated for improved afterload reduction\n -d/c swan when documented consistent mPAP <35\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with element of\n irreversible pulm HTN, also suggested by absence of response to inhaled\n NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE: INR 2.3 this am\n -cont coumadin (goal INR )\n .\n #Afib\n s/p successful cardioversion yesterday and remains in NSR\n -cont lopressor for rate-control\n -continue coumadin to maintain INR 2.0-3.0\n .\n #CRI\n Cr stable\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570594,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns trending slowly down to 25-29. Pt LS CTA. Pt denies SOB/CP. O2\n sats >95% on room air.\n Action:\n 20 mg IVP lasix given. w/ 150cc response, 40 mg given at 1400\n .Captopril 12.5 mg given.\n Response:\n Poor response to initial 20 mg lasix,450cc out over 2 hrs after 40 mg\n lasix given. Pt continues to deny SOB/CP, frequently turning/changing\n position independently without complaint, LS CTA. Voiding via urinal.\n Cr 1.6 this afternoon up from 1.5 this am. K 4.0 at 1500.\n Plan:\n Continue to diurese, follow PAD\ns.No co.ci per resident. Cont to\n monitor resp status. Continue with teaching/encourage knowledge as\n indicated.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant..pt\n with 1 BM today. Pt A&Ox3. Talkative with RN and asking appropriate\n questions/appropriate statements about POC and disease.\n Action:\n Lactulose Q4H given and rifaxamin given.\n Response:\n Awaiting BM.\n Plan:\n Continue with lactulose for BM daily, f/ with MD\ns re. increasing\n bowel regimen to meet goal BM\ns. Continue to f/u with LFT\ns, ammonia\n levels, mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571632,
"text": "Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571633,
"text": "53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571768,
"text": "Chief Complaint: Acute on chronic diastolic CHF, pulm HTN\n 24 Hour Events:\n -not meeting diuresis goals with bolus lasix therefore was started on\n lsix gtt with 120mg IV lasix bolus\n -INR 1.9 therefore coumadin restarted\n -I/O check @ 1400 - 900cc negative, inc lasix gtt from 10 to 20mg/hr\n -I/O check @ 1900 - 1600cc negative; re-bolused with lasix 120mg IV @\n , however had minimal response\n -bolused 500cc diuril @2300\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Furosemide (Lasix) - 20 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies CP, palp, cough, SOB, abd pain, N/V\n Flowsheet Data as of 05:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.1\nC (97\n HR: 51 (48 - 69) bpm\n BP: 99/62(71) {93/56(67) - 132/85(95)} mmHg\n RR: 23 (12 - 25) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: 5 (3 - 12)mmHg\n PAP: (45 mmHg) / (20 mmHg)\n PCWP: 27 (27 - 27) mmHg\n Total In:\n 1,236 mL\n 135 mL\n PO:\n 780 mL\n TF:\n IVF:\n 456 mL\n 135 mL\n Blood products:\n Total out:\n 2,950 mL\n 725 mL\n Urine:\n 2,950 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,714 mL\n -590 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///36/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan site c/d/i\n CV: reg rate nl S1S2 no m/r/g\n PULM: CTAB no w/r/r\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 123 K/uL\n 14.8 g/dL\n 89 mg/dL\n 1.9 mg/dL\n 36 mEq/L\n 3.6 mEq/L\n 28 mg/dL\n 97 mEq/L\n 139 mEq/L\n 43.7 %\n 9.5 K/uL\n 03:17 PM\n 05:23 AM\n 04:20 PM\n 05:22 AM\n 06:24 AM\n 05:22 PM\n 01:58 AM\n 02:10 PM\n 05:20 AM\n 05:36 PM\n WBC\n 10.5\n 11.1\n 12.5\n 8.4\n 9.5\n Hct\n 43.4\n 44.0\n 44.0\n 42.2\n 44.1\n 43.7\n Plt\n 116\n 128\n 100\n 116\n 123\n Cr\n 1.7\n 1.5\n 1.9\n 1.9\n 2.0\n 1.8\n 1.9\n 1.8\n 1.9\n Glucose\n 111\n 94\n 125\n 89\n 131\n 100\n 128\n 89\n 89\n Other labs: PT / PTT / INR:28.5/38.9/2.9, ALT / AST:43/39, Alk Phos / T\n Bili:69/1.1, Amylase / Lipase:/39, Differential-Neuts:61.8 %,\n Lymph:23.9 %, Mono:12.1 %, Eos:1.7 %, Albumin:3.0 g/dL, Ca++:8.5 mg/dL,\n Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF- hemodynamics improving, -9.5L LOS; Cr\n has remained relatively stable despite diuresis\n -cont lasix gtt with diuril/metolazone prn to achieve volume balance\n negative 2-3 L\n -continue lisinopril for afterload reduction, amlodipine for LV\n relaxation\n - lytes\n .\n #Pulm HTN\n pulm pressures improving but not consistently at\n pre-transplant target of mPAP 35 mmHg, consistent with inadequate\n diuresis, as well as element of irreversible pulm HTN (as suggested by\n absence of response to inhaled NO at cath )\n -cont amlodipine\n -cont treat left-sided CHF, as above\n .\n # Thrombocytopenia\n stable\n -cont monitor daily\n .\n #DVT/PE - INR therapeutic\n -cont coumadin\n .\n #Afib\n s/p successful cardioversion, remains in NSR\n -telemetry\n .\n #CKD\n Cr remains stable at 1.8-2.0 despite aggressive diuresis\n -cont to monitor while diuresing\n .\n #Cirrhosis\n stable w/o evidence of decompensation; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; 1L fluid restriction; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition: low Na diet, 1 L fluid restriction\n Lines:\n PA Catheter - 10:30 AM\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT: systemic AC\n Stress ulcer: PPI\n Communication: patient; sister \n status: FULL\n Disposition: CCU for hemodynamic monitoring while swan in place\n ------ Protected Section ------\n Agree with excellent PGY1 note. Patient was weighed when mean PA\n pressures were sustained below < 35mmHg and after 8.5L of diuresis.\n His weight was 78kg. At this point, plan is for more diuresis until\n dry weight is reached.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:34 ------\n I have reviewed the above progress note and addendum on at\n 07:49 AM by Drs. and . I have personally reviewed the\n history with the patient, and the physical examination noted above is\n consistent with my own today. I concur with the assessment and\n treatment plan as outline above. Mr. presented with a acute on\n chronic diastolic left and right ventricular failure and was admitted\n for tailor therapy in the CCU with invasive monitoring. He continues\n to diuresed slowly with an additional 2-3 liters over the past 24\n hours. in the mid 30s. Our plan is outlined above and we\n will continue diuresis and aggressive treatment of his acute on chronic\n diastolic heart failure with intravenous diuretics.\n , MD Cell \n ------ Protected Section Addendum Entered By: , MD\n on: 15:56 ------\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 570822,
"text": "53 y/o M w/ h/o cryptogenic cirrhosis, portal hypertension, pulmonary\n hypertension, afib, admitted on for R-heart cath. In cath lab\n patient had a Swan placed-> PCWP 25, PA pressure 68/30 (mean 51), RV\n 64/15 (mean 22), RA 16-19. CI 2.5. Per report, pt with severe LV\n diastolic dysfunction, pulmonary hypertension. Pt admitted to the CCU\n for tailored diuresis.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n PAD\ns 20-30. Pt denies SOB/CP. LS clear. O2 sats >95% on room air. Has\n remained in NSR/SB since cardioversion yesterday. Coumadin w/ INR 2.4\n Action:\n 40 mg IV lasix given. X2 yesterday, last at 1630..\n Response:\n Good response to lasix, ~1L neg at mn.. Pt continues to deny SOB,\n frequently turning/changing position independently, Voiding via urinal.\n Plan:\n Continue to diurese, follow PAD\ns. Cont to monitor resp status.\n Monitor rhythm. Continue with teaching/encourage knowledge as\n indicated.\n Cirrhosis of liver, other\n Assessment:\n H/o cryptogenic cirrhosis as child. Pt w/u for liver transplant, pt had\n lg BM overnight. Pt A&Ox3. Talkative with RN and asking appropriate\n questions/appropriate statements about POC and disease. N/V at 0330\n Action:\n Lactulose Q4H, senna and rifaxamin given. Given Zofran 4mg x1\n Response:\n Lg BM overnight, held 4am lactulose d/t N/V\n Plan:\n Continue with lactulose for goal of BM\ns/day. Continue to f/u with\n LFT\ns, ammonia levels, mental status.\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 572145,
"text": "52 yo male with history of cryptogenic cirrhosis which he has had since\n childhood is referred for a right heart cath as part of the liver\n transplant work up. He had been experiencing dyspnea with mild activity\n relieved with rest. for about a year. His cirrohosis has been\n complicated by portal hypertension and variceal hemorrhages, as well as\n hepatic encephalopathy requiring hospitalizations. The cath revealed\n acute and chronic diastolic CHF.and pulm HTN, pt swaned and diuresed\n aggressively w/ improvement in PAD\ns.. pt in a fib when admitted and\n cardioverted to sinus rhythm .\n Ineffective Coping\n Assessment:\n Patient appearing more comfortable with PA line removed. Talking\n about going to regular floor. Resting comfortably\n Action:\n discussed plan of care with patient\n Response:\n Appears to be coping effectively\n Plan:\n Continue to discuss plan of care with patient, answer all his questions\n Cirrhosis of liver, other\n Assessment:\n Long standing. Vomited several times clear fluid, denied nausea abdomen\n soft nontender BS+\n Action:\n Lactulose, rifaximin, senna and polyethylene glycol given as ordered.\n INR 3.0\n Response:\n Had a large BM\n Plan:\n Optimize hemodynamics for possible liver transplant, cont diuresis,\n lasix po, monitor I+O continue lactulose rifaximin, senna and\n polyethylene glycol. ?hold coumadin\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Cr 2.3 bun 42, 24 hr output neg 500 cc given 40meq kcl po and 2gm of\n mag sulfate IV\n Action:\n On lasix 40mg qd, K+4.2 mag 2.4\n Response:\n Urine output slowing down ? dry\n Plan:\n Follow hemodynamics, monitor output, cr and bun, monitor lytes treat as\n needed\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 572234,
"text": "52 yo male with history of cryptogenic cirrhosis which he has had since\n childhood is referred for a right heart cath as part of the liver\n transplant work up. He had been experiencing dyspnea with mild activity\n relieved with rest. for about a year. His cirrohosis has been\n complicated by portal hypertension and variceal hemorrhages, as well as\n hepatic encephalopathy requiring hospitalizations. The cath revealed\n acute and chronic diastolic CHF.and pulm HTN, pt swaned and diuresed\n aggressively w/ improvement in PAD\ns.. pt in a fib when admitted and\n cardioverted to sinus rhythm .\n Ineffective Coping\n Assessment:\n Patient appearing more comfortable with PA line removed. Talking\n about going to regular floor. Resting comfortably\n Action:\n discussed plan of care with patient\n Response:\n Appears to be coping effectively\n Plan:\n Continue to discuss plan of care with patient, answer all his questions\n Cirrhosis of liver, other\n Assessment:\n Long standing. Vomited several times clear fluid, c/o nausea abdomen\n soft nontender BS+\n Action:\n Given 8 mg zofran,Lactulose, rifaximin, senna and polyethylene glycol\n given as ordered. INR 3.0\n Response:\n Had a large BM\n Plan:\n Optimize hemodynamics for possible liver transplant, cont diuresis,\n lasix po, monitor I+O continue lactulose rifaximin, senna and\n polyethylene glycol.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Cr 2.3 bun 42, 24 hr output neg 500 cc\n Action:\n On lasix 40mg qd,\n Response:\n Urine output slowing down ? dry\n Plan:\n Follow hemodynamics, monitor output, cr and bun, monitor lytes treat as\n needed\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n PULMONARY HYPERTENSION RIGHT HEART CATH\n Code status:\n Full code\n Height:\n 75 Inch\n Admission weight:\n 83.3 kg\n Daily weight:\n 79.2 kg\n Allergies/Reactions:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Precautions:\n PMH:\n CV-PMH: Hypertension, PVD\n Additional history: Cryptogenic cirrhosis from childhood for which he\n developed portal HTN and variceal hemorrhages, s/p central\n splenorenal shunt and splenectomy with the splenic vein anastomosed to\n the L renal vein, UGI bleed d/t esophageal varices s/p side to\n side portacaval shunt for closure of the splenorenal shunt, UGI\n bleed d/t persistent varices ( a failed shunt was again noted), \n s/p an end vena cava to side superior mesenteric vein anastomosis, \n hepatic encephalopathy requiring multiple admissions to Hosp,\n DVT 3 yrs ago, pulmonary emboli yrs ago, atrial fib, GERD, HOH.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:118\n D:74\n Temperature:\n 97.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 59 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 24h total in:\n 1,034 mL\n 24h total out:\n 1,225 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 02:59 AM\n Potassium:\n 4.2 mEq/L\n 02:59 AM\n Chloride:\n 98 mEq/L\n 02:59 AM\n CO2:\n 25 mEq/L\n 02:59 AM\n BUN:\n 42 mg/dL\n 02:59 AM\n Creatinine:\n 2.3 mg/dL\n 02:59 AM\n Glucose:\n 104 mg/dL\n 02:59 AM\n Hematocrit:\n 44.0 %\n 02:59 AM\n Finger Stick Glucose:\n 117\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 1 PIV Left\n Valuables / Signature\n Patient valuables:\n Other valuables: bag of clothes with pt.\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: F3\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571185,
"text": "Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571186,
"text": "Knowledge Deficit\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1076015,
"text": " 7:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate line placement?\n Admitting Diagnosis: PULMONARY HYPERTENSION\\RIGHT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with PAH with Swan-ganz cath in place.\n REASON FOR THIS EXAMINATION:\n evaluate line placement?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, :\n\n Comparison study of two days earlier.\n\n INDICATION: Pulmonary arterial hypertension.\n\n Findings: Swan-Ganz catheter tip remains unchanged in position, overlying the\n inferior aspect of the right hilum and could be retracted several centimeters\n for standard positioning. Marked enlargement of central pulmonary arteries is\n consistent with pulmonary arterial hypertension. Mild cardiac enlargement is\n without change, and lungs are grossly clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1075542,
"text": " 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PULMONARY HYPERTENSION\\RIGHT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pulm HTN s/p swan, CHF\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 9:29 AM\n Swan-Ganz ends in the right lower lobe artery. No other change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE\n\n REASON FOR EXAM: 53-year-old man with pulmonary hypertension, status post\n Swan CHF. Evaluate for interval change.\n\n Since yesterday, the Swan-Ganz catheter still ends in the right lower lobe\n pulmonary artery, and is currently inflated, should be pulled back 3.5 cm.\n Enlarged central pulmonary arteries and cardiomegaly are unchanged in this\n patient with known pulmonary hypertension. Old rib fractures are unchanged.\n Note that the left costophrenic angle was excluded. Lungs are otherwise\n clear.\n\n Results were discussed on the phone with at the time of dictation.\n\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572035,
"text": "52 yo male with history of cryptogenic cirrhosis which he has had since\n childhood is referred for a right heart cath as part of the liver\n transplant work up. He had been experiencing dyspnea with mild activity\n relieved with rest. for about a year. His cirrohosis has been\n complicated by portal hypertension and variceal hemorrhages The cath\n revealed acute and chronic diastolic CHF.and pulm HTN. PMH includes\n HTN, atrial fibrillation, DVT, PE. He is on coumadin. He has had a\n number of episodes of hepatic encephalopathy requiring\n hospitalizations. He is on lactulose.\n Ineffective Coping\n Assessment:\n Patient appearing more comfortable with PA line removed. Talking about\n going to regular floor. Resting comfortably\n Action:\n discussed plan of care with patient\n Response:\n Appears to be coping effectively\n Plan:\n Continue to discuss plan of care with patient, answer all his questions\n Cirrhosis of liver, other\n Assessment:\n Long standing\n Action:\n Lactulose, rifaximin, senna and polyethylene glycol given as ordered\n Response:\n Had a large BM\n Plan:\n Optimize hemodynamics for possible liver transplant, cont diuresis,\n lasix po, monitor I+O continue lactulose rifaximin, senna and\n polyethylene glycol\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Cr 2.3 24 hr output\n Action:\n On lasix 40mg qd\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 572033,
"text": "52 yo male with history of cryptogenic cirrhosis which he has had since\n childhood is referred for a right cath as part of the liver transplant\n work up. He had been experiencing dyspnea with mild activity relieved\n with rest. For about a year. His cirrohosis has been complicated by\n portal hypertension and variceal hemorrhages The cath revealed acute\n and chronic diastolic CHF.and pulm HTN. PMH includes HTN, atrial\n fibrillation, DVT, PE. He is on coumadin. He has had a number of\n episodes of hepatic encephalopathy requiring hospitalizations. He is on\n lactulose.\n Ineffective Coping\n Assessment:\n Patient appearing more comfortable with PA line removed. Talking about\n going to regular floor. Resting comfortably\n Action:\n discussed plan of care with patient\n Response:\n Appears to be coping effectively\n Plan:\n Continue to discuss plan of care with patient, answer all his questions\n Cirrhosis of liver, other\n Assessment:\n Long standing\n Action:\n Lactulose, rifaximin, senna and polyethylene glycol given as ordered\n Response:\n Had a large BM\n Plan:\n Optimize hemodynamics for possible liver transplant, cont diuresis,\n lasix po, monitor I+O continue lactulose rifaximin, senna and\n polyethylene glycol\n"
},
{
"category": "Nutrition",
"chartdate": "2139-05-28 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 572142,
"text": "No nutrition risk is identified at this time\n Comments:\n 53 year old male with cirrhosis awaiting transplant, patient admitted\n for elective RHC showing acute on chronic LV diastolic CHF and\n pulmonary hypertension. Patient re-screened today, patient eating\n without any problem, with good appetite at this time, will cont to f/u\n re intakes. \n"
},
{
"category": "Physician ",
"chartdate": "2139-05-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571122,
"text": "Chief Complaint:\n 24 Hour Events:\n -continued diuresis with IV lasix; increased bolus dose from 40mg to\n 80mg IV - got IV lasix x3\n -remained in NSR\n - mean PAP 35-37\n S: pt feels well denies SOB, CP, N/V, fevers or chills.\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.5\n HR: 51 (51 - 68) bpm\n BP: 108/61(72) {96/53(64) - 126/92(96)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: -1 (-1 - 5)mmHg\n PAP: (35 mmHg) / (19 mmHg)\n Total In:\n 1,030 mL\n 184 mL\n PO:\n 790 mL\n 120 mL\n TF:\n IVF:\n 240 mL\n 64 mL\n Blood products:\n Total out:\n 2,225 mL\n 300 mL\n Urine:\n 1,825 mL\n 300 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -1,195 mL\n -117 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 2L\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 116 K/uL\n 14.4 g/dL\n 125 mg/dL\n 1.9 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 97 mEq/L\n 139 mEq/L\n 43.4 %\n 10.5 K/uL\n [image002.jpg]\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n WBC\n 8.1\n 11.6\n 10.5\n Hct\n 44\n 44.8\n 47\n 43.7\n 40\n 43.4\n Plt\n 162\n 156\n 116\n Cr\n 1.6\n 1.5\n 1.6\n 1.6\n 1.7\n 1.5\n 1.9\n Glucose\n 107\n 119\n 128\n 97\n 111\n 94\n 125\n Other labs: PT / PTT / INR:24.0/39.0/2.7,\n Ca++:8.8 mg/dL, Mg++:1.8 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -5.7L LOS. In\n order to meet transplant requirements, mean PA pressures need to be\n less than 35. mPAP at 40 this am. Pt is getting close to dry volume\n status by exam and labs.\n -cont diuresis to goal 500cc-1 L neg today, creatinine likely to rise\n with this diuresis\n -lasix 80mg IV this am then prn\n - lytes\n -cont. captopril prn\n -cont swan\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with element of\n irreversible pulm HTN, also suggested by absence of response to inhaled\n NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE: INR 2.7 this am\n -cont coumadin (goal INR )\n .\n #Afib\n s/p successful cardioversion and remains in NSR\n -cont lopressor for rate-control\n -continue coumadin to maintain INR 2.0-3.0\n .\n #CRI\n Cr increased\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2139-05-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 571123,
"text": "Chief Complaint:\n 24 Hour Events:\n -continued diuresis with IV lasix; increased bolus dose from 40mg to\n 80mg IV - got IV lasix x3\n -remained in NSR\n - mean PAP 35-37\n S: pt feels well denies SOB, CP, N/V, fevers or chills.\n Allergies:\n Sulfa (Sulfonamides)\n Unknown; Hives;\n Cardizem (Oral) (Diltiazem Hcl)\n Unknown; Hives;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.9\nC (98.5\n HR: 51 (51 - 68) bpm\n BP: 108/61(72) {96/53(64) - 126/92(96)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 75 Inch\n CVP: -1 (-1 - 5)mmHg\n PAP: (35 mmHg) / (19 mmHg)\n Total In:\n 1,030 mL\n 184 mL\n PO:\n 790 mL\n 120 mL\n TF:\n IVF:\n 240 mL\n 64 mL\n Blood products:\n Total out:\n 2,225 mL\n 300 mL\n Urine:\n 1,825 mL\n 300 mL\n NG:\n Stool:\n 400 mL\n Drains:\n Balance:\n -1,195 mL\n -117 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 2L\n SpO2: 98%\n ABG: ///33/\n Physical Examination\n GEN: well-appearing NAD\n HEENT: anicteric\n NECK: R swan cath c/d/i\n CV: reg rate nl S1 S2 no m/r/g\n PULM: no rales/rhonchi/wheezes\n ABD: soft NTND normoactive BS\n EXT: warm, dry +PP no edema\n Labs / Radiology\n 116 K/uL\n 14.4 g/dL\n 125 mg/dL\n 1.9 mg/dL\n 33 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 97 mEq/L\n 139 mEq/L\n 43.4 %\n 10.5 K/uL\n [image002.jpg]\n 02:38 PM\n 11:11 PM\n 04:23 AM\n 04:53 AM\n 02:10 PM\n 03:59 AM\n 04:28 AM\n 03:17 PM\n 05:23 AM\n 04:20 PM\n WBC\n 8.1\n 11.6\n 10.5\n Hct\n 44\n 44.8\n 47\n 43.7\n 40\n 43.4\n Plt\n 162\n 156\n 116\n Cr\n 1.6\n 1.5\n 1.6\n 1.6\n 1.7\n 1.5\n 1.9\n Glucose\n 107\n 119\n 128\n 97\n 111\n 94\n 125\n Other labs: PT / PTT / INR:24.0/39.0/2.7,\n Ca++:8.8 mg/dL, Mg++:1.8 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n .\n #Acute on chronic diastolic CHF: hemodynamics improving, -5.7L LOS. In\n order to meet transplant requirements, mean PA pressures need to be\n less than 35. mPAP at 40 this am. Pt is getting close to dry volume\n status by exam and labs.\n -cont diuresis to goal 500cc-1 L neg today, creatinine likely to rise\n with this diuresis\n -lasix 80mg IV this am then prn\n - lytes\n -cont. captopril prn\n -cont swan\n .\n #Pulm HTN\n pulm pressures improving but not yet consistently at\n preoperative target of mPAP 35 mmHg, consistent with element of\n irreversible pulm HTN, also suggested by absence of response to inhaled\n NO at cath \n -cont amlodipine although not likely to produce substantial response\n given lack of vasodilator response\n -treat left-sided CHF, as above\n .\n #DVT/PE: INR 2.7 this am\n -cont coumadin (goal INR )\n .\n #Afib\n s/p successful cardioversion and remains in NSR\n -cont lopressor for rate-control\n -continue coumadin to maintain INR 2.0-3.0\n .\n #CRI\n Cr increased\n -cont monitor while diuresing\n .\n #Cirrhosis\n stable; awaiting transplant\n -continue rifaxamin, lactulose\n .\n #HTN: well-controlled\n -continue BB, CCB\n .\n #FEN: low Na diet; replete lytes prn\n .\n #Access: PIV; Swan\n .\n #PPx: PPI, bowel regimen, systemic AC\n .\n #Emergency contact: sister \n .\n #. Code: FULL\n .\n #. Dispo: CCU for hemodynamic monitoring while swan in place\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PA Catheter - 10:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n Chart reviewed. Patient interviewed and examined. I agree with Dr.\n \ns H+P, A+P. Although creatinine has increased a bit, we will\n continue gentle diuresis in an effort to reduce PA pressures further.\n If creatinine continues to rise, we will need to back off diuresis.\n Dr. covering as of .\n ------ Protected Section Addendum Entered By: , MD\n on: 11:01 ------\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571221,
"text": "52 yo male with a history of HTN, atrial fibrillation, DVT, PE and\n cryptogenic cirrhosis since childhood complicatied by portal\n hypertension and variceal hemorrhages He comes to for right\n heart catheterization as part of liver transplant work up. Patient\n reports sob with mild activity relieved with rest for about a year. He\n was recently admitted in for hepatic encephalopathy . This has\n been controlled with lactulose. Echo done EF > 55% mildly\n dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic root\n at the sinus level and mildly dilated ascending aorta. Mild pulm artery\n systolic HTN A heart cath done showed severe LV diastolic\n dysfunction and pulm htn. He had a Swan placed at that time which\n showed PCWP 25 PA pressure 68/30 mean 51, RV 64/15 mean 22, RA 16-19 He\n has been given lasix goal of pa mean pressures of <35 A DC\n cardioversion preformed Atrial fibrillation on \n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary hypertension (Pulm HTN, PHTN)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571279,
"text": "52 yo male with a history of HTN, atrial fibrillation, DVT, PE and\n cryptogenic cirrhosis since childhood complicatied by portal\n hypertension and variceal hemorrhages He comes to for right\n heart catheterization as part of liver transplant work up. Patient\n reports sob with mild activity relieved with rest for about a year. He\n was recently admitted in for hepatic encephalopathy . This has\n been controlled with lactulose. Echo done EF > 55% mildly\n dilated LA, mild symmetric LV hypertrophy, mildly dilated aortic root\n at the sinus level and mildly dilated ascending aorta. Mild pulm artery\n systolic HTN A heart cath done showed severe LV diastolic\n dysfunction and pulm htn. He had a Swan placed at that time which\n showed PCWP 25 PA pressure 68/30 mean 51, RV 64/15 mean 22, RA 16-19 He\n has been given lasix goal of pa mean pressures of <35 A DC\n cardioversion preformed Atrial fibrillation on \n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n CVP 5 CO fick 7.2 CI 3.4 PA 60/35-55/27 means 38-45 mixed venous o2\n sat 72%. Lungs clear LOS output neg 6 liters output yesterday neg 1\n liter\n Action:\n Given lasix yesterday 20mg \n Response:\n 1 liter neg\n Plan:\n Lasix prn, Captopril to be increased prn for improved Afterload\n reduction, goal PA mean <35\n Cirrhosis of liver, other\n Assessment:\n w/u for liver transplant in progress, PA mean pressures continue to be\n high 38-45 patient anxious to have PA line removed. A/O x3 lactulose\n given\n Action:\n Lactulose q 4hr for BM qd, follow LFT, ammonia levels and mental\n status\n Response:\n 3 large BM\ns \n Plan:\n Follow LFTs, ammonia levels and mental status\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571388,
"text": "Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Cirrhosis of liver, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2139-05-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 571776,
"text": "53 M h/o cryptogenic cirrhosis awaiting transplant, portal HTN, pulm\n HTN, chronic diastolic dysfunction, CRI, PE and Afib on coumadin\n admitted for elective RHC demonstrating acute on chronic LV diastolic\n CHF and pulmonary hypertension.\n Heart failure (CHF), Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n"
}
] |
3,915 | 198,555 | 68 yo male with multiple medical problems, recent sepsis and R knee who was admitted to the MICU for hypotension and unresponsiveness. . Given the patient's elevated lactate, it was thought that his hypotension was most likely due to sepsis. Early goal-directed therapy was initiated in the ED and continued on arrival to the ICU. The patient was given broad spectrum antibiotics including Vancomycin, Levofloxacin, and Zosyn given recent instrumentation and possible new opacity on chest x-ray. Vascular surgery was consulted in the ED to evaluate his surgical wounds. It was felt by the surgery team that his wound was most likely not the source of infection as the site appeared relatively clean, with no frank pus. Plain films were done and did not show any evidence of osteomyelitis, emphysema, or effusion. Renal was also consulted as he was a dialysis patient. It was felt that he did not require acute HD at that time, and it was recommended to pursue CVVH overnight if the patient became more overloaded with fluid resuscitation. His elevated troponin in the setting of ESRD and hypotension was thought to be from demand rather than ACS, as his CK enzymes were flat and his EKG did not have any ST changes suggestive of ischemia. An echo was ordered to assess for any wall motion abnormalities and it was planned to obtain his medical record from the VA to better understand his cardiac history. Although the patient was found to be unresponsive in the ED, he was awake and oriented x 2 on arrival to the ICU. He was able to follow commands and answer some questions. He repeatedly remarked "just let me go". The need for the IVF, antibiotics, and possible pressors was explained to the patient multiple times. His daughter and HCP was by phone and she arrived to the ICU about two hours after the patient was admitted. She explained that the patient was DNR/DNI and that we "should listen to him and just let him go". She stated that she did not want central line placement, pressors, or antibiotics. She explained that he had endured a prolonged hospitalization at the VA, and that he had wanted to stop all care at that point, but that she pushed him to hold on and continue. She said now she just wanted to honor his wishes. Another daughter was also present for the conversation, and it was discussed with both family members and the patient about what the cause of his hospitalization was thought to be, what role the antibiotics and IVF played in treating him, and that if these measures were to be stopped, he would most likely die. Both the patient and the family expressed understanding of these risks, but still wanted to stop care and make him comfortable. The overnight intensivist was notified of the patient and his family's wishes and the plan to withdraw care; agreed with the decision as the patient and family were competent. The patient was given a dose of morphine to help with his progressing respiratory distress. The patient became apneic, bradycardic, and eventually asystolic. He was pronounced dead at 10:17 pm. His family members were present at the bedside. The overnight intensivist was notified. An autopsy was offered and declined. | Right pleural effusion, and questionable opacity in the right lower lobe. Additional area of ill-defined opacity in the right lower lobe likely represents pneumonic consolidation vs. atelectasis. PORTABLE SUPINE RADIOGRAPH: Study is markedly limited secondary to significant patient rotation. There may be a small superficial ulcer, anteriorly, with no evidence of deeper subcutaneous emphysema or gas-filled tract reaching the underlying bone. Additionally, there is an area of ill-defined opacity in the right lower lobe. No definite left pleural effusion is seen. No definite pneumothorax seen. 2) Right pleural effusion. osteomyelitis or gas. There is no definite evidence of osteomyelitis. Modest low amplitude lateral T waves are non-specific andmay be within normal limits. The soft tissue stump is, overall, unremarkable in appearance. Sinus tachycardia. IMPRESSION: Limited study secondary to patient rotation. FINDINGS: Two views are provided, with no comparisons on record. No pneumothorax. IMPRESSION: 1) Interval placement of right IJ line, with the tip in the lower SVC. There is a right pleural effusion. There is limited assessment for cardiomegaly. A right-sided hemodialysis catheter is again seen in the distal SVC. There is amorphous radiodense material in the deep soft tissues between the stump margin and the fibular resection site, which may represent heterotopic ossification, dressing material within the deep ulcer, or less likely, retained surgical material. The knee joint, itself, is unremarkable, with no effusion or acute osseous abnormality. COMPARISON: None. PORTABLE AP CHEST RADIOGRAPH: There has been interval placement of a right IJ line, with the tip at the cavoatrial junction. The pulmonary vasculature is not particularly congested. IMPRESSION: Status post below-knee amputation, with sharp surgical margins. There is a right pleural effusion, an area of increased opacity in the right lower lobe which is difficult to assess due to the marked rotation. No previous tracing available for comparison. The patient is status post below-knee amputation with the proximal tibial and fibular margins, sharp and regular. Noted is vascular calcification. COMMENT: Comparison with any (outside) post-amputation radiographs may be helpful. There remains probable ulceration, anteriorly, and amorphous radiodense material may represent implanted dressing/sponge, but should be closely correlated clinically. No pneumothorax is seen. There is a hemodialysis catheter, with the tip in the SVC. LINE PLACEMENT Clip # Reason: line placement MEDICAL CONDITION: 68 year old man with unresponsiveness, prurulent drng from wound REASON FOR THIS EXAMINATION: line placement FINAL REPORT INDICATION: Evaluation of line placement. 12:49 PM CHEST PORT. 12:32 PM CHEST (PORTABLE AP) Clip # Reason: r/o cardiopulm process MEDICAL CONDITION: 68 year old man with unresponsiveness, prurulent drng from wound REASON FOR THIS EXAMINATION: r/o cardiopulm process FINAL REPORT INDICATION: 68-year-old woman with purulent drainage from her surgical wound, evaluate for acute cardiopulmonary process. 2:37 PM KNEE (2 VIEWS) RIGHT PORT Clip # Reason: osteo, gas MEDICAL CONDITION: 68 year old man with s/p BKA +infection REASON FOR THIS EXAMINATION: osteo, gas FINAL REPORT TWO VIEWS OF THE RIGHT KNEE DATED HISTORY: 68 year-old man, status post right BKA with "(+)infection;" ? | 4 | [
{
"category": "Radiology",
"chartdate": "2178-04-07 00:00:00.000",
"description": "RP KNEE (2 VIEWS) RIGHT PORT",
"row_id": 962171,
"text": " 2:37 PM\n KNEE (2 VIEWS) RIGHT PORT Clip # \n Reason: osteo, gas\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with s/p BKA +infection\n REASON FOR THIS EXAMINATION:\n osteo, gas\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEWS OF THE RIGHT KNEE DATED \n\n HISTORY: 68 year-old man, status post right BKA with \"(+)infection;\" ?\n osteomyelitis or gas.\n\n FINDINGS: Two views are provided, with no comparisons on record. The patient\n is status post below-knee amputation with the proximal tibial and fibular\n margins, sharp and regular. The soft tissue stump is, overall, unremarkable\n in appearance. There may be a small superficial ulcer, anteriorly, with no\n evidence of deeper subcutaneous emphysema or gas-filled tract reaching the\n underlying bone. There is amorphous radiodense material in the deep soft\n tissues between the stump margin and the fibular resection site, which may\n represent heterotopic ossification, dressing material within the deep ulcer,\n or less likely, retained surgical material. The knee joint, itself, is\n unremarkable, with no effusion or acute osseous abnormality. Noted is vascular\n calcification.\n\n IMPRESSION: Status post below-knee amputation, with sharp surgical margins.\n There remains probable ulceration, anteriorly, and amorphous radiodense\n material may represent implanted dressing/sponge, but should be closely\n correlated clinically. There is no definite evidence of osteomyelitis.\n\n COMMENT: Comparison with any (outside) post-amputation radiographs may be\n helpful.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-04-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962149,
"text": " 12:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with unresponsiveness, prurulent drng from wound\n REASON FOR THIS EXAMINATION:\n r/o cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old woman with purulent drainage from her surgical wound,\n evaluate for acute cardiopulmonary process.\n\n COMPARISON: None.\n\n PORTABLE SUPINE RADIOGRAPH: Study is markedly limited secondary to\n significant patient rotation. There is a hemodialysis catheter, with the tip\n in the SVC. There is a right pleural effusion, an area of increased opacity\n in the right lower lobe which is difficult to assess due to the marked\n rotation. No definite pneumothorax seen.\n\n IMPRESSION: Limited study secondary to patient rotation. Right pleural\n effusion, and questionable opacity in the right lower lobe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-04-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 962151,
"text": " 12:49 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with unresponsiveness, prurulent drng from wound\n\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of line placement.\n\n COMPARISON: Study from the same day, approximately 30 minutes prior.\n\n PORTABLE AP CHEST RADIOGRAPH: There has been interval placement of a right\n IJ line, with the tip at the cavoatrial junction. A right-sided hemodialysis\n catheter is again seen in the distal SVC. There is a right pleural effusion.\n Additionally, there is an area of ill-defined opacity in the right lower lobe.\n The pulmonary vasculature is not particularly congested. No definite left\n pleural effusion is seen. There is limited assessment for cardiomegaly. No\n pneumothorax is seen.\n\n IMPRESSION:\n 1) Interval placement of right IJ line, with the tip in the lower SVC. No\n pneumothorax.\n 2) Right pleural effusion. Additional area of ill-defined opacity in the\n right lower lobe likely represents pneumonic consolidation vs. atelectasis.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2178-04-07 00:00:00.000",
"description": "Report",
"row_id": 268475,
"text": "Sinus tachycardia. Modest low amplitude lateral T waves are non-specific and\nmay be within normal limits. No previous tracing available for comparison.\n\n"
}
] |
22,851 | 110,089 | The patient was initially evaluated in the emergency room and admitted to the vascular service. She was begun on vanco, levofloxacin for antibiotic care. Her preoperative medications were continued. She did have some EKG changes with ST depressions in V4-V5, questionable myocardial infarction. The patient's admitting CKs were 387 and over the next 48 hours CK was 209. CK MBs were 3 and 4. Troponin levels were 0.2. Cardiology was requested to see the patient for preoperative assessment for evaluation. Recommendations-she was a high surgical candidate with known severe ischemic cardiomyopathy with a semi-compensated left ventricular function. They felt that no further cardiac workup was indicated at this time. The patient should be restarted on her Lasix, spironolactone should be added to her regimen and increase from 12.5 to 25 mg daily with monitoring of K. Diltiazem should be discontinued secondary to myocardial suppression, a beta blockade, Toprol, should be advanced to 150 mg a day. Digoxin should be changed to 0.125 mg per day and gemfibrozil should be changed to fenofibrate. The patient's Coumadin was held and she was placed on IV heparin for anticoagulation for a chronic atrial fibrillation. Long discussions with the family to determine plan of action, arteriogram to see if we can reconstruct or just undergo amputation. The patient's family was undecided. The was consulted for diabetic management. The patient was preopped on for anticipated left AKA and underwent a left AKA without complication on . She was transferred to the PACU in stable condition. Postoperatively, she remained hemodynamically stable. Her postoperative crit was 31.1, BUN 15, creatinine 0.7. The patient remained intubated overnight and was transferred to the SICU for continued monitoring and care. She was weaned overnight and extubated. She remained hemodynamically stable. Her physical examination was unremarkable. Her dressing was clean, dry, and intact. She was transferred to the VICU for continued care. She required readjustment in her regular insulin dose for her hyperglycemia with slow improvement. On postoperative day #1 the patient was converted to p.o. medications. Ambulation to the chair was begun. Heparin was restarted and Warfarin was reinstituted. Her antibiotics were discontinued on postoperative day #2. Her Swan line was converted to CVL on postoperative day #2. She continued to require Lasix for diuresis. The A-line was discontinued. Hematocrit was 28.7, BUN 11, creatinine 0.7. She continued to be followed by the vascular service and her primary care physician. Physical therapy evaluated the patient on postoperative day #3. The recommendations were that the patient could be discharged to home with home physical therapy and 24-hour care. The family is aware of this and this was their decision. A repeat echocardiogram will be obtained prior to the patient's discharge to determine her left ventricular function. On postoperative day #5 she continued to do well, was afebrile. Her left flap was warm, pink, without erythema. The right DP and PT were Dopplerable signals only. The IV heparin was continued until her INR was greater than 2.0. The patient will continue with diuresis. She is at baseline. Will be planning discharge to home with services in the next 24 hours. | Sinus rhythm.Possible anterior infarct - age undeterminedInferior/lateral ST-T changesSince previous tracing, no significant change Sinus rhythmDiffuse ST-T wave abnormalities - cannot exclude in part anterolateral ischemia- clinical correlation is suggestedSince previous tracing of , probable no significant change CVP 10. weaned off levophed. Respiratory Care: Pt came from OR. Admitted for overnight ventilation, with a view to wean and extubate in the AM.Patient weaned from ventilation and sedation, extubated 0500 without event.Review of Systems:Resp - Currently on 2l FiO2 via NC, SpO2 99-100% RR 20-25bpm, post-extubation ABG pH 7.41, PaCO2 39, PaO2 123, BE 0. There is no pericardialeffusion.Compared with the prior study (images reviewed) of , systolic functionappears similar and c/w multivessel CAD (was regional dysfunction previously)and the severity of mitral regurgitation is reduced (previouslymild-moderate).Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a low risk (prophylaxis not recommended). Mild to moderate [+] TR.Moderate PA systolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. abd soft + BS.endo- followed by . The mitral valveappears structurally normal with trivial mitral regurgitation. ABP 130-150's systolic. will cont to wean to extubated in am.renal- foley u/o avg 50/hr. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Based on AHA endocarditis prophylaxis recommendations, the echo findings indicate a lowrisk (prophylaxis not recommended). b/p now 180. down to 120's with propofol on. Received ^narcotic in OR. + peripheral pulses, Left AKA warm, no edema noted. Lactate 1.3. Peripherally cool, with weak pedal/radial pulses, cap refill <3 seconds. pt sedated on propofol. Sinus rhythmPremature ventricular contractionsPossible anterior infarct - age undeterminedLateral ST changes are nonspecificSince previous tracing, no significant change Basalsegments are hypokinetic. Last abg results were normal acid-base balance with excellent oxygenation.RSBI = 91.4 on 0-PEEP and 5 cm PSV.Patient extubated. weak but paplable pulses.Resp- lung sounds clear. when med off for wake up assesment pt opens eyes, denies pain, follows commands.CV- hr 50-80 SR-SB with occ/freq PVC. Congestive heart failure.Height: (in) 66Weight (lb): 152BSA (m2): 1.78 m2BP (mm Hg): 147/62HR (bpm): 88Status: InpatientDate/Time: at 14:30Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: DefinityTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Blood sugars being controlled currently.ID - afebrile, continues antibiotics.Skin - All skin intact besides operative site. Primary OR dressing intact.Resp - Lungs clear throughout, dim at bases. Diet cardiac/diabetic. C.O ~4.0 this shift. team aware of marginal urine output.Endo - Continues on insulin gtt. There is variation in the precordial lead placement and noapparent diagnostic interim change compared to the previous tracing of . HR 80-105bpm, SBP 130-170, MAP 85-110, CVP 9-17, PAP mean 30-43, CO 2.17 (at 0400), SR 2876. Left amputation site not viewed secondary to primary OR dressing intact.Psych/social - Large family. No LV mass/thrombus.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Normal aortic valve leaflets. admit notept recieved from OR post left AKA. Sinus rhythm. Sinus rhythm. Extubated this am 0500, awake and alert since extubation no problems.CV - HR 70-90's NSR with occasional PVC's. TSICU Nursing Progress NoteNeuro - Pt A&O x3. 0200 labs K+ 3.8 (repleted with 20mEq KCl), Mg 1.8 (repleted with 2g MgSO4), Ca 9.2. pa cath intact. PA catheter in place 48cm. There ismoderate pulmonary artery systolic hypertension. plan wean to extubate. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Not wedging due to INR 1.8. Left ventricular wall thicknesses and cavitysize are normal. no IVF.GI- npo. Diffuse ST-T wave abnormalities in the context of a tracing withbaseline artifact. pt remained intubated, swaned. s/p left AKA. Coughing and clearing secretions.CVS - Sinus rhythm-sinus tachycardia with ocassional to frequent PVCs (one noted run of self-terminating V-Tach). CVP 7-12. Tolerationg POs well, VSS.Plan - Continue to monitor VS, urine output, mental status, s/s bleeding and infection. bs post op 215. ins gtt started at 2units/hr.skin- LLE AKA. + bowel sounds x4. No respiratory distress, or SOB.GI - Abdomen soft, nontender, nondistended. OR primary dressing intact.Access - R IJ PA Catheter, R radial Aline, 2xperipheral cannula patent, dressings intact.Family - Frequent calls from concerned family members, son is HCP.PLAN - D/C oxygen as tolerated maintaining >93% Q4 CO measurement Maintain SBP <150 Maintain HR <90 if possible Reconsider the need for furosemide Encourage patient to verbalise pain needs - PRN morphine Consider escalation of diet/PO meds Review OR primary dressing/flap assessment with vascular team Contact family with changes Transfer to VICU when a bed becomes available (transfer noted begun No complaints of pain, given 2mg morphine prior to extubation.GI - NPO, abdomen soft/nontender, +ve bowel sounds in all 4 quadrants, no BM this shift. Clinical correlation is suggested. Started on NPH this am in hopes to wean gtt to off. There is severe regional left ventricular systolicdysfunction with near akinesis of the distal 2/3rds of the ventricle. 0200 labs HCT upto 33.5%, Hb upto 11.4, WCC upto 21.9. Continues of vancomycin (trough level drawn this AM), levofloxacin, and metronidazole.Renal - UO 15-240ml/hr (with 10mg furosemide overnight), 24 hour balance -ve 200ml. Taking POs well. Will attempt early wean in am. Clinical decisions regarding the need forprophylaxis should be based on clinical and echocardiographic data.Conclusions:The left atrium is elongated. TRansfer to VICU when bed available. The aorticvalve leaflets appear structurally normal with good leaflet excursion. monitor cardiac status. NO BM today.GU - Foley draining clear yellow urine ~30cc/hr. Work with recommendations for blood sugar control. Pressure areas intact. Continue diet as tolerated. BUN/Creatinine WNL.Neuro - GCS 15 (e4v5m6), Pupils 3mm/3mm brisk reactive, alert and oriented x 3, MAE. | 11 | [
{
"category": "Nursing/other",
"chartdate": "2111-04-15 00:00:00.000",
"description": "Report",
"row_id": 1561369,
"text": "admit note\n\npt recieved from OR post left AKA. pt remained intubated, swaned.\n\n pt sedated on propofol. when med off for wake up assesment pt opens eyes, denies pain, follows commands.\n\nCV- hr 50-80 SR-SB with occ/freq PVC. pa cath intact. CO 2.8 no wedge due to high INR. CVP 10. weaned off levophed. b/p now 180. down to 120's with propofol on. weak but paplable pulses.\n\nResp- lung sounds clear. intubated and vented changed to SIMV 40% tv 500 rate 10 peep 5. sat 100%. will cont to wean to extubated in am.\n\nrenal- foley u/o avg 50/hr. labs sent to monitor lytes. no IVF.\n\nGI- npo. abd soft + BS.\n\nendo- followed by . bs post op 215. ins gtt started at 2units/hr.\n\nskin- LLE AKA. DDI\n\nsocial- son and daughter in to visit. contact info on board.\n\nplan- team called for orders, Labs sent results pending. plan wean to extubate. monitor cardiac status. support pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-04-15 00:00:00.000",
"description": "Report",
"row_id": 1561370,
"text": "Respiratory Care: Pt came from OR. s/p left AKA. Currently on Simv 500x10 .40 . Received ^narcotic in OR. Will attempt early wean in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-04-16 00:00:00.000",
"description": "Report",
"row_id": 1561371,
"text": "Respiratory Care:\nPatient was weaned to CPAP/PSV, first at 40%, and then later to 30%, . Last abg results were normal acid-base balance with excellent oxygenation.\n\nRSBI = 91.4 on 0-PEEP and 5 cm PSV.\n\n\nPatient extubated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-04-16 00:00:00.000",
"description": "Report",
"row_id": 1561372,
"text": "T/SICU Shift Report 1900 - 0730\n81 Year old female NKA FULL CODE Universal Precautions\n\nAdmission - Post Op AKA\n\nPMH - CAD/CHF(EF 10-15%)/MI/Hypertension/Hypercholesterolemia\n PVD\n Diabetes\n Nephrolisais\n\nPatient admitted from OR following AKA, with cardiac induction with 700mcg fentanyl. Admitted for overnight ventilation, with a view to wean and extubate in the AM.\n\nPatient weaned from ventilation and sedation, extubated 0500 without event.\n\nReview of Systems:\n\nResp - Currently on 2l FiO2 via NC, SpO2 99-100% RR 20-25bpm, post-extubation ABG pH 7.41, PaCO2 39, PaO2 123, BE 0. Breath sounds clear throughout. Coughing and clearing secretions.\n\nCVS - Sinus rhythm-sinus tachycardia with ocassional to frequent PVCs (one noted run of self-terminating V-Tach). HR 80-105bpm, SBP 130-170, MAP 85-110, CVP 9-17, PAP mean 30-43, CO 2.17 (at 0400), SR 2876. 0200 labs HCT upto 33.5%, Hb upto 11.4, WCC upto 21.9. Lactate 1.3. Peripherally cool, with weak pedal/radial pulses, cap refill <3 seconds. Continues of vancomycin (trough level drawn this AM), levofloxacin, and metronidazole.\n\nRenal - UO 15-240ml/hr (with 10mg furosemide overnight), 24 hour balance -ve 200ml. No maintenance fluid overnight. 0200 labs K+ 3.8 (repleted with 20mEq KCl), Mg 1.8 (repleted with 2g MgSO4), Ca 9.2. BUN/Creatinine WNL.\n\nNeuro - GCS 15 (e4v5m6), Pupils 3mm/3mm brisk reactive, alert and oriented x 3, MAE. No complaints of pain, given 2mg morphine prior to extubation.\n\nGI - NPO, abdomen soft/nontender, +ve bowel sounds in all 4 quadrants, no BM this shift. Blood glucose erratic with insulin infusion.\n\nSkin - Given full bed bath at beginning of shift, turned Q4. Pressure areas intact. OR primary dressing intact.\n\nAccess - R IJ PA Catheter, R radial Aline, 2xperipheral cannula patent, dressings intact.\n\nFamily - Frequent calls from concerned family members, son is HCP.\n\nPLAN - D/C oxygen as tolerated maintaining >93%\n Q4 CO measurement\n Maintain SBP <150\n Maintain HR <90 if possible\n Reconsider the need for furosemide\n Encourage patient to verbalise pain needs - PRN morphine\n Consider escalation of diet/PO meds\n Review OR primary dressing/flap assessment with vascular team\n Contact family with changes\n Transfer to VICU when a bed becomes available (transfer noted begun\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-04-16 00:00:00.000",
"description": "Report",
"row_id": 1561373,
"text": "TSICU Nursing Progress Note\nNeuro - Pt A&O x3. MAE's follows commands consistently. Pupils PERRL. Extubated this am 0500, awake and alert since extubation no problems.\n\nCV - HR 70-90's NSR with occasional PVC's. PA catheter in place 48cm. Long cardiac hx, EF 10-15% a few years prior to admission. ABP 130-150's systolic. Not wedging due to INR 1.8. C.O ~4.0 this shift. CVP 7-12. PA pressures mean 35-40. + peripheral pulses, Left AKA warm, no edema noted. Primary OR dressing intact.\n\nResp - Lungs clear throughout, dim at bases. O2 via NC at 2lpm, sats 96-100%. No respiratory distress, or SOB.\n\nGI - Abdomen soft, nontender, nondistended. + bowel sounds x4. Taking POs well. Diet cardiac/diabetic. Ate good lunch and drinking gingerale and ice water without a problem. NO BM today.\n\nGU - Foley draining clear yellow urine ~30cc/hr. team aware of marginal urine output.\n\nEndo - Continues on insulin gtt. Started on NPH this am in hopes to wean gtt to off. Blood sugars being controlled currently.\n\nID - afebrile, continues antibiotics.\n\nSkin - All skin intact besides operative site. Left amputation site not viewed secondary to primary OR dressing intact.\n\nPsych/social - Large family. 12 children. Family in today very concerned. Eldest son requests no more than two visitors at a time otherwise pt becomes anxious and tachycardic.\n\nA - Minimal post-op pain. Tolerationg POs well, VSS.\n\nPlan - Continue to monitor VS, urine output, mental status, s/s bleeding and infection. Continue diet as tolerated. Monitor blood sugars closely. Work with recommendations for blood sugar control. TRansfer to VICU when bed available.\n"
},
{
"category": "Echo",
"chartdate": "2111-04-20 00:00:00.000",
"description": "Report",
"row_id": 95117,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Congestive heart failure.\nHeight: (in) 66\nWeight (lb): 152\nBSA (m2): 1.78 m2\nBP (mm Hg): 147/62\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 14:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Severe regional LV\nsystolic dysfunction. No LV mass/thrombus.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nModerate PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Based on \nAHA endocarditis prophylaxis recommendations, the echo findings indicate a low\nrisk (prophylaxis not recommended). Clinical decisions regarding the need for\nprophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thicknesses and cavity\nsize are normal. There is severe regional left ventricular systolic\ndysfunction with near akinesis of the distal 2/3rds of the ventricle. Basal\nsegments are hypokinetic. No masses or thrombi are seen in the left ventricle.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets appear structurally normal with good leaflet excursion. There\nis no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , systolic function\nappears similar and c/w multivessel CAD (was regional dysfunction previously)\nand the severity of mitral regurgitation is reduced (previously\nmild-moderate).\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2111-04-15 00:00:00.000",
"description": "Report",
"row_id": 253746,
"text": "Sinus rhythm. Diffuse ST-T wave abnormalities in the context of a tracing with\nbaseline artifact. There is variation in the precordial lead placement and no\napparent diagnostic interim change compared to the previous tracing of .\n\n"
},
{
"category": "ECG",
"chartdate": "2111-04-10 00:00:00.000",
"description": "Report",
"row_id": 253747,
"text": "Sinus rhythm\nDiffuse ST-T wave abnormalities - cannot exclude in part anterolateral ischemia\n- clinical correlation is suggested\nSince previous tracing of , probable no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2111-04-09 00:00:00.000",
"description": "Report",
"row_id": 253748,
"text": "Sinus rhythm.\nPossible anterior infarct - age undetermined\nInferior/lateral ST-T changes\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2111-04-08 00:00:00.000",
"description": "Report",
"row_id": 253749,
"text": "Sinus rhythm\nPremature ventricular contractions\nPossible anterior infarct - age undetermined\nLateral ST changes are nonspecific\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2111-04-19 00:00:00.000",
"description": "Report",
"row_id": 253745,
"text": "Sinus rhythm. Diffuse ST-T wave abnormalities are non-specific, but cannot\nexclude antolateral ischemia. Clinical correlation is suggested. Since the\nprevious tracing of further ST-T wave changes are suggested, but\nbaseline artifact on previous tracing makes comparison difficult.\n\n"
}
] |
54,041 | 122,513 | 83M with h/o prostate cancer s/p brachytherapy and radiation c/b radiation proctitis and prostatitis with hematuria, BPH, recently diagnosed Pseudomonal urinary tract infecton admitted with septic shock probably related to epididymo-orchitis from previous urinary tract infection. . #Septic Shock/Urinary Tract Infection/Epididymo-orchitis: Patient was admitted with hypotension to the ICU requiring transient vasopressor support. Labs were notable for leukocytosis with bandemia. He was emprically treated with Vancomycin, Ciprofloxacin, and Zosyn and then changed to Vancomycin and Meropenem as previous urine cultures grew Pseudomonas with intermediate sensitivity to Zosyn. He improved and was transferred to the medical floor. He was seen by Urology in the ICU and exam was consistent with epididymo-orchitis which was confirmed by testicular ultrasound without evidence of abscess. Blood and urine cultures were no growth. Therefore, given that initial urine culture with Pseudomonas was from and antibiotics were not started until it was felt that the patient's sepsis was due to deep seeding of epididymis/testicular bed from Pseudomonal UTI and not from a failure of cipro since we would have expected bacterial growth if the causal organism was resistant to Ciprofloxacin given how ill the patient was on presentation. Also, although there was consideration of scrotal cellulitis when Vancomycin was started, it was later felt that this presented epididymo-orchitis and not cellulitis. Therefore, patient was discharged on ciprofloxacin for quinolone sensitive Pseudomonal urinary tract infection and epididymo-orchitis for a total of 3 weeks after discussion with Urology. The patient will follow up in clinic in 3 weeks. . #BPH: Doxazosin was held initially for hypotension and Foley was placed. There was no blood clots noted on bladder irrigation. Foley catheter was removed once hemodynamically stable and patient was able to void, although incontinent of urine. Patient was discharged to restart doxazosin at half his home dose (4mg po qhs-since it had been held for a few days) to reduce risk of postural hypotension (as he already has parkinson's disease). This can be increased to usual home dose of 8mg po qhs in days from discharge if tolerated well. . #Hematuria: Although patient had had hematuria recently, continuous bladder irrigation was performed during hospitalization and there was no evidence of bleeding from the urinary tract. Aspirin 81 was resarted on discharge. . #Congestive heart failure, chronic, diastolic: Initially betablocker and diuretics were held as patient was hypotensive. Home betablocker and Lasix were restarted on day of discharge. . #Acute renal failure: This was felt to be related to septic shock and improved with hydration and improvement in blood pressure. Nephrotoxic medications were held. Renal function improved to baseline on discharge. . #Wheeze: Patient had intermittent wheezing which seemed unrelated to his volume status. He said this was chronic but he does not carry a diagnosis for this. He was discharged on Combivent inhalers/Duonebs prn with further workup deferred to his outpatient PCP. . #Coronary artery disease: Since patient did not have any further hematuria, he was restarted on his home aspirin 81mg po daily. . #Parkinson's Disease: Patient was continued on his home Sinement and Ropinorole. . #Pernicious Anemia: Home B12 was continued. . #GERD: PPI was continued. . #CODE:FULL . #Disposition: Patient was discharged back to his previous rehabilitation facility. He should have electrolytes checked in 7 days to monitor electrolytes and renal function to ensure they are stable. He should follow up with PCP and Urology as noted in discharge paperwork. | The left ventricular cavity size istop normal/borderline dilated. Top normal/borderline dilated LVcavity size. IMPRESSION: Stable small left-sided pleural effusion with associated atelectasis. Mild (1+) mitralregurgitation is seen. There is nopericardial effusion. The remainder of the chest is unchanged, with continued moderate size left pleural effusion and left basilar opacity likely reflecting atelectasis. Mild mitralannular calcification. Mild [1+]TR. Left anteriorfascicular block. Allowing for this, there is unchanged blunting of the left costophrenic angle suggesting a stable left-sided pleural effusion with associated atelectasis. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Theaortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. Left ventricular function.Height: (in) 71Weight (lb): 200BSA (m2): 2.11 m2BP (mm Hg): 117/48HR (bpm): 70Status: InpatientDate/Time: at 09:29Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. There is a small amount of simple appearing peritesticular fluid. Low precordial voltage. Small epididymal head cysts as described. Suboptimal image quality - patient unable to cooperate.Conclusions:The left atrium is mildly dilated. COMPARISON: Semi-upright AP and lateral radiographs of the chest. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace aortic regurgitation is seen. This was a portable examination. Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality as the patient was difficult toposition. Findings are suggestive of a left-sided epididymo orchitis. Suboptimal technical quality, a focal LV wall motion abnormalitycannot be fully excluded. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. SEMI-UPRIGHT AP VIEW OF THE CHEST: Right internal jugular central venous catheter tip terminates in the region of the SVC. FINDINGS: Bilateral scrotal subcutaneous edema is noted. Multiseptated fluid surrounding the left testis and epididymis. No concerning mass lesions. Sinus rhythm. The left testis is surrounded by a complex hydrocele, the fluid containing thin internal septations. Normal interatrial septum.No ASD by 2D or color Doppler. The right lung is grossly clear. RIGHT SIDE: The right testis has a homogenous echotexture. FINDINGS: This study is technically limited by patient rotation and low inspiratory lung volumes. Leftventricular wall thicknesses are normal. Right ventricular chamber size and free wall motion are normal.The diameters of aorta at the sinus, ascending and arch levels are normal. The mediastinal and hilar contours are stable and within normal limits. Clinical correlation issuggested. No AS. Baseline artifact. No pneumothorax. RSR' pattern in lead V2. IMPRESSION: 1. There is no ventricularseptal defect. The tricuspid valve leaflets are mildly thickened. IMPRESSION: Right internal jugular central venous catheter tip in the mid SVC. The aorta is tortuous with calcification of the aortic knob. No MVP. No resting LVOT gradient. Thepulmonary artery systolic pressure could not be determined. No definite focal consolidation is seen. TECHNIQUE: Portable semi-erect AP radiograph of the chest. There is no mitral valve prolapse. The right epididymis contains a 5-mm simple epididymal head cyst. No TS. Intraventricular conduction delay.No previous tracing available for comparison. No pneumothorax is present. There is no definite focal consolidation. DFDdp No MS. Due to suboptimal technical quality, a focalwall motion abnormality cannot be fully excluded. Again, note is made of a 4 x 3 mm epididymal head cyst. TECHNIQUE: Grayscale and color Doppler were used to evaluate the scrotum and contents. Degenerative changes are noted in the left shoulder joint. The cardiac silhouette is enlarged. No atrial septal defect is seen by 2D orcolor Doppler. 2. There are no pneumothoraces. Normal IVC diameter (>2.1cm) with >50% decreasewith sniff (estimated RA pressure (5-10 mmHg).LEFT VENTRICLE: Normal LV wall thickness. Coronary artery disease. 3. Request is to evaluate for orchitis, epididymitis or evidence of torsion. COMPARISON: , at 10:33. LEFT TESTIS: The left testis has a slightly heterogenous echotexture and demonstrates increased blood flow on Doppler examination on comparison with the right side. The estimated right atrial pressure is 5-10 mmHg. The mitral valve leaflets aremildly thickened. COMPARISON: Reference is made to a recent renal ultrasound of . The left epididymis appears slightly thickened and overall demonstrates increased blood flow in comparison with the right epididymis. PATIENT/TEST INFORMATION:Indication: Congestive heart failure. The left epididymis appears thickened in comparison with the contralateral side and there is increased blood flow in the left epididymis and testis. 7:22 AM SCROTAL U.S. PORT; DUPLEX DOPP ABD/PEL Clip # Reason: Eval for orchitis, epididymitis, torsion Admitting Diagnosis: SEPSIS MEDICAL CONDITION: 83 year old man with prostate CA, urosepsis now, with tender testes and swollen scrotum REASON FOR THIS EXAMINATION: Eval for orchitis, epididymitis, torsion FINAL REPORT INDICATION: 83-year-old male with prostate carcinoma and urosepsis, now has bilateral testicular tenderness and swelling. 11:19 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval line placement MEDICAL CONDITION: 83 year old man with new RIJ REASON FOR THIS EXAMINATION: eval line placement FINAL REPORT INDICATION: New right internal jugular central venous catheter. | 5 | [
{
"category": "Echo",
"chartdate": "2120-08-23 00:00:00.000",
"description": "Report",
"row_id": 71977,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Left ventricular function.\nHeight: (in) 71\nWeight (lb): 200\nBSA (m2): 2.11 m2\nBP (mm Hg): 117/48\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 09:29\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler. Normal IVC diameter (>2.1cm) with >50% decrease\nwith sniff (estimated RA pressure (5-10 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Top normal/borderline dilated LV\ncavity size. Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild [1+]\nTR. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - patient unable to cooperate.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. The estimated right atrial pressure is 5-10 mmHg. Left\nventricular wall thicknesses are normal. The left ventricular cavity size is\ntop normal/borderline dilated. Due to suboptimal technical quality, a focal\nwall motion abnormality cannot be fully excluded. There is no ventricular\nseptal defect. Right ventricular chamber size and free wall motion are normal.\nThe diameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened. The\npulmonary artery systolic pressure could not be determined. There is no\npericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-08-23 00:00:00.000",
"description": "P SCROTAL U.S. PORT",
"row_id": 1209579,
"text": " 7:22 AM\n SCROTAL U.S. PORT; DUPLEX DOPP ABD/PEL Clip # \n Reason: Eval for orchitis, epididymitis, torsion\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with prostate CA, urosepsis now, with tender testes and swollen\n scrotum\n REASON FOR THIS EXAMINATION:\n Eval for orchitis, epididymitis, torsion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old male with prostate carcinoma and urosepsis, now has\n bilateral testicular tenderness and swelling. Request is to evaluate for\n orchitis, epididymitis or evidence of torsion.\n\n COMPARISON: Reference is made to a recent renal ultrasound of .\n\n TECHNIQUE: Grayscale and color Doppler were used to evaluate the scrotum and\n contents. This was a portable examination.\n\n FINDINGS:\n\n Bilateral scrotal subcutaneous edema is noted.\n\n RIGHT SIDE: The right testis has a homogenous echotexture. There is a small\n amount of simple appearing peritesticular fluid. The right epididymis\n contains a 5-mm simple epididymal head cyst.\n\n LEFT TESTIS: The left testis has a slightly heterogenous echotexture and\n demonstrates increased blood flow on Doppler examination on comparison with\n the right side. The left testis is surrounded by a complex hydrocele, the\n fluid containing thin internal septations. The left epididymis appears\n slightly thickened and overall demonstrates increased blood flow in comparison\n with the right epididymis. Again, note is made of a 4 x 3 mm epididymal head\n cyst.\n\n IMPRESSION:\n 1. Multiseptated fluid surrounding the left testis and epididymis. The left\n epididymis appears thickened in comparison with the contralateral side and\n there is increased blood flow in the left epididymis and testis.\n 2. Findings are suggestive of a left-sided epididymo orchitis.\n 3. No concerning mass lesions.\n Small epididymal head cysts as described.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1209471,
"text": " 10:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with hypotension\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old male with hypotension, here to assess for pulmonary\n infiltrate.\n\n COMPARISON: Semi-upright AP and lateral radiographs of the chest.\n\n TECHNIQUE: Portable semi-erect AP radiograph of the chest.\n\n FINDINGS: This study is technically limited by patient rotation and low\n inspiratory lung volumes. Allowing for this, there is unchanged blunting of\n the left costophrenic angle suggesting a stable left-sided pleural effusion\n with associated atelectasis. There is no definite focal consolidation. The\n right lung is grossly clear. There are no pneumothoraces. The cardiac\n silhouette is enlarged. The aorta is tortuous with calcification of the\n aortic knob. The mediastinal and hilar contours are stable and within normal\n limits. Degenerative changes are noted in the left shoulder joint.\n\n IMPRESSION: Stable small left-sided pleural effusion with associated\n atelectasis. No definite focal consolidation is seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1209481,
"text": " 11:19 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with new RIJ\n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New right internal jugular central venous catheter.\n\n COMPARISON: , at 10:33.\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: Right internal jugular central venous\n catheter tip terminates in the region of the SVC. No pneumothorax is present.\n The remainder of the chest is unchanged, with continued moderate size left\n pleural effusion and left basilar opacity likely reflecting atelectasis.\n\n IMPRESSION: Right internal jugular central venous catheter tip in the mid\n SVC. No pneumothorax.\n DFDdp\n\n"
},
{
"category": "ECG",
"chartdate": "2120-08-22 00:00:00.000",
"description": "Report",
"row_id": 178738,
"text": "Baseline artifact. Sinus rhythm. Low precordial voltage. Left anterior\nfascicular block. RSR' pattern in lead V2. Intraventricular conduction delay.\nNo previous tracing available for comparison. Clinical correlation is\nsuggested.\n\n"
}
] |
3,008 | 157,843 | Within less than ten minutes from arrival the patient was taken emergently to the Operating Room. He underwent an exploratory laparotomy which demonstrated some mesenteric bleeds and small bowel injuries. He had three segmental resections with segmental enterotomies and a primary repair of an injury to the ileum. He underwent an appendectomy. The patient was stable in the Operating Room and tolerated the procedure well. His postoperative course was unremarkable. He was alert, oriented and his pain was controlled with a morphine PCA. He was stable hemodynamically. He extubated with no difficulty and was sating well post extubation. He had an nasogastric tube connected to low wall suction with minimal output and he is NPO. His urine output was good and his kidney functions were maintained. His hematocrit on postoperative day #1 was 29.7 and his white count is down to 15.4. Perioperatively he was covered with Kefzol and Flagyl and these were discontinued. After arraignment by the police on , they requested that the patient be transferred to Hospital for further treatment and follow up. After discussion with the Surgical Service there the patient was transferred in stable condition with the following recommendations: 1. Continue current medications, heparin subcutaneously 5000 units b.i.d., Morphine PCA, currently at 1 mg q. 6 minutes with a lockout at 10 mg/hr and Pantoprazole 40 mg intravenously q. 24 hours; 2. The patient is currently NPO and has a nasogastric tube. Once he regains bowel function according to the examination of the following surgical team, nasogastric tube can be discontinued and diet advanced; 3. The patient is getting out of bed to chair currently, this should be continued. He can be ambulated as tolerated. It is recommended that he use his incentive spirometry as frequently as possible. Transfer was discussed with the surgical resident at Hospital and the patient is being transferred to the care of the attending, Dr. . , M.D. Dictated By: MEDQUIST36 D: 17:31 T: 17:26 JOB#: | 0700-1500;NEURO; AOOx3, MAE TO COMMAND DENIES NUMBNESS OR TINGLING.PERLA 3MM FLAT WITHDRAWN AFFECT.REMAINS CO-OPERATIVE WITH CARE.RESP; BILATERAL BREATH SOUNDS PRESENT.UPPER LOBES CLEAR DIMINISHED BIBASILAR.UNPRODUCTIVE COUGH ATTEMPTING TO USE I.S. NGT to LWS with sm amts of bilieous output. Right mainstem bronchus intubation. SUPINE AP CHEST: The study is limited by interferring trauma board. Cardiac, mediastinal and hilar contours are within normal limits. Pt denies nausea. ETT has tip in right mainstem bronchus and partial withdrawl by 3.5 cm is recommended. Elevated to 180/90's Lopressor 5mg iv x 3. Resp Care: PT RECEIVED FROM OR INTUBATED VIA #7.5 ETT SECURED 24CM AT LIP. pt with 3 periph IVs, l radial A-line. BS WNL.WOUND; ABDOMINAL WOUND OPEN TO AIR STAPLES WELL APPROXIMATED. BS BILAT RHONCHI. SATs 95-100% 3lnc.Abg's wnlGI: Abd firm nondistended. Pt arrived intubated, taken directly to OR for ex-lap due to visiable GSW with hemmorhage and grossly positive DPL. SX'ING BY RT. Ex-lap incision approximated/intact without drainage.ENDO: Glucose wnlID: Tmax 99.7 Levo/Flagyl/Kefzol.SOCIAL: Followed by social work/plan to arraign this am.A/P: Transfer to floor. Heparin/p-boots.SKIN: Entrance wnd right lower quadrant with penrose drain intake draining sm amts of sanginous fluid. BP maintaining @ 160's/80's.RESP: Lung sounds clear. NPO status maintained. Extremites warm and well perfused, easily palpable pulses.GI: Abd distended, midline abd incision with DSD; 2 GSW, 1 to RUQ, 1 to LLQ, both with penrose drains in place and DSD. 2GM mag given on admission, lytes otherwise stable.Skin: Intact other than GSW X2 and incision.Endo: FS persistantly elevated, recent FS to 160.ID: Afebrile; on flagyl, ancef and levoflox;Social: See SW note; multiple family members phoning into unit for updates on pt. Check position of endotracheal tube. WITH PENROSE DRAINS DRAINING SEROSANGUINOUSUSING MSO4 PCA WITH GOOD EFFECT. The heart, lungs, pleura and mediastinum are well within normal limits. DR. Pt arrived to SICU intubated and sedated, aggressively fluid ressucitated, stablized and extubated in afternoon. NG tube has tip below the diaphragm. Logroll precautions and C-spine precautions maintained. FREQ. Pt lives in . for pt to be arraigned at bedside in AM. T. MAX 99.1 PO.HR 88-112 BP BY ALINE 168-189/85,BY NIBP 153/64T/SICU AWARE WILL ACCEPT HTN AT PRESENT.G/U; CONTINUES TO PUT OUT GOOD QUANTITIES OF URINE.CLEAR YELLOW WITH SOME WHITE SED .G/I; NPO ,NO BS,NO STOOL,NO FLATUS. Exit wnd left lower quadrant with penrose drain intact with scant amts of drainage. Trauma team was notified. PLAN TO WEAN AS TOL AND EXTUBATE TODAY IF POSS. R.O F.B. N.P.N. PORTABLE ABDOMEN: The NG tube is identified with its tip in the stomach. There are surgical clips in the midline, surgical sutures are seen to the right of L3. The endotracheal tube and NG tube are in good position. TSICU NPNNEURO: A&Ox3. Denies areas of numbness tingling. Cough/gag intact.COMF/MOB:Pain controlled with 2mg Mso4 ivp q 1-2 hours. INR 1.5 on admissions, no intervention at this time, SC heparin held per dr. . NGT to LWS, minimal bilious output.GU/renal: Large fluid requirement due to acidosis; u/o 60-200cc/hr. Pt is under State Police custody at current time, plan for pt to be arraigned at bedside in AM.PMH/PSH:s/p tonsillectomy as a childALL: NKDAMeds PTA: NoneROS:Neuro: Pt awake, alert and oriented X3 and following commands, MAE. Diminished at bases. Patient able to sufficiently turn with cue/mod assistance. NPO. DRAINING SCANT AMOUNTS SEROUS DRAINAGE. Lungs CTAB, strong cough noted.Cardiac: ST, 100-130's, BP stable, SBP 120-150's. 9:38 AM PORTABLE ABDOMEN IN O.R. Hct 38.5 up from 38.3, no transfusions post-op. Pt noted to have multiple areas of injured bowel, s/p resection, primary repair of terminal ileal injury and appy. IMPRESSION: 1. Pupils 3mm/bsk.MAE. FINAL REPORT INDICATIONS: History of wounds to the abdomen, now for incorrect count. Clip # Reason: H/O GSQ OF THE ABD, MOW FOR INCORRECT COUNT. RR12-17 SATS 97-100% ON 3LFIO2.CVS. Pt rec'd 3L IVF bolus prior to extubation for significant metabolic acidosis; current IVF is LR at 150cc/hr. Pager . Pager . SOCIAL WORK NOTE:New trauma pt on T-SICU. Tol well.CV:HR 80-100's BP with overall hypertensive picture. BELLY SOFT NON DISTENDED. Pt is being transferred to Hospital later today and remains in custody and under arrest. The NG tube tip is in the distal portion of the stomach. IMPRESSION: No significant cardiopulmonary abnormality. Protonix.GU: u/o ~100cc/hr clear yellow urine vis Foley cath.HEME: HCT 34. father, , knows that pt is here. ENTRANCE AND EXIT WOUNDS ON EITHER SIDE OF ABDOMEN. 3. Patient states adequate pain control and falls into nap state easily. Free intraperitoneal gas cannot be excluded on this supine study. Lungs appear clear with no pneumothoraces. Cooperative but overall withdrawn. In the left lower lower quadrant there is a tubular structure which might represent a drain. NOT REQ. MSO4 IMG DOSE 6MIN LOCKOUT 10 MGS /HR TOTAL DOSE.SOC. This SW spoke with pt after arraignment and he is aware of planned transfer. Pupils 2-3mm and reactive. 2. This SW is available as needed. No central access. Pt with large EBL intra-op (3L), large fluid/blood requirements (5U PRBCs, 6.5L IVF), significant metabolic acidosis throughout case and in T-SICU. COMPARISON: None. FINDINGS: The endotracheal tube is well positioned with its tip approximately 5 cm above the carina. He states that pt will likely be arraigned at bedside tomorrow. Pt in 4pt restraints for pt/staff safety due to nature of incident preceding pt's injury. Osseous structures show no fractures. The presence of intraabdominal free gas cannot be assessed on this supine study. No pneumothorax or other abnormalities of the chest. There are no pleural effusions. No pneumothorax is seen. RED. Cont with Police coverage and no visitors or phone calls at this time. Police guard at door.Resp: Extuabted at 3pm, sats 98% on 3L NP. due to nature of injury, pt is on police guarde, and per state police pt is not to have visitors. No unexplained radiopaque foreign bodies are seen in the chest. | 9 | [
{
"category": "Radiology",
"chartdate": "2183-08-06 00:00:00.000",
"description": "O PORTABLE ABDOMEN IN O.R.",
"row_id": 767580,
"text": " 9:38 AM\n PORTABLE ABDOMEN IN O.R. Clip # \n Reason: H/O GSQ OF THE ABD, MOW FOR INCORRECT COUNT. R.O F.B.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: History of wounds to the abdomen, now for incorrect count.\n\n PORTABLE ABDOMEN: The NG tube is identified with its tip in the stomach. There\n are surgical clips in the midline, surgical sutures are seen to the right of\n L3. In the left lower lower quadrant there is a tubular structure which might\n represent a drain.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2183-08-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 767585,
"text": " 9:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: REval ETT position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 37 year old man with\n REASON FOR THIS EXAMINATION:\n REval ETT position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post gun shot wound chest and abdomen. Check position\n of endotracheal tube.\n\n FINDINGS: The endotracheal tube is well positioned with its tip approximately\n 5 cm above the carina. The NG tube tip is in the distal portion of the\n stomach. The heart, lungs, pleura and mediastinum are well within normal\n limits. There is no evidence of any pulmonary infiltrate or effusion. No\n pneumothorax is seen.\n\n IMPRESSION: No significant cardiopulmonary abnormality. The endotracheal\n tube and NG tube are in good position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-06 00:00:00.000",
"description": "TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT)",
"row_id": 767552,
"text": " 4:58 AM\n TRAUMA SERIES (LAT C-SPINE, AP CXR, AP PELVIS PORT) Clip # \n Reason: s/p gunshot wound to chest/abd\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old man with\n REASON FOR THIS EXAMINATION:\n s/p gunshot wound to chest/abd\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post gunshot wound to chest and abdomen.\n\n COMPARISON: None.\n\n SUPINE AP CHEST: The study is limited by interferring trauma board. ETT has\n tip in right mainstem bronchus and partial withdrawl by 3.5 cm is recommended.\n NG tube has tip below the diaphragm. Cardiac, mediastinal and hilar contours\n are within normal limits. Lungs appear clear with no pneumothoraces. There\n are no pleural effusions. No unexplained radiopaque foreign bodies are seen\n in the chest. Osseous structures show no fractures. The presence of\n intraabdominal free gas cannot be assessed on this supine study.\n\n IMPRESSION: 1. Right mainstem bronchus intubation. Trauma team was notified.\n 2. No pneumothorax or other abnormalities of the chest.\n 3. Free intraperitoneal gas cannot be excluded on this supine study.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-08-06 00:00:00.000",
"description": "Report",
"row_id": 1300995,
"text": "SOCIAL WORK NOTE:\nNew trauma pt on T-SICU. Pt is s/p gun-shot wounds after allegedly shooting a police sergeant who was responding to 911 calls from two women. The police sergeant is at another hospital. Pt lives in . Pt is a 37 year old man. Other history is not known at this time. Pt is under arrest and State Police are here on unit to watch pt who is in 4-point restraints. father, , knows that pt is here. Pt is not allowed to have visitors. This SW spoke with State Police Trooper who is here at this time. He states that pt will likely be arraigned at bedside tomorrow. This SW is available as needed. Pager .\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-08-06 00:00:00.000",
"description": "Report",
"row_id": 1300996,
"text": "Resp Care: PT RECEIVED FROM OR INTUBATED VIA #7.5 ETT SECURED 24CM AT LIP. BS BILAT RHONCHI. NOT REQ. FREQ. SX'ING BY RT. PLAN TO WEAN AS TOL AND EXTUBATE TODAY IF POSS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-08-06 00:00:00.000",
"description": "Report",
"row_id": 1300997,
"text": "SICU Admit note\nPt is a 37 yr old male admitted to TSICU from OR s/p ex-lap for gunshot wound to abd. Pt was allegedly involved in an altercation with 2 women who called 911, when police arrived, shots were fired and both pt and police officer were struck. Pt arrived intubated, taken directly to OR for ex-lap due to visiable GSW with hemmorhage and grossly positive DPL. Pt noted to have multiple areas of injured bowel, s/p resection, primary repair of terminal ileal injury and appy. Pt with large EBL intra-op (3L), large fluid/blood requirements (5U PRBCs, 6.5L IVF), significant metabolic acidosis throughout case and in T-SICU. Pt arrived to SICU intubated and sedated, aggressively fluid ressucitated, stablized and extubated in afternoon. Pt is under State Police custody at current time, plan for pt to be arraigned at bedside in AM.\n\nPMH/PSH:\ns/p tonsillectomy as a child\n\nALL: NKDA\n\nMeds PTA: None\n\nROS:\nNeuro: Pt awake, alert and oriented X3 and following commands, MAE. Pupils 2-3mm and reactive. Logroll precautions and C-spine precautions maintained. Pt in 4pt restraints for pt/staff safety due to nature of incident preceding pt's injury. Police guard at door.\n\nResp: Extuabted at 3pm, sats 98% on 3L NP. Lungs CTAB, strong cough noted.\n\nCardiac: ST, 100-130's, BP stable, SBP 120-150's. Pt rec'd 3L IVF bolus prior to extubation for significant metabolic acidosis; current IVF is LR at 150cc/hr. pt with 3 periph IVs, l radial A-line. No central access. Hct 38.5 up from 38.3, no transfusions post-op. INR 1.5 on admissions, no intervention at this time, SC heparin held per dr. . Extremites warm and well perfused, easily palpable pulses.\n\nGI: Abd distended, midline abd incision with DSD; 2 GSW, 1 to RUQ, 1 to LLQ, both with penrose drains in place and DSD. NPO status maintained. Pt denies nausea. NGT to LWS, minimal bilious output.\n\nGU/renal: Large fluid requirement due to acidosis; u/o 60-200cc/hr. 2GM mag given on admission, lytes otherwise stable.\n\nSkin: Intact other than GSW X2 and incision.\n\nEndo: FS persistantly elevated, recent FS to 160.\n\nID: Afebrile; on flagyl, ancef and levoflox;\n\nSocial: See SW note; multiple family members phoning into unit for updates on pt. due to nature of injury, pt is on police guarde, and per state police pt is not to have visitors. for pt to be arraigned at bedside in AM. Of note, pt lives with his father , and has children, is 14, is 10.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-08-07 00:00:00.000",
"description": "Report",
"row_id": 1300998,
"text": "TSICU NPN\nNEURO: A&Ox3. Cooperative but overall withdrawn. Pupils 3mm/bsk.\nMAE. Denies areas of numbness tingling. Cough/gag intact.\n\nCOMF/MOB:Pain controlled with 2mg Mso4 ivp q 1-2 hours. Patient states adequate pain control and falls into nap state easily. Patient able to sufficiently turn with cue/mod assistance. Tol well.\n\nCV:HR 80-100's BP with overall hypertensive picture. Elevated to 180/90's Lopressor 5mg iv x 3. BP maintaining @ 160's/80's.\n\nRESP: Lung sounds clear. Diminished at bases. SATs 95-100% 3lnc.\nAbg's wnl\n\nGI: Abd firm nondistended. NPO. NGT to LWS with sm amts of bilieous output. Protonix.\n\nGU: u/o ~100cc/hr clear yellow urine vis Foley cath.\n\nHEME: HCT 34. Heparin/p-boots.\n\nSKIN: Entrance wnd right lower quadrant with penrose drain intake draining sm amts of sanginous fluid. Exit wnd left lower quadrant with penrose drain intact with scant amts of drainage. Ex-lap incision approximated/intact without drainage.\n\nENDO: Glucose wnl\n\nID: Tmax 99.7 Levo/Flagyl/Kefzol.\n\nSOCIAL: Followed by social work/plan to arraign this am.\n\nA/P: Transfer to floor. Cont with Police coverage and no visitors or phone calls at this time.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-08-07 00:00:00.000",
"description": "Report",
"row_id": 1300999,
"text": "SOCIAL WORK NOTE:\nPt arraigned today with his state defense attorney present. Judge and other court representatives came to pt's room and hospital security were present. Pt is being transferred to Hospital later today and remains in custody and under arrest. This SW spoke with pt after arraignment and he is aware of planned transfer. Pager .\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-08-07 00:00:00.000",
"description": "Report",
"row_id": 1301000,
"text": "N.P.N. 0700-1500;\n\nNEURO; AOOx3, MAE TO COMMAND DENIES NUMBNESS OR TINGLING.PERLA 3MM FLAT WITHDRAWN AFFECT.REMAINS CO-OPERATIVE WITH CARE.\n\nRESP; BILATERAL BREATH SOUNDS PRESENT.UPPER LOBES CLEAR DIMINISHED BIBASILAR.UNPRODUCTIVE COUGH ATTEMPTING TO USE I.S. RR12-17 SATS 97-100% ON 3LFIO2.\n\nCVS. T. MAX 99.1 PO.HR 88-112 BP BY ALINE 168-189/85,BY NIBP 153/64\nT/SICU AWARE WILL ACCEPT HTN AT PRESENT.\n\nG/U; CONTINUES TO PUT OUT GOOD QUANTITIES OF URINE.CLEAR YELLOW WITH SOME WHITE SED .\n\nG/I; NPO ,NO BS,NO STOOL,NO FLATUS. BELLY SOFT NON DISTENDED. BS WNL.\n\nWOUND; ABDOMINAL WOUND OPEN TO AIR STAPLES WELL APPROXIMATED. RED. DRAINING SCANT AMOUNTS SEROUS DRAINAGE. ENTRANCE AND EXIT WOUNDS ON EITHER SIDE OF ABDOMEN. WITH PENROSE DRAINS DRAINING SEROSANGUINOUS\nUSING MSO4 PCA WITH GOOD EFFECT. MSO4 IMG DOSE 6MIN LOCKOUT 10 MGS /HR TOTAL DOSE.\n\nSOC. PATIENT ARRAIGNED AND CHARGED INFRONT OF JUDGE CURTAIN THIS AFTERNOON.FATHER CALLED AND WAS DIRECTED TO CONTACT PATIENTS LEGAL REPRESENTATION.\nTO BE TRANSFERRED TO HOSPITAL. ARRANGEMENTS MADE WITH CAPTAIN OF THE SHERIFFS OFFICE FOR TRANSFER APPROXIMATELY AT 1730 THIS AFTERNOON.AMBULANCE ARRANGED WITH AMBULANCES PATIENT REMAINS WITH HANDCUFFS ON RIGHT ARM LEATHER RESTAINT ON LEFT TWO OFFICERS ONE FROM STATE POLICE AND OTHER FROM TRIAL COURT.IN ATTENDENCE.\n"
}
] |
28,212 | 190,127 | A/P:Mr. is a 81yo male with LVEF 25%, mult CABG, MVR, DM, AF on coumadin, s/p PPM, s/p evacuation of iatrogenic pseudoaneurysm, RUE DVT-on coumadin, called out of MICU. Pt initially transferred to for R subclavian pseudoaneurysm repair, transferred to the MICU for hypotension, somnolence, and increasing oxygen requirement. Diuresed and transferred out to the floor. . 1)Hypoxia: likely secondary to CHF exacerbation in the setting of chronic co2 retention. S/p significant diuresis with lasix gtt, stopped on . Now continues to diurese on his own. Torsemide was restarted at low doses, but became dehydrated so was held as of . Diamox was added along with torsemide for high bicarb, but studies have shown that this does not add any benefit in heart failure patients so it was stopped. He was found to be - breathing at night, so we have maintained him on BiPAP 12/8 with moderate benefit. He can continue to be maintained on CPAP 8 on the floor. He does continue to have continued O2 requirement however, possibly due to atelectasis vs continued volume overload and hypercapnea. He was ruled out for aspiration by speech and swallow on , and although he has improved from initial MICU transfer, respiratory status will still need to be addressed. On the floor, pt's 02 requirement became much less, sating anywhere from 92-98% on 2L-RA. . 2)Hypotension secondary to hypovolemia: brief and now resolved. No evidence of sepsis, thought to be secondary to diuresis. Because of pt's acute systolic CHF, he required diuresis. However, he had been difficult to diurese as boluses of diuretics transiently had caused hypotension. Pt's BP has been stable since transfer out of the MICU on the new regimen. . 3)Acute on chronic renal failure: Patient has stage 3 CKD at baseline. s/p diuresis and now auto-diuresis, patient's creatinine continues to improve and is now below his baseline. Holding acei. Restarted torsemide and added diamox briefly but holding in the setting of dehdyration by labs. . 4)Acute on chronic systolic heart failure: Likely exacerbated by significant amount of fluids he received during peri-operative period. Repeat ECHO with global systolic hypokinesis with LVEF 30-40%. ACE held due to renal failure, then restarted. S/P lasix gtt for diuresis which was stopped on and torsemide readded. Low dose beta blocker added on AM of . . 5)Right upper extremity weakness: Likely brachial plexus injury in the setting of recent R subclavian pseudoaneurysm repair. MRI not possible at this time due to pacemaker. Pt has been seen by physical and occupational therapy who should continue to work with him in the rehab setting. In addition, pt has a volar split that should remain in place during the night and for 2 hours/off/on during the daytime hours. If weakness persists, pt should have further evaluation by neurology with perhaps and EMG. . 6)Right upper extremity DVT: In setting of PICC line. Patient is already on Coumadin for atrial fibrillation. INR is 2.3 today. PICC line replaced on (now in LUE). . # Pseudoaneurysm: Iatrogenic R axillary artery PSA and hematoma from OSH in setting of central line placement. Transferred on , s/p R sublclav exploration, arteriotomy closure, clavicle rsxn, & hematoma evac . Vascular surgery following and arrangement is made for pt to f/u in 2 weeks with Dr. . Staples and sutures were removed on , day of discharge. Wound evaluated by vascular surgery. . 7)Hyperbilirubinemia: With mixed hyperbilirubinemia (both direct and indirect). With e/o cholelithiasis, no abdominal pain. Pt underwent RUQ u/s for further evaluation which found no cause. Bilirubin trended down. . 8)Diabetes type 2 uncontrolled: Pt was continued glargine 20 qhs and a regular insulin SS was added. . 9)CAD: PT was continued on ASA. His ACEI and BB were restarted upon discharge from the MICU> . # Delirium: Per pt's wife this is not new and often occurs at home and in the hospital setting. Pt was given frequent reorientation and lines and tubes were minimized. In addition, wife states pt tends to be sleepy during the day and this is not new. Pt on occasion has become confused in the evenings. Seroquel may be given prn. . 9)FEN: dysphagia diet, speech and swallow cleared. . | Old Right neck JP site oozing moderate serosanguinous; dsg changed x2. Pt is COPD/Co2 retainer.GI: Abd distended/ SNT w/ +BS x4. Right supraclavicular staples from the recent hematoma evacuation is noted. reason for hypotenstion/lethargy; held here in unit today. 1100-190077yoM Aditted to MICU7 @1015 from w/ Hypotenstion and lethargy. Total body pitting edema and weakness.CV: HR 60's VPaced w/ frequent PVC'c. Has extensive cardiac/ Afib Hx and had been on coumadin @ home.Resp: Lungs diminished. Single lead pacemaker device, with the right ventricular lead is evident. right groin tl dsg changed/intact. Pt is retainer; goal SATs 87-92%.GI/GU: ABD/ distended/SNT w/ +BS x4. npn 23:00-07:00 (please also see carevue flownotes for objective data)dx: OR for Rt subclavian artery pseudoanurysm2 L EBL, receuved 3 units PRBCs, 1 unit FFP;81M admitted w/ hx CAD, CABG , chronic afib w/ PPM set at 60;admitted to OSH for w/u sepsis/CHF; in ER dur attempt rt subclav cvl placement, SC artery punctured, developed pseudoaneurysm/hematoma; transferred to for tx of aboveSedated overnight on low dose propofol, mcgs, likely plan to extubate on day shift;Pt responsive to questions w/ nod of head;ABG alk despite elevated pCO2 to 54, pt likely CO2 retainer;in PS/CPAP overnoc on 0.50;05:00 a.m. RISBI good per resp therapist, will likely extubate this a.m.;PPM at 60, pt w/ non to occasional PVC's; a.m. serum K+ wnls, not repleated acc to cardiac status d/t elevated creatinine 1.7; pt's reported pre-hospital baseline 1.7;1/2 dose lopressor given at 12a d/t parameters;received 2 gms calcium gluconate for low Ion ca++ per a.m. labs;pt s/p multiple blood transfusions, citrate likely binding to Ca++;briefly on insulin gtt, off again early in a.m.; need to make sure to check FS's before IV Cipro given, is mixed in D5;rt neck/subclav area w/ much swelling, bruising; pt's back also w/ much superficial bruising--likely d/t elevated coags and pt being transferred to and from OR table;rt neck/subclav drssg w/ sm amt sero-sang drainage;JP w/ small amts drainage, clot in bulb;a-line w/ sharp wave-form though mildy positional;rt fem cvl patent;left forearm PIV hurt at flushing, will be dc'd;a.m. labs showed stable hct and INR, though mild correction w/ PRBC's, and no correction w/ FFP given approx 12a; no new blood products were ordered for these 02:10 labs results;pt's Lt hand does go for ETT when untied, therefore limb immobilizer utilized to prevent pt self harm;Rt arm flaccid so far, no movement; + mvt other 3 extremities;PLAN:1) likely serial hcts, PTT/INR, and Ion Ca++ still today2) wean on propofol, likely extubation today3) IV abx as ordered4) further plans per a.m. rounds The right ventricular free wall ishypertrophied. Trace aortic regurgitation is seen. Moderateglobal LV hypokinesis. Trivial (intravalvar)mitral regurgitation is seen. Portable chest reveals marked cardiomegaly, in the setting of prior median sternotomy and valve replacement. The aorta is atherosclerotic and ectatic. CXRay today reveals "s/p median sternotomy and mult. Unchanged small right pleural effusion and right basilar atelectasis is noted. A right PICC line terminates in the distal SVC. The right ventricular cavity is dilated with depressed freewall contractility. Focal calcifications in aortic root.Mildly dilated ascending aorta. Thickened MVRleaflets.. Normal MVR gradient. REMAINS A DNR/DNI.PT. DENIES PAIN AT THIS TIME.CV: PT WITH AN UNDERLYING RYTHYM OF AFIB. Remove indwelling right-sided PICC. There is bibasilar atelectasis with tenting of the left diaphragmatic pleura, unchanged. There is a left upper extremity PICC line to the superior vena cava. eff., R base atelect.". PT HAS PLUS 2 PITTING EDEMA IN LOWER EXT BILATERALLY. Moderately dilated LV cavity. The indwelling right PICC was then removed. The trachea is midline. Abnormal systolic septal motion/position consistent with RV pressureoverload.AORTA: Moderately dilated aortic sinus. SCROTUM IS EDEMATOUS. IMPRESSION: Unchanged bilateral pleural effusions, moderate on the right and small on the left, with associated bibasilar atelectasis. There is moderate pulmonary artery systolichypertension. An endotracheal tube has been inserted and terminates at the thoracic inlet. There is mild symmetric leftventricular hypertrophy. ]TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. PT HAD MED SIZED BM THIS AM. ON COUMADIN FOR AFIB. ABG reveals compensated resp acidosis w/ hypoxia. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. PATIENT/TEST INFORMATION:Indication: Left ventricular functionHeight: (in) 68Weight (lb): 185BSA (m2): 1.98 m2BP (mm Hg): 129/64HR (bpm): 60Status: InpatientDate/Time: at 09:47Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Marked LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. OTHERWISE, PT. ABP 130'S-170'S. There is abnormal systolic septal motion/positionconsistent with right ventricular pressure overload. valve replacements. The right atrium is markedly dilated. Nebs given per order. Left PICC terminating at the brachiocephalic confluence is noted. Resp CarePt placed on BIPAP for noc use tol BIPAP well, ALB/ATR nebs were given. LYTES PER CAREVUE. LYTES PER CAREVUE. REMAINS A DNR/DNI AT THIS TIME.PT. CXR DONE.GI/GU: ABD SOFT AND DISTENDED WITH +BS. If hypotensive; tx w/ colloid and continue diuresis. LS CLEAR WITH DIMINISHED BASES. LS CLEAR WITH DIMINISHED BASES. OTHERWISE PT. Aline, slightly dampened-correlates w/ NIBP.Pulm: on/off bipap throughout day. Abd distended/ SNT. Did expectorate small amount of pale, yellw/tan sputum w/ Neb and CPT. uop 80-220cc/hr.skin: sutures c/d/i--dsd in place. HAS BEEN AFEBRILE. NEBS AS ORDERED. HAS NKDA.PT. S1S2, murmur noted. AFEBRILE. Frequentventricular ectopy. 2+ PERIPHERAL EDEMA. Has B/L pleural effusions. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. HHN given as ordered. Plan: cont nebs/bipap. CONTINUES WITH 2+ LE AND RUE EDEMA. Plan: wean as tol. GENERALIZED PITTING EDEMA.GI: ABD IS SOFT, DISTENDED. loose bm's overnight.Gu: foley w/ adequate clear/yellow output. Creatine stable 2.4. BP 118-154/36-62. Bipap hs.GI: abd soft, bs +, denies nausea. HS GLARGINE AND SSRI Q6HRS. POSSIBLE RESTART FOR TODAY SINCE U.O IS STARTING TO TREND DOWN.PT'S LUNGS REMAIN COARSE, AND DIMINIHED BIBASILAR. Answers questions appropriately w/ intermittent confusion. ABG 7.43/55/63/38. Compared to the previous tracing ventricular ectopy isnew. FOLLOWS COMMANDS APPROPIATELY. currently on 3L NC-keep sats 88-92. lungs diminished BUL w/ bibalsilar crax. PERL. colace held, secondary to mult. Resp CarePt was found on NIV, he was maintained on NIV. SS TIGHTENED. PT IS . Respiratory Care:Pt recieved on NIPPV. CREAT UNCHANGED @1.7.FEN: HELD HS DIURETICS, STILL -11.2L LOS. FS Q6HRS WITH SSRI AND HS GLARGINE. Tolerating Lasix gtt. Encourage PO as tolerates. PPP. PPP. Pt currently on NC. Placed on N/C in AM. DENIES SOB.GI/GU: ABD SOFT AND DISTENDED WITH +BS. MAE EXCEPT RUE. taking pos's w/o difficulty. ABG WNL (compensated resp acidosis) BS clear, decreased L base. Tol w/o incident. nursing note 7a-7pPt remains DNR/DNINeuro: L pupil pinpoint and sluggish (baseline) R pupil 2 mm and briskly reactive. | 48 | [
{
"category": "Nursing/other",
"chartdate": "2108-06-09 00:00:00.000",
"description": "Report",
"row_id": 1631116,
"text": "Resp Care\nPatient was started on non invasive vent. at 2400 due to hypercarbia,somnulence. After 3 hours, pt was awake and taken off the vent. Currently on 35% face tent with sats in mid 90s.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-09 00:00:00.000",
"description": "Report",
"row_id": 1631117,
"text": "nursing add:\nInsulin gtt started for blood sugars >300. titrated per cvicu protocol. Wean to off as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-09 00:00:00.000",
"description": "Report",
"row_id": 1631118,
"text": "Resp Care\nPt from OR intubated. Current vent settings: A/C 500 x 12 5P 50%. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-09 00:00:00.000",
"description": "Report",
"row_id": 1631119,
"text": "0700-1900\n\nEvents: Patient sent to OR @ 0900; returned to @ 1100. S/P R subclavian exploration; evacuation of hematoma and repair of pseudoaneurysm. EBL 2L; recieved 3units PRBC and 1 unit FFP intra-op. Post HCT 31 and INR 2.1; received another 2units FFP @1600. Remains intubated on propofol. HCT checks Q6 hours. RUE still not moving, even to painful stimuli. R femoral TCL and L brachial Aline placed in OR.\n\nNeuro: Prior to OR patient was confused and constantly yelling out in pain and yelling that he was \"going to die\"; \"why are you killing me\". Was not able to move RUE; but moving all other extremities with normal strength. Radial pulse to RUE is palable and extremity is eccymotic and swollen. Now sedated on Propofol 5cc/hour; is arousable and following commands and is still not moving RUE. PERRL.\nCV: VPaced @ 60 w/ occ. PVC. BP stable 110-130/40. Has never required pressors. Lopressor 5mg IVP Q6 hours. Has extensive cardiac/ Afib Hx and had been on coumadin @ home.\nResp: Lungs diminished. AC x12/5/500/50%. Occ. will overbreath vent 14-16 when stimulated. SATs 100%. Pt is COPD/Co2 retainer.\nGI: Abd distended/ SNT w/ +BS x4. NPO. FSBS have been 80s; remains off insulin gtt. 1/2NS @ 40cc/hour.\nGU: Foley w/ adequate OUP. Creatine 1.7\nID: Afebrile.\nHeme: Next set of labs due to be sent 1800. Continue Q6 hours.\nSkin: Eccymosis to R neck; L chest wall; Across back and flank. R fem TLC oozing. R PICC intact. Primary R neck dsg saturated w/ serosanguinous drainage. JP to R neck draining moderate bloody.\nSocial: Son and daughter both updated on the phone. They are planning on visiting today with patients wife.\n: Serial HCTs overnight. If patient remains hemodynamically stable, will extubate in am and possible transfer back to .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-09 00:00:00.000",
"description": "Report",
"row_id": 1631120,
"text": "CVICU NPN: see flowsheet for objective data\n\nHeme:26.3 @ 5pm being transfused with one unit PRBC's,to recieve 1 UFFP for INR 1.8\n\nEndocrine: insulin drip resumed at 8pm at 2U/hr increased 3 U/hr for FS 168,next FS 118 drip decreased to 1.5 at 11pm FS 122 now increased to 2.5 units/hr per protocol.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-10 00:00:00.000",
"description": "Report",
"row_id": 1631121,
"text": "npn 23:00-07:00 (please also see carevue flownotes for objective data)\n\ndx: OR for Rt subclavian artery pseudoanurysm\n2 L EBL, receuved 3 units PRBCs, 1 unit FFP;\n\n81M admitted w/ hx CAD, CABG , chronic afib w/ PPM set at 60;\nadmitted to OSH for w/u sepsis/CHF; in ER dur attempt rt subclav cvl placement, SC artery punctured, developed pseudoaneurysm/hematoma;\n\n transferred to for tx of above\n\nSedated overnight on low dose propofol, mcgs, likely plan to extubate on day shift;\nPt responsive to questions w/ nod of head;\n\nABG alk despite elevated pCO2 to 54, pt likely CO2 retainer;\nin PS/CPAP overnoc on 0.50;\n05:00 a.m. RISBI good per resp therapist, will likely extubate this a.m.;\n\nPPM at 60, pt w/ non to occasional PVC's; a.m. serum K+ wnls, not repleated acc to cardiac status d/t elevated creatinine 1.7; pt's reported pre-hospital baseline 1.7;\n1/2 dose lopressor given at 12a d/t parameters;\n\nreceived 2 gms calcium gluconate for low Ion ca++ per a.m. labs;\npt s/p multiple blood transfusions, citrate likely binding to Ca++;\n\nbriefly on insulin gtt, off again early in a.m.; need to make sure to check FS's before IV Cipro given, is mixed in D5;\n\nrt neck/subclav area w/ much swelling, bruising; pt's back also w/ much superficial bruising--likely d/t elevated coags and pt being transferred to and from OR table;\nrt neck/subclav drssg w/ sm amt sero-sang drainage;\nJP w/ small amts drainage, clot in bulb;\n\na-line w/ sharp wave-form though mildy positional;\nrt fem cvl patent;\nleft forearm PIV hurt at flushing, will be dc'd;\n\na.m. labs showed stable hct and INR, though mild correction w/ PRBC's, and no correction w/ FFP given approx 12a; no new blood products were ordered for these 02:10 labs results;\n\npt's Lt hand does go for ETT when untied, therefore limb immobilizer utilized to prevent pt self harm;\nRt arm flaccid so far, no movement; + mvt other 3 extremities;\n\nPLAN:\n1) likely serial hcts, PTT/INR, and Ion Ca++ still today\n2) wean on propofol, likely extubation today\n3) IV abx as ordered\n4) further plans per a.m. rounds\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-10 00:00:00.000",
"description": "Report",
"row_id": 1631122,
"text": "Resp Care\nRemains intubated and ventilated. Had been on a/c overnight but currently on cpap/psv 5/5/50% awaiting extubation this morning. RSBI = 43. Suctioned for scant clear secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-09 00:00:00.000",
"description": "Report",
"row_id": 1631115,
"text": "Nursing 7p-7a\n81yr old male w/significant cardiac pmh. Redo cabg/mvr . Presented to osh, was being treated for sepsis and chf. In osh ED during R SC vein CVL placement, R SC artery was punctured. Pt developed pseudoaneurysm/hematoma. Transferred to ( 5) for further management. Pt arrived to wearing fent patch to R arm. Per report from rn: 1mg SC dilaudid was to pt on 5. Desatted to 86% on RA, 92% 4L. NRB 100% was started for labored breathing, sats low 90s. Pt transferred to for ?increasing R neck hematoma. In pt placed on 100% FT, sat 100%. RR 7. ABG revealed pco2 of 80. Lethargic but arousable. Transferred to CVICU for bipap, possible intub. Family unaware of transfer.\n\nSee flowsheet for full assessment: Pt arrived on NRB 100%, sat 100%. Pupils pinpoint, nonreactive. Lethargic only arousable to sternal rub. Lungs coarse dim in bases. ABG revealed compensated resp acidosis, paO2 240. Fent patch removed. Team denied narcan at this time. Placed on bipap mmv 35% 5/5 for lethargy. No repeat abg needed NP . Pt became more alert after 1.5hr on bipap. Pt was yelling he was in pain. Bipap removed, pt began singing loudly. Placed on 35% FT w/sat 90s. Only Ox1-2. Stated he was in hosp then later stated he didn't know where he was and that he was dead. Bed alarm on. Pt was reassured/reoriented. Cont yelling that he was in pain in R shoulder. 0.25mg dilaudid sc prn NP . Team aware that pt unable to move R shoulder/arm.\n\nPt was ordered for urgent CTA of check to eval ?leak of pseudoaneurysm. Pt unable to lie flat even w/bipap on. Desatted to 70s w/tidal volumes <100. NP and MD aware. CT scan delayed until morning.\n\nPlan: monitor neuro/resp status. Monitor hematoma in R neck. CTA in am. ?return to . Orient, provide support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-10 00:00:00.000",
"description": "Report",
"row_id": 1631123,
"text": "Neuro: Received intubated & slightly sedated on propofol, following commands consistently, MAE's except RUE, PERRL 2mm brisk, sedation shut off & extubated, initially confused to place & time, Ox3 after reorientation\n\nCV: Afebrile; V paced 60's by perm pacer; SBP 120's-140's, getting ATC IV lopressor, tolerated well, palp pulses x4, RSC JP drain clotty with minimal serousang drainage; R brachial PICC +flush, -blood return\n\nResp: Received intuabte on CPAP 5/5 40%, ABG showing metabolic alkalosis, OK to extubate per team, +cuff leak, able to pick head off pillow, extubated without incident, now on 4L NC sat >95%\n\nGI: Abd soft, non-tender, +BS; tolerating ice chips & liquid, will advance diet as tol; hernia near umbillicus has no change per family\n\nGU: Foley draining clear yellow urine, UO adequate\n\nInteg: Multiple old bruises on chest & back\n\nPain: Denies pain\n\nID: Cont on vanco, cipro & flagyl\n\nActivity: Not OOB d/t elevated INR & fem CVL in place\n\nSocial: Family in for visit & updated, family wanted update from vascular team, paged every MD's listed under vascular on call list, no response from anyone\n\nPlan: Monitor hemodynamics, resp status; DC fem CVL to get OOB;l advance diet as tol; tranfer to /floor\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-11 00:00:00.000",
"description": "Report",
"row_id": 1631124,
"text": "7p-7a\nNeuro: Pt a/ox3, voice soft/slightly hoarse. perrla, moves extremites except right arm team aware, neurology following. Pt denies any pain.\n\nCV: v-paced with frequent pvc's, perm pacer vvi rate 60 lytes repleted, palpable pulses, sbp 130's, iv lopressor given every 6hours. right groin tl dsg changed/intact. ? d/c this am\n\nResp: ls dim bilat, sats 96% on nc 4l, open face tent for 1 hour with desats to 88%. is/chest pt done weaned off open face tent, still on 4lnc. ? restart lasix per pt home regimen.\n\nGI/GU: abd soft/slightly distended, +bs, foley to gravity draining adequate amounts of urine\n\nEndo: regular insulin sliding scale\n\nSkin: see flowsheet, bruising all over back/chest area, purple/healing, small amounts of serosng drainage over incision.\n\nSocial: no calls this shift\n\nPlan: ? transfer to /de-line, pulmonary toilet, ? lasix, pt/ot consults due to right arm immobility.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-20 00:00:00.000",
"description": "Report",
"row_id": 1631125,
"text": "1100-1900\n\n77yoM Aditted to MICU7 @1015 from w/ Hypotenstion and lethargy. Pt was transfered to on from OSH where he was being treated for sepsis and CHF. Developed R subclavian psuedoanuerysm/hematoma during central line placement and was transfered to for further management. Origionally was on the floor when he became lethargic and SOB; went to and developed severe respiratory acidosis with PCO2 of 80 and was continuing to de-saturate with increased respiratory effort on NRB. Transfered to CVICU and placed on Bi-pap (Pt has hx of COPD and CO2 retainer). Mental status improved with Bi-pap and was weaned off to NC. Went to OR here at on for evacuation of hematoma and repair of artery. Uneventful OR/ Post-op course. Extubated on ; transfered to on . Admit to MICU7 this am.\n\nPMH: Anemia, Uncontrolled DM2, MI and CABG ', re-do CABG/MVR with post-op endocarditis/cardiomyopathy w/ EF 25%, CRI w/ R nephrectomy, AFIB w/ permanent pacer VVI/60.\n\nNeuro: AAO x3 with periods of confusion. easily re-orients. Agitated, yelling out consistantly. Complains he hurts \"all over\". Asking to die. Constantly yelling \"ouch\". Received Haldol x2 overnight and ? reason for hypotenstion/lethargy; held here in unit today. Does not pull at medical equipement or attempt to get OOB, no restraints at this time. PERRL/pinpoint-2mm/brisk. Right arm paralysis from psuedoanuerysm/bleed. Has not moved since admission. Moves RLE in bed; weak. Able to lift and hold LUE/LLE. Total body pitting edema and weakness.\nCV: HR 60's VPaced w/ frequent PVC'c. BP 148/60 upon arriveal on Neo gtt; has remained off since arrival. Received 1 Liter NS in transport. BP 100-140/50. Started on Lasix gtt @ 1400 w/ 40mg IV bolus given. Foley was not draining; flushed and advanced w/ 400cc out. Will titrate gtt to UOP 100cc/hour for fluid overload/CHF. CXR done; pending. Coumadin held for tonight.\nResp: Lungs diminished @ bases. NC weaned to 1-2 liters NC. SATs 86-91% ABG: 48/34/7.31. Pt is retainer; goal SATs 87-92%.\nGI/GU: ABD/ distended/SNT w/ +BS x4. Has had soft, formed BM almost every hour. Tolerated regular/cardiac/diabetic diet. Needs to be fed. Foley patent. UOP goal 100cc/hour on Lasix gtt. Creat 2.4.\nSkin: Old eccymotic bruises to flank and back. Right neck incision intact w/ staples; no drainage. Old Right neck JP site oozing moderate serosanguinous; dsg changed x2. Rectal area pink; no open areas; moisture barrier applied w/ peri-care with stools.\nID: Afebrile. Blood cultures snet x1 off Aline; unable to get peripheral due to edema. HO aware. UA/Cult sent.\nEndo: RISS w/ no coverage. Lantus QHS.\nSocial: Have not heard from family since transfer to ICU. Wife is next of .\nPLAN: Monitor VS/Labs; titrate lasix gtt; maintain SATs 87-91%/ pulmonary toilet.\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1014675,
"text": " 11:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for acute pulmonary process\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CHF with acute hypoxia\n REASON FOR THIS EXAMINATION:\n evaluate for acute pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Congestive failure with acute hypoxia.\n\n FINDINGS: In comparison with the study of , there is little change.\n Again, there is enlargement of the cardiac silhouette in a patient with\n previous CABG and midline sternal sutures. Bilateral pleural effusions and\n elevated pulmonary venous pressure persists.\n\n IMPRESSION: Little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-15 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 1014674,
"text": " 9:43 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: evaluate CBD\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with coagulopathy and hyperbilirubinemia\n REASON FOR THIS EXAMINATION:\n evaluate CBD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old man with coagulopathy and hyperbilirubinemia. Please\n evaluate the common bile duct.\n\n No comparison is available.\n\n The liver demonstrates normal echogenicity. A simple cyst is noted within the\n left lobe of the liver measuring 17 mm. No other concerning liver lesion is\n noted. The liver demonstrates normal hepatopetal flow. Small amount of\n ascites is noted in the peritoneal cavity. The gallbladder contains stones\n with no evidence of cholecystitis. The common bile duct is in the upper limit\n of normal range measuring 6 mm. The right kidney contains a simple cyst\n within its lower pole measuring 36 x 32 x 30 mm. The spleen is enlarged\n measuring 13.6 cm. Incidental note is made of a small amount of right-sided\n pleural effusion.\n\n IMPRESSION:\n 1. The common bile duct has normal diameter for the patient age .\n 2. Cholelithiasis with no evidence of cholecystitis.\n 3. Small amount of ascites and right-sided pleural effusion.\n 4. Moderate splenomegaly.\n 5. Simple cyst of the left lobe of the liver.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1014121,
"text": " 10:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmonary edema?\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with desaturation. s/p R SCA hematoma evacuation POD3\n REASON FOR THIS EXAMINATION:\n pulmonary edema?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old man with desaturation status post right ICA hematoma\n evacuation, postop day 3. Evaluate for pulmonary edema.\n\n SINGLE AP UPRIGHT RADIOGRAPH OF THE CHEST AT 10:20 A.M.: Comparison is made\n with , radiograph.\n\n Accounting for positional changes, the bilateral moderate pleural effusions\n are unchanged. Retrocardiac opacity possibly representing left lower lobe\n atelectasis is unchanged. There is relatively better aeration in the right mid\n lung. Stable severe cardiomegaly with intact median sternotomy suture wire is\n evident. There is no evidence of volume overload. Right supraclavicular\n staples from the recent hematoma evacuation is noted. Single lead pacemaker\n device, with the right ventricular lead is evident. There is a mitral valve\n prosthesis.\n\n IMPRESSION: Unchanged moderate bilateral pleural effusions with stable severe\n cardiomegaly. No pneumonia or pulmonary edema. Unchanged bibasilar\n atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1014036,
"text": " 3:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?acute process\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with decreased O2 sats. h/o R subclavian artery injury, s/p\n embolectomy & repair\n REASON FOR THIS EXAMINATION:\n ?acute process\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 81-year-old man with increased O2 saturation, history of right\n subclavian artery injury status post embolectomy repair.\n\n FINDINGS:\n\n Severe stable cardiomegaly along with stable moderate left pleural effusion\n and worsening of right pleural effusion which is small to moderate. Worsening\n left lower lobe opacity likely atelectasis. A stable single left-sided\n pacemaker with a ventricular lead is unchanged. Surgical clips are seen in\n the right upper extremity.\n\n IMPRESSION:\n\n 1) Worsening moderate to severe right pleural effusion.\n\n 2) Stable moderate left pleural effusion.\n\n 3) Stable cardiomegaly.\n\n 4) Worsening left lower lobe atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1015750,
"text": " 3:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CHF exacerbation\n REASON FOR THIS EXAMINATION:\n please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 3:52.\n\n INDICATION: CHF - check for interval change.\n\n COMPARISON: at 04:00.\n\n FINDINGS:\n\n Cardiomegaly and bilateral effusions are again noted. Accounting for some\n positioning differences, I see no significant interval change. Upper lungs\n remain clear, and the pulmonary vasculature is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-14 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1014554,
"text": " 4:59 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place new PICC on pacer side. and remove right sided\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with right sided DVT\n REASON FOR THIS EXAMINATION:\n please place new PICC on pacer side. and remove right sided PICC\n ______________________________________________________________________________\n FINAL REPORT\n CLINICL HISTORY: 81-year-old male with right-sided DVT. Please place new\n PICC on pacer side. Remove indwelling right-sided PICC.\n\n RADIOLOGISTS: Dr. and attending radiologist, Dr. .\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right brachial\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a double-lumen PICC measuring 42.5 cm in length was then placed\n through the peel-away sheath with the tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest. The peel-away sheath and guidewire were\n then removed. The catheter was secured to the skin, flushed and a sterile\n dressing applied. The patient tolerated the procedure well. There were no\n immediate complications. The indwelling right PICC was then removed.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double-lumen\n PICC placement via the left brachial venous approach. Final internal length\n is 42.5 cm with the tip positioned in SVC. The line is ready for use.\n\n Indwelling right PICC was removed and adequate hemostasis was achieved with 5\n minutes of manual compression.\n\n\n\n"
},
{
"category": "Echo",
"chartdate": "2108-06-14 00:00:00.000",
"description": "Report",
"row_id": 85046,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function\nHeight: (in) 68\nWeight (lb): 185\nBSA (m2): 1.98 m2\nBP (mm Hg): 129/64\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 09:47\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV. Increased IVC diameter\n(>2.1cm) with <35% decrease during respiration (estimated RAP (10-20mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Moderate\nglobal LV hypokinesis. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. RV function depressed.\nParadoxic septal motion consistent with conduction abnormality/ventricular\npacing. Abnormal systolic septal motion/position consistent with RV pressure\noverload.\n\nAORTA: Moderately dilated aortic sinus. Focal calcifications in aortic root.\nMildly dilated ascending aorta. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). Thickened MVR\nleaflets.. Normal MVR gradient. Trivial MR. [Due to acoustic shadowing, the\nseverity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Thickened/fibrotic\ntricuspid valve supporting structures. Mild to moderate [+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is markedly dilated. The right atrium is markedly dilated. The\nestimated right atrial pressure is 10-20mmHg. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity is moderately dilated.\nThere is moderate global left ventricular hypokinesis (LVEF = 30-40 %). There\nis no ventricular septal defect. The right ventricular free wall is\nhypertrophied. The right ventricular cavity is dilated with depressed free\nwall contractility. There is abnormal systolic septal motion/position\nconsistent with right ventricular pressure overload. The aortic root is\nmoderately dilated at the sinus level. The ascending aorta is mildly dilated.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Trace aortic regurgitation is seen. A bioprosthetic mitral valve\nprosthesis is present. The prosthetic mitral valve leaflets are thickened. The\ntransmitral gradient is normal for this prosthesis. Trivial (intravalvar)\nmitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] The tricuspid valve\nleaflets are mildly thickened. The supporting structures of the tricuspid\nvalve are thickened/fibrotic. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-08 00:00:00.000",
"description": "RP UNILAT UP EXT VEINS US RIGHT PORT",
"row_id": 1013704,
"text": " 8:31 PM\n UNILAT UP EXT VEINS US RIGHT PORT Clip # \n Reason: ? hematoma size and arterial flow ? aa sizePICC line positin\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with SCA pseudoaa and hematoma\n REASON FOR THIS EXAMINATION:\n ? hematoma size and arterial flow ? aa sizePICC line positin\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old male with apparently known (from OSH) subclavian\n artery pseudoaneurysm and hematoma. Evaluate hematoma size and\n pseudoaneurysm.\n\n LIMITED RIGHT UPPER EXTREMITY DUPLEX DOPPLER ULTRASOUND: The prompting\n OSH studies are not currently available to us. There is an 8.5 x 3.2 x 2.5 cm\n hematoma in the right subclavian region. Within this larger hematoma, there is\n a 2.3 x 2.0 x 2.0 cm pseudoaneurysm with a neck measuring 5 mm in width x 7 mm\n in length, originating directly from the subclavian artery.\n\n IMPRESSION:\n 2 cm pseudoaneurysm off of the right subclavian artery, within the large\n hematoma in this region.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1015300,
"text": " 12:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with worsening hypoxia\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old man with worsening hypoxia, assess for interval\n change.\n\n COMPARISON: .\n\n SINGLE BEDSIDE RADIOGRAPH OF THE CHEST AT 12:50 P.M.: There are bilateral\n pleural effusions, moderate on the right and small on the left, unchanged.\n There is bibasilar atelectasis with tenting of the left diaphragmatic pleura,\n unchanged. There is no pulmonary edema. There is no pneumothorax. Pacer\n device with a single ventricular lead is in unchanged location. Left PICC\n terminating at the brachiocephalic confluence is noted.\n\n IMPRESSION: Unchanged bilateral pleural effusions, moderate on the right and\n small on the left, with associated bibasilar atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1015512,
"text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval progression\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CHF, hypoxia\n REASON FOR THIS EXAMINATION:\n eval progression\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 81-year-old man with congestive heart failure and hypoxia, evaluate\n for progression.\n\n FINDINGS:\n\n The moderate-to-severe cardiomegaly is stable. The bilateral right more than\n left small-to-moderate pleural effusion is also stable. Pulmonary vascularity\n is still engorged and ill defined indicative of a volume overload. The left\n subclavian PICC line tip terminates in the SVC. A single-leaded left\n pacemaker is stable in location. The patient is status post cardiothoracic\n surgery.\n\n IMPRESSION:\n\n No change concerning the moderate-to-severe cardiomegaly, mild pulmonary\n edema, and bilateral small-to-moderate right more than left pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-18 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1015006,
"text": " 7:37 AM\n RENAL U.S. Clip # \n Reason: r/o hydro, other renal pathology; please evaluate with doppl\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with CHF, DM, A-fib with worsening renal function on diuretics\n and now oliguric. Pt does not have left kidney\n REASON FOR THIS EXAMINATION:\n r/o hydro, other renal pathology; please evaluate with dopplers\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old man with single right kidney presenting with\n worsening renal function, past medical history of congestive heart failure,\n diabetes, and atrial fibrillation.\n\n FINDINGS: The right kidney measures 11.7 cm. The cortex is thin; however,\n echogenicity is within normal limits. Multiple simple cysts are noted in the\n renal parenchyma, the largest arising from the lower pole and measuring 4.0 x\n 3.5 x 3.3 cm. The urinary bladder is collapsed around a Foley catheter.\n\n Color Doppler flow and arterial waveforms were obtained from upper, mid and\n lower renal pole arteries.\n\n IMPRESSION:\n\n 1. Single right kidney, with renal cortical thinning but normal echogenicity.\n\n 2. Multiple simple renal cysts.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1013769,
"text": " 2:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check ETT location\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man intubated s/p evacuation of subclavian hematoma.\n REASON FOR THIS EXAMINATION:\n check ETT location\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Check ET tube location after intubation.\n\n One view.\n\n Comparison with .\n\n The patient is status post median sternotomy and valve replacement surgery as\n before. There is hazy at the lung bases consistent with pleural fluid and\n increased density in the retrocardiac area consistent with atelectasis and/or\n consolidation, not significantly changed. A transvenous pacemaker and PICC\n line remain in place. An endotracheal tube has been inserted and terminates\n at the thoracic inlet. There is no other significant change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1015656,
"text": " 3:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with respiratory failure likely due to volume overload\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST.\n\n INDICATION: 81-year-old with respiratory failure.\n\n A single supine portable radiograph of chest performed and compared to\n .\n\n Study is limited by motion. There is a pacer device to the right ventricle.\n There is a left upper extremity PICC line to the superior vena cava. The\n patient is status post median sternotomy and multiple valve replacements. The\n heart is markedly enlarged. The aorta is atherosclerotic and ectatic. The\n trachea is midline. Unchanged small right pleural effusion and right basilar\n atelectasis is noted. There is no pneumothorax. There are surgical clips in\n the right upper chest wall.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2108-06-13 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 1014346,
"text": " 2:36 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: thrombus around PICC?\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81M subclavicular art pseudoaneurym s/p hematoma evacuation, clavicle\n resection, now with RUE edema, old PICC in right arm\n REASON FOR THIS EXAMINATION:\n thrombus around PICC?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old male with pseudoaneurysm status post hematoma\n evacuation, now with right upper extremity edema, old PICC line in the right\n arm.\n\n COMPARISON: .\n\n FINDINGS: -scale and color Doppler son of the right internal\n jugular vein, subclavian vein, axillary vein, brachial veins, and basilic\n veins were obtained. PICC line is seen coursing through the basilic and into\n the axillary vein. Surrounding the PICC line within the proximal basilic and\n into the axillary vein, there is an echogenic focus, consistent with thrombus\n around the PICC line. The thrombus does not appear to extend into the\n subclavian vein, with normal color flow demonstrated within the subclavian\n vein.\n\n IMPRESSION: Thrombus surrounding the PICC line involving the proximal basilic\n and extending into the axillary vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1013703,
"text": " 7:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o acute process\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man 82%4L\n REASON FOR THIS EXAMINATION:\n r/o acute process\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST.\n\n No prior studies available for comparison.\n\n Portable chest reveals marked cardiomegaly, in the setting of prior median\n sternotomy and valve replacement. Single lead pacemaker projects over the\n left hemithorax with continuous lead to the right atrium. There is increased\n density at the bases, likely representing a combination of small effusions and\n associated atelectasis, left slightly more so than right. No focal airspace\n consolidation is evident. Mild pulmonary vascular congestion. A right PICC\n line terminates in the distal SVC.\n\n IMPRESSION: Severe cardiomegaly and congestion. Bibasilar effusions and\n associated airspace disease, atelectasis versus pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-06-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1014470,
"text": " 9:35 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: evaluate for progression of interval progression\n Admitting Diagnosis: RIGHT SUBCLAVIAN ARTERY PSEUDOANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with clinical e/o heart failure\n REASON FOR THIS EXAMINATION:\n evaluate for progression of interval progression\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Clinically heart failure, to evaluate for progression.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Again there is enlargement of the cardiac silhouette with bilateral\n pleural effusions. Some indistinctness of pulmonary vessels suggests\n increased pulmonary venous pressure. Pacemaker leads persist in this patient\n with midline sternal sutures and CABG.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-23 00:00:00.000",
"description": "Report",
"row_id": 1631135,
"text": "Resp Care\npt was placed on NIV he tol well for some time, latteron he was notted to be desaturating, Pt had a leak, this was fixed and he tol NIV well throughout the night.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-23 00:00:00.000",
"description": "Report",
"row_id": 1631136,
"text": "Resp Care: Pt found on Respironics Bipap (S/T mode) w/ 5-6 L O2 bled in. ABG reveals compensated resp acidosis w/ hypoxia. SpO2= 84% Placed on NRb w/ gd effect. Spo2 ^'d to 100%. Placed on .35 high flow OFM. ABG no change. Pt cont to have desat episodes t/o shift. RN aware. Currently on 3L/min N/C, SpO2= 92-100%. Alb/atrov nebs given x2. Tol well. BS sl decreased, clear bilat. CXRay today reveals \"s/p median sternotomy and mult. valve replacements. Heart markedly enlarged, sm. R pl. eff., R base atelect.\". Plan: cont nebs q6, back on NIV if neccessary. PLease see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-23 00:00:00.000",
"description": "Report",
"row_id": 1631137,
"text": "NPN: 0700-1900\nNEURO:PT IS ALERT AND ORIENTED TIMES THREE. WITH PERIODS OF CONFUSION/FORGETFULNESS. PT IS VERY . FOLLOWS ALL COMMANDS. CAN STATE NEEDS. DENIES PAIN AT THIS TIME.\n\nCV: PT WITH AN UNDERLYING RYTHYM OF AFIB. FREQUENT PVC'S. HR 54-62. ABP 130'S-170'S. PT RESTARTED ON TORSEMIDE AND ACETAZOLAMIDE. ON COUMADIN FOR AFIB. PT HAS PLUS 2 PITTING EDEMA IN LOWER EXT BILATERALLY. LOWER EXT PLUSES ARE WEAK BUT PALPABLE. R ARM IS EDEMATOUS AND WEEPING.\n\nRESP: PT IS ON BIPAP. PT WAS TO HI MASK AND EVENTUALLY SWITCH TO NC AT 4 LITERS---PLEASE SEE CAREVUE FOR ABG'S. LUNGS ARE CLEAR AND DIMINSHED WITH CRACKLES NOTED IN THE BASES AT TIMES. PT HAS SO FAR DIURESED OVER LITER--PT GOAL IS TO BE NEGATIVE 2 LITERS BY MN.\n\nGI/GU: PT HAS POSITIVE BOWEL SOUNDS. PT HAD MED SIZED BM THIS AM. PT SWALLOWS PILLS CRUSHED IN APPLESAUCE. PT HAS A HEALTHY APPETITE---MECHANICAL SOFT DIET. PT ?? HX OF CHRONIC ASPRIATION---SPEECH AND SWALLOW ORDERED. FOLEY IN PLACE--30-160CC/HR.\n\nSKIN: SACRUM IS PINK BUT NOT BROKEN--CREAM APPLIED. SCROTUM IS EDEMATOUS. PT HAS SUTURES BY RIGHT CLAVICLE HEMATOMA EXTRACTION. PT RIGHT ARM STILL HAS NO SPONTANEOUS MOVEMENT. ?? NERVE DAMAGE DURING SURGERY, PT .\n\nACCESS: A LINE AND PICC LINE.\n\nSOCIAL: FAMILY AT BEDSIDE UPDATED BY MD AND THIS RN. PT REMAINS DNR/DNI.\n\nPLAN: BIPAP TONIGHT. C/O TOMORROW\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-22 00:00:00.000",
"description": "Report",
"row_id": 1631131,
"text": "PT. REMAINS A DNR/DNI.\n\nPT. HAS NKDA.\n\nPT. REMAINS A/A/O AND DENIES PAIN THROUGHOUT THIS SHIFT. PT. DOES HAVE FEW EPISODES THAT HE IS UNAWARE OF HIS SURROUNDINGS. OTHERWISE, PT. IS A/A/O. PT. HAS BEEN AFEBRILE THROUGHOUT THIS SHIFT.\n\nPT. HAS BEEN AT RATE IN THE 60'S. B/P HAS RANGED 130-150'/60-70'S. PULSES ARE WEAK BUT PALPABLE, +2 PITTING EDEMA NOTED. PT. REMAINS ON LASIX GTT AT 10MG/HR.\n\nPT. REMAINS ON BIPAP THROUGHOUT THIS SHIFT. LUNG SOUNDS ARE CLEAR, WITH PERIODS OF COARSE BREATH SOUNDS. PT. WAS HAS TOLERATED CHEST PT, WITH SMALL AMT'S OF YELOWISH SECRETION EXPECTORATED. 02 SATS REMAIN 92-95%, PT. IS A KNOW CO2 RETAINER.\n\nPT. TOLERATED MEALS YESTERDAY WHICH HE REMAINS ON REGULAR CCU DIET. BLOOD SUGARS REMAIN WNL'S WITH NO COVERAGE REQUIRED. PT. HAD BEEN IN THE LOW 60'S IN THE PERVIOUS 24HRS. ABD. IS OTHERWISE BENIGN IN ASSESSMENT WITH BOWEL SOUNDS EASILY AUDIBLE AND PT. HAVING THREE MODERATE SEMIFORMED STOOLS. FOLEY CATHETER REMAINS IN PLACE WHILE DRAINING LARGE AMT'S OF LIGHT YELLOW URINE RANGING 100-400CC/HR WHILE ON THE LASIX GTT.\n\nSKIN EXHIBITS MULTIPLE ECCHYMOTIC AREAS TO PT. FLANKS. PT. ALSO HAS STAPLES TO INCISION TO RIGHT SUBCLAVIAN AREA FROM THE EVAC OF THE PT'S HEMATOMA. THIS AREA REMAINS OTA WELL APPROXIMATED WITH NO DRAINAGE NOTED. PT. HAS TWO TRANSPARENT DRESSING TO HIS RIGHT ARM, WHICH ARE FROM OLD VENA PUNCTURE SITE. THESE AREAS CONTINUE TO DRAIN SEROUS FLUID. PT. HAS ALINE TO RIGHT RADIAL, WHICH REMAINS INTACT, SECURED, AND FUNCTIONING WELL, WAVEFORM REMAINS WNL'S. LEFT BRACHAIL PICC REMAINS INTACT, SECURED, WITH DRESSING CHANGED. PT. ALSO HAS MULTIPLE EXCORIATED AREAS ON COCCYX, AND SCOTUM.\n\nPLAN IS TO MONITOR I&O CLOSELY WHILE ON LASIX GTT. CHECK WITH TEAM ON DAILY GOAL FOR PT. PROVIDE PT. AND FAMILY EMOTIONALLY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-22 00:00:00.000",
"description": "Report",
"row_id": 1631132,
"text": "Respiratory care:\npt on and off NIPPV today when desating to 80%. pt tolerated well NIPPV. Lung sounds coarse. Nebs given per order. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-22 00:00:00.000",
"description": "Report",
"row_id": 1631133,
"text": "nursing note 7a-7p\nPt remains DNR/DNI\n\nNeuro: L pupil pinpoint and sluggish (baseline) R pupil 2 mm and briskly reactive. mostly a/o x3. occasionally confused, but orients quickly. agitated @ xs. follows. rue paresis. all other ext . +cough, tol po's without difficulty.\n\nCV: V-paced @ 60. S1S2, murmur noted. 3+ generalized, pitting edema, palpable pulses X4 ext. Aline, slightly dampened-correlates w/ NIBP.\n\nPulm: on/off bipap throughout day. removed @ 15:00 secondary to apneic episodes. currently on 3L NC-keep sats 88-92. lungs diminished BUL w/ bibalsilar crax. productive cough-swallows secretions. last C02 67 @ 13:40. Bipap hs.\n\nGI: abd soft, bs +, denies nausea. taking pos's w/o difficulty. assist w/ feedings. colace held, secondary to mult. loose bm's overnight.\n\nGu: foley w/ adequate clear/yellow output. lasix gtt off @ 13:40. call HO w/ decreased u/o.\n\nIV: Lt brachial dl picc-patent. red port draws.\n\ninteg: rsc staples intact/ota, rsc sutures ota. bilat flant ecchymosis.\n\npain: denies pain\n\nendocrine: fsbs ac/hs, 12:00=237; 17:00= 165. SSI rx'd\n\nplan: diurese, transfer to floor if able to remain of bipap, eventually will need .\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-23 00:00:00.000",
"description": "Report",
"row_id": 1631134,
"text": "PT. REMAINS A DNR/DNI AT THIS TIME.\n\nPT. HAS NKDA.\n\nPT. REMAINS A/A/O AND DENIES ANY PAIN OR DISCOMFORT THROUGHOUT THIS SHIFT. PT. DOES HAVE PERIODS OF CONFUSION WHICH HE IS QUICKLY RE ORIENTED. PT. HAS BEEN AFEBRILE. PT. STILL HAS NO MOVEMENT IN HIS RIGHT UPPER EXTREMITY. TEAM IS QUESTIONING BRACHIAL NERVE INVOLVEMENT.\n\nPT. HAS BEEN V PACED RATE OF 60-62 WITH NO NOTED ECTOPY. B/P REMAINS STABLE AS WELL RANGING 120-150'S/70-80'S. RIGHT RADILA ALINE REMAINS INTACT, SECURED, AND FUNCTIONING WELL. WAVEFORM DOES DAMPEN AT TIMES, BUT THIS CONTINUES TO CORREALTE WITH CUFF PRESSURES. PULSES REMAIN WEAK TO PALPATE, AND + PITTING EDEMA NOTED TO LOWER EXTREMITIES, WHILE GENERALIZED EDEMA NOTED TO ARMS, LEGS, PENIS, SCROTUM, AREAS. PT'S LASIX GTT WAS D/C'D YESTERDAY AFTERNOON AFTER GOAL OF -2.5 LITERS WAS REACHED. POSSIBLE RESTART FOR TODAY SINCE U.O IS STARTING TO TREND DOWN.\n\nPT'S LUNGS REMAIN COARSE, AND DIMINIHED BIBASILAR. PT. HAS RECEIVED CHEST PT, PRIOR TO BIPAP. PT. DID EXPECTORATE SMALL AMT'S OF TANNISH SPUTUM. PT. WAS PLACED ON BIPAP AROUND 2200 AND HAS RESTED AND TOLERATED THIS OVERNIGHT. OTHERWISE PT. IS ON 3-6L/MIN VIA N/C THROUGHOUT THE DAY. PT. IS A KNOWN CO2 RETAINER. TEAM HAS BEEN TOLERATING O2 SATS OF 88-92%. RESP RATE IS CONTROLLED AND SATS HAVE REMAINED WITHIN GOAL.\n\nPT. ABD. REMAINS BENIGN IN ASSESSMENT. BOWEL SOUNDSARE EASILY AUDIBLE AND NO STOOLS NOTED THIS SHIFT. THIS IS AN IMPROVEMENT, AS PT. HAS HAD SEVERAL STOOLS PER LAST FEW SHIFTS. PT. HAS BEEN TOLERATING HIS DAILY REGULAR CCU DIET. BLOOD SUGARS HAVE REMAINED WNL'S WITH NO COVERAGE REQUIRED. PT. DID NOT RECEIVED TOTAL DIALY DOSE OF INSULIN REGIME DUE TO SMALL ORAL INTAKE FOR BREAKFAST AND DINNER.\nFOLEY CAHETER REMAINS INTACT, WHILE DRAINING 40-240CC/HR OF CLEAR YELLOW URINE. IN PAST FEW HRS. U.O HAS DROPPED TO THE 40'S.\n\nSKIN EXHIBITS MULTIPLE ECCHYMOTIC AREAS TO BOTH FLANKS. THIS ARE DIMINISHING. PT. HAS SEVERAL TRANSPARENT DRESSINGS OVER OLD PUNCTURE SITES. PERINEUM REGION REMAINS EXCORIATED AND FEW SMALL OPEN AREAS NOTED TO SCROTUM. PT. HAS A LEFT BRACHIAL PICC LINES WHICH REMAINS INTACT, SECURED, AND FUNCTIONING WELL.\n\nPLAN IS TO MONITOR I&O CLOSELY AND ASSESS FOR NEED FOR LASIX GTT. MONITOR FOR ANY RIGHT ARM MOVEMENT, AND ASSIST WITH MEALS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-21 00:00:00.000",
"description": "Report",
"row_id": 1631126,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: ALERT AND ORIENTED X 2- NEEDS FREQUENT REORIENTATION. CONFUSED AT TIMES. CONSTANTLY PULLING OFF HIS O2 MASK- LOOSE WRIST RESTRAINTS APPLIED FOR SAFETY. AFEBRILE. NO SEIZURE ACTIVITY NOTED.\n\nRR: BBS= ESSENTIALLY CLEAR TO BILATERAL UPPER LOBES AND DIMINISHED TO THE BASES. PT NOTED TO BECOME APNEIC WHEN ASLEEP. O2 REQUIREMENTS HAVE BEEN UP AND DOWN ALL EVENING- CURRENTLY ON 3L NC AND OFM AT 50%. AGGRESSIVE PULMONARY TOILETING HOWEVER, WEAK COUGH EFFORT- UNABLE TO EXPECTORATE SPUTUM APPROPRIATELY. ATTEMPTED TO NT-SUCTION- SMALL AMOUNT OF THICK, YELLOW SPUTUM EVACUATED. BILATERAL CHEST EXPANSION NOTED. SP02 88-92%.\n\nCV: S1 AND S2 AS PER AUSCULTATION. PT IS . HR 60'S. SBP > OR = TO 90 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. DENIES ANY CHEST PAIN. GENERALIZED PITTING EDEMA.\n\nGI: ABD IS SOFT, DISTENDED. BS X 4 QUADRANTS. PT HAS HAD MULTIPLE SMALL, SOFT, BROWN GUIAC NEGATIVE STOOLS. PASSING FLATUS. ABLE TO TAKE PO'S WITH ASSISTANCE.\n\nGU: INDWELLING FOLEY CATHETERE IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS. TOLERATING LASIX GTT- GOAL FOR 100CC/HR.\n\nINTEG: PT NOTED TO HAVE ANASARCA TO BILATEARL UPPER EXTREMITIES. PURPLE AND BLACK CONTUSION TO BACK- HOWEVER NO OPEN AREAS APPRECIATED. RT NECK INCISION IS CLEAN, WELL APPROXIMATED WITH NO REDNESS NOTED.\n\nSOCIAL: NO CONTACT FROM FAMILY THIS SHIFT.\n\nPLAN: MONITOR RESPIRATORY STATUS. AGGRESSIVE PULMONARY TOILETING. REOIRENT AND WATCH FOR SAFETY. GOAL OF 100CC/HR UOP ON LASIX GTT. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-21 00:00:00.000",
"description": "Report",
"row_id": 1631127,
"text": "Respiratory Therapy\nNIV initiated for hypercarbia and high O2 requirement. PSV 10/8 .6 med FM. Sats 95% BS clear but diminished. Plan: wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-21 00:00:00.000",
"description": "Report",
"row_id": 1631128,
"text": "0700-1900\n\nShift Events: On/Off CPAP to maintain SATs 88-92%. Remains hypercarbic. has been off CPAP since @ 1300 on 4-6liters NC. Continue Lasix gtt w/ goal UOP >100cc/hour; remains at 10cc/hour. Mental status waxes and wanes. Family in to visit and updated by MICU fellow Dr. . PT/OT done at bedside.\n\nNeuro: Alert; slept off and on t/o day. Answers questions appropriately w/ intermittent confusion. States he is at ; that it is ; does not consistently remember month/season. When asked why he is here, states: \"to get the water out of my legs\". Will c/o generalized aches and pains; has not received and sedation. RUE paralysis persists; moves right toes; unable to bend or lift RLE. LUE strength 4/4; lifts and holds. Moves LLE in bed. Pupils noted to be unequal and slugglish this am w/ no change in baseline mental status or motor ability; discussed at rounds and will continue to monitor. Right pupil 3-4mm/ Left pinpoint.\n\nCV: VVI paced @ 60 w/ occ. PVC's. BP remains stable off pressors. Tolerating Lasix gtt. Continues to have 4+ total body edema.\n\nResp: Lungs diminished. coarse at times; clears w/ cough and pulmonary toilet. Did expectorate small amount of pale, yellw/tan sputum w/ Neb and CPT. Has B/L pleural effusions. SATs have been 87-91% off CPAP since 1300. Will most likely need to be rested overnight.\n\nGI/GU: Foley. Lasix gtt. Creatine stable 2.4. Abd distended/ SNT. BS+ multiple soft stools. No N/V. Tolerated soft//Cardiac diet. Is able to take liqiuds, but crushed pills in applesauce. Blood sugars 70-100.\nIVF-KVO.\n\nID: Afebrile. Blood/Urine cultures NTD.\n\nSkin: Right neck incision and old JP site OTA; no drainage. Is oozing serous fluid from ols IV sites on right arm from edema; DSD applied.\nSore and pink @ rectum from multiple stools; moisture barrier applied; no open areas. Has old eccymotic bruises on back/flank; resolving.\n\nSocial: Wife, daughter, grandson, and all in to visit and given ICU update from Dr. . Pt has in who ia a cardiologist; has not called today.\n\nDispo: Continue Lasx gtt w/ goal of 2 liters neg. If hypotensive; tx w/ colloid and continue diuresis. Maintain SATs 88-92% on/off bipap as tolerates. Pulmonary toilet. Encourage PO as tolerates.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-21 00:00:00.000",
"description": "Report",
"row_id": 1631129,
"text": "Respiratory Care:\nPt recieved on NIPPV. Pt on and off NIV, abgs showed partially compensated respirtary acidosis with moderate hypoxemia. Pt currently on NC. Pt to go back on NIV if needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-22 00:00:00.000",
"description": "Report",
"row_id": 1631130,
"text": "Resp Care\nPt was found on NIV, he was maintained on NIV. he seems to tol well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-25 00:00:00.000",
"description": "Report",
"row_id": 1631143,
"text": "MICU NPN 7P-7A\nNEURO: INITIALLY LETHARGIC BUT DID AWAKEN ON OWN. EASILY AROUSABLE SINCE THEN. INITIALLY HELD SERAQUEL AS IT WAS THOUGHT IT WAS CAUSING HIS PROFOUND LETHARGY YESTERDAY, BUT AFTER SEVERAL EPISODES OF YELLING OUT HE WAS GIVEN HALF A DOSE (12.5MG). ALERT AND ORIENTED X3 BUT FORGETFUL RESULTING IN HIS YELLING OUT THAT HE WANTED TO LEAVE OR HE WANTED LEMONADE AND POPCORN. DENIES PAIN. FOLLOWS COMMANDS APPROPIATELY. MAE EXCEPT RUE. PERL. WRIST RESTRAINT TO LEFT ARM AS HE WILL PULL OFF BIPAP MASK.\n\nCARDIAC: HR 60-63 WITH FREQUENT PVC'S. BP 107-144/39-55. WILL START LISINOPRIL TODAY. PPP. HCT STABLE @33.7, INR 2.2, ON COUMADIN, NO SIGNS OF BLEEDING.\n\nRESP: RECEIVED ON 4L N/C CHANGED TO BIPAP DURING THE NIGHT. RR 15-24 AND SATS 89-100%. ABG ON BIPAP 7.40/60/72/35. LS CLEAR WITH DIMINISHED BASES. DENIES SOB.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. NO STOOL. UOP 100-150CC/HR YELLOW AND CLEAR. CREAT UNCHANGED @1.7.\n\nFEN: HELD HS DIURETICS, STILL -11.2L LOS. 2+ PERIPHERAL EDEMA. LYTES PER CAREVUE. FS Q6HRS WITH SSRI AND HS GLARGINE. DIET AS TOLERATED.\n\nID: TMAX 97.4 WITH WBC 4.6. NO CURRENT ID ISSUES.\n\nSKIN: WEEPING FROM RIGHT ARM. SUTURES C/D/I TO RSC HEMATOMA EVACUATION.\n\nACCESS: LEFT BRACHIAL PICC, RIGHT ART LINE.\n\nSOCIAL/DISPO: DNR/DNI. NO CONTACT FROM FAMILY. NEED TO EVALUATE ABG'S OFF/ON BIPAP, NEEDS FORNAL SLEEP STUDY BUT THIS SHOULD NOT PREVENT HIM FROM BEING TRANSFERRED TO THE FLOOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-24 00:00:00.000",
"description": "Report",
"row_id": 1631138,
"text": "MICU NPN 7P-7A\nNEURO: ALERT AND ORIENTED X3. DESPITE HIS ORIENTATION HE WAS CONSTANTLY CALLING OUT FOR STAFF, REMOVING GOWN, AND PULLING OFF HIS BIPAP. DENIED PAIN, REPOSITIONED FOR COMFORT. WRIST RESTRAINT PLACED ON LEFT ARM. SLEPT WELL ONCE COMFORTABLE WITH MASK AND RECEIVED HIS SEROQUEL. FOLLOWING COMMANDS. ABLE TO MOVE THUMB ONLY ON RIGHT ARM.\n\nCARDIAC: HR 60-63 V-PACED WITH FREQUENT PVC'S. BP 118-154/36-62. HCT STABLE @35. PPP. INR 2.3, ON COUMADIN, NO SIGNS OF BLEEDING.\n\nRESP: RECEIVED ON 3L N/C WITH SATS MID 90'S. RR 13-27. PLACED ON BIPAP, PULLED OFF BUT ONCE SETTLED HE LEFT IT ON. SATS 90-97%. ABG 7.43/55/63/38. DENIES SOB. LS CLEAR WITH DIMINISHED BASES. NEBS AS ORDERED. CXR DONE.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. NO STOOL. UOP 100-300CC/HR YELLOW AND CLEAR, CREAT REMAINS @1.8.\n\nFEN: ON DIAMOX AND TORSEMIDE . WAS -1.5L @MIDNOC, SINCE -1.2L AND OVERALL -8.2L LOS. CONTINUES WITH 2+ LE AND RUE EDEMA. LYTES PER CAREVUE. HS GLARGINE AND SSRI Q6HRS. SS TIGHTENED. TOLERATED DIET WELL, NO SIGNS OF ASPIRATION.\n\nID: TMAX 98.5 WITH WBC 4. NO CURRENT ID ISSUES.\n\nSKIN: SUTURES/STAPLES TO RSC C/D/I.\n\nACCESS: RIGHT ART LINE, LEFT BRACHIAL PICC.\n\nSOCIAL/DISPO: DNR/DNI. NO CONTACT FROM FAMILY. ?CALL OUT TODAY IF ABLE TO MAINTAIN BIPAP AT NOC ON THE FLOOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-24 00:00:00.000",
"description": "Report",
"row_id": 1631139,
"text": "Resp Care\nPt maintained on BIPAP for the most of the night, Pt tol BIPAP well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-24 00:00:00.000",
"description": "Report",
"row_id": 1631140,
"text": "Resp Care: Pt conts to use BIPAP at noc. ABG slight resp alkalosis. Placed on N/C in AM. ABG WNL (compensated resp acidosis) BS clear, decreased L base. HHN given as ordered. Tol w/o incident. Plan: cont nebs/bipap. Please see carevue for further vent inqueries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-24 00:00:00.000",
"description": "Report",
"row_id": 1631141,
"text": "npn: 0700-1900\nneuro: pt has been increasingly more lethargic throughout the day. pt is difficult to arouse, pt requires alot of encouragement to follow commands. hold this evenings dose of seroquel possible reason for lethargy.\n\ncv: pt v paced. hr 54-63. bp stable 115-140's. frequent runs of pvc's. weak but ppp bilaterally with plus three pitting edema. pt's right arm is swollen and weepy----soft sorb and kerlix dressing.\n\nresp: pt lungs are clear and diminshed. pt had multiple abg's sent. originally thought pt lethargy was due to hypercarbia however pco2 has been stable. pt wears bipap at night but has been on 3-4l nc throughout shift.\n\ngi/gu: pt ate breakfast this am, however since lunch pt has been awake long enough to lunch. held 1600 pills concern for aspiration. holding this evenings dose of torsemide/acetazolmide over diuresis. ?? metabolic process maybe cause this lethargy---chem 10 pending. uop 80-220cc/hr.\n\nskin: sutures c/d/i--dsd in place. no breakdown noted.\n\nendo: fsq6hrs----last bs was 149.\n\nplan: bipap this evening, monitor mental status---may need ct of head, dnr/dni, family updated by this rn.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-06-25 00:00:00.000",
"description": "Report",
"row_id": 1631142,
"text": "Resp Care\nPt placed on BIPAP for noc use tol BIPAP well, ALB/ATR nebs were given.\n"
},
{
"category": "ECG",
"chartdate": "2108-06-17 00:00:00.000",
"description": "Report",
"row_id": 216765,
"text": "Regular ventricular pacing with underlying atrial fibrillation. Frequent\nventricular ectopy. Compared to the previous tracing ventricular ectopy is\nnew.\n\n"
},
{
"category": "ECG",
"chartdate": "2108-06-12 00:00:00.000",
"description": "Report",
"row_id": 216766,
"text": "Regular ventricularly paced rhythm. Underlying rhythm is atrial fibrillation.\nCompared to the previous tracing of frequent ventricular ectopy has\nresolved.\n\n"
},
{
"category": "ECG",
"chartdate": "2108-06-08 00:00:00.000",
"description": "Report",
"row_id": 216767,
"text": "Regular ventricular pacing with ventricular ectopy. No previous tracing\navailable for comparison.\n\n"
}
] |
10,422 | 113,048 | MICU COURSE: The patient is a 66 yo M recently admitted with an UGIB and was discharged home only to return 12 hours later to the ED with dizziness. In the ED, the patient was hypotensive and eceived 3L NS. His pressures increased from 90/50 to 135/70. His hct was stable from the time of discharge (32 -->31). He was admitted to the floor where he then became tacycardic and again hypotensive. He was thought to be re-bleeding and was transferred to the ICU for an EGD. Upon arrival in the ICU, he was again stable with BP's in the 120's and HR 70's. 4 hours later (prior to the EGD), the patient acutely dropped his pressures to the 60's and was tachycardic to the 150's. A hct showed a drop from 31 --> 24. He was transfused 5 units of PRBC and had approximately 4L of NS. He was intubated and an EGD was performed which showed his known gastric varice with evidence of recent bleeding. tube was inflated and arrangements were made for an urgent TIPS procedure. He was taken to IR and a TIPS was attempted but unsuccessful. The tube was deflated after 12 hours. The patients hct again stabalized. A TIPS was then reattempted x 3 and was successful on third try On HD# 6, pt spiked a temp to 101. Sputum from ET tube grew out 4+GNR and 4+GPC. Given his recent hospitalization, he was broadly covered with vancomycin and zosyn. Also, pt was noted to be minimally responsive off sedation thought to be slowed clearance of versed by his liver. Head CT was negative. His mental status was initially poor in the unit. On HD # Pt. was transferred out to the floor. He susequently developed respiratory distress and was readmitted to the MICU for aspiration pneumonia. He was treated with Levoquin and Flagyl in the unit and became afebrile. He continued to have ascites and paracentesis was performed in the unit. Pt's respiratory status improved after paracentesis. 600cc ascites fluid was negative for SBP, and patient was prophylaxed on Rifaxamin. He progressively regained mental status and respiratory status and after remaining afebrile he came back to the floor on HD# 19 with no antibiotic coverage. Once on the floor Pt's course continued as follows. # Respiratory Distress: Ddx included PE (pt has not been on SQ hep coagulopathy from liver dz), aspiration (tube feeds), increasing abdominal distention leading to atelectasis and poor inspiration, fluid overload, hepatopulm syndrome. to NC with sats>95. CTA was not done as suspicion was low for PE due to adequeate oxygenation. Pts breathing was much more comfortable after paracentesis. Pt. initially suspicious for Pulm edema. He was diuresed with Lasix and Spirinolactone. His respiratory status and CXR improved with diuresis. Pt. O2 requirement progressed from non-rebreather to NC and by HD#26 he was saturating 95% on RA. | Tolerating TF via NGT. Care: Pt. Pt + ascities. Pt s/p paracentesis. Lytes sent and EKG done MICU team made aware. Resp. remains intubated and on vent.support. ABG WNL with adeqaute oxygenation on present vent settings. Decision made to intubate. Intubated and CXR done to confirm placement. Foley patent drng amber urineEndo: RISSID: Remains on ABXPlan: Cont with current plan of care. Gave albuterol MDI x 1 PRN. + PPP BILAT. Plan to extubate in am if secretions decrease.CV: Pt remains with low grade temps. SX'D X 1 FRO SM AMT BLOODY SECRETIONS.CV: PT HAS BEEN HEMODYNAMICALLY STABLE OVERNOC. AM ABG: 182/39/7.33/21. Pt remains on Propofol gtt. extubation. MDIs given as ordered. NGT intact TF restarted tolerating well. Nursing Progress NotePlease see carvue for specifics:Neuro: Remains on prop gtt. TPN STARTED. Hypo BS stool X1. See carevue for objective data.Transferred from 7 after episiode of BRBPR. ABG reveals a mild met. Plan: continue to mon resp status and potential to extubate. OCTREOTIDE GTT RESTARTED.RESP: LS COARSE. GI: ABD softly distended, bs present. NGT removed at this time, dobhoff has been placed and placement confirmed. Pt did desat X1 to 92/93 which returned to baseline post lavage.GI/GU: NGT in place ? exp wheezes treated with alb. Also started on scheduled doses of haldol. Right IJ triple lumen removed and tip sent for culture. Minimal amount of BRB via NGT which cleared with 180cc lavage this AM. NGT IN PLACE. Lungs clear to diminished at bases. + PPP BILAT. Post transfusion crit 31.1 and INR 1.5. SKIN W+D. Respiratory CarePt. Respiratory CarePt. Melena stool continues as well as lactulose po q6hrs. REPEAT SWALLOW EVAL. WILL MONITOR RESPIRATORYSTATUS. PROPOFOL GTT. aspiration PNA. PBOOTS ON. LS diminished but otherwise clear.GI: + BS in 4 quadrents, + ascites. New left Ij triple lumen placed. TOL TF. Palp dp/pt bilat. laculose resumed for hepatic encephalophathy.Cv/resp Nsr no ectopy. +PP. WEAN SEDATION AND VENTILATOR AS TOLERATED. Bp stable. + PEDAL EDMA. Restarted on LevaquinPLAN: Cont. AM ABG: 119/44/7.34/25/-2. DENIES PAIN.CV- BP STABLE, HYPOTENSIVE THIS AM TO 85-88 SYSTOLIC FOLLOWING HALDOL IV AND ZYPREXA, PROPOFOL TURNED OFF AND BP RETURNED TO 100-130'S. positive bowel sounds abdomen distended/ascites. Maintenance fluid d/c'd. HCTS STABLE IN LOW 30'S X 24 HRS NOW.NEURO: REMAINS WELL SEDATED ON FENTYNL 100 MCG'S AND VERSED 7.5 MG'S. SM MELENA STOOL PER RECTAL BAG.NEURO: REMAINED UNRESPONSIVE UNTIL 0500. SANDOSTATIN GTTS CONT, HCT STABLE.RESP: LUNG SOUNDS COARSE BILATERALLY. Palpable DP/PT pulses bilaterally. NPN (NOC):RESP: PT REMAINS INTUBATED. Pos cough, neg gag.CV: Remains in NSR, no ectopy noted. Resp CarePt remains intubated on A/C. Condition UpdateAssessment:Please see carevue for detailsNeuro: Pt remains off all sedation. Abd w. ascites, soft, NT. Palp dp/pt bilat.GI: Abd obese, hypoactive bs. having very liq. data: low grade temp 99.5-100.5 hr 80-96nsr w/o ect.cvp 5-10. urine output 25-40cc/hr.pt slightly sedated on olw dose ppf. NURSING UPDATECV: SLIGHTLY TACHY IN LOW 100'S AT TIMES, NO ECTOPY. OCTREOTIDE GTT CONTINUES.GI: HYPO BS. resp care - Pt extubated this AM. cxr done this am.gi: hypoactive bowel sounds. PBOOTS ON FOR DVT PROPHYLAXIS. Fluid boluses for hypernatremia q4hr as ordered, f/u Na level pending. if tachycardia d/t resp issues.Resp: Pt placed back on A/C today. Pt switched from CPAP to A/C last d/t HTN and tachycardia. ABG's adequate/sats adequate.GI/GU: Unchanged TF via NGT Abd soft very distended. albuterol inhaler as per order. 2 albuterol nebs given. INR 1.9 today, s/p 1 unit FFP- liver bx cancelled.F/E/N: NPO maintained- TF at goal 60ml/hr, tolerating well. Monitor resp status closely, encourage C/DB, albuterol nebs prn. pt attempted CPAP this am. MD Albuterol and Atrovent Q4. PERRLCV: pt remains NSR/ST, occasional PAC's noted. min melena stool output. pt responds to voice and follows commands inconsistently.CV: Cont with low grade temps. Attempted SBT after RSBI = 62. Alb mdi given as ordered. resp care - pt BS wheezes t/o with decreased aeration. FINDINGS: An endotracheal tube is in place with tip terminating 6.9 cm from the carina. Left basilar subsegmental atelectasis appears no different, and slight blunting at the right costophrenic sulcus suggests a small amount of pleural fluid. A right internal jugular venous access catheter has been placed in the interval, terminating in the lower SVC. Compared to the previous tracingof multifocal atrial tachycardia has appeared. FINDINGS: Mild enlarging bilateral pleural effusions. Two lytic lesions in the vertebral bodies as described above. There is ascites with a moderate sized pocket of fluid identified in the right lower quadrant. Mark for paracentesis. Multifocal atrial tachycardia. Persistent basilar retrocardiac atelectasis. On one attempt, a small vein was catheterized across the midline and a selective venogram was obtained. CLINICAL INDICATION: Malpositioned PICC line. Left lower lung opacity representing atelectasis or consolidation with possible component of a small left effusion. The endotracheal tube cuff appears overinflated. The rate has slowed.The right precordial forces are diminished - question interim myocardialinjury. A right subclavian central catheter terminates in the distal SVC. Evaluate for thrombus. CHEST, SINGLE AP VIEW: The patient is rotated. Right jugular CV line is in mid SVC. Grayscale and Doppler son of the left internal jugular, subclavian, axillary, brachial, and basilic veins were performed. Patent TIPS with low TIPS velocities, but appropriate reversal of flow in the right and left portal veins. FINDINGS: The right lower lung is off the film. Normal flow, augmentation where appropriate, compressibility where appropriate and waveforms are demonstrated within the left internal jugular, subclavian, and axillary veins are noted. Palatal elevation was mildly reduced, as well as laryngeal elevation and valve closure. Flow is appropriately reversed within the anterior right, and left portal veins. A right IJ sheath is present, tip overlying proximal SVC. FINDINGS: There is a left subclavian PICC line with tip in superior vena cava. REASON FOR THIS EXAMINATION: R/O dislodged dobhoff tube. COMPARISON: Right upper quadrant ultrasound dated . Moderate intra-abdominal ascites. | 106 | [
{
"category": "Nursing/other",
"chartdate": "2123-07-01 00:00:00.000",
"description": "Report",
"row_id": 1400018,
"text": "See carevue for objective data.\n\nTransferred from 7 after episiode of BRBPR. Arrived awake/alert though somewhat lethargic. O2 NC applied at 2L.\nStable VS upon arrival. C/O lower quadrant abd pain \"no worse than it usually is\". Abd soft but distended.\nFoley catheter inserted with clear yellow return. Inc of large amts of melana stool-mushroom cath placed and later changed to FIB.\nReceived (2) U PRBC's prior to endoscopy which demonstrated gastric varices that are no longer bleeding. Protonix gtt initiated.\nReceived versed/fentanyl during the procedure and tolerated well.\nAwaiting orders for beta blockade to reduce portal pressure. ? TIPS procedure in the furure.\n1600 HCT pending.\nNPO. SSRI per FSBS.\n\nMonitor and support VS,monitor HCT and melana stools,pain control and contine to support pt and family.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-01 00:00:00.000",
"description": "Report",
"row_id": 1400019,
"text": "Pt on mech. vent. due to lower GI bled and requiring tube. Pt. has a 7.5ETT taped 21 at the lip, and is A/C 600 by 12 100% and 5of peep.Pt. was transferred up from the floors because he was actively bleeding . Pt. was a difficult intubation requiring 3 attempts.ABGs pending as of this note.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-03 00:00:00.000",
"description": "Report",
"row_id": 1400028,
"text": "CONDITION UPDATE:\nD/A: T MAX 98.1\n\nNEURO: SEDATED ON FENTANYL AND VERSED AND SEEMS TO BE PROVIDING ADEQUATE SEDATION AND PAIN CONTROL. ONCE TUBE REMOVED, VERSED DECREASED SLIGHTLY. PT WITHDRAWS TO PAIN. + COUGH AND GAG. PERL.\n\nCV: HR 70'S-110 NSR/ST. ABP ~100/58 WITH MAP > 65. FLUID BALANCE MN-1800 + 2 LITERS. + PPP BILAT. P BOOTS APPLIED PER MICU. HCT CHECKS Q 8 HOURS WITH LAST CHECK HCT 31.1, INR 1.5. NO S+S OF ACTIVE BLEEDING.\n\nRESP: LS COARSE TO CLEAR. ETT ADVANCED PER MICU DUE TO CHEST X-RAY. VENT SETTINGS CHANGED TO CPAP + PS, 40%, 5 PEEP, 8 PS WITH ABG: 7.35, 46, 82, 26, 0.\n\nGI: TUBE D/C'D. ABDOMEN OBESE, SOFT, NO S+S OF ACTIVE BLEEDING. TPN STARTED. FIB BAG IN PLACE, NO NEW STOOL, SOME OLD RESIDUAL IN BAG.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSX: HCP CALLED AND WAS UPDATED. OTHER BROTHER VISITED, UNDERSTOOD THAT HE WOULD NEED TO CALL FOR INFORMATINO.\n\nR: D/C'D, NO S+S OF ACTIVE BLEEDING. VENT WEAN.\n\nP: CONTINUE Q 8 HOUR LAB CHECKS. CONTINUE CLOSE MONITORING OF VITALS, RESP STATUS, GI STATUS. TPN. PAIN CONTROL. INSULIN GTT. PT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-03 00:00:00.000",
"description": "Report",
"row_id": 1400029,
"text": "RESPIRATORY CARE: PT W/ A 7.5 ORAL ETT IN PLACE.\nCHANGED TO PS 8/.40/5 PEEP. ABG STABLE. SX FOR\nBLOOD-TINGED SPUTUM BUT IMPROVED SINCE YESTERDAY.\n TUBE OUT TODAY. WILL KEEP ON PS AS\nTOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-01 00:00:00.000",
"description": "Report",
"row_id": 1400020,
"text": "Addendum:\n\nTachycardiac at 120 and normotensive. MICU team called. Became hypotensive within minutes. GI up to attempt to scope and place . Decision made to intubate. Anaethesia called. Intubated and CXR done to confirm placement. + color change of CO2 detector.\n+ lung sounds. Remained hypotensive requiring total 4 U PRBc's and 2.5L of NS.\n tube inserted after endoscopy which demonstrated active bleeding. GI spoke to IR re: TIPS.\nXRAY done to confirm placement and read pending for mask to be placed. MD placed 20 cc's of air in tube.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-02 00:00:00.000",
"description": "Report",
"row_id": 1400021,
"text": "Respiratory Care:\nPatient to IR for TIPS. Back to ICU on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results at this time. No RSBI measured due to the level of PEEP currently required.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-02 00:00:00.000",
"description": "Report",
"row_id": 1400022,
"text": "NPN (NOC):\n\nRESP: PT REMAINS INTUBATED. CURRENT VENT SETTINGS: A/C 12X600X50%. TOTAL RR HIGH TEENS. AM ABG: 182/39/7.33/21. LUNGS CLEAR. SX'D X 1 FRO SM AMT BLOODY SECRETIONS.\n\nCV: PT HAS BEEN HEMODYNAMICALLY STABLE OVERNOC. SBP'S RISING AFTER PROPAFOL CHANGED TO FENTYNL/MIDAZ. MIDAZ TITRATED UP TO 7.5 MG AND SBP'S NOW IN 150'S. MICU RESIDENT AWARE. SHE WILL CONSIDER BETA BLOCKERS.\n\nNEURO: PT HAS BEEN WELL SEDATED OVERNOC. PSYCH MEDS ALL PO. MICU TEAM AWARE. THEY WILL CONSIDER IV ALTERNATIVES TODAY.\n\nGI: FIB DRAINING MELENA. TUBE INTACT. LATEST HCT 36% AFTER A TOTAL OF 6 UNITS PRBC'S.\n\nGU: UO IS GOOD. NEEDS CALCIUM REPLACEMENT. MICU RESIDENT AWARE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-02 00:00:00.000",
"description": "Report",
"row_id": 1400023,
"text": "RESPIRATORY CARE: PT REMAINS INTUBATED AND ON THE\nAC MODE. ABG STABLE. SX FOR BLOODY SPUTUM. BE\nGOING TO ANGIOGRAPHY TODAY FOR A PROCEDURE. WILL\nC/W AC MODE AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-08 00:00:00.000",
"description": "Report",
"row_id": 1400048,
"text": "Respiratory Care: Pt remains intubated and vented on PS as recorded on care view. Able to wean PEEP to 5 with good follow up ABG. Pt's breath sounds coarse. Suctioned for moderate amount of thick yellow secretions. MDIs given as ordered. will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-08 00:00:00.000",
"description": "Report",
"row_id": 1400049,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Prop gtt stopped this am pt following commands and nodding appropriately to questions. Prop restarted for comfort d/t pt thrashing. Plan to extubate in am if secretions decrease.\nCV: Pt remains with low grade temps. Diuresed today responded well to 10mg lasix. Pt with 7 beat run of VTACH at approx 1800. Lytes sent and EKG done MICU team made aware. Pt otherwise with stable hemodynamics no evidence of bleeding 1 sm melena stool. S/P US today to eval TIPS-patent flow\nResp: Vent settings currently CPAP .40% FIo2 . Tons of copious amts of secretions sxning frequently. Lungs coarse to diminished at the bases. Pt with strong productive cough.\nGi/GU: Abd remains soft ? acities vs obese belly. Hypo BS stool X1. NGT intact TF restarted tolerating well. Foley patent drng amber urine. Some hematuria noted in afternoon MICU team made aware.\nEndo: Cont on insulin gtt.\nID: Vanco/Zosyn d/c'd started on levaquin\nSkin: Blisters on RUE cont to drain copious amts. Otherwise Integ intact.\nPlan: Cont to monitor for bleeding. Cont to monitor respiratory status cont to prepare for extubation in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-04 00:00:00.000",
"description": "Report",
"row_id": 1400030,
"text": "Update\nSee careview for details.....\nNeuro: Pt sedated on fentanyl and versed gtts, sedation weaned for ? extubation, Pt off sedation and remains unresponsive, MICU team aware, ABG drawn Co2 47, PERL 2mm, withdraws to nailbed on LE's only\n\nCV: afebrile, VSS, NSR 80's, generalized edema, + palp pulses to LE's\nSandostatin gtt cont\n\nResp: Vent to CPAP 5/5, RR 8-10, lungs clear, sx mod bld tinged secretions, sats 95-97%\n\nGI: FIB dng sm amts melena stool, abd soft, + BS, TPN for nutrition\n\nGU: good UO via foley\n\nPlan: Monitor neuro status off sedation, ? extubate if awake, Q 8hr HCT's\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-04 00:00:00.000",
"description": "Report",
"row_id": 1400031,
"text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Patient ps was weaned from 8 to 5 secondary to high tidal volumes. Plan was to wean off sedation and extubate, however patient not waking up after being weaned off sedation.\nPlan: Remains intubated for airway protection.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-04 00:00:00.000",
"description": "Report",
"row_id": 1400032,
"text": "RESPIRATORY CARE: PT W/ A 7.5 ORAL ETT IN PLACE.\nREMAINS ON PS 5/.40/5 PEEP. ABG C/W STABLE ACID-BASE\nAND OXYGENATION ALTHOUGH PO2 A BIT LOWER THAN IT HAD BEEN.\nSX FOR TAN SPUTUM WHICH WAS SENT TO LAB FOR ANALYSIS.\nUO IS GOOD BUT FLUID LOS + 9570 CC. WBC 14.6.PT SEDATION\nHAS BEEN OFF SINCE LAST BUT PT REMAINS UNRESPONSIVE\nWITH A POOR GAG REFLEX. GO TO OR IN AM AND WILL REMAIN\nINTUBATED FOR AIRWAY PROTECTION FOR NOW UNTIL MENTAL STATUS\nAND ABILITY TO PROTECT HIS AIRWAY IMPROVES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-13 00:00:00.000",
"description": "Report",
"row_id": 1400066,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Remains on prop gtt. Pt moving all over bed. Haldol increase to Q6hrs. pt responds to voice able to follow simple commands. pt w/ c/o pain post paracentesis. Medicated with morphine X1 for pain.\nCV: HR NSR no noted ectopy. SBP 90-130's. Pt s/p paracentesis. + removal of 100cc of fluid. Specimens sent for culture.\nPt continues with low grade temps.\nResp: Remains with moderate amts of thick yellow secretions. ? Need for bronch. Current vent settings A/C .40% 600X14 w/8 peep. Lungs coarse throughout. Sats 94-97%.\nGi/GU: Tf running through NGT. Pt + ascities. Lactulose conts. Mushroom cath drng large amts of liquid stool. Foley patent drng amber urine\nEndo: RISS\nID: Remains on ABX\nPlan: Cont with current plan of care. Liver biopsy to be done on Wednesday.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-13 00:00:00.000",
"description": "Report",
"row_id": 1400067,
"text": "Resp. Care:\n Pt. remains intubated and on vent.support. BS- coarse bilat. Sx lg. amt's thick yel. sputum. Pt. tachypneic, restless last . Complains of pain, and of discomfort from ETT. Gave albuterol MDI x 1 PRN. Please see flow sheet for more information. ABG reveals a mild met. alkalosis with a mild hypoxemia. SA02 95-97%. RSBI 55. be able to attempt PSV again today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-13 00:00:00.000",
"description": "Report",
"row_id": 1400068,
"text": "Resp Care\n\nPt remains intubated and currently vented on psv/cpap tol well with Vt around 600cc and RR in the mid to upper 20s with stimulation and agitation. ABG WNL with adeqaute oxygenation on present vent settings. BS course sxing for mod amts of thick tan to yellow secretions. ETT rotated and resecured at 25cm at the lip. WIll cont with vent support and reassess for further weaning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-09 00:00:00.000",
"description": "Report",
"row_id": 1400050,
"text": "Focus-Condition Update\nData-Pt rouses to verbal stimuli, nods head appropriately. Pt remains on Propofol gtt. Pt incont of sm amt liquid stool-brown. Tolerating TF via NGT. Pt remains on CPAP 5/5-pt suctioned for large amts of thick yellow/tan secretions frequently.\nAction-TF increased q4 hrs to goal of 40cc/hr. Labs drawn this am as ordered.\nResponse-Hct remains stable. Continues to have a lot of secretions via ETT.\nPlan-Continue to monitor closely. Evaluate for ? extubation.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-09 00:00:00.000",
"description": "Report",
"row_id": 1400051,
"text": "Respiratory Therapy\nPt remains intubated on PSV 5/5 .4. Continues to require frequent suctioning for moderate amounts thick yellow/tan secretions. BS diminished bilaterally despite Vt of 560-580. Plan: continue to mon resp status and potential to extubate. Please see carevue and nsg note for specifics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-09 00:00:00.000",
"description": "Report",
"row_id": 1400052,
"text": "Neuro: Mental status unchanged. Moves all extremities but not always to command. Remains on propofol at 15mcg/kg/min. lightly sedated. Also started on scheduled doses of haldol. laculose resumed for hepatic encephalophathy.\nCv/resp Nsr no ectopy. Bp stable. On Cpap 5/5 increased to 8 peep after difficult recovery after spont. breathing trial. Abg done after 1 hr of trial. po2 70 and pt. was tachypnic and increased secretions.Not able to consider extubation today.\ngi/gu tube feeds at goal. Min. residuals No Tpn tonight. Lasix 10mg ivp x1. Fair dieuresis. Large explosive liquid brown stool. Fecal inc bag placed this am, working well, draining liquid brown stool.\nInteg: skin intact except for mult. open blisters on left arm. Wrapped in quilted pad. Draining serous.\nRemains on insulin gtt. Glucoses stable all day and insulin dose not changed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-20 00:00:00.000",
"description": "Report",
"row_id": 1400088,
"text": "NPN 0700-1900\n\nPlease see transfer note for PMH/HPI\n\nNeuro: Pt and Oriented times 2, Unsure of Date. PEERLA. Moving all 4 extremities, able to lift and hold all 4 extremities.\n\nCV: Tele with SR/SA HR up to 110's ? afib. EKG done, Lytes drawn at 1800. Pt asymptomatic BP 130/60. DP/PT faintly palpable.\n\nResp: Respirations even and unlabored RR 20's, sats greater than 95 on 3 LNC. LS diminished but otherwise clear.\n\nGI: + BS in 4 quadrents, + ascites. Ab distended non tender. Mushroom rectal tube intact drained 500cc black-brown liquid stool. Speech and Swallow eval done yesterday. Per Speech able to tolerate thin liquids and ground solids. NO STRAWS with thin liquids. + coughing with thin liquids. Given Honey thick liquids with spoon without coughing. NGT (dobhoff) intact clamped. Tolerating Meds whole PO.\n\nGU: Voiding dark amber urine via foley at this writing + 2 liters for the day.\n\nSkin: Pt has large area of excoriation on Buttock. ? Yeast infection. Antifungal cream and Double guard applied. Blisters noted on Left Hand, Right shin and Left Shin. Left shin blister with serosang drainage, Left hand and right shin without drainage DSD applied. Wound care consult in AM\n\nID: Afebrile. Was on Leco & Flagyl for ? aspiration PNA. D/C'd today.\n\nF&E: Hypernatremic NA this am 147. Encouraging PO fluids. D5W at 125 for 500 cc Infusing. Electrolytes from 1800 pending\n\nHeme: HCT this AM 25.4. continue to monitor Serial HCT's.\n\nActivity: OOB to chair with max two assist today. Good Bed mobility able to roll side to side independently. Does max assist with ADL's and Feeding.\n\nSee transfer note for plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-13 00:00:00.000",
"description": "Report",
"row_id": 1400069,
"text": "NSG PROGRESS NOTES:\nSEE FLOW SHEET FOR SPECIFIC:\nNEURO: REMAINS ON PROPOFOL GTT@ 10MCG/KG/MNT,MORE ALERT THAN YESTERDAY.Q6H HALDOL WITH GOOD EFFECT,PERL,MOVES ALL EXTRIMITIES,ABLE TO COMMUNICATE WITH NODDING & MOUTHING WORDS,TRIED TO REDUCE PROPOFOL MORE DOWN BUT GETTING AGITATED.\nCV: NSR ,NO ECTOPY HR 72-108,STABLE BP, IVF KVO .\nRESP: REMAINS ON VENT MODE CHANGED TO CPAP WITH PS ,ABG WNL,LS COARSE SXN YELLOW THICK SECRETION ,NEEDS FREQUENT SUCTION.O2 SAT WNL.\nGI: TF TOLERATED,H2O BOLUS Q6H FOR HIGH NA,ABD DISTENDED,+ BS ,MASHROOM CATH DRAINING LARGE AMT LIQ STOOL.\nGU: FOLEY CATH WITH AMBER COLOURED URINE,40-45ML/HR.\nENDO:FS Q6H,SSRI & FIXED DOSE.\nACT: BED FAST TURNED & POSITION CHANGED Q2H.\nID: STILL WITR LOW GRADE FEVER,ON ANBX.\nSOCIAL: BROTHER CALLED UP & UPDATED WITH HIM,HE IS GOING TO VISIT HIM TONIGHT.AWARE ABOUT LIVER BIOPSY TOMORROW.\nPLAN: CONT CURRENT PLAN,PULM HYGIENE,WEAN OFF PROPOFOL & VENT AS TOLERATES,FOR LIVER BIOPSY TOMORROW\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-13 00:00:00.000",
"description": "Report",
"row_id": 1400070,
"text": "TO KEEP NPO FROM MN & TO GIVE 1 UNIT FFP BEFORE PROCEDURE TOMORROW,MICU MD MADE AWARE OF UO .NO ORDERS .\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-14 00:00:00.000",
"description": "Report",
"row_id": 1400071,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on AC settings. Placed back on AC ventilation from PS ventilation last evening d/t tachycardia/arrythmias and increased WOB. RSBI completed on PS 5=30. Patient scheduled for liver biopsy this AM so there is no need for a SBT.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-06 00:00:00.000",
"description": "Report",
"row_id": 1400041,
"text": "Condition update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt progressively becoming more awake and alert over the course of the morning. Following commands, nodding to yes/no questions, MAE, PEERL. Became more agitated in the afternoon; kicking foot board, pulling against restraints, tonguing ETT out, restless in bed. Recieving haldol 5mg IV q6hrs with little effect. Recieved one dose of prop 20mg IV push with pos effect, tol well, wore off in 20 minutes. Suggested gtt to MICU team, team wants to continue with haldol, not prop. Psyc consulted, has not suggested to r/s psyc meds yet. Pt still neuro intact through agitation. Denies pain.\n\n Resp: No vent changes made. LS coarse bilat throughout. Frequent suctioning of thick blood tinged to tan sputum required. ETT repositioned x2 due to pt tonguing ETT when on the right side of mouth.\n\n CV: Pt remains NSR-NST, no ectopy. Remains edematous. Palp dp/pt bilat. Hypertensive to 170's when agitated, MD Wandt aware, no intervention at this point in time.\n\n GI: ABD softly distended, bs present. Melena stool continues as well as lactulose po q6hrs.\n\n GU: Adequate amounts of clear amber urine via foley cath.\n\n Skin: Bilsters intact on L arm.\n\nPlan: TIPS on , better control of agitation, r/s psyc meds, start tubefeeds after TIPS, monitor for bleeding, pulm toileting, extubate after TIPS, provide emotional support to pt and family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-07 00:00:00.000",
"description": "Report",
"row_id": 1400044,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Pt remains sedated on prop gtt @20mcg/kg/min. Pt withdraws to pain and moves all extremities on the bed. Does not follow commands. pt does not appear to be in pain.\nCV: Pt with large amts of BRBPR this am approx 2000cc. Pt received 4u PRBC's and 2 FFP for INR 1.6. Post transfusion crit 31.1 and INR 1.5. MICU team and hepatology fellow into eval. Pt also received and 500cc bolus. SBP did drop to mid 80's to low 90's which recovered with blood and fluid. Pt sent for emergent tips this at 2pm. Pt continues to be afebrile.\nResp: No vent changes this shift. Po2's in mid 70's via ABG. Team is aware and no changes made. Pt cont to have mod amts thick white and times frothy secretions. Lungs clear to diminished at bases. Sats 96-97%. Pt did desat X1 to 92/93 which returned to baseline post lavage.\nGI/GU: NGT in place ? if clotted d/t low output. Abd soft and very distended (ascities). Hypo BS large amts of melena stool and Large clots as indicated. Foley patent drng amber urine\nEndo: On insulin gtt.\nID: Afebrile and remains on mult abx\nPlan: cont to monitor serial crits. Cont to monitor hemodynamics. Cont to monitor resp and neuro status. Monitor pt response to TIPS procedure.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-07 00:00:00.000",
"description": "Report",
"row_id": 1400045,
"text": "Respiratory Care: Pt remains intubated and vented on PSV as recorded on care view. Pt ABG showed poor oxygenation, team aware of it, no changes made. Pt traveled to OR for TIPS procedure. No vent changes made.will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-07 00:00:00.000",
"description": "Report",
"row_id": 1400042,
"text": "Respiratory Care\nPt. intubated on ventilatory support. Suctioned t/o shift numerous times for very thick tan secretions, gets wheezy after suctioning but clears well with use of albuterol MDI. PT. RSBI nto performed due to change in medical status, hypotension and apparent active bleeding. Remains stable from a respiratory standpoint on current vent settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-07 00:00:00.000",
"description": "Report",
"row_id": 1400043,
"text": "CONDITION UPDATE:\nD/A: T MAX 100.1\n\nNEURO: SEDATED ON PROPOFOL. DOES NOT FOLLOW COMMANDS. + GAG, + COUGH, PERL. MAE'S. ATTEMPTING TO TOUNGE OUT ETT AT TIMES. PROPOFOL GTT. NO S+S OF PAIN.\n\nCV: HR 70'S-90'S NSR, ABP 80'S-140'S/50'S-60'S. CVP~8. ~2AM WITH BATHING AND CHEST PT, RED BLOOD NOTED OUT NGT. MICU TEAM AWARE AND EVALUATED. HCT 25.4. PT BEGAN TO BECOME MORE TACHY IN THE 90'S WITH BP DROPPING TO 80'S. 2 UNITS PRBC GIVEN, REPEAT HCT PENDING. HR NOW 70'S NSR, BP ~ 100/54. PT HAD 350 CC'S BLOOD/CLOTS OUT NGT AND THEN OUTPUT STOPPED. IRRIGATED MANY TIMES WITH NO FURTHER SIGNIFICANT OUTPUT. OCTREOTIDE GTT RESTARTED.\n\nRESP: LS COARSE. SUCTIONED FOR THICK YELLOW/TAN SPUTUM. PT ON CPAP +PS, 40%, 5 PEEP, 5 PS WITH ABG: 7.41, 47, 91, 31, 3.\n\nGI: TF'S STARTED @ 10 CC'S PER MICU TEAM, STOPPED WITH BLEEDING. FIB BAG ON FOR ~ 250 CC'S DARK LIQUID OUTPUT. TPN. INSULIN GTT.\n\nGU: FOLEY - BSD WITH CLEAR AMBER URINE.\n\nSKIN: LEFT ARM WITH MULTIPLE BLISTER AREAS WHICH HAVE BROKEN AND ARE DRAINING SEROUS FLUID.\n\nR: PT , 2 U PRBC GIVEN.\n\nP: CONTINUE TO FOLLOW HCT, MONITOR FOR S+S OF BLEEDING. CONTINUE TO MONITOR VITALS, RESP STATUS, SEDATION. SAFETY. PT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-16 00:00:00.000",
"description": "Report",
"row_id": 1400079,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT AWAKE, ORIENTED X . VOICE SOFT AND DIFFICULT TO UNDERSTAND AT TIMES. CONFUSED AT TIMES. PERRL. USUALLY FOLLOWS COMMANDS. MAE ON BED BUT VERY WEAK.\n\nCV-HR 70'S, SINUS. SBP STABLE. SKIN W+D. +PP. + PEDAL EDMA. PBOOTS ON. FREE H20 STARTED FOR HIGH NA+.\n\nRESP-O2 SAT DOWN TO 92 ON RA AT TIMES. O2 SAT 97% ON 35% FACE TENT.LS DECREASED THROUGHOUT. C+DB ENC.\n\nGI-ABD FIRM WITH + ASCITIES. +BS. NGT IN PLACE. TOL TF. PT WITH LIQ BROWN STOOL VIA MUSHROOM CATH. NPO.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS AMBER URINE.\n\nCOMFORT-DENIES NEED FOR PAIN MED.\n\nENDO-SSRI AND NPH.\n\nACCESS-TRAUMA LINE CHANGED TO CVL. TO IR FOR PICC PLACEMENT TODAY.\n\nA-STABLE FOR TX TO FLOOR WHEN BED AVAIL.\n\nP-TX TO FLOOR. MONITOR FOR CHANGES. ? PT CONSULT. REPEAT SWALLOW EVAL. FOLLOW LABS. SUPPORT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-08 00:00:00.000",
"description": "Report",
"row_id": 1400046,
"text": "Respiratory Care\nPt. intubated on ventilatory support. Mode of ventilation changed to PSV, pt. tol well, oxygenation requirements require peep level of 10. ABG's stable at this time with values in the normal ranges. Pt. continues to require frequent sutioning of thick yellow tan secretions and occ. exp wheezes treated with alb. MDI.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-08 00:00:00.000",
"description": "Report",
"row_id": 1400047,
"text": "CONDITION UPDATE:\nD/A: T MAX 100.6, S/P TIPS PROCEDURE.\n\nNEURO: SEDATED ON PROPOFOL, WILL OPEN EYES TO VOICE, DOES NOT FOLLOW COMMANDS. PERL. + COUGH, + GAG. DOES NOT APPEAR TO BE IN PAIN.\n\nCV: HR 60'S-80'S NSR, ABP ~ 120/50, CVP ~ 8. RETURNED FROM TIPS PROCEDURE AND 2 UNITS PRBC/4 UNITS FFP ORDERED BUT ONLY ONE UNIT PRBC TOTAL GIVEN DUE TO LABS REFLECTING ADEQUATE BLOOD REPLEATION WITH HCT 32.9, AND INR UNCHANGED @ 1.6. NO S+S OF ACTIVE BLEEDING. NO OUTPUT OUT NGT DESPITE IRRIGATING X1, NO STOOL. FLUID BALANCE FOR + 4676 CC'S. FLUID BALANCE MN-0500 + 600 CC'S. + PPP BILAT. P BOOTS ON FOR DVT PROPHYLAXIS. OCTREOTIDE GTT CONTINUES.\n\nRESP: LS COARSE, SUCTIONED FOR THICK YELLOW SPUTUM. PT NOW ON CPAP + PS, 40%, 5 PS, 10 PEEP WITH ABG: 7.39, 45, 92, 28, 1.\n\nGI: NGT NO OUTPUT, CLAMPED, IRRIGATED X1. ABDOMEN LARGE, SOFT. NO STOOL. TPN. INSULIN GTT.\n\nGU: FOLEY-BSD WITH CLEAR AMBER URINE.\n\nSX: BROTHER CALLED AND WAS UPDATED.\n\nR: S/P TIPS PROCEDURE WITH NO S+S OF ACTIVE BLEEDING.\n\nP: CONTINUE CLOSE MONITORING OF VITALS, RESP STATUS, S+S OF BLEEDING. INSULIN, PROPOFOL, OCTREOTIDE GTTS AS ORDERED. WEAN SEDATION AND VENTILATOR AS TOLERATED. PT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-18 00:00:00.000",
"description": "Report",
"row_id": 1400081,
"text": "RESPIRATORY CARE: PT IS A 66 YO MALE PT FROM 11\nFOR DETERIORATION IN RESPIRATORY STATUS. SINCE ADMIT\nTO MICU-6 HIS OXYGENATION HAS IMPROVED. O2 AT 3 LPM\nAND RR 20-25 BPM AND SPO2 98-100 %. WILL MONITOR RESPIRATORY\nSTATUS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-18 00:00:00.000",
"description": "Report",
"row_id": 1400082,
"text": "Addition to previous note:\n\nLiver team in to see pt. and evaluated for possible scope. Holding off at this time. Will re-eval in the am. No further orders rec'd. HCT at 1730 at 28 after 2 un prbc's. Has had a total of 4 episodes of melena (med to large amts.)\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-19 00:00:00.000",
"description": "Report",
"row_id": 1400083,
"text": "NURSING NOTE 1900HRS 0500HRS\n\nRE-ADMIT TO MICU WITH RESP DISTRESS AND POSSIBLE RE GI BLEED..RECEIVED TWO UNITS PRBC WITH DAY STAFF YESTERDAY FOR TACHCARDIA/POS LAVAGE AND FALLING HCT...\n\n\n\nEVENTS..CONTINUED WITH POS LAVAGE,MALAENA PAIN,TACHCARDIA, FALLING HCT BY 2AM ...RECIVED X2UPRBCS...D5 COMMENCED FOR HIGH SODIUM....FOR SCOPE THIS AM AND POSSIBLE TAP OF ASCITES UNDER XR GUIDANCE\n\n\nNEURO...RECEIVED VAGUE, ORIENTATED X1/2..ORDERED LACTULOSE AND TEAM INSISISTED ON PM DOSE BEING GIVEN [DESPITE POS LAVAGE]..AGITATAED BY 12300HRS [ UNABLE TO SIT STILL/CO-OPERATE AND RECEIVED 5MGS OF HADOL WITH SOME EFFECT]..THEN C/ PAIN COMMENCED AT 12MN, RECEIVED 2MGS OF MORPHINE...PRESNTLY A LITTLE MORE CO-OPERATIVE/SETTLED AND HAS SLEPT FOR SHORT PERIODS, DENIES PAIN AT THIS TIME...4AM LACTULOSE HELD...\n\n\n\nRESP..LUNGS SOUND COURSE AT TIMES, ABLE TO COUGH [ NON -PRODUCTIVE] THEN SOUNDS DIMINSHED..SATS MAINTAINED ON NC @ 3L > 95%,... AT TIMES SEEMS TO GRUNT BUT DENIES SOB/DISTRESS...ON XR ? ASPIRATION PNEUMONIA FOR WHICH HE IS ON AB'S...\n\n\nCVS..RECEIVED TACHY AT 120 AND THIS PERSISTED AND INCRESAED TO 130..ONCE PATIENT HAD RECEIVED 2 UPRBS [ FOR FALLING HCT]..HR FELL TO 110 AND HAS BEEN MAINTAINED THERE...B/P SYSTOLIC MAINATINED > 100 AND MAPS > 65...\nREMAINED WITH BORDERLINE TEMP..HAD BEEN PREVIOUSLY FEBRILE [ ] AND HAD BEEN PAN CX THEN...AB THERAPY CONTINUES\nAM LABS SHOWED RISISNG SODIUM THEREFORE D5W COMMENCED @ 0400HRS, CHLORIDE @ 120..LFTS ELEVATED [ LIVER TEAM FOLLOWING]\nCVP TRANSDUCED @ \n\n\nHAEM..RECEIVED PATIENT WITH HCT @ 28 [ POST 2UPRBCS WITH DAY STAFF, AN INCREASE FROM 26] CHECK @ 2200HHRS STABLE @ 28...BY 0200HRS HAD DROPPED TO 25...NUMEROUS EPISODES OF MALAENA, AND X2 POS GASTRIC LAVAGES..ATTENDING INFORMED AND CAME TO REVIEW..AT THIS POINT 2UPRBC ORDERED AND GIVEN OVER 1 HR...INR @ 1.8, TEAM ARE AWARE ? FOR FFP THIS AM...FOR SCOPE THIS AM...\n\n\nGI...AS ABOVE WITH GASTRIC LAVAGEE/EPIOSDES OF MALAENA..BELLY VERY LARGE/ASCITIC, PATIENT HAD ADBO U/S PERFORMED YESTERDAY WHICH SHOWED TIPS PATENT...UNABLE YESTERDAY TO TAP REQUIRES TO HAVE IT DONE WITH XR GUIDANCE AT SOME POINT..PRESENTLY HAS MUSHROOM CATH IN PLACE HAS DRAINED SOME SINCE INSERTION...\n\n\nGU...MAINTAINED > 30CC/HR..AMBER...BLADDER PRESSURE @ 12\n\n\nSKIN...SACRUM IS ABRAISED/VERY RED WITH YEAST INFECTION [ MIC APPLIED] AND BARRIER CREAM...X2 ?? EARLY ULCERATION AREAS @ BOTH ANKKLES..NON-ADHESIVE APPLED WITHTEGADERM ..NEED RE-EVAL TODAY PLEASE..\n\n\nLINES..CENTRAL LINBE/PICC..\n\n\nSOCIAL..FRIEND IS BUT NO ENQUERIES OVERNIGHT...\n\n\nPLAN..MONITOR CVS/HCT/LYTES...SCOPE THIS AM AND POSSIBLE ASCISTIC TAP\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-19 00:00:00.000",
"description": "Report",
"row_id": 1400084,
"text": "ADDENDUM....NPH HELD YESTERDAY BY DAY STAFF IN OF NPO..B/S HAVE REAMINED STABLE OVERNIGHT, CONTINUE TO MONITOR\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-19 00:00:00.000",
"description": "Report",
"row_id": 1400085,
"text": "MICU 6 Nursing Progress Note (0700-1900)\n\nCNS: Pt. initially very confused, agitated, not communicating clearly, flailing around in the bed. As the day progressed he improved to the point where he is much less restless, oriented to person and place and able to follow commands. Able to cooperate with EGD, line placement, paracentesis, etc. He did received 2mg versed and 50mcg fentanyl with EGD and has denied any pain this shift.\n\nGI: Hct has been stable at 27 (checked q6hr). Minimal amount of BRB via NGT which cleared with 180cc lavage this AM. No further vomiting.Total of 300cc liquid, black, guiac positive stool via mushroom catheter this shift. EGD showed non-bleeding varices. NGT removed at this time, dobhoff has been placed and placement confirmed. Speech and swallow study done at the bedside...pt. able to tolerate soft solids/thin liquids/ground solids per report. Thus far, only taking small amounts of water and ice chips due to ? recent bleed. He does cough after swallowing. Paracentesis performed and 600cc clear, straw colored fluid removed.\n\nID: T max of 101.6 rectally. Cool water bath given and he is now 99.8 rectally. Being treated for aspiration pneumonia with flagyl and levo. Right IJ triple lumen removed and tip sent for culture. New left Ij triple lumen placed. PICC remains in, ?pulling it vs drawing blood cultures from line.\n\nRESP: Sats of >95% on 3lnc, even when lying flat. Pt denies any SOB, although he is tachypneic intermittently. Lungs clear, diminished at the left base. Strong, congested cough without sputum production.\n\nCVS: B/P stable at 120's/50's. Heart rate 100-115, ST with occasional PVC.\n\nF and E: UOP of approximately 80cc/hr. Currently even. Continues to receive D5W at 70cc/hr d/t hypernatremia. (first liter of 1500cc up) 1700 Na pending.\n\nENDO: NPH restarted at 1/2 usual dose. Pt. also being covered with regular insulin...2U at 1200 and 1800 due to fingerstick of 150-160.\n\nSKIN: Please see carevue for description of skin breakdown and treatments.\n\nSOCIAL: Brother for consent for line, EGD and paracentesis. Updated by housestaff and nursing.\n\nPLAN: Follow Hct and lytes\n Follow fever curve, continue with antibiotic therapy as ordered.\n Allow clear fluids in moderation.\n Monitor respiratory status, at risk for aspiration.\n Skin care RN to be consulted in AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-18 00:00:00.000",
"description": "Report",
"row_id": 1400080,
"text": "MICU 6 Admitting Note and Nursing Progress Note for 7a-7p:\n\nThis is a 66 y/o gentleman who was previously in SICU () w/ dx of BRBPR and drop in HCT. Transferred out last night to 10, but readmitted to MICU w/ resp. distress requiring 100% NRB. His past med. hx includes Hep B cirrohsis, ETOH/drug abuse, schizonphrenia, dementia, prior UGIB from esophageal tear. Arrived to MICU 6 on 100% NRB. Please see flowsheet for more detailed vitals.\n\nNeuro: AOx2, PERLA. MAE. Denies any pain or discomfory at this time.\n\nCV: ST w/ no ectopy. ECG done on admit showing no sign. changes. BP stable, but dropped to systolic of 89. Given a total of 1500cc of LR so far. 3 pt. HCT drop to 26. Rec'd a total of 2 unit of PRBC's. Afebrile since admission, but was febrile to 101 on floor w/ urine/blood cx's sent last night. Palp. peripherial pulses x 4. CVP's ranging from .\n\nResp: Weaned off NRB to 3l NC and maintaining O2 sat > 92%. Lung sounds remain coarse to fine crackles in upper lobes and diminished in bases. RR labored at times w/ RR into upper 20's. Denies any SOB/dsypnea. Non-productive congestive cough. Portable chest x-ray revealed RLL collapse and MD's requesting aggressive pulmonanry toileting.\n\nGI/GU: NPO w/ NGT to R nares in place. Noted to have bright red blood via NGT. Lavaged by Resident. Abd w. ascites, soft, NT. He has had a total of 3 large melena stool since admission. Foley in place w/ dark yellow urine draining at > 30cc/hr.\n\nACCESS: R IJ TLC and L upper arm SL PICC in place w/ dressings changed today.\n\nID: ? aspiration pna (was on TF's on floor). Restarted on Levaquin\n\nPLAN: Cont. w/ current plan of care. Monitor per protocol. HCT to be checked at 1800 (post 2u of prbc's). Aggressive pulmonary toileting. AM labs ordered.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-20 00:00:00.000",
"description": "Report",
"row_id": 1400086,
"text": "cv: hr to 118 st with many pac's to 80 nsr with occasional pac.bp 115-120's/\n\nresp: o2 at 3 l nc. breath sounds clear upper and diminished at basas. o2 sats 95-97 %. pt has strong cough raises and swallows.\n\ngi: dobhoff for meds.. otherwise clamped. positive bowel sounds abdomen distended/ascites. mushroom catheter draining copious amounts liquid black stool( 1100 cc this shift)\n\ngu: foley draining amber yellow urine 40-100 cc/hr.\n\nintegumentary: drssings intact on r ankle,l ankle and L wrist. Perianal area is red ..miconazole powder and double cream applied.\n\nendo: bs -149 no treatment. pt of 10 nph at 8 pm and a.m. dose at 0600 ie 10 nph.\n\nlabs hct 26.2 K=3.2 repleted with 60 kcl 20 meq via dobhoff and 40 meq iv. na =152. 500 cc d5w bolus given and pt to receive 500 cc bolus of d5w q 6 hours for total cc.\n\nneuro status: pt slept for a few hours overnight. pt requesting ice frequently. pt is oriented to name and place.perrl.mae to command.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-20 00:00:00.000",
"description": "Report",
"row_id": 1400087,
"text": "addendum: temp max = 100.1 po,decreased to 99.1 without treatment\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-02 00:00:00.000",
"description": "Report",
"row_id": 1400024,
"text": "NPN: Review of Systems\nNeuro: Sedated on fentanyl and versed. Fentanyl increased to 125mcg/hr and versed increased to 10mg/hr d/t Pt beginning to move and becoming increasingly tachycardic.\n\nResp: Continues on AC 12x600 w/5 PEEP. Breathing over the vent. Fio2 decreased to 40% and Sao2 has maintained 96-100%. Pt appears comfortable. BS CTA bilaterally w/ exception of left base which sounds slightly diminished. Suctioned thick blood tinged secretions.\n\nCV: As noted above HR increasing up to 114, down to 90s after increase in pain/sedative meds. Afebrile. MAP has been >70 throughout the day. Palpable DP/PT pulses bilaterally. Pt received 3gms calcium gluconate for ca++=1.02.\n\nGI: Traction removed from tube. Balloon deflated. 50cc remains in it per GI to prevent it from slipping out. Octreotide infusing as ordered. Abdomen is soft. (+) bowel sounds. Rectal bag for melena. Medications held d/t no access for oral medications. MICU team aware.\n\nEndo: Fingerstick glucose=184->3 units regular insulin administered. Sliding scale changed d/t sugar level rising on previous scale.\n\nGU: Foley to gravity draining clear yellow urine.\n\nHeme: HCT=34.6 from 35.8.\n\nSocial: Family called and updated on Pt's condition. Nursing Directer from Pt's residence visited and left a copy of healthcare proxy. Social worker also updated on Pt's hospitalization.\n\nA: Hemodynamics have been stable. Comfortable on current vent settings. Increased amt of sedatives/ pain medication required to maintain comfort/safety.\n\nP: Serial HCTS. Maintain MAP> 60. Transfuse if HCT <25. Continue to evaluate comfort and adjust medications accordingly. ? surgical intervention. Consult family regarding Pt's wishes abt treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-02 00:00:00.000",
"description": "Report",
"row_id": 1400025,
"text": "Addendum to NPN\nHCT=30.8 at 6pm from 34.6. Will continue to follow and recheck HCT at 12am. Fingerstick glucose=211-> Spoke w/ MICU intern and Regualr insulin drip started. will check glucose q 1hr per protocol. Brother, called. He is Proxy and will be the person to call to receive information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-03 00:00:00.000",
"description": "Report",
"row_id": 1400026,
"text": "NPN (NOC):\n\nRESP: PT REMAINS INTUBATED. CURRENT VENT SETTINGS: A/C 12X600X40%. TOTAL RR 12-14/MIN. AM ABG: 119/44/7.34/25/-2. BS'S CLEAR. SX'D FRO THICK BROWN SECRETIONS.\n\nCV: HAS REMAINED HEMODYNAMICALLY STABLE OVERNOC, ALBEIT MILDLY TACHYCARDIC. HCTS STABLE IN LOW 30'S X 24 HRS NOW.\n\nNEURO: REMAINS WELL SEDATED ON FENTYNL 100 MCG'S AND VERSED 7.5 MG'S. RELUCTANT TO WEAN FURTHER GIVEN TACHYCARIDA.\n\nGI: NO FURTHER MELENA NOTED IN FIB. BLAKEMEORE TUBE REMAINS INTACT.\n\nGU: UO = 70-80/HR. RPT CA2+ = 1.18, REST OF LYTES PND.\n\nENDO: INSULIN DRIP TITRATED PER CSRU SCALE FOR GOAL FSBS 100-120. CURRENTLY AT 9U/HR.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-03 00:00:00.000",
"description": "Report",
"row_id": 1400027,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter setting changes made throughout the night. Morning abg results determined a mild respiratory acidosis with very good oxygenation on the current settings.\n\nRSBI = 15.6 on 0-PEEP and 0-PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-05 00:00:00.000",
"description": "Report",
"row_id": 1400036,
"text": "Condition Update\nAssessment:\nPlease see carevue for details\n\nNeuro: Pt remains off all sedation. Only responding to nailbed pressure to L foot by lifting L toes and withdrawing slightly. No other movements noted in any other extremities. Opens eyes spontaneously, but does not focus or track. Pupils equal and reactive. Head CT today was neg.\n\nResp: No vent changes made. LS coarse to clear bilat throughout. Suctioned frequently for copiuous amounts of thick blood tinged secretions. Lavaged on occation with pos effect. Pos cough, neg gag.\n\nCV: Remains in NSR, no ectopy noted. VSS, low grade temp, pan cultured. Remains edematous all over body. Maintenance fluid d/c'd. Palp dp/pt bilat.\n\nGI: Abd obese, hypoactive bs. NGT placed at bedside @ 1700 by GI fellow, remains clamped. Lactulose enemas continue, not tol very well, can only take in small frequent amounts. Mod amount of melena stool, FIB intact.\n\nGU: Adequate amounts of clear yellow urine via foley cath.\n\nEndo: Remains on insulin gtt, sugars remain b/w 100-120.\n\nID: Sputum grew out gram pos cocci, gram neg rods, and yeast. Recieving flagyl, vanco, and zosyn.\n\nSkin: LL arm, new blisters noted, all intact.\n\nPlan: Pt to go for TIPS attempt again tomorrow, change lactulose enemas to po, r/s psyc meds, Hct to be drawn at 2200, montior for bleeding, cont with neuro exams, continue with abx, transplant team cont to follow, keep sugars controlled, provide pt and family with emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-05 00:00:00.000",
"description": "Report",
"row_id": 1400037,
"text": "Resp care\nPt remains intubated on PSV. pt went to CT for head scan this morning results negative, no changes. no vent changes noted this shift. pt has course bs alb MDI given, pt suctioned for mod amt of blood tinged/tan secretions. plan at this time is for pt to remain on current settings until pt becomes responsive, all sedation has been off for > 36 hours. will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-06 00:00:00.000",
"description": "Report",
"row_id": 1400038,
"text": "Respiratory Care\nPt.remains intubated on ventilatory support for airway protection. Tol minimal levels of CPAP/PS, very congested, being sx for copious amounts of thick bloody secretions. Plan is to assess pt, mental status as sedation wears off prior to extubation. RSBI= 30.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-06 00:00:00.000",
"description": "Report",
"row_id": 1400039,
"text": "NURSING UPDATE\nCV: SLIGHTLY TACHY IN LOW 100'S AT TIMES, NO ECTOPY. NORMOTENSIVE. SANDOSTATIN GTTS CONT, HCT STABLE.\n\nRESP: LUNG SOUNDS COARSE BILATERALLY. SXN COPIOUS AMOUNTS BLOODY SECRETIONS WITH PLUGS. SATS 96-100%. NO VENT CHANGES OVERNOC.\n\nENDO: GLUCOSE STABLE, INSULIN GTTS CONT.\n\nID: TMAX 100.2, ABX REGIMEN CONT.\n\nGI: NGT PLACEMENT VERIFIED BY CXR, NPO IN PREP FOR TIPS PROCEDURE TODAY. SM MELENA STOOL PER RECTAL BAG.\n\nNEURO: REMAINED UNRESPONSIVE UNTIL 0500. SUDDENLY MORE AWAKE, ATTEMTED TO STICK OUT TONGUE ON COMMAND X1 BUT EFFORT INCONSISTENT. MOVING LOWER EXTREMITIES MORE RT>LT. STILL NO SPONTANEOUS MOVEMENT OBSERVED IN UPPER EXTREMITIES.\n\nSKIN: SOME BLISTERS ON RT ARM BROKEN, WEEPING SEROUS FLUID, ARM LOOSELY WRAPPED.\n\nSOCIAL: VISITED BY SISTER-IN-LAW AND LAST .\n\nPLAN: ATTEMPT AT TIPS PROCEDURE TODAY, FAMILY AWARE.\n\nPT MONITORED CLOSELY OVERNOC. SEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-06 00:00:00.000",
"description": "Report",
"row_id": 1400040,
"text": "Resp Care\nPt remains intubated on PSV, no vent changes, stable shift. Pt was sx for copius amt secretions. Plan to keep intubated until secretion improve.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-11 00:00:00.000",
"description": "Report",
"row_id": 1400060,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT WEANED OFF PROPOFOL THIS AM AND TOLERATED HAVING NO SEDATION FOR A FEW HOURS. AFTER A FEW HOURS, PT BECAME TACHYPNEIC, AGITATED, MOVING LEG OVER SIDERAILS AND HANDS TO FACE. PROPOFOL RESTARTED AT 20MCGS ONLY, PT REMAINS TO VOICE BUT CALM WHEN NOT STIMULATED. PERRL. OCCASIONALLY FOLLOWING SIMPLE COMMANDS, NODDING HEAD TO QUESTIONS. DENIES PAIN.\nCV- BP STABLE, HYPOTENSIVE THIS AM TO 85-88 SYSTOLIC FOLLOWING HALDOL IV AND ZYPREXA, PROPOFOL TURNED OFF AND BP RETURNED TO 100-130'S. HR 90'S, OCCASIONAL PACS. SODIUM RECHECKED THIS AFTERNOON AND A LITER OF D5 STARTED TO IMPROVE SODIUM LEVEL OF 150.\nRESP- LUNGS COARSE AT TIMES. SUCTIONED SEVERAL TIMES FOR THICK YELLOW SPUTUM, MOSTLY ORAL. NO VENT CHANGES MADE TODAY, APPEARS TO BE BREATHING COMFORTABLY ON MILD SEDATION.\nGI/GU- ABD SOFT AND DISTENDED. CONTINUES TO HAVE LARGE AMOUNTS OF LOOSE STOOL VIA MUSHROOM CATH. UOP ADEQUATE, DARK AVERAGING ABOUT 45-50CC/HR.\nID- TMAX 101.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-11 00:00:00.000",
"description": "Report",
"row_id": 1400061,
"text": "Resp Care\nPt remains intubated on A/C. no ABGs this shift and no vent changes made RR mid 20s to low 30s, pt continues to have mod amt of thick secretions, MDIs given. plan at this time is to continue on current settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-12 00:00:00.000",
"description": "Report",
"row_id": 1400062,
"text": "Resp Care\nPt remains intubated on CMV, no vent changes, pt tachypnic at times, sx for mod amts yellow. Plan to wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-12 00:00:00.000",
"description": "Report",
"row_id": 1400063,
"text": "data: low grade temp 99.5-100.5 hr 80-96nsr w/o ect.\ncvp 5-10. urine output 25-40cc/hr.\npt slightly sedated on olw dose ppf. opening eyes @ times. nodding head to verbal stimuli.\nabd. softly distended. having very liq. stool via mushroom cath.(lactulose q8hr)\nt. fdg stopped @ 12mn for proceedure today-insulin gtt off along w/ stopping t. fdg. w/ bs <100.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-12 00:00:00.000",
"description": "Report",
"row_id": 1400064,
"text": "Resp Care\n\nPt remains intubated and currently vented on full support with no changes made to parameter settings this shift. BS slightly course at times sxing for mod to large amts of thick white to yellow secretions. ETT secured/patent. Will cont with vent support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-12 00:00:00.000",
"description": "Report",
"row_id": 1400065,
"text": "Nsg.progress notes:\nSee flow sheet for specific:\nNeuro: On propofol gtt 10-20mcg /kg/mt,responding to verbal commands by openining eyes,MAE,agitated when propofol down to 10mcg aware to MICU team Haldol increased to Q6H.PERL.\nCV: NSR HR 59-82,No ectopy,SBP drops to 90 when go up with propofol back to normal when propofol reduces. IVF KVO only ,potassium 40mmol repleeted today.2 units of FFP given today INR repeated 1.6 MICU MD aware.\nResp: remains on vent AC mode with FiO2 40% RR 14 ,TV 600 peep 8cm,LS coarse to clear sxn copious yellow thick secretion.o2 sat WNL.Sputum C/S sent today.ABG acceptable.no vent change today.\nGI: was NPO till 4pm For needle liver biopsy Feeding restarted as procedure postpond for .@ 60ml /hr soft distended.mash room cath draining with liq yellow stool,+ bS.\nGU: foley cath patent with amber urnie adq amt.\nEndo : FS Q6H was on insulin drip off since MN as NPO,now changed to SSRI & fixed dose.\nACT: bed fast turned & position changed Q2H,& prn.\nID: afebrile ,on anbx.pan cultured ,MRSA & VRE screening sent\nprocedure: U/S abd for mark paracenthesis done .for paracenthesis later today.\nPlan: cont .monotoring,pulm.hygiene.bld sug monotoring.PTT INR & lytes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-15 00:00:00.000",
"description": "Report",
"row_id": 1400077,
"text": "NURSING TRANSFER NOTE\n66 y.o. male with HX Liver Cirrhosis, Schizophrenia, IDDM, and repeated episodes of UGIB secondary to gastric varices now s/p TIPS procedure and intubated for airway protection\n\nNEURO: Alert, oriented x . Speech garbled secondary to no teeth in place and slow to respond to questions. Follows all commands. RUE and RLE noted to be weaker than left, no further deficits. No agitation or acute change in mental status noted, Haldol decreased to 3mg IV TID.\n\nRESPIRATORY: Extubated , patent airway and good oxygenation- SPO2 94-96% on room air. Lungs decreased and intermittently exp wheeze throughout, albuterol nebs x 2 today- pt denies any resp distress. Nonproductive, congested cough- ebcourage C/DB frequently. Failed speech and swallow study- NPO maintained.\n\nCV/HEMODYNAMICS: NSR 70s-80s, no ectopy. NINV SBP 112-140s. Generalized +2/+3 edema, no significant auto-diuresis yet. OOB to chair without dizziness x 5 hrs. Adequate hourly u.o. No sx GIB, Hct stable 30.2. INR 1.9 today, s/p 1 unit FFP- liver bx cancelled.\n\nF/E/N: NPO maintained- TF at goal 60ml/hr, tolerating well. Fluid boluses for hypernatremia q4hr as ordered, f/u Na level pending. Blood glucose 105 prior to TF resumed, 182 at 1700 and covered with NPH/RISS. No maintenance fluid.\n\nID: Afebrile- previously on Zosyn for klebsiella sputum, now Levaquin, abx coverage D6.\n\nENCEPHALOPATHY: Lactulose q6hr, total stool output 950ml brown, liquid.\n\nACTIVITY: OOB to chair with assist 3, tolerated for 5hrs then request back to bed for fatigue.\n\nPLAN: Transfer to 10 tonight. F/U electrolytes, replete prn. Monitor resp status closely, encourage C/DB, albuterol nebs prn. NPO, f/u speech/swallow study in days. Schizophrenia meds as ordered, see psychiatry consult.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-16 00:00:00.000",
"description": "Report",
"row_id": 1400078,
"text": "11p-7am update\nneuro: pt alert, orienated to name only. pt able to MAE and follow commands. pt weak. pt moves all ext on bed. speech slow. PERRL\n\nCV: pt remains NSR/ST, occasional PAC's noted. HR 90-100's. SBP 110-130's. MAP 80's. pp palable. hct pending\n\nresp: LS coarse with dim bases. pt on RA, o2 sats > 94%. pt with weak non productive cough.\n\ngi/gu: pt with + bs. pt recieving TF at 60 cc/hr (goal), via NG tube. minimal residual. pt continues to recieve 250 cc's free water bolus. mushroom catheter remains intact and draining brown liquid stool. continues on lactulose. foley draining clear yellow urine. UO adequate.\n\nendo: elvated bs treated with ss reg insulin\n\nplan: transfer to 10 - needs trama line changed to multi lumen or PICC line prior to transfer, monitor hcts/lytes, monitor hemodynamcis\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-04 00:00:00.000",
"description": "Report",
"row_id": 1400033,
"text": "CONDITION UPDATE:\nD/A: T MAX 98.5\n\nNEURO: SEDATION REMAINS OFF, PT REMAINS UNRESPONSIVE. PERL, + COUGH, - GAG, LE'S WITHDRAW TO PAINFUL STIMULI. MICU AND HEPATOLOGY/GI TEAMS EVALUATED, LACTULOSE ENEMA'S STARTED. PT BREATHING ON CPAP.\n\nRESP: LS CLEAR TO COARSE, SUCTIONED VERY FREQUENTLY FOR THICK YELLOW/TAN SPUTUM. SPECIMEN SENT FOR CULTURE. VENT ON CPAP + PS, 40%, 5 PEEP, 5 PS WITH ABG: 7.38, 44, 78, 27, 0, 96. CHEST PT AND FREQUENT SUCTIONING CONTINUE, SPUTUM SPECIMEN PENDING.\n\nCV: HR 70'S-80'S NSR, ABP ~ 109/52 WITH MAP >70. FLUID BALANCE MN-1800 + 1200 CC'S. HCT 27.9. NO S+S OF ACTIVE BLEEDING. + PPP BILAT. PBOOTS ON FOR DVT PROPHYLAXIS. OCTREOTIDE GTT CONTINUES.\n\nGI: HYPO BS. NGT INSERTION ATTEMPTED BY HEPATOLOGY/GI, UNABLE TO PLACE. FIB BAG REMOVED DUE TO LEAKING AFTER LACTULOSE ENEMA. TPN. INSULIN GTT.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSX: HCP CALLED AND UPDATED. , OK TO INFORM NURSING HOME OF CONDITION WHEN THE NURSE CALLS.\n\nR: AFEBRILE, NO S+S OF ACTIVE BLEEDING, CONCERNING PULMONARY STATUS.\n\nP: CONTINUE CLOSE MONITORING OF VITALS, LABS, RESP STATUS. AGGRESSIVE PULMONARY TOILETING, CHEST PT, SUCTIONING. CONTINUE TO FOLLOW NEURO STATUS. PATIENT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-05 00:00:00.000",
"description": "Report",
"row_id": 1400034,
"text": "nursing progress note\nPlease see careview for details.\n\nneuro: remains unresponsive, perl, withdraws left foot only to nailbed pressure. pt is on NO sedation.\n\ncv: febrile to 101. sputum cx re sent.\n\npulm: sx q 1-4 hrs for large amts thick tan to blood tinged sputum. ns lavage, humidification added to vent. lung sounds rhonchorous to coarse. albuterol inhaler as per order. chest pt. cxr done this am.\n\ngi: hypoactive bowel sounds. min melena stool output. hct stable, no vomiting.\n\ngu: u/o good.\n\ninsulin drip for blood sugar control. octreotide continues at 50 mcg/hr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-05 00:00:00.000",
"description": "Report",
"row_id": 1400035,
"text": "resp care\nPt maintained on psv5/peep5 and 40% with volumes of 800-900cc and rr 8-18. Suct freq for thick tan sput. Alb mdi given as ordered. Rsbi done with sats from 97-94%. Will cont to follow as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-14 00:00:00.000",
"description": "Report",
"row_id": 1400072,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nPt neuro unchanged. Pt HR nsr with PAC's one episode of SVT which broke w/o intervention. SBP 95-120's. Afebrile. HCT stable.\nResp: Remains with tons of thick yellow secretions. Pt switched from CPAP to A/C last d/t HTN and tachycardia. Pt also slightly desating to 92/93 which resolved once back on A/C. pt attempted CPAP this am. Pt becoming agitated tachy and desating. Pt placed on A/c\nGI/GU; NPO for ultrasound. Urine punch colored with some clots.\nPlan: liver biopsy today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-14 00:00:00.000",
"description": "Report",
"row_id": 1400073,
"text": "resp care - Pt extubated this AM. SBT on 7/0 done prior to extubation. Albuterol MDI puffs given for wheezes. Pt placed on 100% cool aerosol mist. No stridor, productive cough. Liver biopsy scheduled for tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-09 00:00:00.000",
"description": "Report",
"row_id": 1400053,
"text": "Respiratory Therapy\n\nPt remains orally intubated on PSV. Attempted SBT after RSBI = 62. After ~1hour SpO2 dropped to low 90s, Ve increased to >22LPM. ABG showed adequate Ve, but PaO2 70. PEEP increased up to +8cmH2O to maintain adequate SpO2. Remains on +5PSV/+8PEEP. BS coarse, diminished at bases, suctioned for moderate amounts of creamy tan thick sputum. MDI given as ordered. See resp flowsheet for specifics.\n\nPlan: maintain support; reassess for extubation in AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-10 00:00:00.000",
"description": "Report",
"row_id": 1400054,
"text": "Neuro: Pt remains sedated, opens eyes to voice, MAE, withdraws to nailbed pressure. pupils 3mm brisk.\nCV: low grade temp 99.9, HR 60-80's NSR with no noted ectopy. Extremities warm with +PP. SBP 90-140's. HCT 31 awating MICU ? transfusion.\nRESP: lung coarse through-out, Large amounts of thick tan secretions. No vent changes.\nGI: tube feed at goal. Liquid stool per FIB.\nGU: foley draining adequate amount of amber urine.\nENDO: insulin gtt restarted at 12am. presently at 3u/hr.\nPLAN: Cont to monitor HCT. ? wean vent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-10 00:00:00.000",
"description": "Report",
"row_id": 1400055,
"text": "Respiratory Therapy\nPt remains orally intubated on PSV. RR high 20's mid 30's, appears very anxious. Sx for mod amts thick tan secretions. MDI's as ordered. Plan: Wean to ext.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-10 00:00:00.000",
"description": "Report",
"row_id": 1400056,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Pt on cont on prop gtt for sedation while intubated. pt responds to voice and follows commands inconsistently.\nCV: Cont with low grade temps. pt Also becoming increasingly tachycardic over coarse of pm. MD is aware. SBP stable. Pt making adquate u/o. ? if tachycardia d/t resp issues.\nResp: Pt placed back on A/C today. Pt becoming increasingly tachypnic and with visible labored breathing. MD Dayyanni is aware. Lungs very coarse to diminished at tha bases. ABG's adequate/sats adequate.\nGI/GU: Unchanged TF via NGT Abd soft very distended. Free H2o increased to 200cc Q6hrs. Foley patent drng amber urine.\nID: Remains on mult abx\nEndo: RISS\nPlan: Cont to monitor resp status. Monitor for increased s/s of infection. Daily wake up to asses mental status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-10 00:00:00.000",
"description": "Report",
"row_id": 1400057,
"text": "Resp Care\npt remains orally intubated on vent. Pt changed from PSV to A/C this afternoon due to inceased work of breathing, increased HR, and acsesory muscle use. ABG on A/C showed adequate oxygenation and ventilation. pt continues to have mod amt of thick secretions with mod-lg blood tinged plugs. MDIs given as ordered. will continue to follow and wean back to PSV when tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-11 00:00:00.000",
"description": "Report",
"row_id": 1400058,
"text": "Resp Care\nPt remains intubated on CMV overnoight, still tachypnic. Sx for mod thick secretions. Plan monitor resp status, wean as tolerated and ? Bronch.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-11 00:00:00.000",
"description": "Report",
"row_id": 1400059,
"text": "Neuro: Pt remains lightly sedated. Propofol at 20mcg/kg/min. Pupils 3mm brisk. MAE, rarely follows directions.\nCV: temp 100.7, HR 80's NSR with rare PVC. SBP110-130's. CVP 7-9. Extremities cool with +PP.\nRESP: Lungs coarse, frequent suctioning of thick tan secretions. No vent changes overnight.\nGI: tol tube feed, Large liquid brown stool this am.\nGU: foley patent and draining adequate amber urine.\nENDO: insulin gtt continues to be titrated for blood sugars.\nPLAN: ? weaning vent. Monitor blood sugars.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-14 00:00:00.000",
"description": "Report",
"row_id": 1400074,
"text": "Focus Condition Update.\nSee flowsheet for specific info\n\nNeuro: Pt A&O x3, following commands, MAE's. Pt states he wants to go home, moving a lot in bed, Haldol given with effect.Morphine given for pain in abd.\nCV: VSS. SBP 120-150, HR 66-85. A-line redressed, working fine. Per MICU team, can pull CVL if peripheral inserted. IV paged to assess pt. Scheduled for liver bx at 0930.\nResp: Extubated without incident this a.m. sats 98-100 on 40% O2 via shovel mask. Lungs clear to coarse bilaterally, prod cough. Speech and swallow put off until after liver bx tomorrow.\nGi: BS+, TF off, mushroom cath patent, draining brown liquid stool.\nGU: Foley patent, UO WNL.\nPlan: Liver bx in a.m.\n Monitor resp status\n Continue with POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-15 00:00:00.000",
"description": "Report",
"row_id": 1400075,
"text": "nsg progress notes:\nsee flow sheet for specific:\nNeuro:ACX3,PERL,upper extrimity lifts & holds ,LL moves on bed.answring appropriately,slurred speech.asking for water always,morphine x1 for abd pain.haldol Q6H .\nCV: HR 80-92,NSR no ectopy ,SBP WNL,ivf kvo,fluid bal by MN -295,denies for cardiac complaints.\nresp: remains on cool neb 15L o2 40%,good cough,LS coarse & diminished @ bases,O2 sat wnl.\nGI: NPO except for H2O bolus,abd ascitis,+ BS,mashroom cath drainig liq brown stool\nGU: foley cath patent amber coloured urine,adq amt.\nEndo: FS Q6H,on ssri & fixed dose.\nact. bed fast,turned & position changed Q2H,position needs to be changed frequently.\nID: afebrile,on anbx.\nPlan: cont current plan,for liver biopsy this AM to transfuse 1 unit of FFP before the procedure.monitor resp status.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-07-15 00:00:00.000",
"description": "Report",
"row_id": 1400076,
"text": "resp care - pt BS wheezes t/o with decreased aeration. 2 albuterol nebs given. MD Albuterol and Atrovent Q4.\n"
},
{
"category": "ECG",
"chartdate": "2123-07-22 00:00:00.000",
"description": "Report",
"row_id": 201734,
"text": "Sinus rhythm\nAtrial premature complexes\nDiffuse nonspecific low amplitude T wave changes\nSince previous tracing of , multifocal atrial tachycardia absent\n\n"
},
{
"category": "ECG",
"chartdate": "2123-07-20 00:00:00.000",
"description": "Report",
"row_id": 201735,
"text": "Multifocal atrial tachycardia. Diffuse non-specific ST-T wave flattening.\nDelayed precordial R wave progression. Compared to the previous tracing\nof multifocal atrial tachycardia has appeared. The rate has slowed.\nThe right precordial forces are diminished - question interim myocardial\ninjury. Followup and clinical correlation are suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2123-07-18 00:00:00.000",
"description": "Report",
"row_id": 201736,
"text": "Sinus tachycardia. Compared to the previous tracing of the rate is\nfaster.\n\n"
},
{
"category": "ECG",
"chartdate": "2123-07-13 00:00:00.000",
"description": "Report",
"row_id": 201737,
"text": "Sinus rhythm\nSupraventricular extrasystoles\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2123-07-08 00:00:00.000",
"description": "Report",
"row_id": 201738,
"text": "Sinus rhythm with an atrial premature beat. Since the previous tracing\nof the rate has decreased and ST-T wave abnormalities are less.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-01 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 918954,
"text": " 8:22 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: VARICEAL BLEED, RT LESION ON US.\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n Field of view: 44 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with variceal bleed, RT liver lesions on U/S - needs CT prior\n to TIPSS\n REASON FOR THIS EXAMINATION:\n ?hepatoma (multi-phasic liver)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Variceal bleed with liver lesion seen on recent ultrasound.\n\n TECHNIQUE: Multidetector multiphasic study of the liver was performed using\n 150 cc of Optiray. Delayed images through the abdomen and pelvis were\n obtained as well.\n\n CT ABDOMEN WITHOUT AND WITH IV CONTRAST: Axial images through the lung bases\n demonstrates a 6 mm nodule (series 2, image 7), in the right lower lobe. There\n is mild lingular and bibasilar atelectasis. No pleural effusions seen.\n\n The liver has a shrunken nodular appearance, and there is a small amount of\n ascites present. There is caudate lobe hypertrophy. Multiple arterially\n enhancing lesions scattered throughout both lobes of the liver are present,\n however, these are predominantly to a larger extent in segments VI and VII. In\n these segments, the lesions are difficult to measure and almost appear\n confluent. The main portal vein and extrahepatic portions of the right and\n left portal vein are patent. However, portions of the anterior and posterior\n right portal veins are markedly attenuated.\n\n Dilated vessels adjacent to the splenic hilum, indicate varices.\n\n There are gallstones seen in the gallbladder. The pancreas and adrenal glands\n are normal in appearance. There is no hydronephrosis or hydroureter on either\n side. Emanating from the lower pole of the right kidney is an 8 mm lesion\n with peripheral calcification that is likely a hyperdense cyst.\n\n No dilated small and large bowel loops is seen. There is a NG tube in the\n stomach. There is no free air in the abdomen.\n\n CT PELVIS WITH IV CONTRAST: There is a Foley catheter in the bladder. The\n prostate is not enlarged. Evaluation of the rectum and sigmoid colon is\n limited due to the lack of oral contrast.\n\n BONE WINDOWS: A 1.5 cm lytic lesion is identified in the 12th thoracic\n vertebral body. A 1 cm lytic lesion is identified in the 4th lumbar vertebral\n body.\n\n IMPRESSION:\n 1. Multiple arterially enhancing lesions in both lobes of the liver in the\n (Over)\n\n 8:22 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: VARICEAL BLEED, RT LESION ON US.\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n Field of view: 44 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n background of cirrhosis. Lesions are more confluent in segment VI and VII.\n These are worrisome for hepatoma. A MR is recommended for better definition.\n\n 2. Six mm right lower lobe nodule.\n\n 3. Two lytic lesions in the vertebral bodies as described above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-01 00:00:00.000",
"description": "INSERT HEPATIC HUNT TIPS",
"row_id": 918960,
"text": " 9:28 PM\n TIPS Clip # \n Reason: TIPS procedure\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n Contrast: OPTIRAY Amt: 110\n ********************************* CPT Codes ********************************\n * INSERT HEPATIC HUNT TIPS -52 REDUCED SERVICES *\n * NON-TUNNELED -51 MULTI-PROCEDURE SAME DAY *\n * C1751 CATH ,/CENT/MID(NOT D C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER C2628 C=VAS-CATH OCCLUSION *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with gastric varices\n REASON FOR THIS EXAMINATION:\n TIPS procedure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Emergent decompression of bleeding gastric varices in a 66-year-\n old man with chronic liver disease and failed attempts at hemostasis by\n endoscopy on repeated occasions today.\n\n PHYSICIANS: Dr. and Dr. performed the\n procedure. Dr. , the attending radiologist, was present\n and supervised the entire procedure.\n\n TECHNIQUE AND FINDINGS: Informed consent was obtained from the patient's\n brothers before the procedure. The patient was placed supine on the\n angiography table and his right upper neck was draped and prepped using\n sterile technique as usually. The patient was intubated and ventilated, and\n this was monitored continuously during the procedure by the Anesthesiology\n Team.\n\n After local anesthesia with lidocaine 1%, the right internal jugular vein was\n punctured with a 21-gauge needle under real-time ultrasound guidance. An\n 0.018 guidewire was easily advanced through the needle into the vein and the\n needle was exchanged for a 4.5-French micropuncture sheath. The micropuncture\n sheath was exchanged over an 0.035 wire for a 7 French dilator, and\n eventually a 10 French sheath was advanced over wire with its tip placed in\n the cranial portion of the inferior vena cava (IVC).\n\n Based on the recent CT scan examination, multiple attempts were made to\n catheterize selectively the left and the middle hepatic veins by using a\n guidewire and a cobra C2 5 French catheter. These attempts were unsuccessful.\n On one attempt, a small vein was catheterized across the midline and a\n selective venogram was obtained. This vein follows a tortuous cranial course\n and likely represents a parietal or mediastinal branch.\n\n Finally, selective catheterization of the right hepatic vein was obtained\n using the same materials as above. The catheter was exchanged over the wire\n (Over)\n\n 9:28 PM\n TIPS Clip # \n Reason: TIPS procedure\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n for an occlusion balloon, and transcatheter pressure measurements were\n obtained both in free and in wedged conditions. These measurements showed a\n significant portosystemic pressure gradient (approximately 20 mmHg). A wedged\n right hepatic venogram was then obtained in the frontal plane using carbon\n dioxide as contrast. The images show retrograde opacification of the branches\n of the right portal vein, and subsequently the right and left portal vein and\n the main trunk of the portal vein itself. Hepatic parenchymography is also\n noted in the area of wedging. Some opacification of the right hepatic vein\n was also obtained, showing wide patency of this vessel. The presence of a\n Sengstaken- tube was noted.\n\n The catheter was then exchanged over an Amplatz Super Stiff wire, over which\n the 10 French sheath was advanced into the right hepatic vein. The metallic\n cannula and needle of - TIPSS kit were advanced through the\n sheath and attempts were made to puncture from the right hepatic vein up to\n the right intrahepatic branch of the portal vein. Multiple attempts were made\n but were unsuccessful, due notably to the anatomical configuration and\n geometry of the vessels, as well as the hard consistence of the liver. After\n these multiple attempts failed, and after discussing again the findings with\n the referring physician (Dr. from Gastroenterology), and given\n that the patient's hemodynamic parameters had progressively stabilized during\n the entire procedure, it was decided in common agreement to discontinue the\n procedure. The 10 French sheath was removed over the wire and exchanged for\n an 8.5 French triple-lumen catheter. The tip of this catheter was positioned\n at the cavoatrial junction, with a straight course, as shown by a fluoroscopic\n image stored for that purpose. The catheter was sutured to the skin and a\n sterile dressing was applied. The patient was then transferred back to the\n Intensive Care Unit by the Anesthesiology Team.\n\n COMPLICATIONS: Failure to create a portosystemic shunt during the duration of\n the procedure which was then discontinued as the patient's hemodynamic\n parameters had stabilized. No other complication noted.\n\n CONCLUSION: Attempts to create a portosystemic shunt between the right\n hepatic vein and right portal venous branch were unsuccessful. The left and\n middle hepatic vein could not be selectively catheterized. Given progressive\n improvement of the patient's hemodynamics, the procedure was then discontinued\n in agreement with the Gastroenterology Team.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 919188,
"text": " 3:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT placement\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with delta MS, found down, transiently hypoxic now intubated\n\n REASON FOR THIS EXAMINATION:\n eval ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 15:45.\n\n INDICATION: Transiently hypoxic.\n\n COMPARISON: at 09:48.\n\n FINDINGS:\n\n Tip of the ETT is 5.8 cm above the carina, and the right CVL tip is seen in\n the SVC - no PTX. Left basilar subsegmental atelectasis appears no different,\n and slight blunting at the right costophrenic sulcus suggests a small amount\n of pleural fluid. There are no new consolidations.\n\n IMPRESSION: ETT 5.8 cm above the carina, otherwise no significant interval\n change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 918945,
"text": " 6:53 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: placement of blakeomre tube\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with syncope , s/ placement\n\n REASON FOR THIS EXAMINATION:\n placement of blakeomre tube\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 66-year-old man with syncope, status post placement.\n Evaluate placement of tube.\n\n COMPARISON: .\n\n PORTABLE AP SUPINE VIEW OF THE CHEST:\n\n tube is seen extending well below the diaphragm with tip not\n visualized in the field of view. The heart and mediastinal and hilar contours\n are grossly unchanged. There is some increased opacity within the left lower\n lung which may be secondary to cardiac silhouette, however likely represents\n either atypical appearing atelectasis or consolidation as well as a possible\n component of a pleural effusion. The remaining lung parenchyma are\n unremarkable. Surrounding osseous and soft tissue structures are unchanged.\n\n IMPRESSION:\n 1. Status post placement of tube with tip well below the diaphragm\n extending out of the field of view.\n 2. Left lower lung opacity representing atelectasis or consolidation with\n possible component of a small left effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 919000,
"text": " 8:59 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: confirm line placement and balloon placement ? sto\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with syncope , s/ placement\n\n REASON FOR THIS EXAMINATION:\n confirm line placement and balloon placement ? stomach\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post tube placement, confirm line placement and\n balloon placement.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable semi-upright chest.\n\n FINDINGS: An endotracheal tube is in place with tip terminating 6.9 cm from\n the carina. The endotracheal tube cuff appears overinflated. A right\n internal jugular venous access catheter has been placed in the interval,\n terminating in the lower SVC. There is no pneumothorax. tube\n extends below the diaphragm with tip below the borders of the radiograph. No\n inflated balloon is visible. Since the previous examination, there is slight\n improvement in left lower lobe atelectasis. The radiographic appearance of\n the chest is otherwise not significantly changed.\n\n IMPRESSION:\n 1. Endotracheal tube cuff overinflation. tube in place with tip\n not imaged.\n 2. Left lower lobe atelectasis, slightly improved.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-22 00:00:00.000",
"description": "PERIPHERAL W/O PORT",
"row_id": 921629,
"text": " 7:30 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC placement\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ********************************* CPT Codes ********************************\n * PERIPHERAL W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1751 CATH ,/CENT/MID(NOT D C1751 CATH ,/CENT/MID(NOT D *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with liver cirrhosis with episodes of UGIB s/p TIPS, currently\n without IV access\n REASON FOR THIS EXAMINATION:\n PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Exchange for a 4-French PICC line catheter via left basilic vein\n approach.\n\n CLINICAL INDICATION: Malpositioned PICC line.\n\n OPERATORS: , M.D., (fellow).\n , M.D., (supervising staff).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure and appropriate\n requisition material. Once the above were verified, the patient was\n positioned on a special procedures table. Fluoroscopy was then employed to\n visualize the course of the 4-French PICC line which was retracted to the left\n basilic vein. The patient was prepped and draped in the usual sterile\n fashion. A guidewire was advanced by way of the 4-French PICC line and\n advanced to the left subclavian vein. The catheter was removed over the\n guidewire leaving the guidewire in place. Subsequently, a new, 4-French\n single lumen PICC line was cut at the 44 cm mark and delivered over the\n guidewire under flouroscopic guidance. The tip was advanced to the level of\n the caudal superior vena cava. Once satisfactory position was confirmed, the\n catheter was StatLocked in place. The entrance wound was overlaid with\n Tegaderm occlusive patch. The patient tolerated the procedure well. Catheter\n was flushed and heparin locked. Patient tolerated the procedure well without\n complication.\n\n IMPRESSION:\n\n 1. Status post successful exchange of 4-French PICC line. See above. Final\n catheter length is 44 cm. Tip position is in the caudal superior vena cava.\n Catheter is ready to employ. Post-procedural orders were written.\n\n\n\n (Over)\n\n 7:30 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC placement\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 919322,
"text": " 4:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT, lung fields\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with delta MS, found down, transiently hypoxic now\n intubated\n REASON FOR THIS EXAMINATION:\n eval ETT, lung fields\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Patient with change in mental status and transient\n hypoxia.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip and the right internal jugular line tip are in standard\n position. The heart size is enlarged but stable. There is marked worsening\n in the left lower lobe consolidation which is also spreading now upward\n involving part of the left upper lobe. In addition, there is also worsening\n of bilateral pulmonary edema and right lower lung consolidation. The small\n left pleural effusion cannot be excluded and there is no right pleural\n effusion on the current film.\n\n IMPRESSION:\n\n 1) Worsening left lung consolidation as well as worsening of the right lower\n lobe consolidation, likely due to pneumonia.\n\n 2) Worsening perihilar ulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 919230,
"text": " 4:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with delta MS, found down, transiently hypoxic now intubated\n REASON FOR THIS EXAMINATION:\n eval ETT\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 05:05\n\n INDICATION: Transiently hypoxic - check ETT.\n\n COMPARISON: at 15:45.\n\n FINDINGS: Tip of the ETT is a bit lower than prior now at 2 cm above the\n carina. The patient is rotated differently compared to the prior study.\n However, I am concerned about some increased density at the right lung base\n which should be assessed for possible developing consolidation. The lateral\n aspect of the left chest has been cut off from view. Some increased\n interstitial markings are seen bilaterally. The right CVL remains in place\n and there is no PTX.\n\n IMPRESSION:\n\n Lower position of the ETT versus prior at 2 cm above carina.\n\n Slightly worsening of fluid status and possible developing right lower lobe\n airspace process.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 920453,
"text": " 2:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for infiltrate\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with recent UGIB, now intubated and VAP. fevers to 101/\n REASON FOR THIS EXAMINATION:\n please assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fever in patient with recent upper GI bleeding,\n intubated.\n\n Portable AP chest radiograph compared to the previous film from .\n\n The ET tube tip is 2.4 cm above the carina. Right internal jugular line tip\n is at the junction of the right internal jugular vein with the subclavian\n vein. The NG tube tip is in the stomach.\n\n The lung volumes are low, which may explain the enlarged heart and some\n mediastinal widening. There is bilateral lower lobe atelectasis. There is no\n overt pulmonary edema.\n\n IMPRESSION:\n 1. Slightly low position of the ET tube.\n 2. Bibasilar atelectasis, infectious process cannot be excluded.\n 3. No overt CHF/ pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 921131,
"text": " 9:34 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o infiltrate, effusion\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with worsening sob and O2 requirement\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Worsening SOB.\n\n CHEST: The heart is enlarged, and widening of the aorta is present. When\n compared to the prior film of nine hours earlier, the degree of failure has\n improved rather than worsened.\n\n IMPRESSION: Improving failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-06-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 918802,
"text": " 5:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chf? pneumonia? ptx?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with syncope\n REASON FOR THIS EXAMINATION:\n chf? pneumonia? ptx?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old woman with syncope.\n\n PORTABLE AP CHEST RADIOGRAPH: Comparison is made with a prior chest\n radiograph dated . Cardiac and mediastinal contours are unchanged\n allowing for the difference of the technique. Note is made of bibasilar\n opacities, most likely representing atelectasis. No definite congestive heart\n failure is noted. Other than basilar opacities, no definite consolidation is\n noted.\n\n IMPRESSION: Small lung volumes due to low inspiratory level, with bibasilar\n opacities, most likely representing atelectasis. If there is a high clinical\n concern for pneumonia, please repeat PA and lateral chest radiograph with\n better inspiration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-12 00:00:00.000",
"description": "P US ABD LIMIT, SINGLE ORGAN PORT",
"row_id": 920397,
"text": " 2:32 PM\n US ABD LIMIT, SINGLE ORGAN PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: MARK FOR PARACENTISIS, REEVAL TIPS FLOWS\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with recent UGIB gastric varices, s/p TIPS\n\n REASON FOR THIS EXAMINATION:\n please mark for paracentesis\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMINAL ULTRASOUND\n\n INDICATION: 66-year-old man with recent upper GI bleed, gastric varices,\n possible HCC, status post TIPS. Mark for paracentesis. Evaluate TIPS.\n\n FINDINGS: Ultrasound of the abdomen was performed for the purpose of\n evaluating TIPS and to assess the degree of ascites to mark for paracentesis.\n Comparison is made to prior ultrasound dated .\n\n There is ascites with a moderate sized pocket of fluid identified in the right\n lower quadrant. A mark on the abdomen for paracentesis was reportedly made by\n the resident physician, . , during the course of the portable\n ultrasound examination.\n\n The main portal vein is patent, measuring 23 cm/sec in velocity. The TIPS is\n patent. Measured TIPS velocities in the proximal, mid, and distal portion of\n the TIPS are 31, 46, and 79 cm/sec, respectively. There is appropriate\n reversal of flow of the anterior branch of the right portal vein.\n\n IMPRESSION:\n 1. Ascites.\n 2. Patent TIPS with recorded velocities within normal limits.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 919386,
"text": " 11:20 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: change in mental status\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with\n REASON FOR THIS EXAMINATION:\n change in mental status\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old with mental status changes.\n\n TECHNIQUE: CT of the brain without IV contrast.\n\n COMPARISON: .\n\n FINDINGS: There is no acute intracranial hemorrhage, shift of normally\n midline structures, or hydrocephalus. -white matter differentiation is\n preserved. The patient is intubated. Mild mucosal thickening is seen within\n the ethmoidal air cells. There is circumferential mucosal thickening as well\n as a moderate-sized fluid level seen in the sphenoid sinus. Remainder of the\n visualized paranasal sinuses and mastoid air cells are clear. Soft tissues\n and osseous structures are normal.\n\n IMPRESSION:\n\n No acute intracranial hemorrhage. Sinus mucosal thickening with a fluid level\n in the sphenoid sinus, which may be related to the patient's intubated status.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 920039,
"text": " 2:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT, lung fields\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with delta MS, found down, transiently hypoxic now\n intubated\n REASON FOR THIS EXAMINATION:\n eval ETT, lung fields\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW CHEST.\n\n REASON FOR EXAM: Evaluate ETT and lung fields. 66 y/o man with delta MS,\n ___hypoxia.\n\n Comparison made with prior study of .\n\n FINDINGS: Mild enlarging bilateral pleural effusions. Resolving mild\n interstitial pulmonary edema. Persistent basilar retrocardiac atelectasis.\n Stable mild cardiomegaly. The tip of the right internal jugular vein sheath is\n seen in the upper part of the SVC. No ETT is seen in the film.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 920199,
"text": " 7:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: tachycard,tachypneic,rising WBC2-r/o PNA\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with delta MS, found down, transiently hypoxic now\n intubated\n REASON FOR THIS EXAMINATION:\n tachycard,tachypneic,rising WBC2-r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Altered mental status, found down, essentially hypoxic, rising white\n count, rule out pneumonia.\n\n CHEST, SINGLE AP VIEW:\n\n The patient is rotated. An ET tube is present, in satisfactory position,\n approximately 6.3 cm above the carina. An NG tube is present, tip beneath\n diaphragm overlying stomach. A right IJ sheath is present, tip overlying\n proximal SVC.\n\n There is some patchy opacity right greater than left bases. No CHF or\n effusion. Early pneumonic infiltrate or foci of aspiration cannot be\n excluded. Cardiomegaly with unfolded aorta.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-08 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 919856,
"text": " 10:31 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: PLEASE PERFORM DOPPLERS TO EVALUATE TIPS\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with recent UGIB gastric varices, s/p TIPS\n REASON FOR THIS EXAMINATION:\n PLEASE PERFORM DOPPLERS TO EVALUATE TIPS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man status post TIPS on due to gastric\n varices. Evaluate.\n\n COMPARISON: Right upper quadrant ultrasound dated .\n\n RIGHT UPPER QUADRANT ULTRASOUND WITH DOPPLER EXAMINATION: The liver\n parenchyma is shrunken and nodular consistent with cirrhosis. There is a\n moderate amount of intra-abdominal ascites. The previously noted focal\n hypoechoic lesions within the liver parenchyma are incompletely visualized on\n the current study.\n\n 2D, color flow, and Doppler ultrasound of the abdomen was performed. The TIPS\n is visualized in the right liver lobe. The main portal vein is hepatopetal\n and flow with velocities measuring approximately 40 cm/sec. The proximal,\n mid, and distal velocities are 40, 60, and 80-100 cm/sec respectively. The\n TIPS is patent with wall-to-wall flow. Flow is appropriately reversed within\n the anterior right, and left portal veins. Normal direction of flow and\n phasicity is seen within the left and middle hepatic veins. The main, right,\n and left hepatic arteries demonstrate normal flow and phasicity with resistive\n indices measuring 0.70, 0.65, and 0.70 respectively.\n\n IMPRESSION:\n 1. Patent TIPS with low TIPS velocities, but appropriate reversal of flow in\n the right and left portal veins. All intrahepatic vessels are patent.\n Continued followup is recommended.\n 2. Moderate intra-abdominal ascites.\n 3. Shrunken nodular liver echotexture consistent with cirrhosis. The\n previously noted hypoechoic liver lesions are not clearly visualized on\n today's study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 919461,
"text": " 7:41 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: NG line placement\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with delta MS, found down, transiently hypoxic now\n intubated\n REASON FOR THIS EXAMINATION:\n NG line placement\n ______________________________________________________________________________\n FINAL REPORT\n 66-year-old male with change in mental status, found down with hypoxia, now\n intubated and referred for evaluation of endotracheal and nasogastric tube\n placement.\n\n COMPARISON: at 5 a.m.\n\n AP PORTABLE CHEST:\n\n This is a limited view of the chest which does not include the right lateral\n thorax. An endotracheal tube terminates approximately 3.5 cm above the\n carina, in good position. A nasogastric tube terminates below the inferior\n margin of the radiograph below the diaphragm and likely within the stomach. A\n right subclavian central catheter terminates in the distal SVC. The heart\n size and mediastinal contours are unchanged. Again demonstrated is left lower\n lobe consolidation, not significantly changed from this morning. Also\n unchanged is bilateral pulmonary edema and right lower lung consolidation.\n\n IMPRESSION:\n 1. Tubes and lines in appropriate position.\n 2. Bilateral lower lobe consolidation, left greater than right, consistent\n with pneumonia or aspiration.\n 3. Stable pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-16 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 920887,
"text": " 7:36 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC placement\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with liver cirrhosis with episodes of UGIB s/p TIPS\n REASON FOR THIS EXAMINATION:\n PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: 4 French single lumen PICC line placement via left basilic vein\n approach. Ultrasound-guided venipuncture.\n\n CLINICAL HISTORY: 66-year-old male patient with liver cirrhosis. Patient\n presents for IV access.\n\n INFORMED CONSENT: Procedural informal consent for the procedure of PICC line\n placement was obtained prior to the procedure.\n\n OPERATORS: , M.D. (fellow).\n , M.D. (supervising staff).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, appropriate requisition,\n and appropriate informed consent. Once the above were verified, the patient\n was positioned in supine fashion with the left arm abducted and externally\n rotated. The left arm was prepped and draped from the axilla to the\n antecubital fossa. A tourniquet was applied to the upper arm. Utilizing\n ultrasound guidance, the left basilic vein was demonstrated to be widely\n patent and compressible. The skin was then infiltrated with approximately 2\n to 3 cc of 1% Xylocaine for local anesthesia. Low right-sided neck and right\n upper anterior chest wall were prepped and draped in usual sterile fashion.\n Ultrasound was employed to visualize the right internal jugular vein which was\n widely patent and compressible. The skin over the anterior and superior to\n puncture site was then infiltrated with 3 cc of 1% Xylocaine for local\n anesthesia. Uneventful venipuncture was achieved using ultrasound guidance.\n Guidewire was advanced to the caudal superior vena cava under flouroscopic\n guidance. Subsequently, a 4 French single lumen PICC line was tailored at the\n 42- cm mark and delivered using modified Seldinger technique to the level of\n caudal superior vena cava. The catheter was then flushed and heparin lock per\n protocol. Patient tolerated the procedure well. The catheter was secured\n with a StatLock device. Hard copy ultrasound images were obtained before and\n after venous access documenting vessel patency.\n IMPRESSION: Status post successful single lumen PICC line placement via left\n basilic vein. See above for description. The catheter is ready to employ.\n Postprocedural orders were written.\n (Over)\n\n 7:36 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC placement\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 921517,
"text": " 9:58 AM\n CHEST (PA & LAT) Clip # \n Reason: Evaluate aspiration event, bialteral opacities\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with improving sob and O2 requirement.\n\n REASON FOR THIS EXAMINATION:\n Evaluate aspiration event, bialteral opacities\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Improving shortness of breath and oxygen requirement after\n aspiration event.\n\n COMPARISON: .\n\n PA AND LATERAL VIEWS OF THE CHEST: Feeding tube, left internal jugular\n central venous catheter, and left PICC lines remain in unchanged positions.\n Cardiac and mediastinal contours are unchanged. Pulmonary vascularity is\n within normal limits. There is worsening consolidation within the left lower\n lobe with a probable small pleural effusion. The opacity within the right\n lower lobe may also be due to aspiration and is unchanged. There is no\n pneumothorax.\n\n IMPRESSION: Worsening left lower lobe consolidation and small left pleural\n effusion. Persistent patchy opacity within the right lung base. These\n findings are consistent with aspiration.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-21 00:00:00.000",
"description": "P VIDEO OROPHARYNGEAL SWALLOW PORT",
"row_id": 921518,
"text": " 9:26 AM\n VIDEO OROPHARYNGEAL SWALLOW PORT Clip # \n Reason: please do a repeat video study to assess for aspiration\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with etoh cirrhosis, aspiration pneumonia, not doing well with\n thin liquids per nursing report\n REASON FOR THIS EXAMINATION:\n please do a repeat video study to assess for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old male with alcoholic sclerosis and aspiration pneumonia\n referred for evaluation of swallowing function.\n\n VIDEO OROPHARYNGEAL SWALLOW EXAMINATION: An oropharyngeal swallowing\n videofluoroscopy was performed today in collaboration with the speech and\n language pathology division. Various consistencies of barium including thin\n liquid, nectar thickened liquid, puree consistency were administered to the\n patient.\n\n The oral phase is notable for moderate impairment in bolus control with\n premature spillover with nectar-thickened liquids into the valleculae and into\n the piriform sinuses with thin liquids. There was mild impairment of AP\n tongue movement and mildly reduced base of tongue retraction. Oral transit\n was mildly prolonged and a small amount of oral residue spilled into the\n valleculae after the swallow. The pharyngeal phase was notable for mild-to-\n moderate delay in swallow initiation. Palatal elevation was mildly reduced,\n as well as laryngeal elevation and valve closure. Epiglottic deflection was\n incomplete with larger boluses and absent with smaller boluses and dry\n swallows. There was mild prolongation of pharyngeal transit time. There was\n moderate residue in the valleculae after puree and liquid consistencies. There\n was a mild amount of residue in the piriform sinuses after thin liquids. There\n was penetration of thin and nectar-thickened liquids before and during the\n swallow. Most of the penetrated material was cleared during the swallow.\n However, aspiration of mild amounts of thin and nectar-thickened liquids was\n demonstrated during the exam due to pharyngeal residue and premature\n spillover. Aspiration was silent without a spontaneous cough. A cued cough\n was not effective in clearing the aspirated material.\n\n IMPRESSION: Mild oral and moderate pharyngeal dysphagia with mild aspiration\n of thin and nectar-thickened liquids.\n\n For greater detail and for treatment recommendations, please see the dedicated\n speech and language pathology division report of the same date.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 921099,
"text": " 1:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with recent UGIB now extubated. s/p line change over a wire.\n productive cough & fever.\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Upper GI bleed, recently extubated, productive cough.\n\n CHEST: The heart is enlarged. Opacities are present in both the right and\n left lower lobes, which could represent aspiration pneumonia.\n\n The tip of the right IJ line lies in the junction of the SVC and RA. Some\n failure is also probably present.\n\n IMPRESSION: Opacities in both lower lobes consistent with aspiration\n pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 920959,
"text": " 1:58 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: please assess line placement\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with recent UGIB now extubated. s/p line change over a wire\n\n REASON FOR THIS EXAMINATION:\n please assess line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line position. 66-year-old man with recent UGIB, now\n extubated, S/P new line change over a wire.\n\n Comparison is made with prior study dated .\n\n FINDINGS: Right internal jugular vein line with tip in the distal third of\n the SVC. There is no pneumothorax. Small right pleural effusion. Interval\n improvement in the pulmonary edema. ET tube has been removed. NG tube with\n tip not included in the film below the diaphragm. Unchanged right basal\n atelectasis. Widened mediastinum and enlarged cardiac contour remain\n unchanged.\n\n IMPRESSION:1. No pneumothorax.\n\n 2.Small right pleural effusion. Right basal lobe atelectasis.\n\n 3.Improvement of the pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 921910,
"text": " 8:34 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evaluate PICC placement and new NG tube placement\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p NG tube placement and s/p PICC movement.\n REASON FOR THIS EXAMINATION:\n Please evaluate PICC placement and new NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON AT 21:00\n\n HISTORY: Status post PICC line placement and NG tube placement.\n\n FINDINGS: There is a left subclavian PICC line with tip in superior vena\n cava. There is no pneumothorax. There is bibasilar volume loss/infiltrate.\n Compared to the prior study, the feeding tube has been removed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-23 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 921860,
"text": " 1:35 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: Please evaluate for thrombus\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with new onset erythema/edema in L UE\n REASON FOR THIS EXAMINATION:\n Please evaluate for thrombus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New onset erythema and edema in left upper extremity. Evaluate\n for thrombus.\n\n There are no prior studies for comparison.\n\n LEFT UPPER EXTREMITY ULTRASOUND: The examination is slightly limited as the\n patient declined further examination after a portion of the ultrasound was\n performed. Grayscale and Doppler son of the left internal jugular,\n subclavian, axillary, brachial, and basilic veins were performed. The\n cephalic vein was not examined. A PICC line is seen within the left basilic\n vein extending into the left axillary and subclavian veins.\n\n Normal flow, augmentation where appropriate, compressibility where appropriate\n and waveforms are demonstrated within the left internal jugular, subclavian,\n and axillary veins are noted. The brachial and basilic veins within the\n antecubital fossa compresses fully, though sagittal images were not obtained\n at this locale due to the patient's request to discontinue the examination.\n There is no evidence of intraluminal thrombus within the vessels examined.\n\n IMPRESSION: Limited study as described. No intraluminal thrombus is seen\n within the left internal jugular, subclavian, axillary, or brachial veins.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 921784,
"text": " 1:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O dislodged dobhoff tube.\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with improving sob and O2 requirement and dobhoff tube that\n looks displaced.\n REASON FOR THIS EXAMINATION:\n R/O dislodged dobhoff tube.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW CHEST @ 1:30 a.m.:\n\n REASON FOR EXAM: R/O dislodged Dobhoff tube.\n\n COMPARISON: Prior study of .\n\n The patient is rotated and the lateral aspect of the right hemithorax was not\n included on the film. Dobhoff tip is projected likely in the middle third of\n the esophagus but ___position of the distal trachea raises the possibility\n that might be located in the airway. The left lung looks better aerated and\n there is less area of atelectasis in the left lower lobe.\n\n Left PICC line with tip in the proximal third of the SVC but the findings were\n discussed with Dr. at the moment of the interpretation of the\n study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-18 00:00:00.000",
"description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT",
"row_id": 921160,
"text": " 2:25 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL PORT\n Reason: please assess for ascites and mark spot for paracentesis. P\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with recent UGIB gastric varices, s/p TIPS now with\n increasing resp distress, increasing abd distention\n REASON FOR THIS EXAMINATION:\n please assess for ascites and mark spot for paracentesis. PLEASE perform\n DOPPLERS as well to assess TIPS for patency\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old male with recent upper GI bleed, gastric varices,\n possible HCC status post TIPS. Mark for paracentesis, evaluate TIPS.\n\n COMPARISON: .\n\n FINDINGS: The liver parenchyma is shrunken and nodular consistent with\n cirrhosis. There is a moderate amount of intra-abdominal ascites. A spot was\n not marked for paracentesis secondary to underlying bowel. The previously\n noted focal hypoechoic lesions within the liver parenchyma are incompletely\n visualized on the current study.\n\n 2D color flow and Doppler ultrasound of the abdomen was performed. The TIPS\n is visualized in the right liver lobe. The right, left and main hepatic\n arteries demonstrate normal direction of flow and waveforms. The main portal\n vein demonstrates appropriate hepatopetal flow at 90 cm/sec. The TIPS is\n patent with wall-to-wall flow. Flow is appropriately reversed within the\n anterior right and left portal veins. The proximal, mid and distal velocities\n within the TIPS are 83, 69 and 120 cm/sec respectively. Normal direction of\n flow and waveforms seen within the left and middle hepatic veins.\n\n IMPRESSION:\n 1. Patent TIPS with improving TIPS velocities with appropriate reversal of\n flow in the right and left portal veins. All intrahepatic vessels are patent.\n 2. Shrunken nodular liver echotexture consistent with cirrhosis. Previously\n described hypoechoic liver lesions are not clearly visualized on today's\n study.\n 3. Moderate intra-abdominal ascites.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 920462,
"text": " 7:02 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval ETT placement, lung fields and look for free air\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with recent UGIB, now intubated and VAP. fevers to 101, s/p\n paracentesis. ? increasing abdominal distension.\n REASON FOR THIS EXAMINATION:\n please eval ETT placement, lung fields and look for free air s/p paracentesis.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Single AP portable view of the chest.\n\n REASON FOR EXAM: Evaluate ET tube placement and pneumoperitoneum S/P\n paracentesis.\n\n Comparison is made with prior study performed four hours before.\n\n FINDINGS:\n There is no evidence of pneumoperitoneum or pneumothorax. Lines and tubes\n remain in the same positions. Unchanged bilateral lower lobe atelectasis and\n cardiomediastinal contour.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-19 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 921311,
"text": " 3:47 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: confirm left IJ placement\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with worsening sob and O2 requirement. Left IJ placed with\n U/S 15:30 \n REASON FOR THIS EXAMINATION:\n confirm left IJ placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP VIEW.\n\n History of left jugular CV line placement.\n\n Tip of left jugular CV line is in proximal SVC. Right jugular CV line is in\n mid SVC. No pneumothorax. Tip of left-sided PICC line is difficult to\n accurately localize on this film but is in the left brachiocephalic vein,\n probably close to junction with SVC. There is cardiomegaly and bibasilar\n atelectases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-26 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 922164,
"text": " 11:04 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: evaluate ability to swallow\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with etoh cirrhosis, aspiration pneumonia, with failed eval in\n past\n REASON FOR THIS EXAMINATION:\n evaluate ability to swallow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old male with ETOH cirrhosis and aspiration pneumonia.\n\n TECHNIQUE: This study was performed in conjunction with the speech and\n swallow therapist. Multiple consistencies of barium were self administered by\n the patient. The images were recorded in a DVD.\n\n VIDEO SWALLOW FLUOROSCOPY: The patient is edentulous, limiting the ability of\n mastication. During this study, there was aspiration with thin liquids and\n penetration with nectar. There was no aspiration with pudding; however, there\n was a moderate-to-large amount of residue in the vallecula after swallowing\n pudding. This could be cleared with a sip of nectar. The patient has no\n spontaneous or cued cough.\n\n IMPRESSION:\n 1. Aspiration with thin liquids.\n 2. Inability to cough.\n 3. Moderate-to-large amount of residue within the vallecula with pudding but\n which could be cleared with nectar.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-07-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 921928,
"text": " 10:15 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Failed NGT placement, ? coughing evaluate for aspiration\n Admitting Diagnosis: HYPOTENSION;PRE-SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man evaluate after failed NG tube placement and coughing\n\n REASON FOR THIS EXAMINATION:\n Failed NGT placement, ? coughing evaluate for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW, ON AT 2200.\n\n HISTORY: Failed NG tube placement and coughing, question aspiration.\n\n FINDINGS: The right lower lung is off the film. There is increased opacity\n at the right heart border that could represent volume loss in that region.\n There is patchy opacity at the left base that could represent volume loss or\n infiltrate. Aspiration cannot be excluded based on these films. Followup is\n recommended.\n\n\n"
}
] |
86,392 | 193,556 | 65 yo female with PMH of CAD s/p DES to LAD in , squamous cell lung carcinoma s/p left lobectomy, chemo, and XRT, complicated by laryngeal paralysis, COPD on 2L home O2, transferred from for cardiac catheterization. Transferred to CCU post-cath for poor respiratory status . #. Hypoxia- shortness of breath is likely multifactorial, a combination of multifocal pneumonia superimposed on underlying poor pulmonary reserve in setting of cancer with resection and XRT with new development of acute systolic heart failure. Patient has a history of largyngeal paralysis, making her more likely to aspirate. During her stay in the ICU she was found to have a pneumonia. She was covered for both CAP and aspiration pneumonia with ceftriaxone, levofloxacin, and metronidazole. Discharged on Flagyl and Levofloxacin for total of 14 day course. Spiriva and Advair were continued. CT of Chest report read: PE was of concern given tachycardia and SOB, however patient was ruled out with CTA. Lymphadenopathy in the mediastinum and right hilum extending along the bronchovascular structures in the right lung could be reactive due to infection, but is concerning for neoplasm given the patient's previous history of lung neoplasm and should be followed up with repeat CT thorax in 2 months to ensure resolution. . Systolic and Diastolic congestive Heart Failure: EF 25%: It is possible that her elevated , changes, and TTE findings of apical hypokinesis represents stress induced cardiomyopathy. It may have been caused by stress of pneumonia on top of already compromised lungs. viral cardiomyopathy is also a possiblility. Patient was diuresed with IV lasix with improvement of respiratory symptoms. She also received scheduled nebulizer treatments and had gradual resolution of her symptoms. Her pneumonia was treated as above. . #. H/o CAD, stress cardiomyopathy/focal myopericarditis - s/p to LAD in . TTE at OSH showed LVEF of 30% which is decreased from a reported 50% in . TTE on this admission shows EF of 25% with severe hypokinesis to akinesis of the septum, anterior wall, distal third of the left ventricle. Given these focal wall motion abnormalities she was taken to cath which showed patent LAD stent with 50% prox LCx lesion and 50% mid RCA lesion, and given these findings of non-flow limiting CAD in the setting of focal wall motion abnormalities, the pt was felt to have a stress related cardiomyopathy vs focal myo/pericarditis. EKG post-cath still showed ST elevations however these resolved over time and the pt was without significant Q waves. Patient was continued on aspirin, plavix, atorvastatin, and metoprolol. Losartan was temporarily held given hypotension but was added back by discharge. . #. Hypotension - patient was initially hypotensive with SBP in the 70-80s, for which antihypertensives were held. Concern was for sepsis given her pneumonia. As her blood pressure stabilized, beta blockers and Losartan were restarted. By discharge, her blood pressures were in the 90's to low 100's. . # Tachycardia - The pt was initially in the 140's on admission, with narrow complex sinus tachycardia and frequent ectopy. As her above problems were addressed, her heart rate gradually came down, and beta blockade was also added. By discharge, her heart rate had come down to consistently in the 90-100's. . #. Severe COPD - patient is on 2L home O2. During her admission, she saturated in the mid 90's on 3-4L of supplemental O2. Patient had long acting tiotropium held while acutely sick. She was continued on advair and ipratropium nebulizers. . #. Seizure Disorder- patient has history of seizure disorder following head injury 11 years ago. Patient was continued on dilatin. . #. Chronic left side and low back pain - patient was continued on home regimen of MS contin and gabapentin . #. Anxiety - patient has a history of anxiety for which she received ativan PRN | Mild [1+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -hypo; basal anteroseptal - akinetic; mid anteroseptal - hypo; basalinferoseptal - hypo; mid inferoseptal - akinetic; mid anterolateral - hypo;anterior apex - hypo; septal apex- akinetic; inferior apex - akinetic; lateralapex - hypo; apex - akinetic;RIGHT VENTRICLE: Normal RV chamber size. Moderate pulmonaryhypertension. No PR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: The patient appears to be in sinus rhythm. There is moderate pulmonaryartery systolic hypertension. ST-T wave configurationwith ST segment elevation consistent with acute ischemic injury, althoughpattern is diffuse. Sinus tachycardia with ventricular premature beats. Sinus tachycardia with ventricular premature beats. Right ventricular chamber size is normalwith moderate global free wall hypokinesis and distal dyskinesis of the apex.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No pneumothorax.P ostoperative pleural thickening at the left lung apex. Diffuse coronary artery and aortic valvular calcification is noted. PATIENT/TEST INFORMATION:Indication: CAD, s/ to LADHeight: (in) 66Weight (lb): 138BSA (m2): 1.71 m2BP (mm Hg): 106/69HR (bpm): 140Status: InpatientDate/Time: at 15:48Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness and cavity size. Marked tachycardia. Otherwise, the appearance of the lungs are unchanged compared to , and patient is status post left upper lobe resection. ST segment configurationwith ST segment elevation consistent with acute ischemic injury, althoughpattern is diffuse. There is an anterior space which most likelyrepresents a prominent fat pad.IMPRESSION: Extensive regional left ventricular systolic dysfunction c/wmultivessel CAD or stress-induced cardiomyopathy (or focal myocarditis).Distal right ventricular dyskinesis. Normal ascending aorta diameter. Tachycardia and shortness of breath. The mitral valve leaflets are mildlythickened. There continues to be patchy peribronchial and alveolar opacities, left greater than right, of unclear etiology. No MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal aortic arch diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Tachycardic and SOB, concerning for PE REASON FOR THIS EXAMINATION: please evaluate for PE No contraindications for IV contrast WET READ: JXKc TUE 10:44 PM 1. Now s/p cath with concerns for fluid overload. FINDINGS: was a preoperative chest radiograph. On today's image there is evidence of status post left upper lobe resection. Moderate global RV free wallhypokinesis.AORTA: Normal aortic diameter at the sinus level. No mitral regurgitation is seen.The tricuspid valve leaflets are mildly thickened. Mediastinal and hilar adenopathy. Restingtachycardia (HR>100bpm). Circumferential lymph node enlargement around (Over) 5:30 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: please evaluate for PE Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION; CHF;SHORTNESS OF BREATH\CATH Contrast: OPTIRAY Amt: FINAL REPORT (Cont) the right mainstem bronchus and mediastinum, up to 14 mm in the subcarinal region is pathological by CT size criteria. TECHNIQUE: MDCTA chest was performed initially as a low-dose non-contrast study and then following the administration of IV contrast, transaxial images were acquired from the apices to the lower lungs with multiplanar reformats. Mild thickeningof mitral valve chordae. In addition, peribronchial opacities are seen in the remaining left lung parenchyma and in the upper and lateral basal parts of the right lower lobe parenchyma. 3)Post-surgical changes following left upper lobectomy and post-radiotherapy fibrosis and traction bronchiectasis in the left apex. No acute aortic pathology, the aortic arch contains mixed atherosclerotic plaque. Consolidation in the left apex with traction bronchiectasis is most likely due to post-radiotherapy fibrosis; however discrete areas of multifocal consolidation throughout the left lower lobe (4.35), the anterior segment of the right upper lobe, the right middle and lower lobe are superimposed on diffuse centrilobular emphysema which were probably not within the radiation field and most likely due to pneumonia. FINDINGS: There is satisfactory contrast opacification of the pulmonary arteries with no pulmonary embolism to subsegmental level. This examination was not designed for subdiaphragmatic evaluation which is unremarkable except to note a foci of high attenuation in the left renal collecting system which could be due to a recent contrast-enhanced radiological examination or possibly a non- obstructing calculus. FINAL REPORT PROCEDURE: CTA chest. The referring physician, . FINDINGS: There is a new left-sided PICC line with tip in the right atrium. Diffuse bronchial wall thickening is throughout the lungs and particularly severe along the peribronchial structures at the right hilum. A left pleural effusion is small. Focal calcifications inaortic root. Severe regional LVsystolic dysfunction. There is severe regional left ventricular systolicdysfunction with extensive severe hypokinesis to akinesis of the septum,anterior wall, distal third of the left ventricle (including the apex).Ejection fraction is difficult to assess in setting of marked tachycardia butappears severely depressed (EF 25). Heart size is normal with a small pericardial effusion. LINE PLACEMENT Clip # Reason: 48cm left picc. | 6 | [
{
"category": "Radiology",
"chartdate": "2170-06-17 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1136045,
"text": " 9:15 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 48cm left picc. tip?\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION; CHF;SHORTNESS OF BREATH\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with new picc\n REASON FOR THIS EXAMINATION:\n 48cm left picc. tip?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: New PICC line.\n\n FINDINGS: There is a new left-sided PICC line with tip in the right atrium.\n Otherwise, the appearance of the lungs are unchanged compared to ,\n and patient is status post left upper lobe resection. There continues to be\n patchy peribronchial and alveolar opacities, left greater than right, of\n unclear etiology.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-06-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1135339,
"text": " 12:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for infiltrates, effusions\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION; CHF;SHORTNESS OF BREATH\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with history of lung ca s/p lobectomy. Question of\n pneumonia in OSH. Now s/p cath with concerns for fluid overload.\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrates, effusions\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of lung carcinoma and lobectomy, questionable pneumonia\n in outside hospital.\n\n COMPARISON: .\n\n FINDINGS: was a preoperative chest radiograph. On today's image there\n is evidence of status post left upper lobe resection. In addition,\n peribronchial opacities are seen in the remaining left lung parenchyma and in\n the upper and lateral basal parts of the right lower lobe parenchyma. In the\n appropriate setting, these findings are suggestive of pneumonia.\n\n There is no evidence of larger pleural effusions. No pneumothorax.P\n ostoperative pleural thickening at the left lung apex. The referring\n physician, . has been paged for notification at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-06-12 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1135413,
"text": " 5:30 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please evaluate for PE\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION; CHF;SHORTNESS OF BREATH\\CATH\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with history of CAD s/p DES to LAD, lung cancer s/p upper\n left lobectomy, chemo, XRT. History of laryngeal paralysis with pneumonias.\n Tachycardic and SOB, concerning for PE\n REASON FOR THIS EXAMINATION:\n please evaluate for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc TUE 10:44 PM\n 1. No PE.\n 2. Post-surgical changes following left upper lobectomy with left upper\n pleural and parenchymal opacification, which may reflect scarring.\n 3. Increased reticular opacities throughout the left lung and in the right\n upper and lower lobes may reflect post-treatment changes. However,\n superimposed are ill-defined air-space opacities which likely reflect\n superimposed infection.\n 4. Mediastinal and hilar adenopathy.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CTA chest.\n\n REASON FOR EXAM: Evaluate for pulmonary embolism.Previous history of lung\n cancer with left upper lobectomy, chemotherapy, and radiotherapy. Tachycardia\n and shortness of breath.\n\n TECHNIQUE: MDCTA chest was performed initially as a low-dose non-contrast\n study and then following the administration of IV contrast, transaxial images\n were acquired from the apices to the lower lungs with multiplanar reformats.\n\n No previous CT was available for comparison.\n\n FINDINGS:\n There is satisfactory contrast opacification of the pulmonary arteries with no\n pulmonary embolism to subsegmental level. No acute aortic pathology, the\n aortic arch contains mixed atherosclerotic plaque. The patient is status\n post left upper lobectomy with surgical clips at the bronchial stump and\n volume loss in the left hemithorax.\n Consolidation in the left apex with traction bronchiectasis is most likely due\n to post-radiotherapy fibrosis; however discrete areas of multifocal\n consolidation throughout the left lower lobe (4.35), the anterior segment of\n the right upper lobe, the right middle and lower lobe are superimposed on\n diffuse centrilobular emphysema which were probably not within the radiation\n field and most likely due to pneumonia.\n\n A left pleural effusion is small. Diffuse bronchial wall thickening is\n throughout the lungs and particularly severe along the peribronchial\n structures at the right hilum. Circumferential lymph node enlargement around\n (Over)\n\n 5:30 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please evaluate for PE\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION; CHF;SHORTNESS OF BREATH\\CATH\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the right mainstem bronchus and mediastinum, up to 14 mm in the subcarinal\n region is pathological by CT size criteria. Heart size is normal with a small\n pericardial effusion. Diffuse coronary artery and aortic valvular\n calcification is noted.\n\n\n This examination was not designed for subdiaphragmatic evaluation which is\n unremarkable except to note a foci of high attenuation in the left renal\n collecting system which could be due to a recent contrast-enhanced\n radiological examination or possibly a non- obstructing calculus.\n\n No destructive or sclerotic bone lesions concerning for malignancy, Post\n thoracotomy changes in the left ribs are present.\n\n IMPRESSION:\n 1)No pulmonary embolism or acute aortic pathology.\n\n 2)Diffuse severe centrilobular emphysema with superimposed multifocal\n ground glass opacities and consolidation, most likely pneumonia.\n\n 3)Post-surgical changes following left upper lobectomy and post-radiotherapy\n fibrosis and traction bronchiectasis in the left apex.\n\n 4)Lymphadenopathy in the mediastinum and right hilum extending along the\n bronchovascular structures in the right lung could be reactive due to\n infection, but is concerning for neoplasm given the patient's previous history\n of lung neoplasm and should be followed up with repeat CT thorax in 2 months\n to ensure resolution.\n\n\n\n"
},
{
"category": "Echo",
"chartdate": "2170-06-12 00:00:00.000",
"description": "Report",
"row_id": 81466,
"text": "PATIENT/TEST INFORMATION:\nIndication: CAD, s/ to LAD\nHeight: (in) 66\nWeight (lb): 138\nBSA (m2): 1.71 m2\nBP (mm Hg): 106/69\nHR (bpm): 140\nStatus: Inpatient\nDate/Time: at 15:48\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Severe regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; basal anteroseptal - akinetic; mid anteroseptal - hypo; basal\ninferoseptal - hypo; mid inferoseptal - akinetic; mid anterolateral - hypo;\nanterior apex - hypo; septal apex- akinetic; inferior apex - akinetic; lateral\napex - hypo; apex - akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild thickening\nof mitral valve chordae. No MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS. No PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Resting\ntachycardia (HR>100bpm). Echocardiographic results were reviewed by telephone\nwith the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. There is severe regional left ventricular systolic\ndysfunction with extensive severe hypokinesis to akinesis of the septum,\nanterior wall, distal third of the left ventricle (including the apex).\nEjection fraction is difficult to assess in setting of marked tachycardia but\nappears severely depressed (EF 25). Right ventricular chamber size is normal\nwith moderate global free wall hypokinesis and distal dyskinesis of the apex.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. No mitral regurgitation is seen.\nThe tricuspid valve leaflets are mildly thickened. There is moderate pulmonary\nartery systolic hypertension. There is an anterior space which most likely\nrepresents a prominent fat pad.\n\nIMPRESSION: Extensive regional left ventricular systolic dysfunction c/w\nmultivessel CAD or stress-induced cardiomyopathy (or focal myocarditis).\nDistal right ventricular dyskinesis. Marked tachycardia. Moderate pulmonary\nhypertension.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2170-06-13 00:00:00.000",
"description": "Report",
"row_id": 200519,
"text": "Sinus tachycardia with ventricular premature beats. ST segment configuration\nwith ST segment elevation consistent with acute ischemic injury, although\npattern is diffuse. Clinical correlation is suggested. Since the previous\ntracing of probably no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2170-06-12 00:00:00.000",
"description": "Report",
"row_id": 200520,
"text": "Sinus tachycardia with ventricular premature beats. ST-T wave configuration\nwith ST segment elevation consistent with acute ischemic injury, although\npattern is diffuse. Clinical correlation is suggested. Since the previous\ntracing of findings as outlined are now present.\nTRACING #1\n\n"
}
] |
23,281 | 139,060 | Patient tolerated procedure well and was transported to Fa9 VICU. Post-operative course was unremarkable. Pain was well controlled. She was anticoagulated post-op with Heparin gtt. On POD#1, she was found to have Proteus in urine and was treated accordingly with Bactrim. After a rehab facility was found, she was deemed suitable and stable for discharge to rehab on POD#4. | Right internal iliac artery has been embolized. Left internal iliac artery is patent. The proximal inferior mesenteric artery is not opacified, but the remainder of the is opacified, presumably from retrograde flow. IMPRESSION: 1) Endotracheal tube and right IJ line as described above; no pneumothorax. 2) Medium sized left pleural effusion with associated atelectasis. The renal arteries demonstrate calcifications at their ostia, with no significant stenosis on the right, but moderate renal artery stenosis on the left. TECHNIQUE: CT arteriogram of the abdomen and pelvis was obtained with and without IV contrast. Celiac iliac artery and superior mesenteric artery demonstrate ostial calcifications, but no significant stenosis. There is a small to moderately sized left pleural effusion with associated atelectasis. Old anterior myocardial infarction. Renal cysts are noted. CT ABDOMEN WITH IV CONTRAST: Lung bases demonstrate atelectatic changes, and trace bilateral pleural effusions. LowQRS voltage in the precordial leads. CT PELVIS WITH IV CONTRAST: Uterus and colon are unremarkable. Compared to the previous tracing of no significantdiagnostic change.TRACING #1 Endotracheal tube in satisfactory position. Compared to tracing #1 no significant diagnostic change.TRACING #2 IMPRESSION: No evidence of endoleak status post endovascular repair of (Over) 12:54 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # CT 150CC NONIONIC CONTRAST Reason: endo leak Admitting Diagnosis: AORTIC ANEURYSM Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) abdominal aortic aneurysm. Sinus rhythm. Sinus rhythm. Diffuse non-specific T waveflattening. First degree A-V block. 3:09 PM OR VASCULAR A-GRAM Clip # Reason: ENDOVASCULAR ABDOMINAL AORTIC ANEURYSM Admitting Diagnosis: AORTIC ANEURYSM ********************************* CPT Codes ******************************** * ENDOVASCUALR REPAIR OF ABD AOR PLCT EXT PROTHESIS FOR ENDOVAS * * PLCT EXT PROTHESIS FOR ENDOVAS * **************************************************************************** FINAL REPORT For complete report please see operative note in CareWeb Clinical Lookup. Aortic volume from the lowest renal artery to the aortic bifurcation measures 122cc. Gallstones are noted. AP UPRIGHT CHEST: Compared to the film of . CT ARTERIOGRAM WITH IV CONTRAST: Since the prior study, the patient has undergone endovascular repair of the previously described infrarenal abdominal aortic aneurysm. Stable cardiomegaly. Dense material within the gallbladder may be due to recent iodinated contrast load. Right-sided IJ line with its tip at the atriocaval junction. Degenerative changes are seen within the spine. Comparison is made with a preoperative study dated . Stomach and small bowel are unremarkable. 12:54 PM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # CT 150CC NONIONIC CONTRAST Reason: endo leak Admitting Diagnosis: AORTIC ANEURYSM Contrast: OPTIRAY Amt: 150 MEDICAL CONDITION: 88 year old woman with AAA endo repair REASON FOR THIS EXAMINATION: endo leak No contraindications for IV contrast FINAL REPORT INDICATION: Status post endovascular repair of abdominal aortic aneurysm. Liver, adrenals, spleen, and pancreas are unremarkable. A Foley catheter is seen within the urinary bladder. The patient is slightly rotated to the left on this film. Multiplanar reconstructions were generated, which were helpful for diagnosis. BONE WINDOWS: No suspicious bony lesions. No evidence of endoleak. Multiplanar reconstructions confirm the above findings, and were helpful for diagnosis. The aneurysm sac diameter measures up to approximately 5 cm x 5 cm in diameter. | 5 | [
{
"category": "Radiology",
"chartdate": "2135-07-21 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 870277,
"text": " 12:54 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: endo leak\n Admitting Diagnosis: AORTIC ANEURYSM\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with AAA endo repair\n REASON FOR THIS EXAMINATION:\n endo leak\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post endovascular repair of abdominal aortic aneurysm.\n\n TECHNIQUE: CT arteriogram of the abdomen and pelvis was obtained with and\n without IV contrast. Multiplanar reconstructions were generated, which were\n helpful for diagnosis. Comparison is made with a preoperative study dated\n .\n\n CT ABDOMEN WITH IV CONTRAST: Lung bases demonstrate atelectatic changes, and\n trace bilateral pleural effusions.\n\n Liver, adrenals, spleen, and pancreas are unremarkable. Renal cysts are\n noted. Dense material within the gallbladder may be due to recent iodinated\n contrast load. Gallstones are noted. Stomach and small bowel are\n unremarkable.\n\n CT PELVIS WITH IV CONTRAST: Uterus and colon are unremarkable. A Foley\n catheter is seen within the urinary bladder.\n\n BONE WINDOWS: No suspicious bony lesions. Degenerative changes are seen\n within the spine.\n\n CT ARTERIOGRAM WITH IV CONTRAST: Since the prior study, the patient has\n undergone endovascular repair of the previously described infrarenal abdominal\n aortic aneurysm. The aneurysm sac diameter measures up to approximately 5 cm\n x 5 cm in diameter. Aortic volume from the lowest renal artery to the aortic\n bifurcation measures 122cc. No evidence of endoleak.\n\n Celiac iliac artery and superior mesenteric artery demonstrate ostial\n calcifications, but no significant stenosis. The renal arteries demonstrate\n calcifications at their ostia, with no significant stenosis on the right, but\n moderate renal artery stenosis on the left. The proximal inferior mesenteric\n artery is not opacified, but the remainder of the is opacified, presumably\n from retrograde flow. Right internal iliac artery has been embolized. Left\n internal iliac artery is patent.\n\n Multiplanar reconstructions confirm the above findings, and were helpful for\n diagnosis.\n\n IMPRESSION: No evidence of endoleak status post endovascular repair of\n (Over)\n\n 12:54 PM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: endo leak\n Admitting Diagnosis: AORTIC ANEURYSM\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n abdominal aortic aneurysm.\n\n\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-07-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 870047,
"text": " 5:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: central line placement\n Admitting Diagnosis: AORTIC ANEURYSM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old woman with endo-AAA repair\n\n REASON FOR THIS EXAMINATION:\n central line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post endo AAA repair.\n\n AP UPRIGHT CHEST: Compared to the film of . Endotracheal tube in\n satisfactory position. Right-sided IJ line with its tip at the atriocaval\n junction. The patient is slightly rotated to the left on this film. Stable\n cardiomegaly. There is a small to moderately sized left pleural effusion with\n associated atelectasis.\n\n IMPRESSION:\n 1) Endotracheal tube and right IJ line as described above; no pneumothorax.\n 2) Medium sized left pleural effusion with associated atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-07-19 00:00:00.000",
"description": "ENDOVASCUALR REPAIR OF ABD AORTA",
"row_id": 870023,
"text": " 3:09 PM\n OR VASCULAR A-GRAM Clip # \n Reason: ENDOVASCULAR ABDOMINAL AORTIC ANEURYSM\n Admitting Diagnosis: AORTIC ANEURYSM\n ********************************* CPT Codes ********************************\n * ENDOVASCUALR REPAIR OF ABD AOR PLCT EXT PROTHESIS FOR ENDOVAS *\n * PLCT EXT PROTHESIS FOR ENDOVAS *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n For complete report please see operative note in CareWeb Clinical Lookup.\n\n"
},
{
"category": "ECG",
"chartdate": "2135-07-19 00:00:00.000",
"description": "Report",
"row_id": 309306,
"text": "Sinus rhythm. Compared to tracing #1 no significant diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2135-07-18 00:00:00.000",
"description": "Report",
"row_id": 309307,
"text": "Sinus rhythm. First degree A-V block. Old anterior myocardial infarction. Low\nQRS voltage in the precordial leads. Diffuse non-specific T wave\nflattening. Compared to the previous tracing of no significant\ndiagnostic change.\nTRACING #1\n\n"
}
] |
12,277 | 175,101 | The patient was admitted to the CCU. Cardiac wise he was continued on the aspirin, Plavix, Lopressor 25 b.i.d. CKs were serially checked and they began to trend down. On the day of discharge his CK was 648. The patient had no further episodes of chest pain or EKG changes during his hospital course. He was on telemetry and throughout his hospital stay he was in normal sinus rhythm. There were no other ectopies. The patient's LV function was 60%. The LV had a 60% ejection fraction. He was continued on IV fluids at 150 cc per hour to maintain his preload, given his territory of his myocardial infarction. For his right groin hematoma, the Integrilin was stopped at 1800 hours on . The patient showed no further signs of bleeding. The right groin hematoma was serially followed. It was stable throughout his hospital course and was beginning to decrease. There were no bruits auscultated throughout his hospital course. Hyperlipidemia. He was started on Lipitor 20 mg q.d. On discharge he was given a prescription for Lescol XL 80 mg q.d. The patient was noted to have an elevated LDL during his hospital course. The patient was seen by physical therapy and they recommended that he have outpatient cardiac rehabilitation for a week post MI. | Mild (1+) mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation. There is mild global right ventricularfree wall hypokinesis.AORTA: The aortic root is mildly dilated. The estimated pulmonary artery systolic pressure isnormal.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation. The right ventricular cavity is mildly dilated.There is mild global right ventricular free wall hypokinesis. Overall left ventricular systolicfunction is normal (LVEF 60%), with mild hypokinesis of the midventricular andapical segments of the inferior and posterior walls. No aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. There are focalcalcifications in the ascending aorta.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but notstenotic. Mild (1+) mitralregurgitation is seen. The leftventricular cavity size is normal. The aortic valve leaflets (3) are mildly thickened but notstenotic. The ascending aorta is normal in diameter. There is mild mitral annular calcification. Left ventricular wall thicknesses are normal.The left ventricular cavity size is normal. There is nomitral valve prolapse. The aortic rootis mildly dilated. Myocardial infarction.Height: (in) 67Weight (lb): 170BSA (m2): 1.89 m2BP (mm Hg): 119/61HR (bpm): 53Status: InpatientDate/Time: at 13:12Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is elongated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. The rightventricular cavity is mildly dilated. The estimated pulmonary artery systolic pressure isnormal. The mainpulmonary artery and its branches are normal. No masses or thrombi are seen in the left ventricle.RIGHT VENTRICLE: The right ventricular wall thickness is normal. No color Doppler evidence for apatent ductus arteriosus is visualized.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is elongated. Overall left ventricular systolic functionis normal (LVEF>55%). addendum to above note: potassium repleted 40mcq for 3.7 and calcium 7.2 pt given 2 tums pt remains pain free stable, 2nd liter of fluid up and then d/c ivf. The tips of the papillary musclesare calcified. echo done post procedure preliminary report looked fine per tech. pt's hr sb 50's rare pvcs, bp 100-140/50, 99-100% 3l n/c. No masses or thrombi areseen in the left ventricle. pt reported being more comfortable after medication. There is no mitral valve prolapse. PATIENT/TEST INFORMATION:Indication: Left ventricular function. There are focal calcifications inthe aortic root. Sinus rhythmProbable inferior infarct - age undeterminedInverted T waves in leads ll, lll, aVF, biphasic T waves in leads V4-6Since previous tracing, deeper Q waves in lead lll, T wave changes are present There is no pericardial effusion. There is no resting left ventricular outflow tractobstruction. pt c/o back aching from lying in one position for a while rate as gave percocet 2 tabs with some effect. No aortic regurgitation is seen. urine in foley some hematuria output 80-200/hr. Sinus bradycardiaVentricular premature complexNondiagnostic Q waves in leads ll, lll, aVFNo previous tracing There ismild thickening of the mitral valve chordae. The mitral valve leaflets aremildly thickened. otherwise skin intact pos pulses, abs soft pos bs nontender, tolerated 4 pieces of toast with gingerale well, pt has been dozing on/off all shift wife present. labs drawn at 3p and magnesium repleted 1.8 po given at 3p per ho. during the sheath pull pt c/o pain in back still and pain in r groin also per ho pt medicated 2mg mso4 iv x 2 5mins apart. lidocaine drip (started at osh) d/ced at 10am pre sheath removal. pt arrived from cath lab via stretcher around 0830. pt a/o with femstop in place act drawn at 0900 175, ho came to pull sheath around 10am. | 5 | [
{
"category": "Echo",
"chartdate": "2172-07-10 00:00:00.000",
"description": "Report",
"row_id": 75642,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 67\nWeight (lb): 170\nBSA (m2): 1.89 m2\nBP (mm Hg): 119/61\nHR (bpm): 53\nStatus: Inpatient\nDate/Time: at 13:12\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is elongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%). There is no resting left ventricular outflow tract\nobstruction. No masses or thrombi are seen in the left ventricle.\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. The right\nventricular cavity is mildly dilated. There is mild global right ventricular\nfree wall hypokinesis.\n\nAORTA: The aortic root is mildly dilated. There are focal calcifications in\nthe aortic root. The ascending aorta is normal in diameter. There are focal\ncalcifications in the ascending aorta.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is mild mitral annular calcification. There is\nmild thickening of the mitral valve chordae. The tips of the papillary muscles\nare calcified. Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. The estimated pulmonary artery systolic pressure is\nnormal.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation. The main\npulmonary artery and its branches are normal. No color Doppler evidence for a\npatent ductus arteriosus is visualized.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thicknesses are normal.\nThe left ventricular cavity size is normal. Overall left ventricular systolic\nfunction is normal (LVEF 60%), with mild hypokinesis of the midventricular and\napical segments of the inferior and posterior walls. No masses or thrombi are\nseen in the left ventricle. The right ventricular cavity is mildly dilated.\nThere is mild global right ventricular free wall hypokinesis. The aortic root\nis mildly dilated. The aortic valve leaflets (3) are mildly thickened but not\nstenotic. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. The estimated pulmonary artery systolic pressure is\nnormal. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2172-07-10 00:00:00.000",
"description": "Report",
"row_id": 180870,
"text": "Sinus bradycardia\nVentricular premature complex\nNondiagnostic Q waves in leads ll, lll, aVF\nNo previous tracing\n\n"
},
{
"category": "ECG",
"chartdate": "2172-07-11 00:00:00.000",
"description": "Report",
"row_id": 180871,
"text": "Sinus rhythm\nProbable inferior infarct - age undetermined\nInverted T waves in leads ll, lll, aVF, biphasic T waves in leads V4-6\nSince previous tracing, deeper Q waves in lead lll, T wave changes are present\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-07-10 00:00:00.000",
"description": "Report",
"row_id": 1423265,
"text": "pt arrived from cath lab via stretcher around 0830. pt a/o with femstop in place act drawn at 0900 175, ho came to pull sheath around 10am. pt c/o back aching from lying in one position for a while rate as gave percocet 2 tabs with some effect. during the sheath pull pt c/o pain in back still and pain in r groin also per ho pt medicated 2mg mso4 iv x 2 5mins apart. pt reported being more comfortable after medication. hematoma noted on rac and r groin (why pt came here to be observed for groin site d/t all the clot busters). lidocaine drip (started at osh) d/ced at 10am pre sheath removal. echo done post procedure preliminary report looked fine per tech. pt's hr sb 50's rare pvcs, bp 100-140/50, 99-100% 3l n/c. otherwise skin intact pos pulses, abs soft pos bs nontender, tolerated 4 pieces of toast with gingerale well, pt has been dozing on/off all shift wife present. urine in foley some hematuria output 80-200/hr. labs drawn at 3p and magnesium repleted 1.8 po given at 3p per ho.\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-07-10 00:00:00.000",
"description": "Report",
"row_id": 1423266,
"text": "addendum to above note: potassium repleted 40mcq for 3.7 and calcium 7.2 pt given 2 tums pt remains pain free stable, 2nd liter of fluid up and then d/c ivf.\n"
}
] |
22,671 | 182,499 | A/P: 86 yoM with PMH CAD, ischemic cardiomyopathy, MDS, recent admission for presumed C. difficile colitis, admitted to the MICU with diarrhea and hypotension admitted to floor . After family meetings to address goals of care in this patient with chronic pain and MDS most likely with leukemic transformation, not likely a candidate for therapy per hematology, the patient was made DNR/DNI/CMO. . 1. Diarrhea. The diarrhea continued to improve with decreased stool number and volume on the floor. CT abdomen showed diffuse rectal, sigmoid, and descending colon wall thickening suggestive of colitis. With the patient's elevated WBC, there was concern for an infectious source. His stool cultures were negative x2 and C. difficile toxin was negative x3, however, the patient had a history of recent antibiotic use. The original plan with the GI consult team was to perform a colonoscopy once the patient was stable to elucidate the cause of the diarrhea; this was no longer necessary as the patient is CMO. The patient's initial antibiotic treatment included levofloxacin and flagyl on admission. The patient continued to spike fevers despite antibiotic treatment. Levofloxacin was discontinued and ceftriaxone was started to broaden coverage . Infectious disease was consulted to comment on antibiotic coverage. Flagyl was discontinued , with vancomycin IV started . Vancomycin by mouth and imipenum was started . The patient was continued on vancomycin IV and by mouth and imipenum until the decision was made for the patient to be CMO . The patient was kept hydrated intravenously and with free water boluses through his feeding tube to replace his GI losses. . 2. Fever/leukocytosis. The patient was started on levofloxacin and flagyl for presumptive infectious colitis, with antibiotic changes as above per ID recommendations. Blood cultures taken , , , , were negative. Urine cultures 7/28, , were negative. Multiple chest x-rays were within normal limits. An echocardiogram did not show evidence of endocarditis. As above, the patient continued to spike low grade fevers despite treatment with antibiotics. The patient's white blood cells at baseline were 19-25 thought secondary to MDS. The white blood cell count elevated to 80s on this admission. Hematology felt that the patient's blood smears were concerning for leukemic transformation of the MDS. Cytology was sent prior to the decision for CMO and was pending at the time of discharge. . 3. MDS. Hematology/oncology followed the patient during hospitalization. The team confirmed the diagnosis of MDS from his original smear. This was an atypical presentation as the patient was diagnosed in and an extended lifespan is inconsistent with the diagnosis of MDS. As above, the team felt that the patient's blood smears during the end of his hospitalization were concerning for leukemic transformation. The patient was not a good candidate for chemotherapy. Cytology was sent prior to the decision for CMO and was pending at the time of discharge. . #) Thrombocytopenia. The patient had platelets in the 40s in the past. On this admission, the patient's platelets dropped as low as 12. The thrombocytopenia was likely secondary to acute illness and the patient's underlying bone marrow disorder. DIC/ were thought unlikely although there were occasional schistocytes on smear. The patient was given a platelet transfusion at the time his platelets were 12. His platelets responded immediately afterwards but continued to drop and his last measurement was 31. . #) Anemia. The patient's hematocrit decreased during his hospital course. His baseline was low: 28-32. The anemia was macrocytic with recent normal B12, folate . His low reticulocyte count was indicative of a hypoproliferative disorder, most likely secondary to MDS with likely leukemic transformation. He was given two transfusions and when his hematocrit dropped below 25. His hematocrit would respond appropriately immediately afterwards but continued to drop during hospitalization. . #) Shortness of breath. The shortness of breath was most likely secondary to pulmonary edema from the patient's congestive heart failure and bronchoconstriction. The patient was given lasix 10 mg as needed, ipratropium nebulizers as needed, and oxygen as needed. The patient was discharged with nebulizers as needed. . #) Mental status. The patient was alert and oriented on admission. The patient's mental staus waxed and waned throughout admission. His mental status was most likely secondary to underlying dementia with superimposed infection/hospitalization. CT head showed prior infarct. CT head negative for increased ICP, hemorrhage. . #) Pancreatitis. The patient was found to have a chemical pancreatitis; he remained asymptomatic without complaints of epigastric pain. Amylase and lipase continued to trend down throughout admission. The patient was kept NPO with NJ tube placement for feeding. A RUQ ultrasound was negative for gallstones. The NJ tube was removed when the decision was made for CMO. . #) Elevated INR. The patient had an increased INR to 1.8 in the MICU, likely in setting of nutritional deficiency from diarrhea. He was given vitamin K 5 mg SC x 3 doses in the MICU. His INR continued to remain elevated throughout hospitalization. . #) CAD. The patient had no active symptoms and remained stable. Initially he was continued on aspirin, plavix, metoprolol, and his ace-inhibitor. Aspirin and plavix were discontinued when the patient was thrombocytopenic and in anticipation of possible colonoscopy with biopsies. His antihypertensive treatment was discontinued when the decision was made for CMO. . #) Congestive heart failure. The patienet was initially hypovolemic secondary to diarrhea. The patient was continued on maintenance IVF and free water boluses through his NJ tube once placed. The patient's low albumin was counterproductive to keep fluids in the intravascular space. The patient became transiently fluid overloaded and given lasix 10 mg x2 with effective diuresis. IVF and free water boluses were stopped when the patient became CMO. . #) Pain. The patient at baseline had pain with movement of his extremities. There was increased pain with movement of the right upper extremity, films were taken of the wrist, elbow, and shoulder without evidence of destructive disease or any acute issues. The patient was treated with tylenol and morphine with good effect. The patient was continued morphone elixer upon discharge. . #) Hiccups. The patient at times complained of intractable hiccups. Thorazine was given with good effect. This was continued through the patient's CMO status. . #) F/E/N. The patient's tube feeds were continued through the NG tube from the MICU, transiently stopped for placement of an NJ tube per GI recommendations, and restarted. The patient's albumin continued to drop, although the patient was at goal tube feeds. Electrolytes were repleted as necessary. The NJ tube was discontinued when the decision was made for CMO. . #) Precautions. The patient was placed on MRSA precautions were a positive swab . | Mild (1+) aortic regurgitation is seen. C-Diff specimen sent.ID: Pt with low-grade temp 100.7. Pt has edema to lower legs.ID)WBC's remains elevated. Skin dryResp: LS clear,dimish to bases. NIBP 100-120's systolic. Pt cont to have low grade temps Tmax 100.1 (A) at this shift. 02sat 98-100% on RA.GI)Abd sl distended and soft to touch (non-tender) with + hypoactive BS. Mild mitralannular calcification. Mild aortic regurgitation.Compared with the prior study (images reviewed) of , left ventricularsystolic function appears similar. Shift NoteCV: HR 80-114, NSR to ST. Pt had brief asymptomatic episode of tachycardia 140's that quickly resolved on own; team aware. very deconditioned.GI/GU: abd a bit distended, tympanic. Mild-moderateregional LV systolic dysfunction. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Since the previous tracing of sinus tachycardia is present. O2 removed for adequate saturation. There is mild to moderate regional left ventricularsystolic dysfunction with hypokinesis of the anterior wall and septum. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild [1+] TR. All cx's remains pending.RESP)LS CTA wit decreased bases. WBC elevated 43.9.Plan: Pt stable and most likely to be c/o floor. The right basilic vein was found to be patent and compressible. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Moderately dilated aortic root.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Min movement of limbs; rigid limbs, gentle ROM done. 40meq IV KCL ordered as well.ID: WBC 48.3, low-grade temp 100. small L lingular infiltrate. IVF as noted.GU)U/o as noted. Glenohumeral joint is preserved. Lung sounds clear and diminished in bases. Has two PIV's, patent; access poor. received po lopressor as scheduled. Pt given 40meq KCL PO and IV fluids switched to 1Liter NS with 60meq KCL (pt only has peripheral access). NS maintenance fluid infusing.CV: HR 90-115, NSR-ST with occasional PVC's. Congestive heart failure.Height: (in) 68Weight (lb): 140BSA (m2): 1.76 m2BP (mm Hg): 140/70HR (bpm): 111Status: InpatientDate/Time: at 14:55Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Opens eyes to voice, nods head.Resp: O2 2L NC. Shift NotePt admitted to MICU yesterday d/t brief episode of hypotension in EW. BBS clear/diminished in bases.Neuro: Pt speaks portugese only; difficulty comprehending english. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor parasternal views.Suboptimal image quality as the patient was difficult to position.Conclusions:The left atrium is normal in size. There is no pericardial effusion.IMPRESSION: Mild-to-moderate regional left ventricular systolic dysfunction.Mild mitral regurgitation. Stool cultures, C-Diff pending. stool clx x2 needed. Pt has very limited ROM to all ext's ? No focal infiltrates seen; lungs clear.CV: Tachy rate 110-120's. A final limited chest radiography confirmed placement of the tip of the catheter to be in the lower SVC. Mildly atrophic kidneys with diffuse calcification of the renal artery ostia are noted. Right hemidiaphragm is mildly elevated, as seen previously. retroperitoneal lymphadenopathy is noted and unchanged from previous study of undetermined significance. FINAL REPORT REASON FOR EXAMINATION: Tachypnea and tachycardia. There is a fat-containing inguinal hernia, which contains a small amount of fluid on the right. TECHNIQUE: Helically acquired contiguous axial images were obtained from the lung bases to the pubic symphysis with and without IV and oral contrast. Contracted gallbladder, without apparent abnormalities. The sigmoid colon is decompressed. Stable small left pleural effusion and left lower lobe retrocardiac atelectasis. The right lung demonstrates a mild effusion posteriorly with associated passive atelectasis. Enlarged paraaortic lymph nodes noted on previous exam, unchanged and of unknown significance. Diffusely swollen pancreas consistent with mild pancreatitis without peripancreatic fluid collections noted. CT OF THE PELVIS WITH AND WITHOUT IV AND ORAL CONTRAST: The bladder demonstrates wall thickening, unchanged from previous exam, and a Foley is seen within the bladder lumen. CT OF THE PELVIS WITH AND WITHOUT CONTRAST. Again seen is a right lumbar hernia. The paranasal sinuses are clear except for mild mucosal thickening of the right ethmoid air cells. FINAL REPORT PORTABLE CHEST INDICATION: Pancreatitis. pulm edema ? pulm edema ? The lungs are clear except for bibasilar atelectasis. CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: The heart appears normal without pericardial effusion. TECHNIQUE: Non-contrast axial head CT. FINDINGS: There is an NG tube with tip crossing the midline, in the proximal portion of the duodenum. Evaluate for pancreatic abscess or phlegmon. (Over) 10:03 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: Asses pancreatic abscess, phlegmon, subphrenic process Admitting Diagnosis: ABDOMINAL PAIN Field of view: 36 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) BONE WINDOWS: The osseous structures are stable in appearance. The kidneys are mildly atrophic bilaterally. CT OF THE ABDOMEN WITH IV CONTRAST: There are bilateral simple-appearing pleural effusions with associated atelectasis, which appear to have increased slightly in comparison to the prior study. Small bilateral pleural effusions. Coronal and sagittal reconstructions were obtained. CORONAL AND SAGITTAL RECONSTRUCTIONS WERE OBTAINED. The NG tube with tip in the Treitz ligament IMPRESSION: Mild pulmonary edema. Improved mild pulmonary edema. Please rule out gallbladder disease. Now febrile and tachypneic. FINDINGS: Compared with , there is now mild prominence of the pulmonary vascularity probably due at least in part to the elevated hemidiaphragms. Again seen is stranding around the pancreas, consistent with pancreatitis. There has been interval decrease in the degree of colonic wall thickening, though there is residual mild soft tissue stranding around the cecum and the appendix. | 24 | [
{
"category": "Nursing/other",
"chartdate": "2116-07-05 00:00:00.000",
"description": "Report",
"row_id": 1558348,
"text": "MICU 6 Nursing Note 7A-7P\n\nBrief summary: Pt with recent previous admit to for ? C-Diff colitis. D/C to home with services. Presented to ED with several weeks hx diarrhea. iL IVF given for dehydration, admitted to MICU 6 for transient hypotention which resolved with fluids. Pt was called out to floor , but cancelled when pt became tachycardic, tachypnic, and febfile T101.6 Ax.\n\nNeuro: Pt. has decreased LOC, lethargic and sleeping unless stimulated. Pt. speaks only Portugese. Moves hands toward noxious stimuli, no spontaneous movements otherwise. Opens eyes to voice, nods head.\n\nResp: O2 2L NC. RR 30-40. Lung sounds clear and diminished in bases. CXR obtained yesterday evening showed ? small L lingular infiltrate. No focal infiltrates seen; lungs clear.\n\nCV: Tachy rate 110-120's. Single burst to 200 this AM. Frequent PVC's. SBP 130's-140's. IV Lopressor 5mg IVx1 as he was unable to swallow his PO med.\n\nGI: Pt has become unable to take PO, family has agreed to have feeding tube placed to administer nutrition and medication. Abdomen soft, nontender. +BS x4 quads. Fecal incont. bag draining dark brown liquid stool. Stool cultures, C-Diff pending. Pt receiving Flagyl.\n\nGU: Foley cath draining amber urine w/ sediment. 30-60cc/hr.\n\nID: Tmax 101.6, pt has been cultured less than 24 hrs ago. Bilateral eyes with red sclera, green dischare worsening since yesterday. MD aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-07-06 00:00:00.000",
"description": "Report",
"row_id": 1558349,
"text": "Nursing Note (1900-0700)\n\nEvents: febrile again to 101.6, recultured. Increased ectopy of PVC's as well as a short burst of self-resolving SVT at beginning of shift.\n\nNeuro: Moaning and crying aloud with any care. Keeps eyes open large part of the time; smiles to staff at times. Min movement of limbs; rigid limbs, gentle ROM done. SLeeping intermittently thru shift.\n\nCV: HR 80-90's, NSR; occ/freq PVC's as mentioned above. received po lopressor as scheduled. Has two PIV's, patent; access poor. Hct stable, 26.6; plt 53. Repeat K 3.7 last eveing, received additional 20 KCL, repeat now 4.0. Phos 2, Ca 7.8, no alb drawn. No pedal edema. Skin dry\nResp: LS clear,dimish to bases. O2 removed for adequate saturation. Weak cough. Receiving levo/flagyl for +sputum.\n\nGi/GU: TF started, now at 20cc/hr via NGT. Abd firm, sl distended; rectal bag patent for liquid green brown stool, sent for cx. Urine amber with sediment, cx sent as well.\n\nID: Cont to spike temps, received one dose tylenol. WBC rising--now at 52.4; increased drng to bilateral eyes, thick yellow/green drng. RUE with increased sensitivity to touch, swelling improved since when IV was removed. Good pulses to right arm, warm.\n\nPlan: Full code. Cont present level of management, await pan cx. F/U with team re: ?cx eye drng if bacterial inf suspected. Advance TF as tol. Closely observe RUE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-07-04 00:00:00.000",
"description": "Report",
"row_id": 1558345,
"text": "Shift Note\nPt admitted to MICU yesterday d/t brief episode of hypotension in EW. Since arrival to MICU, patient has been normotensive with no further episodes of hypotension. NS maintenance fluid infusing.\n\nCV: HR 90-115, NSR-ST with occasional PVC's. Lytes sent last evening and K 3.1. Pt given 40meq KCL PO and IV fluids switched to 1Liter NS with 60meq KCL (pt only has peripheral access). Repeat K this am 5.2...fluids stopped and patient to have another K sent to recheck.\n\nAccess: Right hand 18g, left arm 20g.\n\nResp: Pt on RA with sats >96%. RR 20-30, breathing easy with no signs of distress. BBS diminished, more audible in LUL.\n\nNeuro: Pt portugese speaking only and so unable to adequately assess neuro status. Opens eyes spontaneously and will moan when moved to be turned/positioned. Otherwise, patient does not move in bed on his own. Per family, when visiting yesterday, patient was oriented x2.\n\nGI/GU: Abdomen soft, BS present. Pt on clear liquid diet. Taking pills and PO's well, but really needs much encouragement to take PO fluids. Foley cath intact draining adequate UO and FIB placed d/t frequent episodes of liquid and gelatin consistency brown-green stool. C-Diff specimen sent.\n\nID: Pt with low-grade temp 100.7. Resident notified and to draw BC and urine cx if temp spikes >101.4. Pt receiving cipro and flagyl. On contact precautions for . WBC elevated 43.9.\n\nPlan: Pt stable and most likely to be c/o floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-07-04 00:00:00.000",
"description": "Report",
"row_id": 1558346,
"text": "MICU-6 Nursing\nPlease see nursing transfer note.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-07-05 00:00:00.000",
"description": "Report",
"row_id": 1558347,
"text": "Shift Note\nCV: HR 80-114, NSR to ST. Pt had brief asymptomatic episode of tachycardia 140's that quickly resolved on own; team aware. NIBP 112-140/50-60's...pt on lopressor.\n\nResp: Pt on 2L NC with sats >99%. BBS clear/diminished in bases.\n\nNeuro: Pt speaks portugese only; difficulty comprehending english. When asked if in pain will nod head appropriately per family. Also, per family patient was oriented to self/place but occasionally experienced mild confusion. Pt c/o pain right arm...right arm puffy and red, so PIV removed and replaced on left arm. Pt moans and yells out with turning and positioning, otherwise sleeps and appears to be resting comfortably. Medicated with 1mg IV morphine with good effect.\n\nGI/GU: Abdomen softly distended, BS present. Foley cath draining adequate UO; amber with sediment. Fecal bag replaced d/t leaking...pt continues to have liquid green stool. Pt on clear liquid diet, but having difficulty taking thin liquids. Last evening was only able to swallow pills with jello. K this am 2.9 and PO repletion attempted, however patient will just hold pills and jello on right side of mouth and not attempt to swallow. 40meq IV KCL ordered as well.\n\nID: WBC 48.3, low-grade temp 100. Cipro switched to Levofloxacin IV. Pt continues on PO flagyl.\n\nPlan: Pt was c/o floor yesterday, but then spiked temp and tachycardic. Status stable through night, c/o floor today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-07-03 00:00:00.000",
"description": "Report",
"row_id": 1558344,
"text": "Nursing Admission Note 1530-1900\nPt brought to ER by family for persistent diarrhea and dehydration. One episode of \"hypotension\"- SBP of 89 in ED. Given 1 Liter NS w/ resolution of s/s. Transfered to MICU 6 for monitoring at MD request. Pt arrives in NAD, normotensive.\n\nROS/PE:\n\nCV: NSR, HR 70-80's. rare PVC. NIBP 100-120's systolic. extremities W&D, neg edema.\n\nRESP: LS CTA, poor inspiratory effort, decreased at bases. no cough or SOB. Spo2 >95% on RA.\n\nNEURO: speaks portugese. Per daughter, pain free. Alert and O x2-3. MAE on the bed, no focal defecits. Low level of functioning- WC and bed bound. very deconditioned.\n\nGI/GU: abd a bit distended, tympanic. no stool out since arrival. reportedly 2 small loose stools in ED. NPO at this time. IVF- NS at 100cc/hr. Foley w/ adeq U/O.\n\nSKIN: Grossly intact. dry.\n\nACCESS: Piv x2, intact.\n\nSOCIAL: Daughter here. Wife is reportedly not in good health, but family does not think that they can make DNR decisions, therefore full code at this time. Lives at home w/ family to take care of him.\n\nPLAN: likely c/o either later tonoc or tomorrow. monitor for s/s of hypotension, may need more fluid. stool clx x2 needed. f/u on culture data. FULL CODE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-07-06 00:00:00.000",
"description": "Report",
"row_id": 1558350,
"text": "7am to 4:30 pm:\n\nNeuro)\nPt is awake and alert, but does not follow any commands. Pt was oriented to person this am per interpreter. Pt is portugese speaking only. Pt has very limited ROM to all ext's ? pain with any movent of ext's ? AR.\n\nCV)\nPt remains in NSR with rare PVC's with HR 80-90's. BP stable at 120-130's. Pt cont to have low grade temps Tmax 100.1 (A) at this shift. Pt has edema to lower legs.\n\nID)\nWBC's remains elevated. Pt is on Levaquin as noted. All cx's remains pending.\n\nRESP)\nLS CTA wit decreased bases. No SOB/DOE. Pt needs to be inc to DB&C W/A. 02sat 98-100% on RA.\n\nGI)\nAbd sl distended and soft to touch (non-tender) with + hypoactive BS. TF at goal at 40 cc/hr with max 5 cc of residuals. NGT in place and placement + via ascultation. Pt cont to have liq dark green stool. Sample sent off this pm (#2). Stool Guiac neg. IVF as noted.\n\nGU)\nU/o as noted. U/o with color and with sediment.\n\nSKIN)\nskin intact as noted. Pt has yellow-green colored drainage from bil eyes. Pt to be started on med's for this.\n\nPLAN:\n Transfer to floor with bed avalible.\n"
},
{
"category": "Echo",
"chartdate": "2116-07-07 00:00:00.000",
"description": "Report",
"row_id": 60023,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Congestive heart failure.\nHeight: (in) 68\nWeight (lb): 140\nBSA (m2): 1.76 m2\nBP (mm Hg): 140/70\nHR (bpm): 111\nStatus: Inpatient\nDate/Time: at 14:55\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild-moderate\nregional LV systolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\nSuboptimal image quality as the patient was difficult to position.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. There is mild to moderate regional left ventricular\nsystolic dysfunction with hypokinesis of the anterior wall and septum. Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmoderately dilated. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nMild (1+) mitral regurgitation is seen. The estimated pulmonary artery\nsystolic pressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Mild-to-moderate regional left ventricular systolic dysfunction.\nMild mitral regurgitation. Mild aortic regurgitation.\n\nCompared with the prior study (images reviewed) of , left ventricular\nsystolic function appears similar. Severity of mitral regurgitation may be\nslightly less. Aortic root dimensions are slightly larger. The other findings\nappear similar.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2116-07-09 00:00:00.000",
"description": "Report",
"row_id": 108963,
"text": "Sinus tachycardia. Ventricular premature beats. Otherwise, probably normal\ntracing. Since the previous tracing of sinus tachycardia is present.\n\n"
},
{
"category": "ECG",
"chartdate": "2116-07-03 00:00:00.000",
"description": "Report",
"row_id": 108964,
"text": "Sinus rhythm with PVCs\nNo change from previous\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-07-10 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 922781,
"text": " 10:09 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC for access.\n Admitting Diagnosis: ABDOMINAL PAIN\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with CAD, admitted with diarrhea, anemia, thrombocytopenia;\n lost IV access overnight.\n REASON FOR THIS EXAMINATION:\n Please place PICC for access.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: 86-year-old man with coronary artery disease admitted\n with thrombocytopenia and has a history of allergy to heparin induced\n thrombocytopenia.\n\n RADIOLOGISTS: The procedure was performed by Drs and , the\n attending radiologist, who was present and supervising throughout.\n\n PROCEDURE AND FINDINGS: The patient's right arm was prepped and draped in\n standard sterile fashion. As no suitable superficial veins were visible,\n ultrasound was used for the evaluation of the right upper extremity veins. The\n right basilic vein was found to be patent and compressible. Local anesthesia\n was achieved with subcutaneous injection of 3 cc of 1% lidocaine. Under\n realtime ultrasound guidance, the vein was accessed using a 21 gauge\n micropuncture needle. Hard copies images of the pre- and post puncture were\n obtained. A 0.018 guidewire was then advanced through the needle using\n fluoroscopic guidance. The needle was then exchanged for the micropuncture\n sheath contained in the catheter kit. line was then\n advanced into the sheath through the superior vena cava. The wire contained\n in the catheter was then removed as well as the peel-away sheath\n The catheter was cut to a length of 40 cm with 34 cm of length,\n corresponding to the distance between the skin puncture and the distal part of\n the SVC. The line was then secured with a StatLock device and a sterile\n transparent dressing. A final limited chest radiography confirmed placement\n of the tip of the catheter to be in the lower SVC. The patient\n tolerated the procedure well with no immediate complications.\n\n IMPRESSION: Successful placement of a single lumen line with 34 cm\n lenght intra-vascular, via the right basilic vein with the tip terminating in\n the lower SVC. The line is ready for use.\n\n\n\n (Over)\n\n 10:09 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC for access.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-07-08 00:00:00.000",
"description": "R WRIST(3 + VIEWS) RIGHT",
"row_id": 922472,
"text": " 11:18 AM\n WRIST(3 + VIEWS) RIGHT; ELBOW (AP, LAT & OBLIQUE) RIGHT Clip # \n SHOULDER VIEWS NON TRAUMA RIGHT\n Reason: Evaluate for degenerative changes, trauma.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man admitted with colitis, history of right arm pain with\n increasing pain.\n REASON FOR THIS EXAMINATION:\n Evaluate for degenerative changes, trauma.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right wrist, three views; right elbow, three views; right shoulder,\n three views; .\n\n HISTORY: Patient with increasing shoulder, elbow, and wrist pain. Evaluate\n for degenerative changes.\n\n FINDINGS:\n\n RIGHT WRIST: No acute fractures or dislocations are identified. There are\n degenerative changes seen of the first MCP joint with osteophyte seen at the\n metacarpal head. There is preservation of the radiocarpal joint space. There\n is normal osseous mineralization.\n\n RIGHT ELBOW: There is no joint effusion. No acute fractures or dislocations\n are seen. There are no soft tissue calcifications.\n\n RIGHT SHOULDER:\n\n There are some degenerative changes seen in the acromioclavicular joint.\n Glenohumeral joint is preserved. However, the humeral head is slightly high\n riding. There is normal mineralization. No abnormal soft tissue\n calcifications are identified.\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-07-08 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 922547,
"text": " 10:03 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Asses pancreatic abscess, phlegmon, subphrenic process\n Admitting Diagnosis: ABDOMINAL PAIN\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with pancreatis and continued fevers, please assess for\n pancreatic abscess, phlegmon, subphrenic process.\n REASON FOR THIS EXAMINATION:\n Asses pancreatic abscess, phlegmon, subphrenic process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old man with pancreatitis and continued fevers. Evaluate\n for pancreatic abscess or phlegmon.\n\n COMPARISON: Study from .\n\n TECHNIQUE: MDCT acquired contiguous axial images were obtained from the lung\n bases to the pubic symphysis. Multiplanar reconstructions were performed.\n\n CONTRAST: Oral contrast and 100 cc of IV Optiray contrast administered due to\n the rapid rate of bolus injection required for this study.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There are bilateral simple-appearing\n pleural effusions with associated atelectasis, which appear to have increased\n slightly in comparison to the prior study. The heart and pericardium are\n normal in appearance.\n\n An NG tube is positioned within the stomach. The spleen, kidneys, adrenal\n glands, and liver are stable in appearance.\n\n Again seen is stranding around the head of the pancreas, and fullness of the\n pancreas, consistent with the known history of pancreatitis. There is\n extension of the stranding into the mesentery of the small bowel, and there is\n soft tissue stranding and fluid extending along Gerota's fascia into the\n pericolic gutters. The amount of fluid in the pericolic gutters and in the\n pelvis appears to have increased slightly in comparison to the prior study.\n There has been interval decrease in the degree of colonic wall thickening,\n though there is residual mild soft tissue stranding around the cecum and the\n appendix. The aorta demonstrates normal caliber and contour, without any\n filling defects. Extensive calcification is seen along the aorta throughout\n its course. No free intraperitoneal air is seen. No definite focal abscesses\n or fluid collections are identified. There is a small amount of fluid around\n the gallbladder, which is not distended, and there is no evidence of intra- or\n extra-hepatic biliary ductal dilatation. Again seen is a right lumbar hernia.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is a small amount of fluid within\n the pelvis, which is increased slightly in comparison to prior study. A Foley\n catheter is seen within the bladder. The sigmoid colon is decompressed. There\n is a fat-containing inguinal hernia, which contains a small amount of fluid on\n the right. No pelvic lymphadenopathy is seen.\n (Over)\n\n 10:03 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Asses pancreatic abscess, phlegmon, subphrenic process\n Admitting Diagnosis: ABDOMINAL PAIN\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: The osseous structures are stable in appearance.\n\n CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating\n the anatomy and pathology.\n\n IMPRESSION:\n 1. Again seen is stranding around the pancreas, consistent with pancreatitis.\n There appears to be some interval increase in the degree of stranding within\n the small bowel mesentery, and along the pericolic gutters. There is a small\n amount of fluid along the pericolic gutters and within the pelvis, which is\n slightly increased from the prior study. No focal abscesses are identified.\n 2. There are bilateral pleural effusions which also have increased slightly\n in comparison to the prior study. The remainder of the exam is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-07-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 922265,
"text": " 7:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for PNA.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 y/o M adm w/pancreatitis, now febrile and tachypneic.\n\n REASON FOR THIS EXAMINATION:\n Assess for PNA.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n INDICATION: Pancreatitis. Now febrile and tachypneic. Evaluate for\n pneumonia.\n\n FINDINGS: Compared with , there is now mild prominence of the\n pulmonary vascularity probably due at least in part to the elevated\n hemidiaphragms. Mild CHF cannot be excluded. No obvious pulmonary\n infiltrates.\n\n Tip of the NG tube remains projected over the right upper quadrant, probably\n at or near the pylorus.\n\n IMPRESSION: No pneumonia identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-07-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 923036,
"text": " 11:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for cardiopulmonary process\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 y/o M adm w/pancreatitis, now tachycardic and tachypneic. Increasing\n oxygen requirement.\n REASON FOR THIS EXAMINATION:\n please assess for cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Single AP portable view of the chest.\n\n REASON FOR EXAM: Assess for changes, patient with increasing oxygen\n requirement, h/o pancreatitis.\n\n COMPARISON: Comparison is made with prior study dated .\n\n FINDINGS: New left pleural effusion with increase in left lower lobe\n atelectasis. Stable mild right lower lobe atelectasis. Mild pulmonary edema.\n The size of the heart is normal. The NG tube with tip in the Treitz\n ligament\n\n IMPRESSION:\n\n Mild pulmonary edema. New left pleural effusion. Increase left lower\n atelectasis and stable right lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-07-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 921835,
"text": " 11:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with n/v, diarrhea, leukocytosis\n REASON FOR THIS EXAMINATION:\n assess for pna\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest, 11:22 a.m. .\n\n HISTORY: Diarrhea and leukocytosis.\n\n IMPRESSION: AP chest compared to :\n\n Lungs are clear. Heart size normal. No pleural abnormality or evidence of\n central adenopathy. Right hemidiaphragm is persistently elevated given part\n to interposition of the hepatic flexure of the colon between diaphragm and\n liver.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-07-03 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 921871,
"text": " 2:44 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: assess for pancreatitis (d/ techologist; pt is\n Admitting Diagnosis: ABDOMINAL PAIN\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with elevated lipase and abd pain, + u/a\n REASON FOR THIS EXAMINATION:\n assess for pancreatitis (d/ techologist; pt is not willing to take\n po contrast; will try w/ IV contrast only)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN WITH AND WITHOUT CONTRAST. CT OF THE PELVIS WITH AND\n WITHOUT CONTRAST. CORONAL AND SAGITTAL RECONSTRUCTIONS WERE OBTAINED.\n\n INDICATION: 86-year-old male with elevated lipase and abdominal pains, assess\n for pancreatitis.\n\n COMPARISON: Comparison is made with CT abdomen and pelvis, .\n\n TECHNIQUE: Helically acquired contiguous axial images were obtained from the\n lung bases to the pubic symphysis with and without IV and oral contrast.\n Coronal and sagittal reconstructions were obtained.\n\n CONTRAST: Oral contrast and IV non-ionic contrast were administered with IV\n 100 cc Optiray 350.\n\n CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: The heart appears normal\n without pericardial effusion. The right lung demonstrates a mild effusion\n posteriorly with associated passive atelectasis. The liver, gallbladder, and\n spleen are visualized and are unremarkable. The pancreas is swollen without\n peripancreatic fluid collection noted. The abdominal aorta demonstrates mural\n thrombus with calcification throughout. Extensive calcification of the renal\n artery ostia bilaterally. The kidneys are mildly atrophic bilaterally. _____\n retroperitoneal lymphadenopathy is noted and unchanged from previous study of\n undetermined significance. There is mild increase in stranding in the\n perirenal spaces when compared to previous exam. There is no free fluid or\n free air within the abdomen.\n\n CT OF THE PELVIS WITH AND WITHOUT IV AND ORAL CONTRAST: The bladder\n demonstrates wall thickening, unchanged from previous exam, and a Foley is\n seen within the bladder lumen. There is diffuse thickening of the rectum,\n sigmoid colon, and descending colon likely representing colitis. There is\n mild enlargement of the prostate.\n\n OSSEOUS STRUCTURES: There is diffuse DJD of the lumbar spine. There are no\n fractures, dislocations, or lesions identified within the bones.\n\n IMPRESSION:\n 1. Diffusely swollen pancreas consistent with mild pancreatitis without\n peripancreatic fluid collections noted.\n (Over)\n\n 2:44 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: assess for pancreatitis (d/ techologist; pt is\n Admitting Diagnosis: ABDOMINAL PAIN\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Mildly atrophic kidneys with diffuse calcification of the renal artery\n ostia are noted. MRA of the renal artery is recommended bilaterally if\n clinical suspicious for stenosis.\n 3. Diffuse rectal, sigmoid, and descending colon wall thickening suggestive\n of colitis.\n 4. Enlarged paraaortic lymph nodes noted on previous exam, unchanged and of\n unknown significance.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-07-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 922003,
"text": " 6:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulm edema ? infiltrate\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 y/o M adm w/pancreatitis, now febrile and tachypneic\n REASON FOR THIS EXAMINATION:\n ? pulm edema ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW, ON \n\n HISTORY: Pancreatitis, febrile, and tachypneic.\n\n REFERENCE EXAM: .\n\n FINDINGS: This is a slightly rotated film. The left heart border is ill\n defined, and it is unclear if this is due to motion or small area of volume\n loss or lingular infiltrate. Otherwise, the lungs are clear without focal\n infiltrate. A lateral film would be helpful to further assess the lingula.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-07-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 922085,
"text": " 3:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NG tube placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 y/o M adm w/pancreatitis, now febrile and tachypneic\n\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: NG tube placement.\n\n FINDINGS: There is an NG tube with tip crossing the midline, in the proximal\n portion of the duodenum. Right hemidiaphragm is mildly elevated, as seen\n previously. There is no infiltrate or effusion. The previous ill-defined\n area in the lingula is better visualized today and appears clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-07-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 922565,
"text": " 1:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Etiology for respiratory distress.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 y/o M adm w/pancreatitis, now tachycardic and tachypneic.\n\n REASON FOR THIS EXAMINATION:\n Etiology for respiratory distress.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Tachypnea and tachycardia.\n\n Portable AP chest radiograph compared to .\n\n The NG tube tip terminates in the stomach. The heart size is normal. The\n mediastinum position, contour and width are unremarkable. The lungs are clear\n except for bibasilar atelectasis. There is no sizeable pleural effusion or\n pneumothorax.\n\n Small bibasilar atelectasis. No evidence of acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-07-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 923319,
"text": " 9:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate if NJ tube post-pyloric.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 y/o M adm w/presumptive c. diff/chemical pancreatitis. NJ tube placed, was\n pulled out approximately 2 inches and replaced. Please evaluate if\n post-pyloric.\n REASON FOR THIS EXAMINATION:\n Evaluate if NJ tube post-pyloric.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Single AP portable view of the chest.\n\n REASON FOR EXAM: Check placement of NG tube. Patient with pancreatitis.\n\n COMPARISON: Comparison is made with prior study dated .\n\n FINDINGS: NG tube tip is located in the third to fourth portion of the\n duodenum. There is no pneumothorax. Improvement in the right lower lobe\n atelectasis. Stable small left pleural effusion and left lower lobe\n retrocardiac atelectasis. Improved mild pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-07-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 922254,
"text": " 11:02 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Increased ICP, hemorrhage.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man admitted with diarrhea, increased wbc count now with change in\n mental status.\n REASON FOR THIS EXAMINATION:\n Increased ICP, hemorrhage.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: _____, increased white blood cell count. Evaluate for\n hemorrhage.\n\n TECHNIQUE: Non-contrast axial head CT.\n\n FINDINGS: There is no evidence for intracranial hemorrhage. There is no mass\n effect, shift of normally midline structures. The ventricles, cisterns, and\n sulci are prominent secondary to marked involutional change. An area of a\n more focal encephalomalacia in the left frontoparietal lobe may be secondary\n to previous infarction. The osseous structures are unremarkable. There is\n atherosclerotic calcification of the cavernous carotids. The paranasal\n sinuses are clear except for mild mucosal thickening of the right ethmoid air\n cells. The mastoid air cells are clear.\n\n IMPRESSION: Brain atrophy, but no evidence for intracranial hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-07-07 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 922285,
"text": " 8:56 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Rule out gallbladder disease.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with f/c/n/v. Please rule out gallbladder disease.\n REASON FOR THIS EXAMINATION:\n Rule out gallbladder disease.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, chills, nausea, and vomiting. Evaluate for gallbladder\n disease.\n\n COMPARISON: CT of the abdomen and pelvis of .\n\n ABDOMEN ULTRASOUND: The liver echotexture is normal. There is no focal liver\n lesion or intrahepatic biliary ductal dilation. The main portal vein is\n patent with the appropriate direction of flow. The gallbladder is contracted,\n without stones. The common duct measures 5 mm. The right kidney measures 9.7\n cm. The left kidney measures 11.9 cm. No hydronephrosis. The spleen is\n normal. The pancreas is not well visualized due to overlying bowel gas. There\n are small bilateral pleural effusions.\n\n IMPRESSION:\n 1. Contracted gallbladder, without apparent abnormalities.\n 2. No intra- or extra-hepatic biliary ductal dilation.\n 3. Small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-07-09 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 922651,
"text": " 1:11 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: Please place -intestinal tube for feeding\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with pancreatitis; please place -intestinal tube for\n feeding.\n REASON FOR THIS EXAMINATION:\n Please place -intestinal tube for feeding\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old gentleman with history of pancreatitis referred for\n placement of postpyloric feeding tube.\n\n PROCEDURE AND FINDINGS: The patient was placed in supine position on the\n fluoroscopy table. Topical anesthetic placed into the right naris of patient.\n An 8-French - feeding tube guided with fluoroscopy through\n right naris into the stomach and advanced, with the tip terminating at the\n ligament of Treitz. Five mL of Conray administered through the -\n feeding tube with opacification of the distal duodenum at the ligament\n of Treitz.\n\n COMPLICATIONS: None.\n\n"
}
] |
59,702 | 154,545 | The patient was brought to the operating room on where the patient underwent CABG x 4 (LIMA-LAD, RSVG-OM1, RSVG-OM2, RSVG-Diag). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD#4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in stable condition on POD#4. | Normal ascending aortadiameter. Normal descending aorta diameter. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. FINDINGS: There is minimal bulb thickening and extension into the internal carotid arteries bilaterally. Cardiomediastinal contours are unchanged with mild cardiomegaly. Good (>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness. The left ventricular cavity sizeis normal. Right bundle-branch block.Non-specific ST-T wave abnormalities. Bilateral pleural effusions are small, probably unchanged allowing the difference in positioning of the patient. Mild (1+) mitral regurgitation is seen.Dr. IMPRESSION: No acute cardiopulmonary abnormality. However, the peak systolic velocities bilaterally are normal as are the ICA/CCA ratios. The cardiac silhouette is top normal. No overt pulmonary edema is seen. Overall left ventricular systolic function is normal (LVEF>55%).Right ventricular chamber size and free wall motion are normal.There are simple atheroma in the descending thoracic aorta.There are three aortic valve leaflets. Normal sinus rhythm. There is some consolidation/volume loss in the retrocardiac region, otherwise the lungs are clear. was notified in person of the results.Post CPB:The patient is being atrial paced.There is trace MR.The biventricular systolic function is preserved.The visible contours of the thoracic aorta are intact. Left lower lobe retrocardiac opacity consistent with atelectasis has minimally improved. Non-specific ST-T waveabnormalities. Trace AR.MITRAL VALVE: No MVP. Intraoperative TEE for CABG.Height: (in) 71Weight (lb): 213BSA (m2): 2.17 m2Status: InpatientDate/Time: at 10:16Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the LAA. Normal LV cavity size. FINDINGS: The endotracheal tube has been removed. Otherwise, no diagnostic change.TRACING #2 There is no aortic valve stenosis.Trace aortic regurgitation is seen.There is no mitral valve prolapse. Left-sided chest tube has been removed. Right lower lobe and right perihilar opacities have minimally worsened consistent with increasing atelectasis. IMPRESSION: Minimal bilateral plaque, however, no appreciable ICA stenosis bilaterally (graded as less than 40% bilaterally). Overallnormal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Results were personally reviewed with the MD caring for thepatient.Conclusions:Pre CPB:No spontaneous echo contrast or thrombus is seen in the body of the leftatrium or left atrial appendage.No atrial septal defect is seen by 2D or color Doppler.Left ventricular wall thicknesses are normal. There is a left-sided chest tube and mediastinal drains in place. Pulmonic valve not well seen.GENERAL COMMENTS: A TEE was performed in the location listed above. Simple atheroma in descendingaorta.AORTIC VALVE: Three aortic valve leaflets. No TEE relatedcomplications. Compared to tracing #1 suggestion of left atrial enlargement isless prominent. The aorta is slightly tortuous. There are low lung volumes. No focal consolidation, pleural effusion, or pneumothorax is seen. There is no pneumothorax. There is no pneumothorax. No PS.Physiologic PR. The patient was undergeneral anesthesia throughout the procedure. There is right IJ line with tip in the SVC. Possible left atrial enlargement. Right IJ line tip is in the right atrium. No previous tracing available forcomparison.TRACING #1 Right bundle-branch block. Sinus rhythm. COMPARISON: None. No AS. No MS. There is volume loss in the left lower lung. There is also normal antegrade flow involving both vertebral arteries. FINDINGS: Frontal and lateral views of the chest are obtained. Mitral valve disease. The sternal wires are aligned. REFERENCE EXAM: ET tube tip is 3.4 cm above the carina. I certifyI was present in compliance with HCFA regulations. The TEE probe was passed withassistance from the anesthesioology staff using a laryngoscope. 3:09 PM CHEST PORT. PATIENT/TEST INFORMATION:Indication: Coronary artery disease. NG tube tip is in the stomach. 1:52 PM CHEST (PA & LAT) Clip # Reason: r/o inf, eff Admitting Diagnosis: DYSPNEA ON EXERTION\RIGHT AND LEFT HEART CATH MEDICAL CONDITION: 62 year old man with s/p CABG REASON FOR THIS EXAMINATION: r/o inf, eff FINAL REPORT PA AND LATERAL VIEWS OF THE CHEST REASON FOR EXAM: Status post CABG, asses pleural effusion. CLINICAL INFORMATION: 62-year-old male with history of coronary artery disease, pre-op chest radiograph. 4:01 PM CAROTID SERIES COMPLETE Clip # Reason: LM DISEASE, R/O CAS MEDICAL CONDITION: 62 year old man with LM disease REASON FOR THIS EXAMINATION: r/o carotid stenosis FINAL REPORT CAROTID STUDY HISTORY: "LM" disease, which is presumed to represent left main coronary disease, though not formally stated. LINE PLACEMENT Clip # Reason: *CARDIAC SURGERY FAST TRACK EXTUBATION PROTOCOL* evaluate li Admitting Diagnosis: DYSPNEA ON EXERTION\RIGHT AND LEFT HEART CATH MEDICAL CONDITION: 62 year old man with s/p CABG REASON FOR THIS EXAMINATION: *CARDIAC SURGERY FAST TRACK EXTUBATION PROTOCOL* evaluate lines, and for hemo/ptx FINAL REPORT CHEST ON HISTORY: Status post CABG. | 8 | [
{
"category": "Radiology",
"chartdate": "2185-09-09 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1157330,
"text": " 6:49 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: DYSPNEA ON EXERTION\\RIGHT AND LEFT HEART CATH\n Admitting Diagnosis: DYSPNEA ON EXERTION\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with cad\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest frontal and lateral views.\n\n CLINICAL INFORMATION: 62-year-old male with history of coronary artery\n disease, pre-op chest radiograph.\n\n COMPARISON: None.\n\n FINDINGS: Frontal and lateral views of the chest are obtained. No focal\n consolidation, pleural effusion, or pneumothorax is seen. The aorta is\n slightly tortuous. The cardiac silhouette is top normal. No overt pulmonary\n edema is seen.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2185-09-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1157924,
"text": " 1:52 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o inf, eff\n Admitting Diagnosis: DYSPNEA ON EXERTION\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n r/o inf, eff\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Status post CABG, asses pleural effusion.\n\n Comparison is made with prior study .\n\n Bilateral pleural effusions are small, probably unchanged allowing the\n difference in positioning of the patient. Left lower lobe retrocardiac\n opacity consistent with atelectasis has minimally improved. Right lower lobe\n and right perihilar opacities have minimally worsened consistent with\n increasing atelectasis. There is no pneumothorax. Cardiomediastinal contours\n are unchanged with mild cardiomegaly. There are low lung volumes. The\n sternal wires are aligned.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2185-09-10 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1157407,
"text": " 3:09 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: *CARDIAC SURGERY FAST TRACK EXTUBATION PROTOCOL* evaluate li\n Admitting Diagnosis: DYSPNEA ON EXERTION\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n *CARDIAC SURGERY FAST TRACK EXTUBATION PROTOCOL* evaluate lines, and for\n hemo/ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Status post CABG.\n\n REFERENCE EXAM: \n\n ET tube tip is 3.4 cm above the carina. Right IJ line tip is in the right\n atrium. There is some consolidation/volume loss in the retrocardiac region,\n otherwise the lungs are clear. NG tube tip is in the stomach. There is a\n left-sided chest tube and mediastinal drains in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2185-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1157495,
"text": " 11:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx\n Admitting Diagnosis: DYSPNEA ON EXERTION\\RIGHT AND LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p ct pull\n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Question pneumothorax.\n\n FINDINGS: The endotracheal tube has been removed. There is right IJ line\n with tip in the SVC. There is volume loss in the left lower lung. Left-sided\n chest tube has been removed. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2185-09-09 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 1157303,
"text": " 4:01 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: LM DISEASE, R/O CAS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with LM disease\n REASON FOR THIS EXAMINATION:\n r/o carotid stenosis\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID STUDY\n\n HISTORY: \"LM\" disease, which is presumed to represent left main coronary\n disease, though not formally stated.\n\n FINDINGS: There is minimal bulb thickening and extension into the internal\n carotid arteries bilaterally. However, the peak systolic velocities\n bilaterally are normal as are the ICA/CCA ratios. There is also normal\n antegrade flow involving both vertebral arteries.\n\n IMPRESSION: Minimal bilateral plaque, however, no appreciable ICA stenosis\n bilaterally (graded as less than 40% bilaterally).\n\n"
},
{
"category": "Echo",
"chartdate": "2185-09-10 00:00:00.000",
"description": "Report",
"row_id": 90170,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Mitral valve disease. Intraoperative TEE for CABG.\nHeight: (in) 71\nWeight (lb): 213\nBSA (m2): 2.17 m2\nStatus: Inpatient\nDate/Time: at 10:16\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the \nLAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal descending aorta diameter. Simple atheroma in descending\naorta.\n\nAORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR.\n\nMITRAL VALVE: No MVP. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Pulmonic valve not well seen.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications. Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nPre CPB:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium or left atrial appendage.\nNo atrial septal defect is seen by 2D or color Doppler.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. Overall left ventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal.\nThere are simple atheroma in the descending thoracic aorta.\nThere are three aortic valve leaflets. There is no aortic valve stenosis.\nTrace aortic regurgitation is seen.\nThere is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen.\nDr. was notified in person of the results.\n\nPost CPB:\nThe patient is being atrial paced.\nThere is trace MR.\nThe biventricular systolic function is preserved.\nThe visible contours of the thoracic aorta are intact.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2185-09-10 00:00:00.000",
"description": "Report",
"row_id": 239243,
"text": "Normal sinus rhythm. Right bundle-branch block. Non-specific ST-T wave\nabnormalities. Compared to tracing #1 suggestion of left atrial enlargement is\nless prominent. Otherwise, no diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2185-09-09 00:00:00.000",
"description": "Report",
"row_id": 239244,
"text": "Sinus rhythm. Possible left atrial enlargement. Right bundle-branch block.\nNon-specific ST-T wave abnormalities. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
}
] |
11,474 | 156,704 | # UGIB: pt is 52 F h/o hepC cirrhosis who underwent 9.8L paracentesis on without receiving albumin, then presented to OSH with LH/dizzy, fatigue. At OSH, pt developed hemetemesis x 1, for which he was transfered to OSH ICU, received 3U PRBC, and underwent EGD which showed oozing at GE junction (erosion vs. variceal bleed), for which he was started on an octreotide gtt and protonix. EGD was repeated on and showed esophageal varices without active bleed. . Pt was transferred to MICU on for TIPS evaluation (he is s/p banding of known esophageal varices). In MICU, patient remained hemodynamically stable and did not experience further episodes of bleeding. He was transfused 1 unit of platelets. Diagnostic tap was performed for ascites, which was negative for SBP. He was transferred to the floor awaiting TIPs. Pt underwent uneventful TIPs on , with confirmation of TIPs patency of . He was discharged home for routine f/u with his hepatologist. An appointment was made for him with Dr. , with whom he would like to transfer his care. . . # FEVER/HYPOTENSION: Upon transfer to the floor, was found to be hypotensive, and febrile 100.7, with drop in SBP to 70s/50s. He was given ~750cc IVF with improvement in SBP to 90s. He was asymptomatic throughout, mentating well, with good urine output. . hypotension concerning for sepsis vs variceal bleeding, though HCT remained stable, and pt responding to small IVF bolus. repeat SBP ~2hr later was 115/80, and pt not tachycardic. black stools presents, however pt s/p recent UGIB. pt was febrile, though no obvious source currently, so he was empirically started on a 7d course of zosyn. no culture data was found, and pt completed his course of zosyn without further event. . . # CIRRHOSIS: pt with cirrhosis c/b recurrent ascites, s/p recent UGIB at OSH. His HCT was stable after transfusion of 3U PRBCs. Repeat EGD was without active bleeding. he was treated with TIPs as above for variceal bleeding. His diuretics were held hyponatremia, which was treated with 1L fluid restriction, and improving upon discharge. he was continued on lactulose. . diagnostic paracentesis in MICU on presentation was negative for SBP. pt underwent 1.5L therapeutic paracentesis at time of TIPs. nadolol was held initially given concern for hypotension in setting of bleeding, then restarted upon discharge. pt will f/u with Dr. as below for transplant evaluation. . . # THROMBOCYTOPENIA: pt presented with platlets of 34, felt to chronic liver disease. he was given 1U platelets in MICU, and his platlets were stable 47-50 throughout his hospitalization. . . # SCHIZOPHRENIA: pt was continued on home regimen of risperdal. . . # TOOTHACHE: pt has poor dentition, with bottom R molar that is causing him significant pain. he was treated with oxycodone for pain, and provided with information on dentists he could contact as an outpatient for extraction. . . # CONTACTS: . is OSH gastroenterologost . PCP . . . # DISPO: pt was discharged home on , after TIPs evaluation by RUQ USN. he will f/u with his current hepatologist regarding restarting diuretic therapy. he will also f/u with Dr. regarding transplanation, as he would like to have his care transferred to . Medications on Admission: MEDICATIONS AT HOME: 1. Nadolol 20 mg QD 2. Lactulose 15 ccs 2-3 times per day 3. Risperdone 1 mg q.h.s. 4. Ciprofloxacin 250 mg q.d. 5. Spironolactone 200 mg 6. Lasix 160 mg 7. Protonix 40 mg QD 8. Calcitriol 0.25 mg QDay 9. Calcium Carbonate 1500 mg QDay . MEDICATIONS ON TRANSFER 1. Pantoprazole 40 mg IV Q12H 2. Octreotide Acetate 50 mcg/hr IV DRIP INFUSION 3. Lactulose 30 ml PO TID 4. Ciprofloxacin HCl 250 mg PO Q24H 5. Risperidone 1 mg PO HS Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 7. Calcium Carbonate 500 mg Tablet Sig: Three (3) Tablet PO once a day. 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for 1 weeks. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Medical Resources Home Health Corp Discharge Diagnosis: primary diagnoses: Hepatitis C cirrhosis upper GI bleed . Secondary diagnoses: Schizophrenia Discharge Condition: stable Discharge Instructions: You were admitted to the hospital because of bleeding from your GI tract. A TIPS (transhepatic intrahepatic porto-systemic shunt placement shunt) was placed; this should help to relieve the pressure that builds up in your abdomen. Hopefully, your ascites will improve. Your lasix and spirinolactone were held because of the bleeding and your low sodium. They were not restarted prior to your discharge. Given your TIPS you may not need as a high a dose of Lasix or spironolactone. Please ask your hepatologist Dr. if you should restart your lasix/spirinolactone when you see her in weeks. if you develop recurrence of your vomitting of blood, abdominal pain, or other worrisome symptoms, you should contact your primary care physician, hepatologist, or the emergency department. Followup Instructions: You have a follow appointment with Dr. on at 10:20AM. (. You should plan to follow up with your local hepatologist Dr. (413)- 5652-4456 within 1-2 weeks. We contact her office and they are aware you are being discharged. They were unable to confirm an appointment time on your day of discharge but they will contact you at home. Please be sure to call them if you don't hear from them in the next 1-2 days. | HE WAS TREATED WITH IV PROTONIX, REGALN AND OCTREOTIDE. A 0.035 glidewire was then advanced through the - set and steered into the main portal vein and finally advanced into the inferior mesenteric vein. am hct 30.9.. repeat pending.. am NA 120.. repeat 124.. 1 L fluid restriction. A 0.035 wire was advanced through the micropuncture sheath up to the levelof the IVC under fluoroscopic guidance. (Over) 2:45 PM LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOPP ABD/PEL Reason: please evaluate for patency of tips. 2:45 PM LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOPP ABD/PEL Reason: please evaluate for patency of tips. Test injection was performed with contrast documenting satisfactory position in the right portal vein. Subsequently, a 0.035 Amplatz guidewire was delivered through the catheter and left in situ as the (Over) 7:53 AM TIPS Clip # Reason: TIPS Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED Contrast: OPTIRAY Amt: 95 FINAL REPORT (Cont) catheter was withdrawn and employed for determination of the transhepatic tract length. The anterior right portal vein demonstrates bidirectional flow, with the main direction being hepatofugal, towards the TIPS shunt. NURSING ADMISSION NOTE -0700(Continued)NK YOU! POSSIBLE EGD TODAY, PT HAS BEEN NPO SINCE MN EXCEPT FOR MEDS. TRANSFERRED TO FOR POSSIBLE TIPS PROCEDURE.ALLERGIES: HALDOL, DOXYCYCLINECODE STATUS: FULL CODEACCESS: #18 PIV IN L HAND, #20 PIV RAC, #20 PIV R HANDNEURO: PT IS ALERT AND ORIENTED X3, CALM AND COOPERATIVE WITH CARE. FLUID RESTRICT ONCE ABLE TO TAKE PO'S HYPONATREMIA. COVERED WITH ALLEVYN DSG. Using the micropuncture system access was gained into the right internal jugular vein under ultrasonographic guidance. The CO2 hepatic venogram demonstrates left hepatic vein, the right and left portal veins, and the main portal vein to be widely patent. A straight multi- side-hole catheter was then delivered over the guidewire position into the main portal vein. MONITOR FOR S/S OF ENCEPHALOPATHY. Direct portal venography was then performed which detected right and left portal veins, main portal vein and mesenteric vein to be widely patent. The micropuncture sheath was exchanged for a 10 French vascular sheath which was connected to a continuous sidearm flush. PER NOTES, THE PT UNDERWENT PARACENTESIS LAST ON AND SUBSEQUENTLY DEVELOPED HYPOTENSION ASSOCIATED WITH WORSENING HYPONATREMIA. Pressure measurements were obtained after the stent deployment in the main portal vein and the hepatic vein and the gradient pressure was recorded as 7 mmHg. NURSING ADMISSION NOTE -0700REPORT RECEIVED, PT ARRIVED TO AT APPROX . There is surrounding ascites and a right lower lobe pleural effusion. Paracenteses of 1500 cc of ascites using ultrasonographic guidance. Using standard sterile technique, the right neck and right abdomen were prepped and draped. BOWEL SOUNDS PRESENT X4, PASSING FLATUS. A TIPS shunt has been placed in the interim between and today's exam. General anesthesia was administered throughout the procedure. Using a C2 Cobra catheter and a 0.035 wire, access was gained into the left hepatic vein and the sheath was advanced with tip within the hepatic vein. Patent high flow velocity TIPS by Doppler analysis. After four passes, the - needle was advanced to the right portal vein. LARGE UMBILICAL HERNIA NOTED. The wire was removed and the patient was transferred to the PACU in good condition. Nursing 7a-7P: please see transfer note for details of admit and latest assessment.. pt tx with 1 bag plts today for plt count 38k.. repeat 50k. Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED FINAL REPORT (Cont) HE WAS TRANSFERRED TO ICU FOR FURTHER EVAL, AND HE UNDERWENT AN UPPER ENDOSCOPY WHICH REVEALED NO ACTIVE SOURCE OF BLEEDING EXCEPT OOZING AT THE GE JUNCTION. PALPABLE RADIAL/DP PULSES BILATERALLY. The C2 catheter was removed and exchanged for a balloon occlusion catheter which was used to perform a CO2 hepatic venogram. The flow in the left portal vein is concerning for possible gradual occlusion, and short term interval follow-up as clinically indicated is recommended. 7:53 AM TIPS Clip # Reason: TIPS Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED Contrast: OPTIRAY Amt: 95 ********************************* CPT Codes ******************************** * INSERT HEPATIC HUNT TIPS PARACENTESIS INITAL PROC * * -51 MULTI-PROCEDURE SAME DAY UD GUID FOR NEEDLE PLACMENT * * -59 DISTINCT PROCEDURAL SERVICE * **************************************************************************** MEDICAL CONDITION: 57 year old man with hep c cirrhosis for TIPS REASON FOR THIS EXAMINATION: TIPS FINAL REPORT INDICATION FOR EXAM: This is a 57-year-old man with hep C cirrhosis with refractory ascites. | 5 | [
{
"category": "Radiology",
"chartdate": "2118-05-04 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 961373,
"text": " 2:45 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: please evaluate for patency of tips.\n Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hepC cirhosis, now s/p TIPS.\n REASON FOR THIS EXAMINATION:\n please evaluate for patency of tips.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old man with hep C cirrhosis, now status post TIPS,\n evaluate.\n\n TECHNIQUE: Dedicated son imaging of the patient's TIPS was performed.\n Findings are compared with patient's prior examination dated , prior to\n TIPS placement.\n\n FINDINGS: The liver demonstrates increased echogenicity, with a small nodular\n and shrunken morphology. There is surrounding ascites and a right lower lobe\n pleural effusion. No focal hepatic masses are appreciated on this limited\n son evaluation of the liver parenchyma.\n\n A TIPS shunt has been placed in the interim between and today's exam.\n There is patent wall- to- wall flow within the TIPS, which is slightly limited\n in evaluation due to artifact within the TIPS wall. Doppler of the liver\n demonstrates flow in the hepatic veins, main portal vein, and inferior vena\n cava. The main portal vein demonstrates a velocity of 78.3 cm per second in\n its proximal aspect. Angle-corrected velocity in the proximal TIPS is 136 cm\n per second in the proximal tips. In the mid TIPS it is 201.5 cm second, and\n in the distal TIPS it is 167 cm per second.\n\n The anterior right portal vein demonstrates bidirectional flow, with the main\n direction being hepatofugal, towards the TIPS shunt. The left portal vein\n similarly demonstrates bidirectional flow, without dominant direction. The\n flow in the left portal vein is concerning for possible gradual occlusion, and\n short term interval follow-up as clinically indicated is recommended. The\n spleen measures 16.1 cm in size. No varices are seen.\n\n IMPRESSION:\n 1. Patent high flow velocity TIPS by Doppler analysis.\n 2. Bidirectional low flow within the left portal vein is concerning for\n possible eventual thrombosis, and short term interval follow up in 3 months as\n clinically indicated is recommended to reasssess.\n\n\n\n\n\n\n\n (Over)\n\n 2:45 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: please evaluate for patency of tips.\n Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-02 00:00:00.000",
"description": "MULTI-PROCEDURE SAME DAY",
"row_id": 960957,
"text": " 7:53 AM\n TIPS Clip # \n Reason: TIPS\n Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 95\n ********************************* CPT Codes ********************************\n * INSERT HEPATIC HUNT TIPS PARACENTESIS INITAL PROC *\n * -51 MULTI-PROCEDURE SAME DAY UD GUID FOR NEEDLE PLACMENT *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hep c cirrhosis for TIPS\n REASON FOR THIS EXAMINATION:\n TIPS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: This is a 57-year-old man with hep C cirrhosis with\n refractory ascites.\n\n RADIOLOGISTS: The procedure was performed by Drs. and , the\n attending radiologist who was present and supervising throughout the\n procedure.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the risks and benefits of the procedure, the patient was placed\n supine on angiography table. General anesthesia was administered throughout\n the procedure. Using standard sterile technique, the right neck and right\n abdomen were prepped and draped. Paracentesis was performed with drainage of\n 1500 cc of ascites before the procedure was initiated. Using the\n micropuncture system access was gained into the right internal jugular vein\n under ultrasonographic guidance. A 0.035 wire was advanced through the\n micropuncture sheath up to the levelof the IVC under fluoroscopic guidance.\n The micropuncture sheath was exchanged for a 10 French vascular sheath which\n was connected to a continuous sidearm flush. Using a C2 Cobra catheter and a\n 0.035 wire, access was gained into the left hepatic vein and the sheath\n was advanced with tip within the hepatic vein. The C2 catheter was removed\n and exchanged for a balloon occlusion catheter which was used to perform a CO2\n hepatic venogram. The CO2 hepatic venogram demonstrates left hepatic vein,\n the right and left portal veins, and the main portal vein to be widely patent.\n The CO2 venogram was also performed on the lateral projection and was employed\n to plan the trajectory of the - access set employed. After four\n passes, the - needle was advanced to the right portal vein. Test\n injection was performed with contrast documenting satisfactory position in the\n right portal vein. A 0.035 glidewire was then advanced through the -\n set and steered into the main portal vein and finally advanced into the\n inferior mesenteric vein. A straight multi- side-hole catheter was then\n delivered over the guidewire position into the main portal vein. Direct\n pressure measurements were obtained at the main portal vein and at the hepatic\n vein levels and the gradient was recorded as 15 mmHg. Direct portal\n venography was then performed which detected right and left portal veins, main\n portal vein and mesenteric vein to be widely patent. Subsequently, a 0.035\n Amplatz guidewire was delivered through the catheter and left in situ as the\n (Over)\n\n 7:53 AM\n TIPS Clip # \n Reason: TIPS\n Admitting Diagnosis: LIVER FAILURE;GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 95\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n catheter was withdrawn and employed for determination of the transhepatic\n tract length. Then, a 10 mm Wallstent was advanced over the wire up to the\n level of the intraparenchymal tract and was deployed followed by post-dilation\n with a 10-mm balloon. Pressure measurements were obtained after the stent\n deployment in the main portal vein and the hepatic vein and the gradient\n pressure was recorded as 7 mmHg. The wire was removed and the patient was\n transferred to the PACU in good condition. The vascular sheath was removed\n and manual compression was held for 10 minutes until hemostasis was achieved\n in the neck.\n\n IMPRESSION:\n 1. Successful TIPS placement.\n 2. Initial gradient pressure of 15 mmHg and final gradient pressure of 7\n mmHg.\n 3. Paracenteses of 1500 cc of ascites using ultrasonographic guidance.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-04-29 00:00:00.000",
"description": "Report",
"row_id": 1412975,
"text": "NURSING ADMISSION NOTE -0700\nREPORT RECEIVED, PT ARRIVED TO AT APPROX . TRANSFERRED FROM STRETCHER TO BED WITHOUT INCIDENT. PT IS A 57 Y.O MALE WITH A PMH SIGNIFICANT FOR CIRRHOSIS AND ESOPHAGEAL VARICIES CHRONIC VIRAL HEPATITIS C - HAS REFRACTORY ASCITES, GI BLEED, CRI AND SCHIZOPHRENIA. APPARENTLY, THE PT UNDERGOES LARGE VOLUME ABDOMINAL PARACENTESIS ON A FREQUENT BASIS WITH REMOVAL OF UP TO 9L OF FLUID. PER NOTES, THE PT UNDERWENT PARACENTESIS LAST ON AND SUBSEQUENTLY DEVELOPED HYPOTENSION ASSOCIATED WITH WORSENING HYPONATREMIA. HE WAS ADMITTED TO . WHILE ON THE MEDICAL FLOOR AT OSH, THE PT A LARGE AMOUNT OF BLOOD X1. HE WAS TRANSFERRED TO ICU FOR FURTHER EVAL, AND HE UNDERWENT AN UPPER ENDOSCOPY WHICH REVEALED NO ACTIVE SOURCE OF BLEEDING EXCEPT OOZING AT THE GE JUNCTION. HE WAS TREATED WITH IV PROTONIX, REGALN AND OCTREOTIDE. HE ALSO RECEIVED SUPPORTIVE TREATMENT WITH PRBC'S AND FFP PRODUCTS. TRANSFERRED TO FOR POSSIBLE TIPS PROCEDURE.\n\nALLERGIES: HALDOL, DOXYCYCLINE\n\nCODE STATUS: FULL CODE\n\nACCESS: #18 PIV IN L HAND, #20 PIV RAC, #20 PIV R HAND\n\nNEURO: PT IS ALERT AND ORIENTED X3, CALM AND COOPERATIVE WITH CARE. PERRL 2MM/BRISK BILATERALLY. MAEX4 WITH FULL STRENGTH AND FOLLOWS COMMANDS CONSISTENTLY. DENIES ANY DISCOMFORT. AFEBRILE. NO SEIZURE ACTIVITY NOTED.\n\nCV: S1 S2 AS PER AUSCULTATION, HR 70'S-80'S NSR WITHOUT ECTOPY NOTED. SBP 90'S-140'S. PT WAS NOTED TO HAVE BRIEF DROP IN SBP TO 88 AT APPROX 0445 WHILE SLEEPING, HOWEVER QUICKLY INCREASED TO >90 WITHOUT INTERVENTION. DENIES CP. PALPABLE RADIAL/DP PULSES BILATERALLY. NO SIGNS OF ACTIVE BLEEDING, HCT STABLE AT 30.9.\n\nRESP: LUNGS ESSENTIALLY CLEAR THROUGHOUT ALL FIELDS, SPO2 > OR = 95% ON ROOM AIR. DENIES DIFFICULTY BREATHING OR SOB. NO INCREASED WOB NOTED. RR 20'S WITH REGULAR PATTERN.\n\nGI/GU: ABDOMEN FIRM, DISTENDED AND NONTENDER - DENIES DISCOMFORT. LARGE UMBILICAL HERNIA NOTED. BOWEL SOUNDS PRESENT X4, PASSING FLATUS. PT HAS BEEN NPO SINCE MIDNIGHT EXCEPT FOR MEDS FOR POSSIBLE EGD . NO STOOL THIS SHIFT. INDWELLING FOLEY CATHETER SECURE AND PATENT WITH APPROX 40-150ML/HOUR CLEAR AMBER URINE.\n\nINTEG: SKIN WARM AND DRY, COLOR NORMAL FOR RACE. NO SIGNS OF BREAKDOWN TO BACK. PT IS NOTED TO HAVE A PINK AREA ON INNER LEFT BUTTOCK WHICH APPEARS TO BE A BOIL OR CALLOUS THAT HAS POPPED. PINK AREA IS APPROX THE SIZE OF A NICKEL WITH SMALL AMT OF SANGUINOUS DRAINAGE FROM AN OPENING IN THE CENTER THAT IS ABOUT HALF THE SIZE OF AN ERASER HEAD. COVERED WITH ALLEVYN DSG. THE PT STATES HE DEVELOPED THIS FROM SITTING WHILE AT HOME.\n\nSOCIAL: PT LIVES ALONE. HE STATES THAT HE HAS 2 SISTERS, ONE OF WHICH IS ACTIVE IN HIS MEDICAL CARE. NO CONTACT FROM FAMILY THIS SHIFT.\n\nPLAN: CONTINUE ICU SUPPORTIVE CARE. MONITOR HCT EVERY 6 HOURS, NEXT DUE AT 1000. MONITOR FOR S/S OF ENCEPHALOPATHY. POSSIBLE EGD TODAY, PT HAS BEEN NPO SINCE MN EXCEPT FOR MEDS. FLUID RESTRICT ONCE ABLE TO TAKE PO'S HYPONATREMIA. ? TIPS PROCEDURE. PLEASE SEE CAREVUE FOR OBJECTIVE DATA, THA\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-04-29 00:00:00.000",
"description": "Report",
"row_id": 1412976,
"text": "NURSING ADMISSION NOTE -0700\n(Continued)\nNK YOU!\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-04-29 00:00:00.000",
"description": "Report",
"row_id": 1412977,
"text": "Nursing 7a-7P:\n please see transfer note for details of admit and latest assessment.. pt tx with 1 bag plts today for plt count 38k.. repeat 50k. am hct 30.9.. repeat pending.. am NA 120.. repeat 124.. 1 L fluid restriction. per IV team ok for pt have 20g iv's for access.. team aware. no further orders at this time.\n"
}
] |
53,804 | 168,109 | He was admitted to the Acute Care Surgery team with a right temporal lobe intraparenchymal hemorrhage, left distal clavicle fracture, left rib fractures , moderate left pneumothorax and spinous process fractures T3,4. he was transferred to the Trauma ICU for close monitoring and hourly neuro checks. Orthopedic and Neurosurgery were consulted and non-operative managements were recommended. He was placed in a sling for the clavicle fracture and is non weight bearing but may actively and passively have range of motion exercises. He was started on Keppra for seizure prophylaxis for a total of 7 days and will follow up in 1 month in clinic for repeat head CT. He is neurologically intact- awake, alert and oriented x3 without any observed or reported seizure activity. He was doing well on hospital day #2 and transferred to regular floor. Once transferred out of the ICU he progressed slowly primarily limited by pain and deconditioned status from being in the ICU. His pain medications were adjusted and an adequate oral pain regimen was eventually in place. He was also treated for a urinary tract infection with Cipro for 5 day course. Sensitivites were pending at time of discharge. Will plan to contact rehab facility once this data is available in the event that therapy needs to be changed. He was evaluated by Physical and Occupational therapy and is being recommended for discharge to rehab after his acute hospital stay. | Moderate left parietal subgaleal hematoma. Moderate left parietal subgaleal hematoma. Moderate left parietal and occipital subgaleal hematoma. Moderate left parietal and occipital subgaleal hematoma. Moderate left pneumothorax. IMPRESSION: Non-displaced left clavicle fracture, probably with some comminution. Left distal clavicle fracture, only slightly displaced. Moderate interval decrease in the left parieto-occipital subgaleal hematoma with surgical staples in place. There is a moderate left parietal (series 2, image 54)and occipital subgaleal hematoma (series 2, image 14). 2.Progression of mild pleural effusion. Progression of bilateral mild pleural effusion. There is moderate left parieto-occipital subgaleal hematoma with surgical staples in place. Left anterior fascicular block.Non-specific lateral ST-T wave abnormalities. The glenohumeral and acromioclavicular joints appear preserved. FINDINGS: The cardiac, mediastinal and hilar contours appear unchanged. There is mild atherosclerotic calcification of the aortic arch. FINDINGS: The previously described right temporal hemorrhagic contusion, appears slightly smaller in the current examination, also there has been interval decrease in the pattern of vasogenic edema in this region. FINDINGS: CT OF THE HEAD: There is acute right temporal lobe intraparenchymal hemorrhage (series 2, image 22) without significant mass effect or midline shift. Grossly unchanged fracture throughout the squamous portion of the left temporal bone, the possible small subdural hematoma in this region is not clearly identified. There is a fracture through the squamous portion of the left temporal bone with a possible tiny subdural hematoma (se 3, img 72). Fracture through the squamous portion of the left temporal bone with a possible tiny subdural hematoma (se 3, img 72). Slight lucency in the left costophrenic angle may reflect a pneumothorax. Fracture of the left distal clavicle 2. Acute right temporal lobe intraparenchymal hemorrhage. Acute right temporal lobe intraparenchymal hemorrhage. Acute right temporal lobe intraparenchymal hemorrhage. COMPARISON: Chest radiograph dated . Left subcutaneous air. Fracture through the squamous portion of the left temporal bone with a possible tiny subdural hematoma. TECHNIQUE: PA and lateral chest radiographs. The right temporal lobe intraparenchymal hemorrhage has been decreased in size, with mild decrease in the pattern of vasogenic edema. Nondisplaced spinous process fractures at T3 and T4. There is an old sternal fracture. Left ribs fractures. Subcutaneous air is noted along the left lateral chest wall. Old sternal fracture. FINDINGS: Heart appears mildly enlarged. Traumatic findings in the chest better delineated on CT. 2. There is no pericardial and only small bilateral pleural effusions are demonstrated. COMPARISON: Prior head CT dated and prior head CT dated , . The fracture of the squamous portion of the left temporal bone remains unchanged, and the possible small subdural hematoma in the region is not visible on the current examination. Non-displaced fractures of the left anterolateral #3 through 8 ribs. Axial, coronal, and sagittal reformats were acquired. Lingular lung contusions. FINDINGS: As depicted on a CT from the same day, there is a left-sided pneumothorax with subcutaneous emphysema. TECHNIQUE: Chest, AP portable supine, and pelvis AP view. Left axis deviation. Sinus rhythm. (Over) 3:58 PM CT CHEST W/CONTRAST Clip # Reason: trauma Contrast: OMNIPAQUE Amt: 75 FINAL REPORT (Cont) BONES: Left comminuted distal clavicle fracture. COMPARISON: Chest radiograph . Coronal and sagittal reformats were acquired. The airways are patent to the subsegmental level. CLINICAL INDICATION: Status post trauma, history of right temporal lobe intraparenchymal hemorrhage and small left subdural hematoma, evaluate for interval change. There are opacities in the lingula, representing contusions. Secretions are seen in the proximal right main stem bronchus (series 2, image 22). Displaced fractures of the left third through eighth ribs with moderate chest wall emphysema and a small-to-moderate pneumothorax. FINDINGS: CT OF THE CHEST: There is a small 11 x 12 mm right lower pole thyroid nodule. Spinous process fracture of #3 and 4. Cardiomediastinal contours are unremarkable. The fracture extends in the greater of the left sphenoid bone with hemorrhage in the sphenoid sinus. The fracture extends in the greater of the left sphenoid bone with hemorrhage in the sphenoid sinus. Several left-sided rib fractures are better delineated on dedicated CT of the same day. There is also subcutaneous emphysema and a non-displaced fracture involving the left mid clavicular shaft. FINDINGS: Amelioration of the bibasal opacities with residual plate-like atelectasis. There are displaced rib fractures of the left third through eighth ribs with moderate soft tissue emphysema at the left chest wall and a small-to-moderate left pneumothorax. There are bibasilar opacities, mainly within the costophrenic angles, most likely representing atelectasis. COMPARISON: Exam compared to a chest CT of . Left-sided pneumothorax with subcutaneous emphysema, associated with left-sided rib fractures, better described on earlier CT of the same day. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. There are spinous process fracture of T3 and T4. No major change from theprevious tracing. Bibasilar opacities likely representing atelectasis. The partially visualized upper abdomen demonstrates gallstones, but no evidence of acute cholecystitis. Bibasilar opacities likely represent sequela of atelectasis. No pneumothorax is appreciated. There is also patchy opacification in the right lung which may be associated with a contusion or atelectasis or both. Borderline widening at the pubic symphysis, of uncertain significance, particularly noting no evidence for fracture or sacroiliac widening. There is a slightly prominent widening at the pubic symphysis, at the upper limits of normal range, but borderline, up to 9 mm. OPINION: 1.Improvement of the bibasal opacities with residual plate-like atelectasis. | 8 | [
{
"category": "Radiology",
"chartdate": "2125-08-05 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1246421,
"text": " 3:58 PM\n CT CHEST W/CONTRAST Clip # \n Reason: trauma\n Contrast: OMNIPAQUE Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man trauma pt\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SUN 4:24 PM\n 1. Fracture of the left distal clavicle\n 2. Non-displaced fractures of the left anterolateral #3 through 8 ribs.\n 3. Moderate left pneumothorax.\n 4. Spinous process fracture of #3 and 4.\n 5. Old sternal fracture.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with status post trauma.\n\n TECHNIQUE: Contiguous MDCT images through the chest were obtained after\n administration of intravenous contrast. Axial, coronal, and sagittal\n reformats were acquired.\n\n COMPARISON: Chest radiograph .\n\n FINDINGS:\n\n CT OF THE CHEST: There is a small 11 x 12 mm right lower pole thyroid nodule.\n There is no axillary, hilar, or mediastinal lymphadenopathy. There is no\n pneumomediastinum, no acute aortic syndrome including no aortic dissection, or\n aortic aneurysm. There is mild atherosclerotic calcification of the aortic\n arch. A stent is seen in the LAD.\n\n There is no pericardial and only small bilateral pleural effusions are\n demonstrated.\n\n There are displaced rib fractures of the left third through eighth ribs with\n moderate soft tissue emphysema at the left chest wall and a small-to-moderate\n left pneumothorax. No mediastinal shift. There are opacities in the lingula,\n representing contusions. Bibasilar opacities likely represent sequela of\n atelectasis.\n\n The airways are patent to the subsegmental level. Secretions are seen in the\n proximal right main stem bronchus (series 2, image 22).\n\n The partially visualized upper abdomen demonstrates gallstones, but no\n evidence of acute cholecystitis. The partially visualized liver, spleen,\n pancreas, adrenal glands, and kidneys are normal.\n\n (Over)\n\n 3:58 PM\n CT CHEST W/CONTRAST Clip # \n Reason: trauma\n Contrast: OMNIPAQUE Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONES: Left comminuted distal clavicle fracture. There are spinous process\n fracture of T3 and T4. There is an old sternal fracture. No evidence of\n thoracic vertebral body fractures.\n\n IMPRESSION:\n 1. Displaced fractures of the left third through eighth ribs with moderate\n chest wall emphysema and a small-to-moderate pneumothorax.\n 2. Lingular lung contusions.\n 3. Nondisplaced spinous process fractures at T3 and T4.\n 4. Left distal clavicle fracture, only slightly displaced.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1246626,
"text": " 10:33 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change in subdural hematoma and right temp\n Admitting Diagnosis: RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p trauma with h/o right temporal lobe intraparenchymal\n hemorrhage and small left subdural hematoma\n REASON FOR THIS EXAMINATION:\n eval for interval change in subdural hematoma and right temporal lobe IPH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Head CT without contrast.\n\n CLINICAL INDICATION: Status post trauma, history of right temporal lobe\n intraparenchymal hemorrhage and small left subdural hematoma, evaluate for\n interval change.\n\n COMPARISON: Prior head CT dated and prior head CT dated , .\n\n TECHNIQUE: Axial MDCT images were obtained through the head, no contrast was\n administered, the images were reviewed using soft tissue and bone window\n algorithms.\n\n FINDINGS: The previously described right temporal hemorrhagic contusion,\n appears slightly smaller in the current examination, also there has been\n interval decrease in the pattern of vasogenic edema in this region. There is\n no evidence of shifting of the normally midline structures or new areas with\n hemorrhage. Grossly unchanged fracture throughout the squamous portion of the\n left temporal bone, the possible small subdural hematoma in this region is not\n clearly identified. There is moderate left parieto-occipital subgaleal\n hematoma with surgical staples in place. The ventricles are normal in size\n and configuration for the patient's age with new areas of hemorrhage.\n Persistent mucosal thickening identified at the sphenoid sinus.\n\n IMPRESSION:\n 1. The right temporal lobe intraparenchymal hemorrhage has been decreased in\n size, with mild decrease in the pattern of vasogenic edema. There is no\n evidence of shifting of the normally midline structures.\n 2. No new areas of intracranial hemorrhage are identified. The fracture of\n the squamous portion of the left temporal bone remains unchanged, and the\n possible small subdural hematoma in the region is not visible on the current\n examination.\n 3. Moderate interval decrease in the left parieto-occipital subgaleal\n hematoma with surgical staples in place.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1246417,
"text": " 3:45 PM\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: please reread head CT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man trauma pt\n REASON FOR THIS EXAMINATION:\n please reread head CT\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SUN 6:05 PM\n 1. Acute right temporal lobe intraparenchymal hemorrhage.\n 2. Fracture through the squamous portion of the left temporal bone with a\n possible tiny subdural hematoma (se 3, img 72). The fracture extends in the\n greater of the left sphenoid bone with hemorrhage in the sphenoid sinus.\n 3. Moderate left parietal and occipital subgaleal hematoma.\n WET READ VERSION #1\n WET READ VERSION #2 JBRe SUN 4:30 PM\n 1. No acute intracranial process.\n 2. Moderate left parietal subgaleal hematoma.\n WET READ VERSION #3 JBRe SUN 5:10 PM\n 1. Acute right temporal lobe intraparenchymal hemorrhage.\n 2. Moderate left parietal subgaleal hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old with trauma.\n\n TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal\n reformats were acquired. The study was performed at an outside hospital. The\n emergency room staff requested a official second read by radiology.\n\n COMPARISON: There are no prior studies for comparison available.\n\n FINDINGS:\n\n CT OF THE HEAD: There is acute right temporal lobe intraparenchymal hemorrhage\n (series 2, image 22) without significant mass effect or midline shift.\n\n There is a fracture through the squamous portion of the left temporal bone\n with a possible tiny subdural hematoma (se 3, img 72). The fracture extends in\n the greater of the left sphenoid bone with hemorrhage in the sphenoid\n sinus. There is a moderate left parietal (series 2, image 54)and occipital\n subgaleal hematoma (series 2, image 14).\n\n The ventricles and sulci are normal in size and configuration. There is no\n hydrocephalus. The basal cisterns are patent.\n\n The maxillary sinuses, frontal sinuses, and mastoid air cells are clear.\n\n IMPRESSION:\n 1. Acute right temporal lobe intraparenchymal hemorrhage.\n 2. Fracture through the squamous portion of the left temporal bone with a\n possible tiny subdural hematoma. The fracture extends in the greater of\n (Over)\n\n 3:45 PM\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: please reread head CT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the left sphenoid bone with hemorrhage in the sphenoid sinus.\n 3. Moderate left parietal and occipital subgaleal hematoma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-07 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1246609,
"text": " 8:51 AM\n CHEST (PA & LAT) Clip # \n Reason: L PTX\n Admitting Diagnosis: RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p bicycle accident\n REASON FOR THIS EXAMINATION:\n L PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old gentleman status post bicycle accident and left\n pneumothorax.\n\n COMPARISON: Chest radiograph dated .\n\n TECHNIQUE: PA and lateral chest radiographs.\n\n FINDINGS: Heart appears mildly enlarged. Cardiomediastinal contours are\n unremarkable. There are bibasilar opacities, mainly within the costophrenic\n angles, most likely representing atelectasis. No pneumothorax is appreciated.\n Subcutaneous air is noted along the left lateral chest wall. There are also\n multiple rib fractures on the left as previously seen.\n\n IMPRESSION:\n 1. Left-sided rib fractures with no radiographic evidence of pneumothorax.\n 2. Bibasilar opacities likely representing atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-05 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 1246409,
"text": " 3:25 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n RADIOGRAPHS OF THE CHEST AND PELVIS\n\n HISTORY: Trauma.\n\n COMPARISONS: The chest can be compared to .\n\n TECHNIQUE: Chest, AP portable supine, and pelvis AP view.\n\n FINDINGS: The cardiac, mediastinal and hilar contours appear unchanged.\n Several left-sided rib fractures are better delineated on dedicated CT of the\n same day. There is also subcutaneous emphysema and a non-displaced fracture\n involving the left mid clavicular shaft. Slight lucency in the left\n costophrenic angle may reflect a pneumothorax. There is no shift of\n mediastinal structures.\n\n Regarding the pelvis, there is no evidence for fracture, dislocation or bone\n destruction. There is a slightly prominent widening at the pubic symphysis,\n at the upper limits of normal range, but borderline, up to 9 mm.\n\n IMPRESSION:\n\n 1. Traumatic findings in the chest better delineated on CT.\n\n 2. Borderline widening at the pubic symphysis, of uncertain significance,\n particularly noting no evidence for fracture or sacroiliac widening. However,\n correlation with clinical presentation and physical findings along the pelvis\n are recommended. Finding discussed with Dr. by telephone at 11:50\n pm by telephone.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1246451,
"text": " 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval chqange\n Admitting Diagnosis: RIB FRACTURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with polytrauma, TBI, ptx\n REASON FOR THIS EXAMINATION:\n interval chqange\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST X-RAY\n\n INDICATION: Polytrauma, traumatic brain injury.\n\n COMPARISON: Exam compared to a chest CT of .\n\n FINDINGS: Amelioration of the bibasal opacities with residual plate-like\n atelectasis. Progression of bilateral mild pleural effusion. No\n pneumothorax. Left subcutaneous air. Left ribs fractures. The heart contour\n seems a slightly enlarged since yesterday, probably secondary to the\n technique. Mediastinal contour is normal.\n\n OPINION:\n\n 1.Improvement of the bibasal opacities with residual plate-like atelectasis.\n 2.Progression of mild pleural effusion. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-05 00:00:00.000",
"description": "L SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT",
"row_id": 1246415,
"text": " 4:36 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p trauma\n REASON FOR THIS EXAMINATION:\n trauma\n ______________________________________________________________________________\n FINAL REPORT\n RADIOGRAPHS OF THE LEFT SHOULDER\n\n HISTORY: Trauma.\n\n COMPARISONS: None.\n\n TECHNIQUE: Left shoulder, four views.\n\n FINDINGS: As depicted on a CT from the same day, there is a left-sided\n pneumothorax with subcutaneous emphysema. There is also patchy opacification\n in the right lung which may be associated with a contusion or atelectasis or\n both. Left-sided rib fractures are also better depicted on the CT. Starting\n the left shoulder, there is a fracture of the distal clavicle, but there is no\n evidence for fracture or dislocation involving the scapula or humerus. The\n glenohumeral and acromioclavicular joints appear preserved.\n\n IMPRESSION: Non-displaced left clavicle fracture, probably with some\n comminution. Left-sided pneumothorax with subcutaneous emphysema, associated\n with left-sided rib fractures, better described on earlier CT of the same day.\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-05 00:00:00.000",
"description": "Report",
"row_id": 228947,
"text": "Sinus rhythm. Left axis deviation. Left anterior fascicular block.\nNon-specific lateral ST-T wave abnormalities. No major change from the\nprevious tracing.\n\n\n"
}
] |
52,978 | 129,936 | 63M with systolic and diastolic CHF with dilated CMP and recent RHC consistent with cardiogenic shock who presents from home for inotrope initiation and diuresis. # Acute on chronic systolic and diastolic CHF with dilated CMP (EF <20%)/PUMP: No clear precipitant for his worsening heart failure, he did not report symptoms of ischemia, infection and denies dietary indiscretion or medication non-compliance. Appeared volume overloaded on exam with crackles and ascites. CI was 1.3 on recent RHC with mean PCWP of 25. The patient was started on a lasix drip and milrinone infusion for inotropic support. Pt's BP tolerated milrinone well with SBPs in 90s-100s. On , pt underwent right heart catheterization with PA cath placement which showed initial numbers: CI 2.92, demonstarting improved hemodynamics on milrinone. The patient spiked a temp to 101 on and therefore the PA catheter was pulled and cultures sent (see below). On lasix gtt was stopped and patient transitioned to PO torsemide. Initially given 60mg torsemide. Patient weaned from milrinone on and isordil and hydralazine were started for afterload reduction. Torsemide increased to 80 mg on . Once patient appeared euvolemic torsemide was decreased to daily and dose titrated to maintain euvolemia. On metoprolol was restarted. Physical therapy evaluated patient and determined ok to return home with walker. He was discharged with a dry weight of 161.5 lbs and on the following diuretic regimen: torsemide 60 mg daily. | Atrial tachycardia and biventricular pacing, similar to that recordedon , without diagnostic interim change.TRACING #2 Atrial tachycardia and biventricular pacing similar to that recordedon .TRACING #1 Compared to the previous tracingof pseudofusion beats are not seen on the current tracing. Unchanged evidence of mild pulmonary edema. Unchanged size of the cardiac silhouette. Cardiomegaly is severe, unchanged. Left pectoral pacemaker, no pleural effusions. There is unchanged appearance of the pacemaker leads. There is interval development of interstitial pulmonary edema. FINDINGS: As compared to the previous radiograph, the patient has received a new Swan-Ganz catheter via a right internal jugular vein approach. Portable AP radiograph of the chest was reviewed in comparison to . Sinus rhythm with biventricular pacing. Atrialtachycardia is not clearly seen on the current tracing, although there is somebaseline artifact which makes interpretation difficult. No pneumothorax. There is improved ventilation of the lung parenchyma in both the retrocardiac lung areas and the right lung bases. More pronounced bibasal opacities might be concerning for interval development of infectious process. 10:56 AM CHEST (PORTABLE AP) Clip # Reason: PTX, new consolidation, edema Admitting Diagnosis: HEART FAILURE MEDICAL CONDITION: 63 year old man with CHF, swan, increasing catheter REASON FOR THIS EXAMINATION: PTX, new consolidation, edema FINAL REPORT CHEST RADIOGRAPH INDICATION: Chronic heart failure, Swan-Ganz catheter, evaluation. 10:02 PM CHEST (PORTABLE AP) Clip # Reason: Evaluate for edema or effusions Admitting Diagnosis: HEART FAILURE MEDICAL CONDITION: 63 year old man with systolic and diastolic heart failure, presenting with fatigue and lethargy REASON FOR THIS EXAMINATION: Evaluate for edema or effusions FINAL REPORT REASON FOR EXAMINATION: Systolic and diastolic heart failure presenting with fatigue and lethargy. | 5 | [
{
"category": "Radiology",
"chartdate": "2196-09-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1256240,
"text": " 10:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for edema or effusions\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with systolic and diastolic heart failure, presenting with\n fatigue and lethargy\n REASON FOR THIS EXAMINATION:\n Evaluate for edema or effusions\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Systolic and diastolic heart failure presenting with\n fatigue and lethargy.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n Cardiomegaly is severe, unchanged. There is unchanged appearance of the\n pacemaker leads. There is interval development of interstitial pulmonary\n edema. More pronounced bibasal opacities might be concerning for interval\n development of infectious process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-09-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1256390,
"text": " 10:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX, new consolidation, edema\n Admitting Diagnosis: HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with CHF, swan, increasing catheter\n REASON FOR THIS EXAMINATION:\n PTX, new consolidation, edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Chronic heart failure, Swan-Ganz catheter, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n new Swan-Ganz catheter via a right internal jugular vein approach. There is\n improved ventilation of the lung parenchyma in both the retrocardiac lung\n areas and the right lung bases. Unchanged size of the cardiac silhouette.\n Unchanged evidence of mild pulmonary edema. Left pectoral pacemaker, no\n pleural effusions. No pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2196-09-25 00:00:00.000",
"description": "Report",
"row_id": 297220,
"text": "Atrial tachycardia and biventricular pacing, similar to that recorded\non , without diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2196-09-24 00:00:00.000",
"description": "Report",
"row_id": 297221,
"text": "Atrial tachycardia and biventricular pacing similar to that recorded\non .\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2196-09-21 00:00:00.000",
"description": "Report",
"row_id": 297222,
"text": "Sinus rhythm with biventricular pacing. Compared to the previous tracing\nof pseudofusion beats are not seen on the current tracing. Atrial\ntachycardia is not clearly seen on the current tracing, although there is some\nbaseline artifact which makes interpretation difficult.\n\n"
}
] |
97,181 | 147,084 | 72 yo female with a PMH significant for ESRD on HD, CAD, CHF with EF 20%, and DM type II admitted with fever, MS change, hypoxia, and AVF failure. . 1) Fever: Had temperature upon arrival to , which resolved within 24 hours. Placed on vancomycin, zosyn for coverage for hospital acquired PNA and left basilar opacity was seen on CXR, althought it was unclear if this was truly a new opacity vs. secondary to pulmonary edema. Bld cxs with no growth. Initial urine cx with 1000 GPC but then subsequent urine cx no growth. Urinary legionella antigen negative. Unable to obtain sputum cultures. There was also initial concern for meningitis; however, the family declined a LP and the pt's mental status did improve off of meningtic doses of abxs. She was then transferred to the medical floor where she remained afebrile. . 2) AMS: MS change improved within 24 hrs of admission and AAO X 2 upon transfer to floor. Initial w/u with NCHCT negative, less likely meningitis/encephalitis given MS improvement on non-meningtis abx coverage as above. However, within 2 hrs of initial medical floor evaluation, pt became obtunded to sternal rub. FS 180s, EKG without ischemic changes, attempted ABG X 3 without success in L wrist. VSS, AF throughout. Stat NCHCT without acute change. Did notice new neck stiffness on exam, and t here was a question of encephalitis/meningitis but it was felt to be unusual to develop meningitis in hospital. Pt's MS eventually improved within 4 hours. Neurology was consulted for question of non-convulsive status epilepticus and EEG obtained that showed no epileptiform waveforms but did reveal diffuse slowing suggestive of encephalopathy from metabolic causes. Another LP was offered to the family, who again declined. Pt was started on ceftriaxone and acylovir in addition to pre-existing vancomycin for meningitic/HSV encephalitis coverage. A MRI head revealed irregularity of the MCA branch vessels that can be suggestive of small vessel disease, meningitis, or vasculitis. The pt's mental status continued to remain poor, and after d/w the pt's PCP, confirmed that pt has had prior dx of Alzheimer's, and the family, it was decided to make the pt comfort measures. Abxs were discontinued, procedures should be avoided with the exception of hemodialysis. . 3) ESRD/clotted AVF: Underwent placement of R temporary femoral HD line for HD access in setting of clotted R AVF upon admission. The patient underwent AVF thrombectomy by transplant surgery on ; however, revision failed and the pt required placement of a tunneled L IJ HD catheter by IR on . The family is in agreement to continue HD for now in spite of being comfort measures; however, did agree to not place any further lines for HD access should her LIJ tunneled catheter fail. The family was made aware of the risks of infection with a tunneled catheter. . 4) CAD: Continued digoxin, ASA, plavix. . 5) Systolic CHF: Chronic. Does have pulm edema on CXR, likely underduiresis as pt unable to be dialyzed upon presentation. O2 sats now improved after HD. Pt was restarted on beta-blocker and ACEI upon transfer out of the ICU. . 6) DM type II: Continued ISS, FS qid. . 7) Transaminitis: Patient with elevated AST of unknown etiology. Appears as if patient has had elevated transaminases since 3/. Possibly med effect (i.e statin) but degree of transaminitis not high enough to hold statin in pt with known DM II and CAD. . 8) Gout: Continued allopurinol. . 9) Psych: Continued wellbutrin and prozac. . 10) FEN: Underwent S&S eval who cleared pt for ground solids, nectar thickened liquids with 1:1 supervision with meals. Pt has poor po intake, will need to encourage po intake. Given comfort measures, would be ok to offer pt thin liquids and solid foods. . 11) Code: DNR/DNI, comfort measures. The patient was at hemodialysis on the final hospital day prior to going back to NH with hospice care when she was noted to be hypotensive in the 80-90s after have 2.5 L UF taken off. Given 1 L IVF bolus which then was followed by report of respiratory distress from HD unit. Report of pt then becoming increasing obtunded, and then expired. Family and PCP notified, family declined autopsy. | # PPx: Heparin sq, famotidine . # PPx: Heparin sq, famotidine . # PPx: Heparin sq, famotidine . # PPx: Heparin sq, famotidine . # PPx: Heparin sq, famotidine . Temporary R femoral HD line placed. # Psych: Continue wellbutrin and prozac. # Psych: Continue wellbutrin and prozac. # Psych: Continue wellbutrin and prozac. # Dispo: ICU level of care for now. # Dispo: ICU level of care for now. # Dispo: ICU level of care for now. # Dispo: ICU level of care for now. # CAD: Continue digoxin, ASA, plavix. # CAD: Continue digoxin, ASA, plavix. # CAD: Continue digoxin, ASA, plavix. # CAD: Continue digoxin, ASA, plavix. # CAD: Continue digoxin, ASA, plavix. # Code: DNR/DNI (confirmed with f . Pt continues on vanc per HD protocol and has been started on zosyn. Pt continues on vanc per HD protocol and has been started on zosyn. Pt continues on vanc per HD protocol and has been started on zosyn. Pt continues on vanc per HD protocol and has been started on zosyn. # Gout: Continue allopurinol . # Gout: Continue allopurinol . # Gout: Continue allopurinol . # Gout: Continue allopurinol . # Gout: Continue allopurinol . Plan to unclot fistula and HD today. Plan: Plan HD once fistula unclotted or adequate access obtained. Plan: Plan HD once fistula unclotted or adequate access obtained. Episode of emesis at HD, ?aspiration. Femoral line inserted for HD. Response: Renal c/s and intervention pnd. # Transaminitis: Patient with elevated AST of unknown etiology. # Transaminitis: Patient with elevated AST of unknown etiology. # Transaminitis: Patient with elevated AST of unknown etiology. # Transaminitis: Patient with elevated AST of unknown etiology. # ESRD: Patient on MWF HD. # ESRD: Patient on MWF HD. # ESRD: Patient on MWF HD. # ESRD: Patient on MWF HD. # ESRD: Patient on MWF HD. Plan: Sputum cx to be sent (imduced), F/U on cx results, de clot the fistula in Rt upper extremity and ? Action: temp and hemodynamic status. Action: temp and hemodynamic status. Action: temp and hemodynamic status. Action: temp and hemodynamic status. Depression: Continue prozac/welbutrin. # Code: DNR/DNI (confirmed with family including HCP) . # Code: DNR/DNI (confirmed with family including HCP) . # Code: DNR/DNI (confirmed with family including HCP) . # Code: DNR/DNI (confirmed with family including HCP) . She was treated with vancomycin Zosyn, received 1L IVF, and was transferred to the for further management. She was treated with vancomycin Zosyn, received 1L IVF, and was transferred to the for further management. Unchanged marked enlargement of the ventricles since , out of proportion to the enlargement of the sulci, which may be related to central atrophy or normal-pressure hydrocephalus. REASON FOR THIS EXAMINATION: r/o encephalitis, ischemia No contraindications for IV contrast PFI REPORT Irregularity of left greater than right MCA branch vessels. # Dispo: ICU level of care for now. Rule out encephalitis or ischemia. Slight interval decrease in possible exophytic right-sided fibroid. # Transaminitis: Patient with elevated AST of unknown etiology. Increased interstitial markings are demonstrated bilaterally, compatible with minimal interstitial edema. REASON FOR THIS EXAMINATION: r/o encephalitis, ischemia No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl MON 3:14 PM Irregularity of left greater than right MCA branch vessels. Restart in AM if hemodynamically stable. The wire was subsequently exchanged for a 0.035 wire, the tip of which was positioned in the inferior vena cava under fluoroscopic guidance. Attenuation of the lenses bilaterally is consistent with prior cataract surgery. # PPx: Heparin sq, famotidine . COMPARISON: Head CTs, , and . Sinus rhythmLeft axis deviationLeft bundle branch blockTall T waves - consider acute ischemia or hyperkalemiaSince previous tracing of , ST-T wave abnormalities more marked # Psych: Continue wellbutrin and prozac. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST ONLY: Limited evaluation of lung bases displays scattered regions of ground-glass opacity noted within the right middle lobe and lower lobes bilaterally as well as more streaky linear opacities at the left base and a small simple right pleural effusion with adjacent compression atelectasis. Marked enlargement of the ventricles, out of proportion to the enlargement of the sulci, is unchanged since . Incidentally noted is a fat- containing right inguinal hernia. Intraventricular conduction delay of left bundle-branch blocktype. Right basal ganglia calcifications again noted. New left basilar opacity concerning for pneumonia or aspiration. A new left basilar opacity is present, which could represent aspiration or infection. There is calcification of the aortic knob. Please place tunneled hemodialysis catheter. Ultrasound images before and after venopuncture were obtained. REASON FOR THIS EXAMINATION: needs HD tunneled catheter. Extensive periventricular white matter hypoattenuating changes, most marked within the right centrum semiovale is stable as is central atrophy. Sterile dressing was applied. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST ONLY: Air is noted within a Foley- containing urinary bladder. mild free fluid in pelvis, stable to slight decrease in size to presumed fibroid. If any, bilateral small pleural effusions are unchanged, greater on the left side. There are changes consistent with mild small vessel occlusive disease. # CAD: Continue digoxin, ASA, plavix. # ESRD: Patient on MWF HD. Diffuse periventricular white matter hypodensities are consistent with a small vessel disease, unchanged. | 30 | [
{
"category": "Physician ",
"chartdate": "2171-09-28 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 538177,
"text": "Chief Complaint: hypoxia, fever\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 72 y.o. nursing home resident seen in dialysis today, noted to had\n altered mental status, temp taken and reportedly was 105, noted to have\n saturation 84%. Episode of emesis at HD, ?aspiration. Called EMTs and\n brought to ED. Noted to be tachypneic at 42, NRB-100% sat. CXR c/w\n LLL pneumonia. Daughters had reported that she often coughs when being\n fed/eating. Vanco/pip/tazo in ED.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: nonverbal at baseline\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n senekot\n compazine\n digoxin\n lisinopril\n welbutrin\n prozac\n ativan prior to dialysis\n simvastatin\n nephrocaps\n allopurinol\n plavix\n humara\n metoprolol\n zantac\n Past medical history:\n Family history:\n Social History:\n CAD\n CHF, EF = 20%, TR/MR\n CRF on hemodialysis\n UTIs\n Gout\n Depression\n Anemia\n Hyperlipidemia\n noncontributory\n Occupation:\n Drugs: none\n Tobacco: quit in ; pack years\n Alcohol: none\n Other:\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Nutritional Support: NPO\n Gastrointestinal: Emesis\n Heme / Lymph: Anemia\n Neurologic: nonverbal\n Pain: No pain / appears comfortable\n Flowsheet Data as of 01:26 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (104.3\n Tcurrent: 37\nC (98.6\n HR: 74 (74 - 74) bpm\n BP: 156/46(71) {156/46(71) - 156/46(71)} mmHg\n RR: 42 (24 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 10 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -10 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), S3\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n left base, Diminished: )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 241\n 38.9\n 186\n 4.2\n 36\n 31\n 90\n 4.2\n 136\n 10.6\n [image002.jpg]\n Other labs: ALT / AST:/46, Alk Phos / T Bili:/0.9,\n Differential-Neuts:87.4, Lymph:8, Mono:3.2, Eos:1, Albumin:3.6,\n Ca++:10.5, Mg++:3.1, PO4:2.5\n Imaging: CXR: enlarged cardiac silohuette, retrocardiac density, some\n silohuetting of left hemidiphragm. No CHF\n ECG: SR @89, LBBB\n Assessment and Plan\n 1. Hypoxia, fever and question of witnessed aspiration. be\n chronically aspirating as fever this high unlikely due to a chemical\n pneumonitis. Likely superimposed infection, nosocomial organisms given\n resident of nursing home. Reasonable to continue current abx.\n Oxygenating fine on 4L NC in MICU.\n 2. CAD/CHF: No evident CHF/edema. Check cardiac enzymes albeit\n suspicion for ischemic event is low.\n 3. CRF: No evidence of volume overload, electrolytes fine. Dose\n medications accordingly.\n 4. Depression: Continue prozac/welbutrin. Follow clinically.\n 5. NPO. Needs speech and swallow evaluation given aspiration risk.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 12:09 AM\n 20 Gauge - 12:10 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP: HOB elevation\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n Total time spent: 50 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2171-09-28 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 538178,
"text": "Chief Complaint: Mental status change, fever, and hypoxia\n HPI:\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\n to have a LLL infiltrate concerning for left basilar pneumonia versus\n aspiration. She was treated with vancomycin and pip/tazo, received 1L\n IVF, and was transferred to the .\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -CAD, s/p \"silent MI\" per patient\n -CHF, systolic dysfunction with EF 20%\n -3+ mitral regurgitation, 3+ TR\n -DM, type 2\n -ESRD on HD\n -Gout\n -Depression\n -GERD\n -Rheumatoid arthritis\n -Anemia\n -Hypercholesterolemia\n Multiple family members with DM II, otherwise non-contributory.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives at nursing home. Has 6 children that live locally. Quit\n smoking in the ; previously smoked approx 5cigs/day x30\n years. Rare EtOH.\n Review of systems:\n Flowsheet Data as of 01:39 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 74 (74 - 74) bpm\n BP: 156/46(71) {156/46(71) - 156/46(71)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 100%\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 10 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -10 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n Gen: Opens eyes to stimuli, unable to follow commands\n HEENT: Perrl, MM dry, neck supple\n Pulm: Bibasilar rales\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\n Abd: S/NT/ND, +bs\n Ext: 2+ dp b/l, trace edema. Right AVF without signs of erythema\n Neuro: Patient non-verbal\n Labs / Radiology\n 241\n 12.2\n 186\n 4.2\n 36\n 31\n 90\n 4.2\n 136\n 38.9\n 10.6\n [image002.jpg]\n Imaging: CXR: 1. Cardiomegaly with mild pulmonary edema.\n 2. New left basilar opacity concerning for pneumonia or aspiration.\n .\n CTH: No acute intracranial pathology. MRI more sensitive for ischemia.\n .\n CTAP: 1. Slightly limited examination due to patient positioning and\n lack of oral contrast. No intra-abdominal source for infection\n identified.\n 2. Patchy right middle and lower lobe opacities, some which are clearly\n compression atelectasis and others of which are suspicious for regions\n of pneumonia or aspiration. Small right effusion.\n 3. Extensive calcified atherosclerotic vascular disease.\n 4. Slight interval decrease in possible exophytic right-sided fibroid.\n Please note it is atypical for the fibroid to not have involuted more\n in a patient of this age. If alteration in care will occur, can\n consider further evaluation with a dedicated pelvic ultrasound and/or\n MRI as no dedicated pelvic imaging of this lesion is noted at .\n Microbiology: Blood cultures - pending\n Urine cultures - pending\n ECG: NSR, old LBBB,interventricular conduction delay\n Assessment and Plan\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\n hypoxia.\n .\n # Fever, mental status change: Patient with acute mental status change\n and fever. Patient was reported to have been hypoxic at outpatient HD\n with vomiting, and has history per family of coughing while eating.\n Given degree of fever, this is unlikely to be a chemical pneumonitis\n and more likely to represent a HA-pneumonia. She also has a urinalysis\n with significant pyuria although with 3-5 epi, with recent admission\n for UTI (urine cultures negative).\n - Continue vanco and pip/tazo for HA-pneumonia and UTI\n - Follow urine and blood cultures\n - Sputum cultures\n - Legionella urinary antigen\n - Wean supplemental O2\n .\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\n secondary to fever, mental status change, and clotted AVF. Discussed\n with renal fellow, and plan to dialysize tomorrow.\n - Renally dose all meds\n .\n # CAD: Continue digoxin, ASA, plavix.\n .\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\n .\n # DM type II: RISS\n .\n # Gout: Continue allopurinol\n .\n # Psych: Continue\n .\n # FEN: NPO, speech and swallow consult. Replete as necessary.\n .\n # PPx: Heparin sq, famotidine\n .\n # Code: DNR/DNI (confirmed with f\n .\n # Lines: PIV, FC\n .\n # Dispo: ICU level of care for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:09 AM\n 20 Gauge - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2171-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 538179,
"text": "Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\n to have a LLL infiltrate concerning for left basilar pneumonia versus\n aspiration. She was treated with vancomycin Zosyn, received 1L IVF,\n and was transferred to the for further management.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2171-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 538249,
"text": "Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\n was found to have a LLL infiltrate concerning for left basilar\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\n received 1L IVF, and was transferred to the for further\n management.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt was febrile in ED, thought to be having PNA or UTI, in ICU afebrile.\n Action:\n 2 sets of bld cx sent in ED. In ICU Given Zosyn one dose and started on\n Zosyn and vancomycin. Breathing regularly on Oe NC 5 LPM (NRB D/Ced\n upon arrival to ICU).\n Response:\n Afebrile, alert, opened eyes first to stimuli then spontaneously, not\n follow commands.\n Plan:\n Sputum cx to be sent (imduced), F/U on cx results, de clot the fistula\n in Rt upper extremity and ? HD today, consult renal fellow, contact\n family (daughters) prior to HD initiation, wean O2 as tolerated..\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt in ESRD on HD MWF, anuric.\n Action:\n Failed to be dialyzed yesterday due to clotting of Fistula.\n Response:\n BUN/Cr 40/4.2, U/O 25 cc/shift.\n Plan:\n For HD today after consulting renal fellow to declot fistula, monitor\n lytes and seria cardiac enzymes.l Monitor FS and insulin per sliding\n scale.\n"
},
{
"category": "Nursing",
"chartdate": "2171-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 538220,
"text": "Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\n to have a LLL infiltrate concerning for left basilar pneumonia versus\n aspiration. She was treated with vancomycin Zosyn, received 1L IVF,\n and was transferred to the for further management.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt was febrile in ED, thought to be having PNA or UTI, in ICU afebrile.\n Action:\n 2 sets of bld cx sent in ED. In ICU Given Zosyn one dose and started on\n Zosyn and vancomycin. Breathing regularly on Oe NC 5 LPM (NRB D/Ced\n upon arrival to ICU).\n Response:\n Afebrile, alert, opened eyes first to stimuli then spontaneously, not\n following commands.\n Plan:\n sputum cx and urine cx to be sent, F/U on cx results, de clot the\n fistula in Rt upper extremity and ? HD today, consult renal fellow,\n contact family (daughters) prior to HD initiation, wean O2 as\n tolerated..\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt in ESRD on HD MWF, anuric.\n Action:\n Failed to be dialyzed yesterday due to clotting of Fistula.\n Response:\n U/O 10-15 cc/shift.\n Plan:\n For HD today after consulting renal fellow to declot fistula, monitor\n lytes and seria cardiac enzymes.l\n"
},
{
"category": "Nursing",
"chartdate": "2171-09-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 538342,
"text": "Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\n was found to have a LLL infiltrate concerning for left basilar\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\n received 1L IVF, and was transferred to the for further\n management.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T-max 105 at HD, 104.8 in EW. Pt w/ recent UTI as above. Pt afebrile\n over noc s/p abx and Tylenol as above. Pt aphasic, though alert and\n follows simple commands at baseline; although pt unresponsive on\n arrival to EW. Pt w/ frequent coughing during meals at NH per report as\n above. Pt also hypoxic w/ SpO2 84% on RA requiring NRB in EW.\n Action:\n temp and hemodynamic status. MS. \n as ordered. Pt continues on vanc per HD protocol and has been started\n on zosyn. Blood and urine cx pnd (U/A + for UTI). Pt NPO w/\n speech/swallow eval pnd. FiO2 weaned to NC on arrival to .\n respiratory status.\n Response:\n Pt remains afebrile. BP remains stable\n see flowsheet. Pt now\n arousable to voice/stimuli, MS improving t/o shift. Pt now following\n commands, mouthing words and occasionally speaking. Pt\ns daughters have\n been in to visit. Pt requesting to eat, team in to discuss w/ pt and\n family, including high risk for aspiration; however pt wishes to be\n able to eat prior to speech/swallow eval., and daughters agree. Pt\n ordered for ground solids, nectar thick liquids. WBC 9.6 down from 10.6\n on admit. SpO2 remains >95% on O2 5L via NC. BBS CTA.\n Plan:\n Continue to monitor temp, hemodynamic status and resp. status. Follow\n . Continue abx as ordered. F/U on culture data. Increase PO intake\n as tolerated. Maintain aspiration precautions. Wean FiO2 as tolerated.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt on HD M/W/F. Fistula clotted as above. Pt unable to undergo HD .\n BUN 40, Creat 4.2.\n Action:\n Renal to see pt. Temporary R femoral HD line placed. Pt underwent HD w/\n 3.5L off.\n Response:\n Pt tolerated HD well.\n Plan:\n Pt to resume M/W/F HD schedule. Pt C/O to w/ plan for\n possible repair of fistula on Monday.\n"
},
{
"category": "Nursing",
"chartdate": "2171-09-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 538391,
"text": "Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\n was found to have a LLL infiltrate concerning for left basilar\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\n received 1L IVF, and was transferred to the for further\n management.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T-max 105 at HD, 104.8 in EW. Pt w/ recent UTI as above. Pt afebrile\n over noc s/p abx and Tylenol as above. Pt aphasic, though alert and\n follows simple commands at baseline; although pt unresponsive on\n arrival to EW. Pt w/ frequent coughing during meals at NH per report as\n above. Pt also hypoxic w/ SpO2 84% on RA requiring NRB in EW.\n Presently, pt is alert, oriented to name and place, though aphacic but\n mouthing words.\n Action:\n temp and hemodynamic status. MS. \n as ordered. Pt continues on vanc per HD protocol and has been started\n on zosyn. Blood and urine cx pnd (U/A + for UTI). Pt NPO w/\n speech/swallow eval pnd. FiO2 weaned to NC on arrival to .\n respiratory status.\n Response:\n Pt remains afebrile. BP remains stable\n see flowsheet. Pt now\n arousable to voice/stimuli; however, does not follow commands. SpO2\n remains >95% on O2 5L via NC. BBS CTA.\n Plan:\n Continue to monitor temp, hemodynamic status and resp. status. Follow\n . Continue abx as ordered. F/U on culture data. Continue NPO pnd\n speech/swallow eval. Wean FiO2 as tolerated.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt on HD M/W/F. Fistula clotted as above. Pt unable to undergo HD .\n BUN 40, Creat 4.2.\n Action:\n Renal to see pt. Plan to unclot fistula and HD on Monday\n Response:\n Renal c/s and intervention pnd. Femoral line inserted for HD.\n Plan:\n Plan HD once fistula unclotted or adequate access obtained.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PNEUMONIA\n Code status:\n DNR / DNI\n Height:\n 60 Inch\n Admission weight:\n 65 kg\n Daily weight:\n Allergies/Reactions:\n Morphine\n Nausea/Vomiting\n Precautions: Contact\n PMH: Anemia, Diabetes - Insulin, HEMO or PD, Renal Failure\n CV-PMH: CAD, CHF\n Additional history: 3+ mitral regurg, goutm depression, GERD,\n rheumatoid arthritis, hypercholesterolemia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:134\n D:65\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 65 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 24h total out:\n 40 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:36 AM\n Potassium:\n 4.6 mEq/L\n 04:36 AM\n Chloride:\n 100 mEq/L\n 04:36 AM\n CO2:\n 27 mEq/L\n 04:36 AM\n BUN:\n 27 mg/dL\n 04:36 AM\n Creatinine:\n 3.7 mg/dL\n 04:36 AM\n Glucose:\n 114 mg/dL\n 04:36 AM\n Hematocrit:\n 35.7 %\n 04:36 AM\n Finger Stick Glucose:\n 120\n 06:00 AM\n Valuables / Signature\n Patient valuables: none\n Other valuables: none\n Clothes: Sent home with:\n Wallet / Money: npne\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: 412\n Transferred to: 921\n Date & time of Transfer: 10/5/08/ 0700\n"
},
{
"category": "Physician ",
"chartdate": "2171-09-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 538442,
"text": "Chief Complaint: Obtundation\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n DIALYSIS CATHETER - START 01:00 PM\n CALLED OUT\n History obtained from Medical records\n Patient unable to provide history: Confused\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Metoprolol - 10:25 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Neurologic: hemiparesis\n Signs or concerns for abuse : No\n Flowsheet Data as of 12:05 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 76 (59 - 76) bpm\n BP: 142/72(87) {112/39(57) - 142/72(87)} mmHg\n RR: 23 (18 - 25) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 200 mL\n 460 mL\n PO:\n 360 mL\n TF:\n IVF:\n 200 mL\n 100 mL\n Blood products:\n Total out:\n 3,525 mL\n 40 mL\n Urine:\n 25 mL\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,325 mL\n 420 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Crackles : scattered)\n Abdominal: No(t) Bowel sounds present, Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed, hemi paresis\n Labs / Radiology\n 11.3 g/dL\n 191 K/uL\n 114 mg/dL\n 3.7 mg/dL\n 27 mEq/L\n 4.6 mEq/L\n 27 mg/dL\n 100 mEq/L\n 139 mEq/L\n 35.7 %\n 7.0 K/uL\n [image002.jpg]\n 02:01 AM\n 11:08 AM\n 04:36 AM\n WBC\n 9.6\n 7.0\n Hct\n 34.0\n 35.7\n Plt\n 174\n 191\n Cr\n 4.2\n 3.7\n TropT\n 0.17\n 0.19\n Glucose\n 209\n 114\n Other labs: PT / PTT / INR:16.2/29.1/1.4, CK / CKMB /\n Troponin-T:22/3/0.19, Differential-Neuts:78.9 %, Lymph:13.0 %, Mono:5.1\n %, Eos:2.7 %, Albumin:3.2 g/dL, Ca++:9.7 mg/dL, Mg++:2.0 mg/dL, PO4:4.5\n mg/dL\n Assessment and Plan\n Obtundation\n UTI\n ESRD\n HD\n Vascular Access\n Much improved. More alert. Seems to be her ususal response to\n infection. Vascular will try to salvage Fistula. Daughters suggest in\n future comfort is their primary priority.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition :\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2171-09-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 538411,
"text": "Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\n was found to have a LLL infiltrate concerning for left basilar\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\n received 1L IVF, and was transferred to the for further\n management.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T-max 105 at HD, 104.8 in EW. Pt w/ recent UTI as above. Pt afebrile\n over noc s/p abx and Tylenol as above. Pt aphasic, though alert and\n follows simple commands at baseline; although pt unresponsive on\n arrival to EW. Pt w/ frequent coughing during meals at NH per report as\n above. Pt also hypoxic w/ SpO2 84% on RA requiring NRB in EW.\n Presently, pt is alert, oriented to name and place, aphasic per\n baseline but mouthing words and occasionally speaking a few words.\n Action:\n temp and hemodynamic status. MS. \n as ordered. Pt continues on vanc per HD protocol and has been started\n on zosyn. Blood and urine cx pnd (U/A + for UTI). Pt has been NPO w/\n speech/swallow eval pnd; however, pt and family wish for pt to be able\n to take PO intake despite high risk for aspiration. Risks discussed w/\n pt and family by team yesterday and ground solids w/ nectar thick diet\n was ordered. FiO2 weaned to NC on arrival to . \n respiratory status.\n Response:\n Pt remains afebrile. BP remains stable\n see flowsheet. Pt now\n arousable to voice/stimuli; however, does not follow commands. SpO2\n remains >95% on O2 5L via NC. BBS CTA. Pt lethargic and unable to take\n PO intake after HD last noc.\n Plan:\n Continue to monitor temp, hemodynamic status and resp. status. Follow\n . Continue abx as ordered. F/U on culture data. Increase PO intake\n as able. Wean FiO2 as tolerated.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt on HD M/W/F. Fistula clotted as above. Pt unable to undergo HD .\n BUN 40, Creat 4.2.\n Action:\n Pt seen by renal yesterday. R femoral temporary HD line placed and pt\n received HD yesterday.\n Response:\n Pt tolerated HD line insertion and HD well yesterday.\n Plan:\n Plan for possible repair of AV fistula on Monday. Anticipate pt to\n resume M/W/F HD schedule. Increase activity as tolerated.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PNEUMONIA\n Code status:\n DNR / DNI\n Height:\n 60 Inch\n Admission weight:\n 65 kg\n Daily weight:\n Allergies/Reactions:\n Morphine\n Nausea/Vomiting\n Precautions: Contact\n PMH: Anemia, Diabetes - Insulin, HEMO or PD, Renal Failure\n CV-PMH: CAD, CHF\n Additional history: 3+ mitral regurg, goutm depression, GERD,\n rheumatoid arthritis, hypercholesterolemia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:134\n D:65\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 65 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 100 mL\n 24h total out:\n 40 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:36 AM\n Potassium:\n 4.6 mEq/L\n 04:36 AM\n Chloride:\n 100 mEq/L\n 04:36 AM\n CO2:\n 27 mEq/L\n 04:36 AM\n BUN:\n 27 mg/dL\n 04:36 AM\n Creatinine:\n 3.7 mg/dL\n 04:36 AM\n Glucose:\n 114 mg/dL\n 04:36 AM\n Hematocrit:\n 35.7 %\n 04:36 AM\n Finger Stick Glucose:\n 120\n 06:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 412\n Transferred to: 9\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2171-09-28 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 538186,
"text": "Chief Complaint: Mental status change, fever, and hypoxia\n HPI:\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\n to have a LLL infiltrate concerning for left basilar pneumonia versus\n aspiration. She was treated with vancomycin and pip/tazo, received 1L\n IVF, and was transferred to the .\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -CAD, s/p \"silent MI\" per patient\n -CHF, systolic dysfunction with EF 20%\n -3+ mitral regurgitation, 3+ TR\n -DM, type 2\n -ESRD on HD\n -Gout\n -Depression\n -GERD\n -Rheumatoid arthritis\n -Anemia\n -Hypercholesterolemia\n Multiple family members with DM II, otherwise non-contributory.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives at nursing home. Has 6 children that live locally. Quit\n smoking in the ; previously smoked approx 5cigs/day x30\n years. Rare EtOH.\n Review of systems:\n Flowsheet Data as of 01:39 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 74 (74 - 74) bpm\n BP: 156/46(71) {156/46(71) - 156/46(71)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 100%\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 10 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -10 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n Gen: Opens eyes to stimuli, unable to follow commands\n HEENT: Perrl, MM dry, neck supple\n Pulm: Bibasilar rales\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\n Abd: S/NT/ND, +bs\n Ext: 2+ dp b/l, trace edema. Right AVF without signs of erythema\n Neuro: Patient non-verbal\n Labs / Radiology\n 241\n 12.2\n 186\n 4.2\n 36\n 31\n 90\n 4.2\n 136\n 38.9\n 10.6\n [image002.jpg]\n Imaging: CXR: 1. Cardiomegaly with mild pulmonary edema.\n 2. New left basilar opacity concerning for pneumonia or aspiration.\n .\n CTH: No acute intracranial pathology. MRI more sensitive for ischemia.\n .\n CTAP: 1. Slightly limited examination due to patient positioning and\n lack of oral contrast. No intra-abdominal source for infection\n identified.\n 2. Patchy right middle and lower lobe opacities, some which are clearly\n compression atelectasis and others of which are suspicious for regions\n of pneumonia or aspiration. Small right effusion.\n 3. Extensive calcified atherosclerotic vascular disease.\n 4. Slight interval decrease in possible exophytic right-sided fibroid.\n Please note it is atypical for the fibroid to not have involuted more\n in a patient of this age. If alteration in care will occur, can\n consider further evaluation with a dedicated pelvic ultrasound and/or\n MRI as no dedicated pelvic imaging of this lesion is noted at .\n Microbiology: Blood cultures - pending\n Urine cultures - pending\n ECG: NSR, old LBBB,interventricular conduction delay\n Assessment and Plan\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\n hypoxia.\n .\n # Fever, mental status change: Patient with acute mental status change\n and fever. Patient was reported to have been hypoxic at outpatient HD\n with vomiting, and has history per family of coughing while eating.\n Given degree of fever, this is unlikely to be a chemical pneumonitis\n and more likely to represent a HA-pneumonia. She also has a urinalysis\n with significant pyuria although with 3-5 epi, with recent admission\n for UTI (urine cultures negative).\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\n - Follow urine and blood cultures, repeat UA and culture\n - Sputum cultures\n - Check Legionella urinary antigen\n - Wean supplemental O2\n .\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\n secondary to fever, mental status change, and clotted AVF. Discussed\n with renal fellow, and plan for dialysis tomorrow.\n - Renally dose all meds\n .\n # CAD: Continue digoxin, ASA, plavix.\n .\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\n .\n # DM type II: RISS\n .\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\n as if patient has had elevated transaminase since 3/.\n - Trend LFTs\n .\n # Gout: Continue allopurinol\n .\n # Psych: Continue\n .\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\n .\n # PPx: Heparin sq, famotidine\n .\n # Code: DNR/DNI (confirmed with family including HCP)\n .\n # Lines: PIV, FC\n .\n # Dispo: ICU level of care for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:09 AM\n 20 Gauge - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2171-09-28 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 538188,
"text": "Chief Complaint: Mental status change, fever, and hypoxia\n HPI:\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n In the ED, VS 104.8 90 138/49 32 100%NRB. On CXR, she was found\n to have a LLL infiltrate concerning for left basilar pneumonia versus\n aspiration. She was treated with vancomycin and pip/tazo, received 1L\n IVF, and was transferred to the .\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n -CAD, s/p \"silent MI\" per patient\n -CHF, systolic dysfunction with EF 20%\n -3+ mitral regurgitation, 3+ TR\n -DM, type 2\n -ESRD on HD\n -Gout\n -Depression\n -GERD\n -Rheumatoid arthritis\n -Anemia\n -Hypercholesterolemia\n Multiple family members with DM II, otherwise non-contributory.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives at nursing home. Has 6 children that live locally. Quit\n smoking in the ; previously smoked approx 5cigs/day x30\n years. Rare EtOH.\n Review of systems:\n Flowsheet Data as of 01:39 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 74 (74 - 74) bpm\n BP: 156/46(71) {156/46(71) - 156/46(71)} mmHg\n RR: 24 (24 - 24) insp/min\n SpO2: 100%\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 10 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -10 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n Gen: Opens eyes to stimuli, unable to follow commands\n HEENT: Perrl, MM dry, neck supple\n Pulm: Bibasilar rales\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\n Abd: S/NT/ND, +bs\n Ext: 2+ dp b/l, trace edema. Right AVF without signs of erythema\n Neuro: Patient non-verbal\n Labs / Radiology\n 241\n 12.2\n 186\n 4.2\n 36\n 31\n 90\n 4.2\n 136\n 38.9\n 10.6\n [image002.jpg]\n Imaging: CXR: 1. Cardiomegaly with mild pulmonary edema.\n 2. New left basilar opacity concerning for pneumonia or aspiration.\n .\n CTH: No acute intracranial pathology. MRI more sensitive for ischemia.\n .\n CTAP: 1. Slightly limited examination due to patient positioning and\n lack of oral contrast. No intra-abdominal source for infection\n identified.\n 2. Patchy right middle and lower lobe opacities, some which are clearly\n compression atelectasis and others of which are suspicious for regions\n of pneumonia or aspiration. Small right effusion.\n 3. Extensive calcified atherosclerotic vascular disease.\n 4. Slight interval decrease in possible exophytic right-sided fibroid.\n Please note it is atypical for the fibroid to not have involuted more\n in a patient of this age. If alteration in care will occur, can\n consider further evaluation with a dedicated pelvic ultrasound and/or\n MRI as no dedicated pelvic imaging of this lesion is noted at .\n Microbiology: Blood cultures - pending\n Urine cultures - pending\n ECG: NSR, old LBBB,interventricular conduction delay\n Assessment and Plan\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\n hypoxia.\n .\n # Fever, mental status change: Patient with acute mental status change\n and fever. Patient was reported to have been hypoxic at outpatient HD\n with vomiting, and has history per family of coughing while eating.\n Given degree of fever, this is unlikely to be a chemical pneumonitis\n and more likely to represent a HA-pneumonia. She also has a urinalysis\n with significant pyuria although with 3-5 epi, with recent admission\n for UTI (urine cultures negative).\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\n - Follow urine and blood cultures, repeat UA and culture\n - Sputum cultures\n - Check Legionella urinary antigen\n - Wean supplemental O2\n .\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\n secondary to fever, mental status change, and clotted AVF. Discussed\n with renal fellow, and plan for dialysis tomorrow.\n - Renally dose all meds\n .\n # CAD: Continue digoxin, ASA, plavix.\n .\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\n .\n # DM type II: RISS\n .\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\n as if patient has had elevated transaminase since 3/.\n - Trend LFTs\n .\n # Gout: Continue allopurinol\n .\n # Psych: Continue wellbutrin and prozac.\n .\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\n .\n # PPx: Heparin sq, famotidine\n .\n # Code: DNR/DNI (confirmed with family including HCP)\n .\n # Lines: PIV, FC\n .\n # Dispo: ICU level of care for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:09 AM\n 20 Gauge - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2171-09-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 538257,
"text": "Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, DM, CAD, CHF with EF 20% admitted from outpatient HD after she\n was found to have a clotted right AVF, MS change, oral temp of 105, and\n hypoxia to 84% on room air. She was noted to have had emesis at HD as\n well. Of note, the patient was admitted to from for\n altered mental status and hypoglycemia secondary to UTI treated with\n ciprofloxacin. Discussing with patient's daughters, she has been\n coughing frequently with meals at her nursing home, and has baseline\n aphasia but is able to follow simple commands.\n .\n At ED, VS revealed 104.8, 90, 138/49, 32, 100%NRB. On CXR, she\n was found to have a LLL infiltrate concerning for left basilar\n pneumonia versus aspiration. She was treated with vancomycin Zosyn,\n received 1L IVF, and was transferred to the for further\n management.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T-max 105 at HD, 104.8 in EW. Pt w/ recent UTI as above. Pt afebrile\n over noc s/p abx and Tylenol as above. Pt aphasic, though alert and\n follows simple commands at baseline; although pt unresponsive on\n arrival to EW. Pt w/ frequent coughing during meals at NH per report as\n above. Pt also hypoxic w/ SpO2 84% on RA requiring NRB in EW.\n Action:\n temp and hemodynamic status. MS. \n as ordered. Pt continues on vanc per HD protocol and has been started\n on zosyn. Blood and urine cx pnd (U/A + for UTI). Pt NPO w/\n speech/swallow eval pnd. FiO2 weaned to NC on arrival to .\n respiratory status.\n Response:\n Pt remains afebrile. BP remains stable\n see flowsheet. Pt now\n arousable to voice/stimuli; however, does not follow commands. WBC 9.6\n down from 10.6 on admit. SpO2 remains >95% on O2 5L via NC. BBS CTA.\n Plan:\n Continue to monitor temp, hemodynamic status and resp. status. Follow\n . Continue abx as ordered. F/U on culture data. Continue NPO pnd\n speech/swallow eval. Wean FiO2 as tolerated.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt on HD M/W/F. Fistula clotted as above. Pt unable to undergo HD .\n BUN 40, Creat 4.2.\n Action:\n Renal to see pt. Plan to unclot fistula and HD today.\n Response:\n Renal c/s and intervention pnd.\n Plan:\n Plan HD once fistula unclotted or adequate access obtained.\n"
},
{
"category": "General",
"chartdate": "2171-09-28 00:00:00.000",
"description": "ICU Event Note",
"row_id": 538280,
"text": "Clinician: Attending\n Critical Care\n Remains profoundly obtunded which occurs each time she develops an\n infection. I think likelihood of meningitis is low so will continue to\n cover broadly but not for CNS infection. CXR is difficult to read but I\n am not convinced she has pneumonia. CHF is currently in good control.\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2171-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 538288,
"text": "Chief Complaint: Fever, hypoxia, mental status change\n 24 Hour Events:\n - No acute events overnight.\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.2\n HR: 69 (65 - 74) bpm\n BP: 114/60(73) {84/44(58) - 156/71(76)} mmHg\n RR: 22 (21 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 100 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 0 mL\n 25 mL\n Urine:\n 25 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 75 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Gen: Opens eyes to stimuli, unable to follow commands\n HEENT: Perrl, MM dry, neck supple\n Pulm: Bibasilar rales\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\n Abd: S/NT/ND, +bs\n Ext: 2+ dp b/l, trace edema. Right AVG without signs of erythema\n Neuro: Patient non-verbal\n Labs / Radiology\n 174 K/uL\n 11.0 g/dL\n 209 mg/dL\n 4.2 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 90 mEq/L\n 135 mEq/L\n 34.0 %\n 9.6 K/uL\n [image002.jpg]\n 02:01 AM\n WBC\n 9.6\n Hct\n 34.0\n Plt\n 174\n Cr\n 4.2\n TropT\n 0.17\n Glucose\n 209\n Other labs: PT / PTT / INR:16.2/29.1/1.4, CK / CKMB /\n Troponin-T:21/3/0.17, Albumin:3.2 g/dL, Ca++:9.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.5 mg/dL\n Assessment and Plan\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\n hypoxia.\n .\n # Fever, mental status change: Patient with acute mental status change\n and fever. Patient was reported to have been hypoxic at outpatient HD\n with vomiting, and has history per family of coughing while eating.\n Given degree of fever, this is unlikely to be a chemical pneumonitis\n and more likely to represent a HA-pneumonia, although her CXR is\n underwhelming for a significant consolidation. She also has a\n urinalysis with significant pyuria although with 3-5 epi, with recent\n admission for UTI (urine cultures negative). Low suspicion at this\n time for meningitis, and patient\ns HCP has repeatedly refused LP on\n past admissions for similar presentation, but will check with family\n regarding LP. Will hold off on empiric treatment of meningitis for\n now.\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\n - Follow urine and blood cultures, repeat UA and culture\n - Sputum cultures\n - Check Legionella urinary antigen\n - Wean supplemental O2\n .\n # ESRD: Patient on MWF HD. Did not receive outpatient HD yesterday\n secondary to fever, mental status change, and clotted AVF. Discussed\n with renal fellow, and plan for dialysis today.\n - Renally dose all meds\n - f/u with renal transplant regarding AVG\n .\n # CAD: Continue digoxin, ASA, plavix. Initial set of cardiac enzymes\n with troponin slightly elevated but a recent baseline with flat CK.\n - CCE\n .\n # CHF: BB and ACE-I held on admission. Patient hemodynamically stable\n overnight, will restart today.\n .\n # DM type II: RISS\n .\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\n as if patient has had elevated transaminase since 3/.\n - Trend LFTs\n .\n # Gout: Continue allopurinol\n .\n # Psych: Continue wellbutrin and prozac.\n .\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\n .\n # PPx: Heparin sq, famotidine\n .\n # Code: DNR/DNI (confirmed with family including HCP)\n .\n # Lines: PIV, FC\n .\n # Dispo: Call out today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:09 AM\n 20 Gauge - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2171-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 538266,
"text": "Chief Complaint: Fever, hypoxia, mental status change\n 24 Hour Events:\n - No acute events overnight.\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.2\n HR: 69 (65 - 74) bpm\n BP: 114/60(73) {84/44(58) - 156/71(76)} mmHg\n RR: 22 (21 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 100 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 0 mL\n 25 mL\n Urine:\n 25 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 75 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 174 K/uL\n 11.0 g/dL\n 209 mg/dL\n 4.2 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 90 mEq/L\n 135 mEq/L\n 34.0 %\n 9.6 K/uL\n [image002.jpg]\n 02:01 AM\n WBC\n 9.6\n Hct\n 34.0\n Plt\n 174\n Cr\n 4.2\n TropT\n 0.17\n Glucose\n 209\n Other labs: PT / PTT / INR:16.2/29.1/1.4, CK / CKMB /\n Troponin-T:21/3/0.17, Albumin:3.2 g/dL, Ca++:9.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.5 mg/dL\n Assessment and Plan\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\n hypoxia.\n .\n # Fever, mental status change: Patient with acute mental status change\n and fever. Patient was reported to have been hypoxic at outpatient HD\n with vomiting, and has history per family of coughing while eating.\n Given degree of fever, this is unlikely to be a chemical pneumonitis\n and more likely to represent a HA-pneumonia. She also has a urinalysis\n with significant pyuria although with 3-5 epi, with recent admission\n for UTI (urine cultures negative).\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\n - Follow urine and blood cultures, repeat UA and culture\n - Sputum cultures\n - Check Legionella urinary antigen\n - Wean supplemental O2\n .\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\n secondary to fever, mental status change, and clotted AVF. Discussed\n with renal fellow, and plan for dialysis tomorrow.\n - Renally dose all meds\n .\n # CAD: Continue digoxin, ASA, plavix. Initial set of cardiac enzymes\n with troponin slightly elevated but a recent baseline with flat CK.\n - CCE\n .\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\n .\n # DM type II: RISS\n .\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\n as if patient has had elevated transaminase since 3/.\n - Trend LFTs\n .\n # Gout: Continue allopurinol\n .\n # Psych: Continue wellbutrin and prozac.\n .\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\n .\n # PPx: Heparin sq, famotidine\n .\n # Code: DNR/DNI (confirmed with family including HCP)\n .\n # Lines: PIV, FC\n .\n # Dispo: ICU level of care for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:09 AM\n 20 Gauge - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2171-09-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 538267,
"text": "Chief Complaint: Fever, hypoxia, mental status change\n 24 Hour Events:\n - No acute events overnight.\n Allergies:\n Morphine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.8\nC (98.2\n HR: 69 (65 - 74) bpm\n BP: 114/60(73) {84/44(58) - 156/71(76)} mmHg\n RR: 22 (21 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 100 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 0 mL\n 25 mL\n Urine:\n 25 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 75 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Gen: Opens eyes to stimuli, unable to follow commands\n HEENT: Perrl, MM dry, neck supple\n Pulm: Bibasilar rales\n CV: Nl S1+S2, III/VI systolic murmur at LUSB, flat JVP\n Abd: S/NT/ND, +bs\n Ext: 2+ dp b/l, trace edema. Right AVF without signs of erythema\n Neuro: Patient non-verbal\n Labs / Radiology\n 174 K/uL\n 11.0 g/dL\n 209 mg/dL\n 4.2 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 40 mg/dL\n 90 mEq/L\n 135 mEq/L\n 34.0 %\n 9.6 K/uL\n [image002.jpg]\n 02:01 AM\n WBC\n 9.6\n Hct\n 34.0\n Plt\n 174\n Cr\n 4.2\n TropT\n 0.17\n Glucose\n 209\n Other labs: PT / PTT / INR:16.2/29.1/1.4, CK / CKMB /\n Troponin-T:21/3/0.17, Albumin:3.2 g/dL, Ca++:9.8 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.5 mg/dL\n Assessment and Plan\n Mrs. is a 72 year old female with a PMH significant for ESRD on\n MWF HD, CAD, CHF with EF 20%, and DM admitted for fever, MS change, and\n hypoxia.\n .\n # Fever, mental status change: Patient with acute mental status change\n and fever. Patient was reported to have been hypoxic at outpatient HD\n with vomiting, and has history per family of coughing while eating.\n Given degree of fever, this is unlikely to be a chemical pneumonitis\n and more likely to represent a HA-pneumonia. She also has a urinalysis\n with significant pyuria although with 3-5 epi, with recent admission\n for UTI (urine cultures negative).\n - Continue vanco and pip/tazo for HA-pneumonia and possible UTI\n - Follow urine and blood cultures, repeat UA and culture\n - Sputum cultures\n - Check Legionella urinary antigen\n - Wean supplemental O2\n .\n # ESRD: Patient on MWF HD. Did not receive outpatient HD today\n secondary to fever, mental status change, and clotted AVF. Discussed\n with renal fellow, and plan for dialysis tomorrow.\n - Renally dose all meds\n .\n # CAD: Continue digoxin, ASA, plavix. Initial set of cardiac enzymes\n with troponin slightly elevated but a recent baseline with flat CK.\n - CCE\n .\n # CHF: Hold BB and ACE-I. Restart in AM if hemodynamically stable.\n .\n # DM type II: RISS\n .\n # Transaminitis: Patient with elevated AST of unknown etiology. Appears\n as if patient has had elevated transaminase since 3/.\n - Trend LFTs\n .\n # Gout: Continue allopurinol\n .\n # Psych: Continue wellbutrin and prozac.\n .\n # FEN: NPO pending speech and swallow consult. Replete as necessary.\n .\n # PPx: Heparin sq, famotidine\n .\n # Code: DNR/DNI (confirmed with family including HCP)\n .\n # Lines: PIV, FC\n .\n # Dispo: ICU level of care for now.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:09 AM\n 20 Gauge - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Radiology",
"chartdate": "2171-09-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037944,
"text": " 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ?LLB pneumonia\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 2:50 PM\n Unchanged left lower lobe consolidation. Band-like atelectasis in the right\n base is new.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Followup left lower lobe pneumonia.\n\n Left lower lobe consolidation is persistent and unchanged. Band-like\n atelectasis in the right base is new. There is no pneumothorax. If any,\n bilateral small pleural effusions are unchanged, greater on the left side.\n Cardiomegaly is stable.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2171-09-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037945,
"text": ", MED 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ?LLB pneumonia\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n PFI REPORT\n Unchanged left lower lobe consolidation. Band-like atelectasis in the right\n base is new.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-09-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1038047,
"text": ", A. MED FA9A 2:21 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o SAH, SDH, hemorrhage, ischemia\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ESRD on HD, DM II p/w fever, AMS, was resolving but now\n obtunded.\n REASON FOR THIS EXAMINATION:\n r/o SAH, SDH, hemorrhage, ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No acute intracranial pathology.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-09-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1038046,
"text": " 2:21 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o SAH, SDH, hemorrhage, ischemia\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ESRD on HD, DM II p/w fever, AMS, was resolving but now\n obtunded.\n REASON FOR THIS EXAMINATION:\n r/o SAH, SDH, hemorrhage, ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr SUN 4:25 PM\n No acute intracranial pathology.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman with acute mental status change and fever.\n\n Comparison is made to , and .\n\n NONCONTRAST HEAD CT: No edema, mass effect, acute hemorrhage, or evidence of\n a major vascular territorial infarction. Marked enlargement of the\n ventricles, out of proportion to the enlargement of the sulci, is unchanged\n since . Diffuse periventricular white matter hypodensities are\n consistent with a small vessel disease, unchanged. The visualized part of the\n paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n 1. No evidence of acute intracranial abnormalities.\n\n 2. Unchanged marked enlargement of the ventricles since , out of\n proportion to the enlargement of the sulci, which may be related to central\n atrophy or normal-pressure hydrocephalus. Clinical correlation is advised.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-10-03 00:00:00.000",
"description": "TUNNELED W/O PORT",
"row_id": 1038997,
"text": " 1:55 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: needs HD tunneled catheter.\n Admitting Diagnosis: PNEUMONIA\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ESRD on HD a/w AMS, thrombosed RUE AVF s/p failed\n revision by transplant surgery yesterday.\n REASON FOR THIS EXAMINATION:\n needs HD tunneled catheter.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female with end-stage renal disease on hemodialysis,\n status post failed revision of right upper extremity AV fistula. Please place\n tunneled hemodialysis catheter.\n\n RADIOLOGISTS: Dr. and attending radiologist, Dr. , who was\n present and supervised the entire procedure.\n\n FINDINGS AND PROCEDURE: The risks and benefits of the procedure were\n explained to the patient and informed consent was obtained. The patient was\n placed supine on the angiographic table and the left neck and chest were\n prepped and draped in standard sterile fashion. A preprocedure timeout was\n performed to identify the patient by name, medical record number, date of\n birth and the nature of the procedure to be performed.\n\n Using ultrasound guidance, the left internal jugular vein was accessed with a\n 21-gauge needle. Ultrasound images before and after venopuncture were\n obtained. A 0.018 wire was then placed through the needle into the SVC under\n fluoroscopic guidance. The needle was exchanged for a 4.5 French\n micropuncture sheath. The wire was subsequently exchanged for a 0.035 \n wire, the tip of which was positioned in the inferior vena cava under\n fluoroscopic guidance. Following this, attention was directed to the\n construction of the tunnel, which was performed using blunt dissection and\n administration of 10 cc of 1% lidocaine with epinephrine. Once the catheter\n was tunneled, a 15.5 French peel-away sheath was then placed over the wire.\n The wire and inner dilator were removed. The catheter was advanced through\n the peel-away sheath and sheath removed.\n\n The neck incision was closed with a 4-0 Vicryl suture. Lumens of the catheter\n were flushed and heplocked, and the line was secured to the skin with two silk\n sutures. Sterile dressing was applied. Final fluoroscopic image of the chest\n demonstrates the tip of the catheter to be located in the right atrium. There\n were no immediate complications.\n\n Moderate sedation was provided by administering divided doses of fentanyl (25\n mcg) throughout the total intra-service time of 55 minutes, during which the\n patient's hemodynamic parameters were continuously monitored.\n\n (Over)\n\n 1:55 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: needs HD tunneled catheter.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Successful placement of a left internal jugular 23 cm tip-to-cuff\n dual-lumen angiodynamics hemodialysis catheter with the tip located in the\n right atrium. The line is ready to use.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-09-29 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1038067,
"text": " 6:05 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: r/o encephalitis, ischemia\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ESRD on HD, DM II a/w MS change and fevers. Now with\n obtundation.\n REASON FOR THIS EXAMINATION:\n r/o encephalitis, ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl MON 3:14 PM\n Irregularity of left greater than right MCA branch vessels. Differential\n diagnoses include vasculitis, meningitis, or atheromatous change. Cerebral\n atrophy, with ventricular enlargement. There is no obstruction, although\n communicating hydrocephalus cannot be excluded.\n ______________________________________________________________________________\n FINAL REPORT\n MRI AND MRA OF THE BRAIN.\n\n HISTORY: 72-year-old woman with end-stage renal disease on hemodialysis,\n diabetes type 2, with mental status change and fevers. Now with obtundation.\n Rule out encephalitis or ischemia.\n\n COMPARISON: Head CTs, , and .\n\n TECHNIQUE: Multiplanar brain MR was obtained without the administration of\n intravenous gadolinium. Three-dimensional time-of-flight MR arteriography was\n performed.\n\n FINDINGS:\n MRI OF THE BRAIN:\n There is no evidence of hemorrhage, edema, masses, mass effect or infarction.\n No diffusion abnormalities are detected. The ventricles are enlarged,\n somewhat out of proportion to the degree of atrophy, but unchanged in\n comparison to , and without evidence of obstruction. There are\n changes consistent with mild small vessel occlusive disease.\n\n MRA OF THE BRAIN: There is irregularity of branches of the middle cerebral\n arteries, right greater than left. However, there is no evidence of\n occlusion. The intracranial vertebral internal carotid arteries and vertebral\n arteries and their branches are normal, without evidence of stenosis,\n occlusion, or aneurysm.\n\n IMPRESSION:\n 1. Irregularity of MCA branch vessels, right greater than left. The\n differential diagnosis includes vasculitis and meningitis. Considerations\n also include atheromatous change, although the location and appearance is\n atypical for atheromatous change.\n 2. Ventricular enlargement, without evidence of obstruction. However,\n communicating hydrocephalus cannot be excluded.\n\n (Over)\n\n 6:05 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: r/o encephalitis, ischemia\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Findings were discussed with Dr. on at 11:00 a.m.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-09-29 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1038068,
"text": ", A. MED FA9A 6:05 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: r/o encephalitis, ischemia\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ESRD on HD, DM II a/w MS change and fevers. Now with\n obtundation.\n REASON FOR THIS EXAMINATION:\n r/o encephalitis, ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Irregularity of left greater than right MCA branch vessels. Differential\n diagnoses include vasculitis, meningitis, or atheromatous change. Cerebral\n atrophy, with ventricular enlargement. There is no obstruction, although\n communicating hydrocephalus cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-09-27 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1037721,
"text": " 7:13 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for intraabdominal process as source of fever/N/V\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ESRD on HD p/w N/V too altered for abd exam to be\n significant\n REASON FOR THIS EXAMINATION:\n eval for intraabdominal process as source of fever/N/V\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKPe FRI 9:10 PM\n no abdominal source for fever. mild free fluid in pelvis, stable to slight\n decrease in size to presumed fibroid. patchy lower lobe opacities may\n represent pna/pneumonitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever of 105, worsening mental status. Patient with end-stage renal\n disease on hemodialysis:\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis with IV contrast only. Oral contrast was not administered due to\n inability to tolerate p.o. and timid airway preventing OGT.\n\n Comparison is made to CT examination and CT\n examination.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST ONLY: Limited evaluation of lung\n bases displays scattered regions of ground-glass opacity noted within the\n right middle lobe and lower lobes bilaterally as well as more streaky linear\n opacities at the left base and a small simple right pleural effusion with\n adjacent compression atelectasis. Heart size is enlarged. No pericardial\n effusion is identified. The liver, spleen with small calcified granulomas,\n stomach, small bowel, atrophic-appearing pancreas, atrophic-appearing kidneys,\n and adrenal glands appear unremarkable. There is extensive vascular\n calcification noted within the aorta and all branch vessels. No free air,\n free fluid or pathologically enlarged lymph nodes are identified within the\n abdominal cavity.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST ONLY: Air is noted within a Foley-\n containing urinary bladder. The uterus is again noted to be enlarged with an\n exophytic low attenuation heterogeneous mass again noted to extend off the\n right fundal region measuring approximately 4.8 x 5.5 cm, slightly decreased\n in size from where it measured 5.6 x 6.9 cm but stable from . A\n mild- to- moderate amount of simple free fluid is noted within the pelvic\n cavity. Intrapelvic bowel and Foley-containing urinary bladder appear normal.\n Incidentally noted is a fat- containing right inguinal hernia.\n\n BONE WINDOWS: No malignant-appearing osseous lesions are identified. Mild\n degenerative disc disease noted at L5-S1 and multiple left-sided rib fractures\n are unchanged.\n\n (Over)\n\n 7:13 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for intraabdominal process as source of fever/N/V\n Field of view: 40 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1. Slightly limited examination due to patient positioning and lack of oral\n contrast. No intra-abdominal source for infection identified.\n\n 2. Patchy right middle and lower lobe opacities, some which are clearly\n compression atelectasis and others of which are suspicious for regions of\n pneumonia or aspiration. Small right effusion.\n\n 3. Extensive calcified atherosclerotic vascular disease.\n\n 4. Slight interval decrease in possible exophytic right-sided fibroid. Please\n note it is atypical for the fibroid to not have involuted more in a patient of\n this age. If alteration in care will occur, can consider further evaluation\n with a dedicated pelvic ultrasound and/or MRI as no dedicated pelvic imaging\n of this lesion is noted at .\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-09-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1037722,
"text": " 7:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with acute change in MS w/ N/V and febrile no visible signs\n of head trauma\n REASON FOR THIS EXAMINATION:\n eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKPe FRI 8:54 PM\n no acute pathology, stable\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever up to 105 with decline in mental status.\n\n Comparison is made to , examination.\n\n NON-CONTRAST HEAD CT\n\n FINDINGS: There is no evidence of intracranial hemorrhage, mass effect, shift\n of midline structures, hydrocephalus, or acute major vascular territorial\n infarct. -white matter differentiation appears well preserved. Extensive\n periventricular white matter hypoattenuating changes, most marked within the\n right centrum semiovale is stable as is central atrophy. Right\n basal ganglia calcifications again noted. Attenuation of the lenses\n bilaterally is consistent with prior cataract surgery. No other soft tissue\n abnormalities are identified. Bony structures are unremarkable, and the\n mastoid air cells and paranasal sinuses are well aerated. Atherosclerotic\n calcifications are noted within the carotid siphons bilaterally.\n\n IMPRESSION:\n\n No acute intracranial pathology. MRI more sensitive for ischemia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037715,
"text": " 6:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with ESRD on HD p/w N/V and hypoxia likely aspiration\n REASON FOR THIS EXAMINATION:\n eval for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage renal disease on hemodialysis with nausea, vomiting,\n and hypoxia. Possibly aspiration.\n\n COMPARISON: Chest radiographs of .\n\n UPRIGHT AP VIEW OF THE CHEST: Cardiomegaly is unchanged from the previous\n exam. There is calcification of the aortic knob. Increased interstitial\n markings are demonstrated bilaterally, compatible with minimal interstitial\n edema. A new left basilar opacity is present, which could represent\n aspiration or infection. Small left pleural effusion may be present. The\n right lung otherwise is grossly clear without focal consolidation or pleural\n effusion. No pneumothorax. Known left-sided healed rib fractures are not as\n well seen on the current examination.\n\n IMPRESSION:\n\n 1. Cardiomegaly with mild pulmonary edema.\n\n 2. New left basilar opacity concerning for pneumonia or aspiration.\n\n\n DFDdp\n\n"
},
{
"category": "ECG",
"chartdate": "2171-09-30 00:00:00.000",
"description": "Report",
"row_id": 134606,
"text": "Sinus rhythm\nLeft axis deviation\nLeft bundle branch block\nTall T waves - consider acute ischemia or hyperkalemia\nSince previous tracing of , ST-T wave abnormalities more marked\n\n"
},
{
"category": "ECG",
"chartdate": "2171-09-29 00:00:00.000",
"description": "Report",
"row_id": 134607,
"text": "Sinus rhythm. The P-R interval is prolonged. Left axis deviation.\nLeft bundle-branch block. Compared to the previous tracing the axis has\nshifted.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2171-09-28 00:00:00.000",
"description": "Report",
"row_id": 134608,
"text": "Artifact is present. Sinus rhythm. Indeterminate axis. Left bundle-branch\nblock. Compared to the previous tracing there is no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2171-09-27 00:00:00.000",
"description": "Report",
"row_id": 134609,
"text": "Sinus rhythm. Intraventricular conduction delay of left bundle-branch block\ntype. Compared to the previous tracing of there is no significant\ndiagnostic change.\n\n"
}
] |
23,317 | 143,562 | 54 yo M w/ETOH cirrhosis, portal vein thrombus, DM, ARF p/w ascites, hepatic encephalopathy and w/u for liver transplant . # CIRRHOSIS: Patient's cirrhosis most likely secondary to alcohol and patient was admitted with multiple complications. Ultrasound at OSH demonstrated possible portal vein thrombosis, although this finding was not present on 1st doppler study at . Patient underwent therapeutic paracentesis many times during this admission. He was always negative for SBP. He was continued on cipro for SBP prophylaxis. Pt's initial U/S was unremarkable for portal vein thrombus, subsequent Abd U/S with doppler as well as CT and MRI, notable for Portal vein thrombus. Anticoagulation was contraindicated given his thrombocytopenia, pt also developed some oozing around temporary central lines. His clot then extended into SVC and was no longer a candidate for transplant surgery. Further transplant work up stopped and pt was made DNR/DNI given no further options for treatment. . # RENAL FAILURE: Patient was admitted with oliguric renal failure. Patient's renal function decreased rapidly during this episode of hepatic decompensation, suggesting hepatorenal syndrome although likely compounded by intravascular depletion and increased intra-abdominal pressure. Patient was started on octreotide, midodrine, and albumin at the OSH. Patient's SBP dropped during HD from base line BP of 90's to low 80's. He was then transferred to the ICU for CVVH. He tolerated several sessions of HD. Plan for continued HD as outpatient as pt would like to continue HD. Plan was to provide HD as outpatient close to home. The patient was admitted to the MICU for ongoing CVVHD given his pressures were prohibitive for traditional HD. The patient was maintained on midodrine and octreotide for possible hepatorenal syndrome and was additionally treated with IV albumin, which was discontinued on . Midodrine was increased to 12.5mg . The patient's pressures tolerated CVVHD well and his creatinine decreased from 5.9 to 2.5. He has required dialysis, though, since being transferred from the MICU to the floor, and his renal function has not improved. Unfortunately, given his coagulopathy, he has had issues with bleeding from the dialysis catheter site following dialysis. He did not bleed following his last course of hemodialysis and was deemed safe to go home. . # COAGULOPATHY: Pt developed some oozing around line sites. Labs showed picture consistent with DIC but this could also be from underlying liver disease. He received FFP/Cryo before procedures. He recieved several units of PRBC for low HCT but remained stable. Had some bleeding from tunneled line. Was given conjugated estrogen and Vitamin K x 3 doses. . # HEPATIC ENCEPHALOPATHY: During this admission, patient had waxing and mental status, suggesting likely hepatic encephalopathy. Patient's mental status much improved with lactulose therapy. The patient was maintained on lactulose for encephalopathy. He was noted to have some fluctuation in mental status but was generally appropriate and oriented. . # LIVER MASS: Patient also noted to have hepatic mass on abdominal ultrasound, suggestive for possible HCC although AFP only 2.9. Unclear etiology of mass. | + palp peripheral pulses.GI - Abd + ascites. NURSING NOTE 0700HRS-1600HRSEVENTS..B/P STABLE AWAIT HD.....IF TOLLERATES ? + contact precautions for c-dif - completed course of flagyl.Endo - RISSAccess - RIJ TLC by MD. run pt slightly neg as BP tolerates given lg + TFB . + contact precautions Vanco dosed by level for staph UTI. SO FAR THIS SHIFT PT IS ANURIC. Sarna lotion to pruritic back.A+P - Continue - replete lytes as indicated. Abd/pelvic CT performed to R/o SMV clot - results pend. Pt completed K phos infusion. Carafate and PPI for varices.F/E - CVVHD initiated with fluid removal rate goal 0. Post transfusion hct 26.1. Remain hyponatremic with Na 132 - on 1000cc fluid restriction. Pt remains hyponatremic, Na 126 - on 1000ml fluid restriction. mae x4 w/equal strength.gi-> abd w/+bs and significant ascites. restarted.Neuro - Pt oriented x 3, fatigued appearing. Vanco level pend this am. Transfuse hct < 25.ID - Afeb, normothermic. 7p to 7a Micu Progress NoteOverview of Events - pt went for abd/pelvic CT - results pend. Vanco level pend. GI/GU: Abdomen ascitic with +bs. staph uti being empirically covered with vanco. REPLETE LYTES PRN. Phos 2.8 Ca and K drips infusing on sliding scale per protocol ( most recent K 4.3 and ionized Ca 1.15). Pt stable during HD. + dry cough.C-V - HR 66-80 NSR. ?another attempt at hd soon since he has been hemodynamically stable.id-> afebrile w/a normal wbc. HR slightly elevated to 105 ST during HD and lowest BP was 80/44.Neuro - Alert and oriented x 3. Transfuse hct< 25.GI - + Ascites. 24hr fluid balance MN->1700 + 1300ml, LOS balance + 4liters.Access: New HD and PICC lines with small amt blood @ sites. Infusion of K-Phos interrupted when pt off floor, now cont to infuse. Anemia rx with epogen 3 x/wk. Epogen given 3 x/wk. K 3.9 Ionized ca 1.20. Still hyponatremic with Na of 129 - on 1000cc fluid restriction. BUN 18 Cr 2.0. + contact precautions - hx c-dif. PT consult ordered as pt's overall strength has deconditioned. SURGICEL AND SURGIFOAM USED. Cipro dose tomm. HD lines heparinized. FS QID ON S/S COVERAGE 118-194. Alternating replacement solution b/w NaCl and prismasate. Hct down 24 (26.2)...transfuse for Hct <21. Abd CT showed atelectasis of RLL. OCTREOTIDE SQ AND MIDODRINE PO CONTINUES. GI/GU: Abdomen ascitic with + bs. Phos 2.4 - Per renal, sucralfate should be dcd. OINTMENT APPLIED BY NRSG. Normalregional LV systolic function. CONTINUE ICU SUPPROTIVE CARE. Pt remains on strict I/O (1000cc fluid restriction);hyponatremic. Cont to receive Lactulose RTC, no BM this shift.GU: Filter of CVVHD clotted @ 1130 and dialysis was subsequently D/C'd. need to adjust SSC.ID: Afebrile. BUN/Cr improving - down to 29/2.5 respectively. Lactulose for encephelopathy prophylaxis.Resp - LS clear. NBP 85-114/40-50.GI - Abd + ascites. restarting HD. Portal thrombus.Height: (in) 66Weight (lb): 200BSA (m2): 2.00 m2BP (mm Hg): 102/60HR (bpm): 64Status: InpatientDate/Time: at 16:17Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement. Endo: Fs 122/135/156. Normal ascending aorta diameter. Receiving lactulose; no BM this shift.ID: low grade temp 99.5. DRSG AND AT THIS TIME. Pt voiding small amts.Review of systems:Neuro: Pt dozing intermit, otherwise AAO X 3. Encourage po intake with fluid restiction. System clotted x 1. Trivial MR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality.Conclusions:Suboptimal study.1. Ascites. Lt sc dialysis line site wnl. Hydrocortisone rectal cream to be ordered by MD.F/E - TFB + 1150ccs ( pt not dialzyed). IR to be consulted re Dialysis line. CVVHD restarted @ 1745, with alternating replacement solutions of NA and Prismasate per order.ID: Afebrile. HEPARIN GIVEN IN HD PORTS ON , CITRATE GIVEN IN HD PORTS INSTEAD TODAY. NBP= 92-108/43-58. NBP=90-110/37-52. Lung snds clear throughout.CV: HR 67-82SR without VEA. KCL and CaGluconate replacement according to sliding scale. BC pnd. ALL RESOLVED AFTER HD COMPLETED. Catheter heparinized. Plan: Start hd tomm. Coagulopathy; FFP/cryo if evidence of bleeding.Resp: RR 10-17; sats >94% RA. Right internal jugular central venous catheter tip terminates in the distal SVC. CONCLUSION: Thrombosis of intrahepatic portal vein. A delayed portal venous phase as well as coronal and sagittal reformatted images were obtained. Ascites marked for paracentesis at right lower quadrant. A mark was made over the right lower quadrant for paracentesis. INDICATION: Cirrhosis, ascites, portal vein thrombosis. Please mark spot for paracentesis. FINAL REPORT HISTORY: Cirrhosis, ascites, status post paracentesis today. Left-sided vascular catheter has been inserted with its tip overlying the expected location of the SVC. A small chronic nonocclusive thrombus within the infrarenal IVC is similar to MR . Portal vein thrombosis extends 1-cm into the superior mesenteric vein and 1.5-cm into the splenic vein. The thrombus extends 1-cm into the SMV and 1.5-cm into the splenic vein. COMPARISON: AP upright portable chest x-ray dated . FINDINGS: Right internal jugular vein with tip in the inferior third of the SVC. CT OF THE PELVIS WITH IV CONTRAST: Ascites tracks into the pelvis. Airways are patent to the subsegmental bronchi bilaterally. CLINICAL INDICATION: Durable hemodialysis access requirement. Splenomegaly with splenic and esophageal varices and ascites indicate portal hypertension. PA AND LATERAL CHEST X-RAY: A right internal jugular central venous catheter terminates in unchanged position in the distal SVC. 4) Cirrhosis with portal hypertension. Small mediastinal venous collaterals feed into a distended azygos vein. A 0.035 wire was advanced into the IVC under flouroscopic guidance. Status post successful placement of tunneled hemodialysis catheter in exchange for a previous positioned left internal jugular post-temporary hemodialysis catheter. Subsequently, a 1.5 mm J, 0.035- inch wire was advanced through the catheter and steered using fluoroscopic visualization to the inferior vena cava. TECHNIQUE: MDCT acquired contiguous axial images from the thoracic inlet to the upper abdomen were obtained without intravenous contrast. Small bilateral pleural effusions, right greater than left, are associated with dependent parenchymal opacities, likely atelectasis. TECHNIQUE: Non-contrast head CT. | 46 | [
{
"category": "Nursing/other",
"chartdate": "2150-07-20 00:00:00.000",
"description": "Report",
"row_id": 1566950,
"text": "NURSING NOTE 0700HRS-1600HRS\n\n\n\nEVENTS..B/P STABLE AWAIT HD.....IF TOLLERATES ? CALL OUT TO FLOOR...\n\n\nNEURO..A/O X3, OOB TO CHAIR WITH X1 NURSE..C/O LOWER BACK PAIN RELIEVED WITH PO ANALAGESIA...\n\n\nRESP..ROOM AIR SATS !@98%..CLERA UPPER DIMINSHED LOWER...\n\n\nCVS...GOOD B/P, CONTINUES ON MIDIRINE, 100-110 SYSTOLIC..WAIT TO OBSERVE ON HD...HR STABLE 65-70BPM...\nAFEBRILE, ALTHOUGH DID HAVE TEMP AT 100.1 LAST PM SO IF TEMP GOES UP AGAIN FOR B/ CULTS..VANC LAST PM WAS LAST DOSE...\nB/S COVERED WITH S/S..\nHCT @ 23.6 THIS AM , DOWN FROM YESTERDAY, FOR RE-CHECK THIS PM...PLTS REMAINS LOW @ 128, IS 1.5FLUID RESTRICTION\n\n\nGI.. LARGE DISTENDED/ASCITES ..LAST TAP ..B/S PRESENT/GAS..TAJKEN SAMLL AMOUNT OF FOOD, NO BOWEL MOTION SO FAR TODAY..CONTINES ON LACTULOSE..\nLIVER TEAM FOLLOWING..CT LAST FRIDAY SHOWED LARGE AMOUNT OF OLD CLOT IN PORTAL VEIN/MESENTERIC ARTERY...MEETING TOMORROW TO DISCUSS LIKELIHOOD OF GOING AHEAD WITH SURGERY GIVEN THIS INFORMATIONAS MAKES TRANSPLANT TECHNIQUELY VERY DIFFICULT\n\n\nGU...FINISHED YESTERDAY @ 1300HRS...AM LABS SATBLE, AWAIT HD BOOKED FOR 1700HRS...NO URINE OUTPUT,NA, FLUID RESTRICTION AS ABOVE...\n\n\nSKIN..ABRASION ON SACRUM, CREAM AAPPLIED..RELECTANT TO TURN ON SIDE..\n\n\nLINES..PICC/DIALYSIS \n\n\nSOCIAL..BROTHER TO VISIT PM..MEETING TOMORROW RE FINAL DECISION OF LIVER/KIDNEY TRANSPLANT...\n\n\n\nPLAN...TO ATTEMPT HD/OBSERVE B/P..TRANSFER WRITTEN IN PREP FOR C/O\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-20 00:00:00.000",
"description": "Report",
"row_id": 1566951,
"text": "ADDENDUM..HCT STABLE, BUT PATIENT STOOLED THIS PM AND STREAKY BLOOD EVIDENT IN STOL..TEAM AWARE..CONTINUE AT PRESEENT AS HCT STABLE AND VITALS STABLE, REPEAT HCT @ 2200HRS\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-21 00:00:00.000",
"description": "Report",
"row_id": 1566952,
"text": "7p to 7a Micu Progress Note\n\nOverview of Events - Pt underwent HD last eve. 02 sat dropped to 84% during procedure. 02 5 L NC applied temporarily with sats increasing to low 90's. HR slightly elevated to 105 ST during HD and lowest BP was 80/44.\n\nNeuro - Alert and oriented x 3. OOB to chair with minimal assist x 1. Lactulose for encephelopathy. Medicated with 5 mg oxycodone for back pain x 1 with good effect.\n\nResp - LS clear, diminished at bases. RR 11-19. Sats > 95% except for above mentioned incident during HD. Expectorating sm amts clear sputum with flecks of blood.\n\nC-V HR 60-110 ST. NBP 80-120/40-50. HR increased with HD and with exertion.\n\nF/E - HD administered over ~ 2 1/2 hrs. 500ccs fluid removed. BUN 24 CR 3.3. K 3.6. Pt remains hyponatremic at 127 despite 1000cc fluid restriction. Voided 30ccs amber colored urine. TFB + ~400ccs .\n\nGI - Abd + ascites +BS. Tolerating renal diet without n/v. Passed mod amt loose green stool on commode. Minute amt of BRB noted on tissue after pt defecated.\n\nHeme/Access- Hct stable throughout the night at 23.6. Transfuse hct < 21. Epogen given 3 x/wk. Pt bleeding from Dial LSC after instillation of heparin by dialysis R.N. Also bleeding from former skin tear site on RUE. Tegaderm dssg reapplied to RUE. Surgicel and DSD to LSC site and former line site above LSC with decrease in bleeding noted. INR 2.3\n\nID - Afeb. WBC 8.5. + contact precautions Vanco dosed by level for staph UTI. Cipro given for hx SBP.\n\nSocial - Brother visited with pt last eve.\n\nA+P - Continue to monitor for bleeding - follow hcts, INR. Pt stable during HD. ? call-out to floor today. Nsg transfer note updated. Surgery to make decision re ? liver transplant today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-20 00:00:00.000",
"description": "Report",
"row_id": 1566949,
"text": "npn 7p-7a\n\n the pt remained off of crrt overnoc with the plan to attempt hd again later today. sbp remain stable ~90-100.\n\nreview of systems\n\nrespiratory-> lung sounds diminished bibasilarly. pt is maintaining sats >93% on room air. he denies c/o sob.\n\ncardiac-> hemodynamically stable. hr 60-70's, sr w/no noted ectopy. sbp @baseline ~90-100.\n\nneuro-> a&o x3. able to participate in care. oob to chair x several hours last noc, but he required a 2 person assist back to bed. mae x4 w/equal strength.\n\ngi-> abd w/+bs and significant ascites. denies c/o n/v. no bm overnoc.\nneeds encouragement to take in more than po fluids. pt is aware that he is on a 1500cc free water fluid restriction.\n\ngu-> no void overnoc. anticipate attempt at hemodialysis again sometime later today.\n\nid-> tmax 100.1 orally earlier in the shift with no actual fever spike. received vancomycin x1 ~2100.\n\nendocrine-> received regular insulin coverage per sliding scale parameters.\n\naccess- right arm dl picc line and a left sc dialysis catheter are both patent and intact. peripheral iv was d/c'd this morning.\n\ndispo-> ?transfer back to floor if pt tolerates hemodialysis.\n\nsocial-> pt's brother was in visiting last evening. plan for family meeting on tues w/the transplant team re: final decision re: possible liver/kidney transplant.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-12 00:00:00.000",
"description": "Report",
"row_id": 1566933,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Pt remains alert and oriented x 3. MAE. Assists with self care. Jaundiced and fatigued appearing. c/o chronic back pain - . Medicated with 5 mg oxycodone x 2 with good results.\n\nResp - LS clear with few crackles. RR 10-16. 02 sat > 96% RA.\n\nC-V - HR 55 SB - 65 SR, no ectopy. NBP 86-100/40's. + Palp peripheral pulses. Hct stable at 26.8. No epistaxis or bleeding from lines noted. Transfuse hct< 25.\n\nGI - + Ascites. Pt not passing stool despite 3 doses of lactulose. + flatus. Tolerating renal diet although appetite is poor.\n\nF/E - Continues on CVVHD, with even fluid goal. System has clotted once and warning has appeared that system is clotting again as of this writing. TFB + 24ccs. Presently +16. No spontaneous voiding of urine. AM lytes pend but BUN/Cr improving to 53/3.2 with eve labs. Still hyponatremic with Na of 129 - on 1000cc fluid restriction. Ca and K infusing via sliding scale per CRRT protocol.\n\nID - Afeb. WBC 3.2. Lactic acid 2.6. + contact precautions.\n\nSocial - Brother and family members visited pm.\n\nA+P - Hemodynamically stable on CVVHD. Electrolye repletion as needed. ? nutrition consult to improve po intake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-12 00:00:00.000",
"description": "Report",
"row_id": 1566934,
"text": "Micu Nursing Progress Note\nEvents: remains on CRRT, filter seems to be clotting ~12h.\n\nNeuro: Pt is awake, alert, pleasant and cooperative. Moving around in bed without difficulty. C/O back pain 1400 and was medicated with oxycodone 5mg given with good relief.\n\nCardiac: B/P 90-104/50's, HR 68-72, SR. K+ 4.3 at 10am and 3.9 at1700, potassium replacement gtt maintained at 20ml/hr, Ca+ 1.14 at 10a and calcium gtt increased to 30ml/hr then decreased to 25 at 1700 for Ca+ 1.25.\n\nResp: breath sounds clear, room air O2 sats 99-100%. RR 10-14.\n\nGI: taking renal diet well with good appetite. Pt taking lactulose tid as ordered. He had a mod amount of soft golden stool X1. Abd- distended with ascities (+) BS.\n\nEndo: BS slightly higher today with 12n 248, covered with 4u regular insulin and 1800 BS 174 covered with 2u insulin.\n\nGU: Pt voided ~300cc amber colored urine, specimen sent for U/A and C&S. CRRT continues, filter started to develope clots arounf 1300 and clotted off at 1700. Flow rate increased to 100 mg at 12n due to increasely positive. FLow rate decreased when access pressure alarming continueously, return and access lines also reversed to help stop the alarm. However due to decreased flow rates pt is currently 380cc positive.\n\nID: remains afebrile, not on any antibotics.\n\nSocial: no contact with pt's family today.\n\nPlan: continue CRRT, attempt to keep pt even. Lab review due at 2200.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-18 00:00:00.000",
"description": "Report",
"row_id": 1566945,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Pt remains oriented x 3. Lethargic and fatigued at times - easily arousable. MAE. Medicated wtih 5 mg oxycodone x 1 for back pain. Sleeping intermittently throughout the night.\n\nResp - LS clear. RR 10-16. 02 sat > 97%. + dry cough.\n\nC-V - HR 66-80 NSR. NBP 110-126/54-61. + palp peripheral pulses.\n\nGI - Abd + ascites. +BS. Pt s/p paracentesis on previous shift. Ate a couple of bites of a tuna after. c/o intermittent abd discomfort assoc with nausea and vomiting x 2. Pt vomiting bilious material with undigested food. MD notified. Abd soft on exam. Hct sent, which was stable at 28.6 KUB taken. Medicated with dolasteron mesylate iv x 2 and one dose of maalox po with fair results. Pt reports feeling better after vomiting and after moving his bowels. Passed a lg amt loose brown guiac neg stool on the bedpan.\n\nF/E - TFB neg ~5000 cc on . Continues on with goal fluid removal rate of neg 30ccs/hr. Presently neg 191. LOS + 345. Access and return lines remain reversed when prisma reaccessed due to fluctuating access pressures. Filter pressures elevated throughout the night to 150-176, despite changing system x 1. Ca and K infusing via sliding scale per protocol. BUN 18 Cr 2.0. Remain hyponatremic with Na 132 - on 1000cc fluid restriction. Pt voided 50ccs clear amber urine with urinal.\n\nHeme - Hct stable at 27.2 this am. s/p transfusion 2 units prbcs on eves. Anemia rx with epogen 3 x/wk. INR 1.8\n\nID - Afeb. WBC 3.6. + contact precautions. Vanco level pend. ? staph uti being empirically covered with vanco. Cipro 1x/wk for hx SBP.\n\nSkin - Barrier cream applied to reddened rectal area. Sarna lotion to pruritic back.\n\nA+P - Continue - replete lytes as indicated. ? gastroenteritis s/p eating tuna - continue to assess abd pain, ? abd CT should pain worsen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-11 00:00:00.000",
"description": "Report",
"row_id": 1566931,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Pt alert and oriented x 3. MAE. Up to commode with minimal assist. Lactulose for encephelopathy prophylaxis. Denies any pain.\n\nResp - LS clear. RR 12-20. 02 sat > 96 on RA.\n\nC-V- HR 60's NSR, no ectopy noted. NBP 86-96/40's. Baseline SBP 90's per pt. No edema.\n\nGI - Abd + ascites. Tolerating renal diet without difficulty but po intake poor. Passed sm amt loose brown stool on commode. Carafate and PPI for varices.\n\nF/E - CVVHD initiated with fluid removal rate goal 0. Ca and K drips infusing per sliding scale protocol. K 3.9 Ionized ca 1.20. BUN and Cr slighlty improved - 88/5.3 respectively. Pt remains hyponatremic, Na 126 - on 1000ml fluid restriction. Pt oliguric but but voided 50ccs clear yellow urine with urinal.\n\nHeme - Pt s/p transfusion 2 units FFP and cryoprecipitate on previous shift. INR 2.1, previously 2.7. Hct 25.3. Transfuse hct < 25.\n\nID - Afeb, normothermic. WBC 3.0. + contact precautions for c-dif - completed course of flagyl.\n\nEndo - RISS\n\nAccess - RIJ TLC by MD. sent for cult. Pt has access port on LSC Quinton catheter. One peripheral #20 angio iv inserted into R forearm. Quinton site bleeding mod amt at onset of shift. Surgicel and new DSD applied with resolution of bleeding.\n\nSocial - Brother, who is HCP, visited with pt last eve.\n\nA+P - Pt tolerating CVVHD with marginal BP. Monitor for bleeding, FFP prior to invasive procedures. ? transfusion PRBCS if hct continues to decline. Na and fluid restriction for hyponatremia. Lyte repletion per sl scale.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-11 00:00:00.000",
"description": "Report",
"row_id": 1566932,
"text": "MICU 6 NSG 7A-7PM\nRESP--PT CONTS ON RA LUNGS STA WITH SOME INTERMITTENT RIGHT BASE CRACKLES. DENIES SOB OR RESP DISTRESS.\n\nCV--REMAINS IN SB 50-60'S, NO ECTOPY NOTED. BP 80'S-100/. TOL CRRT SO FAR THIS SHIFT. NO PERIPHERAL EDEMA NOTED. INTERMITTENTLY MILD EPISTAXIS NOTED. NO FURTHER BLEED ING FROM RIGHT NECK AT SITE OF PREVIOUS TLCL. HD LINE SITE ALSO WITHOUT BLEEDING. CLOT SENT FOR BLOOD BANK WITH REPEAT HCT THIS AFTERNOON.\n\nGI--TOL RENAL DIET WELL. LACTULOSE X1 DOSE WITH NO BM SO FAR THIS SHIFT, PT PASSING FLATUS. ABD REMAINS DISTENDED DUE TO ASCITIES.\n\nRENAL--PT WILL NEED UA NEXT TIME HE VOIDS. SO FAR THIS SHIFT PT IS ANURIC. CONTS ON CVVHDF, FLUID GOAL IS TO RUN PT EVEN, SO FAR TOL WELL. CONTS ON IV KCL AND CALCIUM INFUSIONS, TITRATED PER SS. CRRT SYSTEM CLOTTED X1 AND RESTARTED THIS SHIFT.\n\nNEURO--PT A&OX3. MAE WELL, AND REPSOITIONS SELF IN BED. PNEUMO BOOTS APPLIED FOPR DVT PREVENTION.\n\nSOCIAL--NO CONTACT WITH FAMILY SO FAR THIS SHIFT.\n\nPLAN--F/U HCT TRANSFUSE FOR HCT <25\n--CONTS CRRT WITH FLUID GOAL NET EVEN\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-18 00:00:00.000",
"description": "Report",
"row_id": 1566946,
"text": "MICU NURSING PROGRESS NOTE. 0700-1900\n PLEASE SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Continues on cvvhdf, filter changed this pm. Medicated for nausea x 1. Emesis x 2. No c/o discomfort, reports feeling slightly better this pm.\n\n Neuro: Alert and oriented x 3. Is able to make needs known verbally in soft clear voice in full sentences. Intermittent napping throughout shift, easily arouses to verbal stimulus. Able to move all extrem. freely. Follows commands. Temperature max. 98.0 No c/o discomfort this shift.\n\n Respiratory: Lung sounds are clear throughout. RR 12-20 and non labored. O2 saturation on ra 97-100%. Cxr reportdly showed rll opacity.\n\n CV: Sinus rhythm with no ecopy noted, rate 60's to 70's. Nbp low 100's to 110's systolic. Rt ac picc line patent, site wnl. Lt sc hd line site wnl, remains patent with access reversed. Hct stable this pm at 26.6.\n\n GI/GU: Abdomen ascitic with +bs. Continues nausea although reporting feels better this pm, s/p 12.5mg anzemet i.v. Several episodes of green bilious emesis this am. Reports he is passing gas, no bm this shift. Continues on lactulose. No urine this shift.\n\n Cvvhdf: Continues on crrt, pfr at 90, goal is negative 30 per hr. Filter changed this pm at 1500 hrs with access and return lines reversed. Renal wants crrt to continue thru weekend despite pt being hemodynamically stable and a questionable transplant candidate r/t his large clot in his portal vein.\n\n Social: No social contacts this shift, has received calls in room.\n\n Integ: Skin remains grossly intact, sarna lotion applied to back.\n\n F/e/n: Pneumo boots. Renal diet.\n\n Plan: Continue on crrt. Monitor electorlytes per protocol, next set due at 2200, and adjust potassium, calcium drips accordingly. Medicate for nausea.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-19 00:00:00.000",
"description": "Report",
"row_id": 1566947,
"text": "pmicu npn 7p-7a\n\n crrt clotted off again earlier this morning and was restarted w/o incident ~0230. he has met his fluid removal goal and is actually tfb negative for his los after having a large, liquid stool.\n\nreview of systems\n\nrespiratory-> lung sounds are course w/sats >97% on room air. pt denies c/o sob.\n\ncardiac-> sbp ranging 100-120's. hr 60-70's, sr w/no noted ectopy. pt is receiving continuous potassium and calcium repletion per ccrt sliding scales.\n\nneuro-> pt is alert and cooperative although he requires motivation to be repositioned. he is able to mae x4, ue >le's. c/o lower back pain and medicated w/oxycodeine x1 w/good effect.\n\ngi-> abd w/significant ascites despite recent paracentesis. he denies any n/v overnoc but refuses to eat. he did drink several cups of water and gingerale. he had 500cc of liquid stool x1.\n\ngu-> crrt continues to clot off at least 2-3x/24hrs. he was restarted again this morning. pt's inr is marginally elevated, ?need to start systemtic heparin. as noted above, he is tolerating a goal fluid loss of 30cc/hr and is currently tfb negative for his los. ?another attempt at hd soon since he has been hemodynamically stable.\n\nid-> afebrile w/a normal wbc. awaiting level before redosing w/vanco today.\n\naccess-> right arm dl picc line and a left sc tunneled dialysis catheter are both patent and intact.\n\nsocial-> no contact w/family overnoc. family meeting planned on tuesday w/liver team to discuss possibily of transplantation.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-10 00:00:00.000",
"description": "Report",
"row_id": 1566930,
"text": "Nursing Progress Note.\n\nBriefly, this is a pleasant 51 yr old male transferred to MICU 6 West from 10 for the initiation of CVVHDF. Pt initially admitted on c confusion which responded well to PO Lactulose therapy. PMH includes; cirrhosis, portal vein thrombosis, varices, DM II, SBP, ETOH, cigs and now ARF. Pt had been doing well on 10 (ambulating, self ADL's, fair PO intake) but unfortunately unable to tol regular HD on floor c SBP dropping to low 80's (from a baseline SBP values in the 90's). Pt therefore transferred to MICU WEST 6 for initiation of CVVHDF. NKDA. The pt is a Full Code. Contact precautions in place.\n\nMS: AAO times three currently, follows commands, pleasant/cooperative and appropriate. Poor short term memory noted. Pt reports intermittent R eye pain, intermittent dental and belly pain. Pt currently denies pain, team to assess eye shortly. Pt reports poor PO intake and recent weight loss of 40 lbs in past year. Pt given call light c instruction.\n\nCV: Hemodynamically stable and afebrile. NSR c no ectopy. Pt c an INR value this AM of 2.9 c some minor bleeding around two central lines (RIJ TLC & LSC Quinton), pt received two units of FFP on floor f/b one unit Cryoprecipitate -- HO to d/c RIJ TLC shortly (placed @ an outside facility and deemed unessential @ this time). Nursing staff to place PIV shortly and LSC Quinton cath has a side port for central access needs.\n\nRESP: RA c nl sats, RR and resp effort @ rest in bed.\n\nGI: Pt reports poor PO appetite, will encourage PO supplements and cont to encourage good PO intake.\n\nGU: Oliguric per report from 10.\n\nDERM: Pt is jaundiced.\n\nSOC: Brother now visiting @ BS.\n\nOTHER: Please see CareVue for additional pt care data/comments.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-15 00:00:00.000",
"description": "Report",
"row_id": 1566940,
"text": "Micu Nursing Progress Notes\nEvents: CRRT continued, filter clotted at 12n and changed.\n\nGU: CRRT continued with fluid volume goal continues to be even. Problems with the access pressure continue contributing to the clotting difficulty. Pt will be NPO after MN for a tunnel catheter to be placed tomorrow. He continues to be acidotic so the replacement and dialysate were changed to compensate. Also the blood flow rate was increased to 150 (per Renal fellow Dr. ) to help with the clotting issue.\nPt voided 250cc dark amber urine.\nK+ at 12n 3.8 so gtt increased to 30ml/hr, at 1700 K+ 4.1 so Kcl gtt decreased to 20ml/hr, ionized Ca at 12n was 1.14 so calcium ftt increased to 30mg/hr, but at 1700 ionized Ca was 1.21 so rate decreased to 25ml/hr.\n\nCardiac: B/P 92-101/40's, HR 62-74.\n\nResp: remains on room air with RR 12-18, O2 sats 99-100. Breath sounds clear.\n\nGI: Appetite remains good. Pt receiving lactulose tid. He was transfered to the bedside commode when he had a moderate amount of golden soft stool. Abd remains distended with asities. (+) bowel sounds.\n\nEndo: Blood sugar 150 at 12n and 189 at 1800-received 2u regular insulin.\n\nNeuro: He remains alert and oriented, able to transfer to the bedside commode with minimal assistance.\n\nID: Pt received a one time dose of vanco at 12n for a low vanco level. He remains afebrile with temps 97.0-98.0.\n\nSocial: there is to be a family meeting tomorrow at 1500 with the liver team, transplant, renal and the Micu team to determine if pt will receive enough support if he receives a liver transplant. He will remain on CRRT.\n\nPlan: fluid balance goal is even, NPO after MN for tunnel catheter tomorrow, family meeting tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-16 00:00:00.000",
"description": "Report",
"row_id": 1566941,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVRIONMENT SECURED FOR SAFETY.\n\nTHIS IS A VERY PLEASANT 51 Y/O MALE PT TRANSFERRED TO THE MICU FROM 10 FOR INITIATION OF . PT INITIALLY ADMITTED ON FOR CONFUSION WHICH RESPONDED WELL TO PO LACTULOSE THERAPY. PMH SIGNIFICANT FOR CIRRHOSIS, PORTAL VEIN THROMBOSIS, VARICES, DMII, SBP, ETOH AND ARF. PT HAD BEEN DOING WELL ON 10 (AMBULATING, SELF ADL'S) BUT UNABLE TO TOLERATE HD. S/P ESOPHAGEAL VARICIES BANDING ON - ALSO FOUND TO HAVE NEW LIVER MASS.\n\nNEURO: ALERT AND ORIENTED X 3. SPEECH IS CLEAR, ABLE TO VERBALIZE NEEDS WITHOUT DIFFICULTY. SELF SUFFICIENT IN ADL'S FOR THE MOST PART. AFEBRILE. PERRLA, 3/BRISK. MAE X 4 WITHOUT DIFFICULTY. STEADY GAIT. NO SEIZURE ACTIVITY NOTED.\n\nRR: ROOM AIR. RR 15-20. BBS= ESSENTIALLY CTA X ALL LUNG FIELDS. STRONG COUGH EFFORT- NON-PRODUCTIVE. BILATERAL CHEST EXPANSION NOTED. DENIES ANY SOB OR DIFFICULTY BREATHING. SP02 > OR = TO 95%.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR, HR 60-70'S WITH NO SIGNS OF ECTOPY NOTED. SBP > OR = TO 90 WITH NO HYPER OR HYPOTENSIVE EPISODES NOTED. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. PT NOTED TO HAVE CRIT OF 22- DR/ MADE AWARE. DENIES ANY CHEST PAIN. ALSO NOTED TO HAVE INR OF 2.0.\n\nGI: ABD IS LARGE WITH ASCITES. PT ABLE TO TOLERATE PO'S WITH NO C/O N,V,D. PT HAS BEEN NPO SINCE MIDNIGHT FOR IMPENDING PROCEDURE TODAY. PT HAS BEEN ABLE TO USE THE BEDSIDE COMMODE FAIRLY INDEPENDTLY. I MEDIUM SIZED GOLDEN, SOFT STOOL NOTED. PASSING FLATUS.\n\nGU: PT VOIDS IN URINAL- ALTHOUGH HAS BEEN ANURIC THIS SHIFT. ONGOING AT BEDSIDE. GOAL IS TO RUN PT EVEN. FILTER HAS BEEN CHANGED TOTAL OF 3 TIMES. PLAN IS FOR PT TO HAVE HD TUNNEL CATHETER REPLCMT DONE TODAY. OF NOTE, ALTERNATING NORMAL SALINE AND REPLACEMENT FLUIDS.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS. PT HAS SOME SKIN TEARS TO BILATERAL UPPER EXTREMITIES.\n\nLYTES: PT CURRENTLY ON K AND ION CA GTT. PT TO RECEIVE TOTAL OF 4GMS OF MAG AND 15MMOL OF K-PHOS BASED ON 0400 LABS.\n\nSOCIAL: NO CONTACT FROM FAMILY THIS SHIFT.\n\nPLAN: LABS AT 1000 AND 1600. WILL NEED TO CONSIDER PRBC AND FFP TX FOR DECREASED CRIT AND INCREASED INR. REPLETE LYTES PRN. PT TO HAVE HD TUNNEL CATHETER INSERTION TODAY. CONTINUE AS PT WILL EVENTUAL PLAN TO SWITCH TO HD. FAMILY MEETING TO DISCUSS POSSIBILITY OF LIVER TX. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-16 00:00:00.000",
"description": "Report",
"row_id": 1566942,
"text": "Nursing Progress note 0700-1900\nEvents: off @ 1115 for pt transport to IR for double lumen PICC and tunneled HD lines. Procedure tolerated well. On return to unit, family mtg with liver transplant team/MICU team took place. Pt then prepped for abd CT to check for ?SMV clot, as part of liver transplant check list. Pt also to have PFT's and stress test done before liver transplant team meets next Tuesday.\n\nReview of Systems:\n\nNeuro: Pt generally AAO X 3, cooperative, turning self STS in bed. He C/O back pain @ 1200 and rec'd Oxycodone 5mg X 1 with good results. Pt also rec'd small amts Fentanyl and Versed (0.5mg) in IR for procedure. He remains lethargic, but easily woken and appropriate.\n\nResp: O2 sat 99-100% on RA with RR 11-15 and regular. Lung snds clear throughout. Occas clears throat, but not expectorating sputum.\n\nCV: HR 63-77SR without VEA. BP 101/51-109/48. Infusion of K-Phos interrupted when pt off floor, now cont to infuse. Pt rec'd 1 bag platelets and 1 u FFP before going to IR, and 1 u FFP in IR. Post-procedure labs pndg, with K+ 4.2 and ionized Ca 1.08.\n\nGI: Pt remains NPO except for Baricat solution and ice chips. Abd with ascites, appears larger. Paracentesis planned, ? tomorrow. Bowel snds present and pt passing flatus, no stool.\n\nGU: stopped @ 1115 per above. 24hr fluid balance MN->1700 + 1300ml, LOS balance + 4liters.\n\nAccess: New HD and PICC lines with small amt blood @ sites. Periph IV inserted in L arm for contrast dye for Abd CT scan.\n\nSocial: Family mtg per above. See liver team social worker's note. Nurse re-stated to pt importance of compliance, as his roommate again brought in gum/candy that was not sugarfree.\n\nPlan: Abd CT tonight, PFT's and stress test in next few days if pt candidate for liver transplant. Cont to impress on pt and family necessity of complying with orders in order to qualify for liver transplant(ie. follow /renal diet, fluid restriction, etc.). Re-start this PM after abd CT scan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-17 00:00:00.000",
"description": "Report",
"row_id": 1566943,
"text": "7p to 7a Micu Progress Note\n\nOverview of Events - pt went for abd/pelvic CT - results pend. restarted.\n\nNeuro - Pt oriented x 3, fatigued appearing. Slept most of the night. MAE. Medicated with 5 mg oxycodone x 1 for back pain () with good effect.\n\nResp - LS clear. RR 11-16. 02 sat > 96% RA.\n\nC-V - HR 60-80 NSR, no ectopy noted. NBP 100-110/50's.\n\nGI - Pt given barocat as prep for abd ct. c/o nausea and abd discomfort after ingesting 800ccs of barocat. Medicated with 12.5 mg dolasetron mesylate iv with good results. Abd/pelvic CT performed to R/o SMV clot - results pend. Abd + ascites. + BS. ? paracentesis to be performed today. Passing flatus, no stool.\n\nF/E - restarted ~2300 last eve. Goal even fluid balance. Pt + ~ 2750ccs ( barocat and blood products). Presently running - 13. Access and return lines reversed as access pressure extremely neg. Bld flow rate increased to 80 as filter and effluent pressures began to rise. Bld clots present in filter - anticipate system will need to be changed shortly despite infusion taking place via new tunnel dialysis catheter. Pt completed K phos infusion. Phos 2.8 Ca and K drips infusing on sliding scale per protocol ( most recent K 4.3 and ionized Ca 1.15). BUN 20 Creat 2.2. Pt on 1000cc fluid restriciton. Na decreasing to 132.\n\nHeme - Pt transfused 2 units PRBCS without incident for hct 19.5. Post transfusion hct 26.1. INR 1.7\n\nID - Afeb. WBC 3.8. Pt given one dose of vanco for staph UTI. Vanco level pend this am. Also being rx with cipro once a week for hx of SBP. Remains on contact precautions.\n\nSkin - Minor skin tears and ecchymotic areas to upper exts.\n\nEndo - RISS.\n\nAccess - Minor bleeding from HD LSC insertion site. PIC dssg D+I - line draws and flushes easily. #20 LLA peripheral iv patent.\n\nSocial - No contacts overnight.\n\nA+P - Continue - ? use of citrate as pt continues to clot off filters freq ( no heparin given hx of coagulopathy). ? run pt slightly neg as BP tolerates given lg + TFB . Plan is to proceed with w/u for liver transplant - PFTs and stress test today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-17 00:00:00.000",
"description": "Report",
"row_id": 1566944,
"text": "Nursing Progress note 0700-1900\nEvents: Pre liver transplant tests (PFT's and stress test) cancelled as abd CT revealed portal vein thrombus extends to SMV, making surgery very difficult. Final decision re transplant to be made Tuesday by committee. restarted @ 1230 with pressures high but machine running smoothly @ this time. Paracentesis done, taking off 5 liters fluid.\n\nReview of Systems:\n\nNeuro: Pt remains AAO X 3, occas dozing but woken easily. Rec'd Oxycodone 5mg X 1 for C/O back pain with good relief. When transferring bed to chair pt C/O bilat leg pain (length of legs) and required assist of 1. Tolerating alternating pressure sleeves well on legs.\n\nResp: O2 sat 97-100% on RA with RR 10-14 and regular. Lung snds clear throughout. Abd CT showed atelectasis of RLL. Non-productive cough.\n\nCV: HR 64-83SR without VEA. BP 108/68-118/61. Pt rec'ing Calcium Gluconate and KCL per sliding scale.\n\nGI: Pt with poor appetite which he attributes to increased ascites. Occas belching and flatus, no BM. Multivites changed to nephrocaps.\n\nGU: Pt voided 340ml amber/clear urine X 1. restarted @ 1230, with goal -30ml/hr. Filter pressure remains elevated after red/blue lines switched, but machine running well/continuously @ this time. Site of tunneled HD line C&D.\n\nAccess: Red port of PICC with heparin infused, blue port flushed with NS and good blood return.\n\nSocial: Liver team informed pt and his brother and proxy, , re low chance of transplant D/T clot.\n\nPlan: Cont . Await transplant committee decision on Tuesday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-14 00:00:00.000",
"description": "Report",
"row_id": 1566937,
"text": "Shift Note 1900-0700\nCV: HR 70's, NSR with no ectopy. NIBP 90/40-60's. Pt was running on CVVH until yesterday afternoon when d/c. Hct down 24 (26.2)...transfuse for Hct <21. Coagulopathy; FFP/cryo if evidence of bleeding.\n\nResp: RR 10-17; sats >94% RA. BBS CTA.\n\nNeuro: A/Ox3. Pt c/o aching in back, relieved by repositioning until around 0500 when he awoke and having pain in back. Given prn oxycodone 5mg and currently asleep.\n\nGI/GU: Ascites. BS present. Tolerating renal diet; pt continually requesting PO fluids. Pt remains on strict I/O (1000cc fluid restriction);hyponatremic. Voided urinal for 50cc dark yellow/amber urine. Receiving lactulose; no BM this shift.\n\nID: low grade temp 99.5. BC sent with am labs. Contact precautions.\n\nPlan: ? need for dialysis; possible c/o to floor when okay with renal.\n\nSocial: brother to visit; copy of HCP in chart.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-14 00:00:00.000",
"description": "Report",
"row_id": 1566938,
"text": "Nursing Progress note 0700-1900\nEvents: Restarted on CVVHD @ 1745 in prep for liver transplant.\n\nReview of systems:\n\nNeuro: Pt remains AAO X 3, dozing less freq today. Did not require any pain med for back this shift. Moves self in bed, and amb to commode without assist.\n\nResp: O2 sat 99-100% on RA with RR 9-14 and regular. Lung snds clear throughout.\n\nCV: HR 64-76SR without VEA. BP 84/40-103/48. Hct stable @ 26.\n\nGI: Appetite cont good. Fluid restriction increased to 1200ml/day. Pt with loose brown stool X 2, lactulose and reglan held.\n\nGU: Pt voided 50ml amber urine X 1. CVVHD restarted @ 1745, with alternating replacement solutions of NA and Prismasate per order.\n\nID: Afebrile. Rec'd Vanco X 1.\n\nPlan: Cont CVVHD to stabilize pt for liver transplant.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-15 00:00:00.000",
"description": "Report",
"row_id": 1566939,
"text": "Shift Note 1900-0700\nPt 54 y/o M with ETOH cirrhosis, liver failure, renal failure on CVVH; placed on liver transplant.\n\nCV: HR 60-70's, NSR with no ectopy. NIBP 90's/40(baseline hypotension). Hct 25.5; Plt 53.\n\nAccess: PIV x1 20g right posterior forearm; flushes well\nLSC dialysis with med port.\n\nResp: RR 12-15; sats >98% on RA. BBS CTA. Pt with strong congested cough.\n\nNeuro: Pt receiving lactulose TID; hepatic enceph. improved. A/O x3; pleasant and cooperative with care. c/o aching and pain in back and medicated last at 0200 with prn 5mg oxycodone with some relief. Back pain improves with frequent repositioning.\n\nGI/GU: Ascites, abdomen distended. No UO/BM this shift. BS hyperactive. Pt on renal diet; tolerating well. 1000cc fluid restriction.\n\nCVVH: Pt started on CVVH around 1800 yesterday. Filter clotted around 0100, requiring new set. Blood flow increased from 80 to 100. Goal to run patient even. Alternating replacement solution b/w NaCl and prismasate. Na 128. Following VBG's 7.34/42/30/21 last evening and 7.28/42/30/21 this am. KCL and CaGluconate replacement according to sliding scale. Continue to monitor lytes and VBG Q6hrs.\n\nSkin: Intact; skin cool/dry...jaundiced.\n\nEndo: SSC; BS elevated, monitor closely. need to adjust SSC.\n\nID: Afebrile. BC pnd. Additional set of peripheral BC sent this am with labs. Urine cx from with staph, ?UTI.\n\nSocial: brother to visit last evening.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-21 00:00:00.000",
"description": "Report",
"row_id": 1566953,
"text": "0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET AND TRANSFER NOTE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT ALERT AND ORIENTED X3. PLEASANT AND COOPERATIVE W/ CARE. FOLLOWS COMMANDS, MAE, PERLA. PT DENIES PAIN. OOB TO CHAIR W/ ASSIST X1 FOR MOST OF SHIFT. NSR @ 69-79, NO ECTOPY NOTED. NBP= 92-108/43-58. AM HCT= 23.6, MICU TEAM ORDERED HCT CHECKS DAILY W/ PARAMETERS TO TRANSFUSE IF BELOW 21. AFEBRILE. AM WBC= 8.5. CIPRO PO 1X/WEEK AND NO IV VANCO ORDERED THIS SHIFT. CONTACT PRECAUTIONS CONTINUE FOR STAPH UTI. LEFT DUAL LUMEN PICC INTACT. RIGHT SUBCLAV DIALYSIS INTACT, DRSG X2 THIS SHIFT R/T BLEEDING AT SITE. SURGICEL AND SURGIFOAM USED. AM INR=2.3. LS= CLEAR/DIM. 02 SAT 93-100%. RR=. PT TOLERATING RENAL DIET. PRESENT BS. LACTULOSE CONTINUES TID FOR ENCEPHALOPATHY. OCTREOTIDE SQ AND MIDODRINE PO CONTINUES. POSITIVE ASCITES. NO VOID THIS SHIFT. LAST DIAYLSIS TREATMENT COMPLETED LAST HS AT APPROX 2300, NEXT DUE WED . FS QID ON S/S COVERAGE 118-194. LIVER AND RENAL TEAM MET TODAY TO DISCUSS PLAN OF CARE AND POSSIBILITY OF LIVER TRANSPLANT. SURGICAL TEAM UNABLE TO ATTEND MEETING, DECISION WILL BE MADE TOMORROW REGARDING LIVER TRANSPLANT. PT MADE AWARE, EMOTIONAL SUPPORT PROVIDED R/T PT LOOKING FORWARD TO FINDING OUT SOME NEWS TODAY. PT SPOKE W/ BROTHER AND REPORTS FEELING BETTER. PT CALLED OUT TO FLOOR. PT STABLE, READY TO TRANSFER TO FLOOR WHEN PRIVATE BED AVAILABLE ON 10.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-22 00:00:00.000",
"description": "Report",
"row_id": 1566954,
"text": "7p to 7a Micu Progress Note\n\nOverview of events - pt stable overnight but continued to ooze lg amt BRB from Dial LSC line. Surgicel, gelfoam and elastoplast pressure dssg applied without resolution. FFP to be given and IR consulted re: line.\n\nNeuro - Pt alert and oriented x 3. OOB to chair. Minimal assist with transfers. PT consult ordered as pt's overall strength has deconditioned. Pt declined any pain med for chronic back pain.\n\nResp - LS clear, diminished at bases. RR 11-16. 02 sat > 97% on RA.\n\nC-V - HR 70-80 NSR, no ectopy. NBP 85-114/40-50.\n\nGI - Abd + ascites. Tolerating renal diet without n/v, although intake poor. Nutrition has been consulted. Rx with lactulose tid for encephelopathy. Passed mod amt loose golden guiac + stool on bedpan. c/o pain from hemorrhoids. Hydrocortisone rectal cream to be ordered by MD.\n\nF/E - TFB + 1150ccs ( pt not dialzyed). To have HD today. BUN and Cr rising to 30/4.2 respectively. Phos 2.4 - Per renal, sucralfate should be dcd. Na 126 - remains on 1000cc fluid restriction. Pt voided 25ccs amber colored urine with urinal.\n\nHeme/Access - INR 2.0 at onset of shift. Rx with 5 mg vit K sc. As per above pt continued to bleed lg amt of blood from Dial LSC line despite surgicel, gelfoam and elastoplast pressure dssg. Hct 24.5 last eve, dropping to 22.2 this am. PT 19.5 PTT 57.4. INR 1.9. To be transfused one unit frozen plasma. IR to be consulted re Dialysis line. ? purse string sutures to be applied. Telfa pad applied to RUE skin tear which has also been bleeding.\n\nID - Afeb. WBC 4.5. + contact precautions. Vanco dosed per level for staph uti, no vanco administered. ? vanco to be dcd per transplant team recommendations.\n\nSocial - Brother and numerous family members visited with pt last eve. Liver and surgical service to meet with pt and brother at 3pm today.\n\nA+P - FFP to be administered. ? purse string sutures need to be utilized to prevent further bleeding from dialysis line. Pt to receive HD today. Pt called out - stable to go to floor once bleeding from RSC dialysis line is resolved.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-22 00:00:00.000",
"description": "Report",
"row_id": 1566955,
"text": "0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET AND TRANSFER NOTE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT CALLED OUT TO FLOOR, AWAIT AVAILABLE BED AND LEFT SUBCLAV BLEEDING TO RESOLVE. PT ALERT AND ORIENTED X3. PLEASANT AND COOPERATIVE W/ CARE. PT FOLLOWS COMMANDS, MAE, PERLA. PT DENIES PAIN AT THIS TIME. OOB TO CHAIR X 1 ASSIST. WHILE IN BED EARLIER IN SHIFT, PT C/O BACK PAIN AND MEDICATED W/ OXYCODONE 5MG PO X2 DOSES W/ GOOD EFFECTS. SB TO NSR 62-90. AFEBRILE. NBP=89-110/37-56. PT C/O SLIGHT PALPITATION DURING HEMODIALYSIS TODAY, HR UP TO 104 AND SBP DOWN TO 89. 02 SAT DROPPED TO 85%. 5L N/C AND FACE TENT APPLIED R/T PT ASLEEP AND MOUTH BREATHING. ALL RESOLVED AFTER HD COMPLETED. LS= CLEAR/DIM. RR=. 02 SAT 92-100% ON RA. PT TOLERATING RENAL DIET. PRESENT BS. POSITIVE ASCITES. LACTULOSE CONTINUES TID FOR ENCEPHALOPATHY. PT VOIDS , NONE THIS SHIFT. HEMODIALYSIS DONE FOR APPROX 1 HR TODAY, NO VOLUME REMOVED. LEFT SUBCLAV DIALYSIS LINE INTACT, BLEEDING FROM SITE CONTINUES SINCE LAST HD TREATMENT ON MON PM. HEPARIN GIVEN IN HD PORTS ON , CITRATE GIVEN IN HD PORTS INSTEAD TODAY. AM INR=1.9. AM HCT=22.2. PT RECEIVED K X2 DOSES YESTERDAY. 2 UNITS OF FFP TODAY. DDAVP THIS SHIFT AND MULTIPLE DRSG / SURGICEL AND SURGIFOAM TO AID CLOTTING. IR CONSULTED AND ASSESSED HD LINE FOR POSSIBLE PURSE STRING SUTURE. PLEASE SEE PROGRESS NOTES FOR RECOMM, NO SUTURE PLACED AT THIS TIME. MICU TEAM AWARE SITE STILL BLEEDING AND PM HCT DOWN TO 20.9 AND PM INR 1.7. AMINOCAPROIC ACID OR AMICAR RINSE ORDERED TO BE APPLIED DIRECTLY TO SITE. LIVER AND SURGICAL TEAM MADE FINAL DECISION THIS SHIFT. LIVER ATTENDING DR MET W/ PT AND BROTHER TO INFORM THEM THAT PT IS NO LONGER LIVER CANDIDATE. EMOTIONAL SUPPORT PROVIDED. PT HAS DECIDED AT THIS TIME THAT HE WOULD LIKE TO STOP DIALYSIS AND RETURN HOME. MICU TEAM AWARE AND WILL NEED TO GET PALLIATIVE CARE INVOLVED TOMORROW. PT CALLED BACK IN AND WILL STAY IN MICU TONIGHT DUE TO DROPPING HCT, DOWN 6 PTS SINCE . MICU TEAM ORDER UNITS OF PRBC FOR TONIGHT IF PT AGREES. FS QID ON S/S COVERAGE. FULL CODE. PT AND BROTHER UPDATING REST OF FAMILY R/T FINDINGS.\n\nPLAN- ASSESS DIALYSIS SITE FOR BLEEDING, ADMIN PRBC AND MONITOR HCT AS ORDERED. PROVIDE EMOTIONAL SUPPORT AND FOLLOW UP W/ PALLIATIVE CARE IN AM. SOCIAL WORK CONSULT AS NEEDED. POSSIBLE REMOVAL OF DIALYSIS LINE IN IR TOMORROW IF PT REQUESTS. CONTINUE ICU SUPPORTIVE CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-23 00:00:00.000",
"description": "Report",
"row_id": 1566956,
"text": "MICU Nursing Note 1900-0700\nEvents: Left SC Dialysis catheter continues to ooze during night with HCT down to 20.9. Transfused with 1 unit Cryoprecipitate, 1 unit FFP, and 1 unit pRBC's overnight with am labs to be sent.\n\nNeuro: A+OX3, pleasant and cooperative, verbalizing about plan to go home over next few days, Moves all extremities and follows all commands, OOB to chair until MN and rested in naps overnight. Denies lightheadedness or dizziness.\n\nCardiac: HR= 60-80's SR with no ectopy noted, BP= 95-110/50's, Right PICC site C/D/I with no oozing and ports patent, Left SC Dialysis catheter continued to ooze blood throughout evening---MICU team and Attending assessed pt, HCT down to 20.9, asymptomatic for blood loss, Thrombin dressing placed over site at MN with no further bleeding noted---dressing remains D/I, Transfused with 1 unit cryoprecipitate, 1 unit FFP, and 1 unit pRBC's---without evidence of reaction noted.\n\nResp: Lungs clear upper lobes and rales at bilat. bases, denies SOB, RR= with Sats= 97-99 on RA.\n\nGI: Abd with large amt. ascites, tolerating renal diet, taking sips during night, no N/V, no BM, + bowel sounds all quads.\n\nGU: no void\n\nSkin: no acute change noted.\n\nEndo: fingerstick 199 at MN---treated with 2 units SC insulin and am fingerstick 135.\n\nSocial: pt on phone with family members most of evening. No contact from family members or friends with nursing staff, MICU resident addressed code status with pt during evening and pt remains full code until he can discuss it further with his brother and have more time to think about his options. Stating that he would like to go home to as soon as possible.\n\nPlan: Monitor blood levels and transfuse if needed, Monitor Dialysis site for further bleeding and change dressing prn, ? of HD in future, Begin discharge plan to , If bleeding subsides transfer pt out to medical floor for further management, Support pt and family prn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-23 00:00:00.000",
"description": "Report",
"row_id": 1566957,
"text": "0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET AND TRANSFER NOTE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT ALERT AND ORIENTED X3. PLEASANT AND COOPERATIVE W/ CARE. PT FOLLOWS COMMANDS, MAE, PERLA. PT DENIES PAIN AT THIS TIME, OOB TO CHAIR X 1 ASSIST. WHILE IN BED, C/O BACK PAIN AND MEDICATED W/ OXYCODONE 5MG PO X 2 DOSES PRN W/ GOOD EFFECTS. SB TO NSR @ 56-95. AFEBRILE. NBP=90-110/37-52. LS= CLEAR/DIM. 02 SAT 95-100% ON RA. PT DENIES SOB. NO INCREASED WOB NOTED. PT RECEIVED CRYO, 1U PRBC, AND 3U FFP OVER PAST 24HRS FOR BLEEDING DIALYSIS LINE. HCT DROPPED TO 20.9 FROM 22.2, FOR A TOTAL 6 PT HCT DROP FROM 26.2 ON . TOPICAL THROMBIN APPLIED LAST HS W/ GOOD EFFECTS, NO BLEEDING FOR APPROX 12HRS. PT RECEIVED HEMODIALYSIS TODAY FOR 3 HRS, NO FLUID REMOVED. 02 SAT DROP TO 87%, SBP TO 89, AND HR TO 100. 02 N/C 5L AND FACE TENT APPLIED, 02 SAT UP TO 93-94%. PT TOLERATED WELL, OVERALL ASYMPTOMATIC. BLEEDING FROM DIALYSIS LINE AFTER HD COMPLETE. TOPICAL THROMBIN APPLIED AGAIN W/ GOOD EFFECTS. DRSG AND AT THIS TIME. AM HCT=22.2 AND AM INR=1.6. WILL CONTINUE TO MONITOR DIALYSIS SITE. ABD MORE DISTENDED TODAY, INCREASING ASCITES. MICU TEAM PLANS TO DO PARACENTESIS BEFORE D/C HOME, PT AWARE AND AGREES. PRESENT BS. LOOSE BROWN STOOL W/ BRB DUE TO HEMORRHOIDS. RECTAL EXAM DONE BY LIVER/GI FELLOW TO CONFIRM BRB MOST LIKELY DUE TO HEMORRHOIDS. OINTMENT APPLIED BY NRSG. LACTULOSE CONTINUES TID FOR ENCEPHALOPATHY. PT VOIDS , APPROX 30CC DARK AMBER THIS SHIFT. PALPABLE PEDAL PULSES. FS QID ON S/S COVERAGE. FULL CODE. PT'S FAMILY VISITED AND UPDATED ON CONDITION. EMOTIONAL SUPPORT PROVIDED. MICU AND RENAL SOCIAL WORKER AS WELL AS CASE MANAGEMENT INVOLVED R/T END OF LIFE CARE.\n\n TRANSFER TO 10 WHEN BED AVAILABLE. PT REQUESTS TO BE D/C'D HOME W/ SERVICES ON FRIDAY. PLAN FOR DIALYSIS 3X/WEEK AT FACILITY IN . PROVIDE SUPPORT AND TEACHING R/T CHOICES INVOLVED IN END OF LIFE CARE. CODE STATUS TO BE RE-ADDRESSED BY MICU TEAM. POSSIBLE PARACENTESIS TONIGHT VS TOMORROW. CONTINUE ICU SUPPROTIVE CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-13 00:00:00.000",
"description": "Report",
"row_id": 1566935,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Pt remains alert and oriented x 3. MAE. Medicated with 5mg oxycodone x 2 for back pain with good effect. Lactulose for encephelopathy prophylaxis.\n\nResp - LS clear. + dry cough. RR 10-18. 02 sat > 96%.\n\nC-V - HR 66-80 NSR. NBP 90-110/40's. Hct stable at 26.2. INR increased to 2.7.\n\nGI - Abd + ascites. Tolerating renal diet. No n/v or abd pain. Passed lg amt loose brown stool on bedpan with minute amt of blood - pt reports bleeding from internal hemorrhoids in the past.\n\nF/E - Remains on CVVHD with even fluid rate goal. TFB + 41ccs . Currently + 18. System clotted x 1. Access and Return lines reversed due to high access pressures. Ca and K drips infusing via sliding scale per CCRT protocol. BUN/Cr improving - down to 29/2.5 respectively. Pt with persistant hyponatremia, Na dropping to 129 despite 1000cc fluid restriction. Phos 1.7 - ? replacement. Pt voided 125ccs amber colored urine in urinal.\n\nID - Afeb. WBC 3.9. + contact precautions - hx c-dif. ? VRE in urine - results pend.\n\nSocial - No visitors. Pt spoke with brother on phone.\n\nA+P - BP remains stable during CVVHD. BUN/CR improving. ? pt can return to HD soon.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-13 00:00:00.000",
"description": "Report",
"row_id": 1566936,
"text": "Nursing Progress note 0700-1900\nEvents: CVVHD D/C'd @ 1200. Pt voiding small amts.\n\nReview of systems:\n\nNeuro: Pt dozing intermit, otherwise AAO X 3. Pleasant, follows comands consistantly. Occas slurring of words. Requested pain med for back X 1, rec'd Oxycodone with good relief. Sucking almost continuously on lozanges or chew gum (smoker).\n\nResp: O2 sat 97-99% on RA with RR 8-14 and regular. Lung snds clear throughout.\n\nCV: HR 67-82SR without VEA. BP generally 86/39-103/57, with rare dips in SBP to high 70's. K+ and ionized Ca WNL @ 1100. Phos-lo D/C'd(phos 1.7) and pt started on epogen.\n\nGI: Pt with good appetite, tolerating renal/ diet well. Cont to receive Lactulose RTC, no BM this shift.\n\nGU: Filter of CVVHD clotted @ 1130 and dialysis was subsequently D/C'd. HD lines heparinized. Pt voided 75ml of amber urine with sed in am which was sent for U/A. 24hr fluid balance MN->1700 +555ml, with LOS balance +941ml. Pt cont to push limits of 1000ml/day fluid restriction.\n\nID: T max 99.0po@ 1600. Pt to receive Cipro Q week.\n\nPlan: Straight if pt without void this pm. Cont to monitor blood levels for ? restarting HD. Cont to enforce fluid restriction. Awaiting proxy papers from brother, .\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-19 00:00:00.000",
"description": "Report",
"row_id": 1566948,
"text": "MICU NURSING PROGRESS NOTE. 0700-1900\n PLEASE SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Crrt machine failed this pm, placed on hold by team. Minimal medication changes. Denies any nausea this shift but still only taking po liquids.\n\n Neuro: Alert and oriented x 3. Speach is clear and is able to make needs known verbally. Mae. Following commands. Denies discomfort as of this time. Temperature max. 97.5 oral.\n\n Resp: Lung sounds are clear throughout, diminished in rt base. RR 12-22 and non labored. O2 saturation 95-100% ra.\n\n CV: Sinus rhythm with no ectopy noted, rate 60-100's. Nbp 90's to 110's systolic. Picc line rt ac patent, site wnl. Lt sc dialysis line site wnl.\n\n GI/GU: Abdomen ascitic with + bs. Taking liquid po's. No bm this shift. No urine this shift.\n\n Social: No social contacts this shift.\n\n Crrt: Cvvhdf machine failed, failure code 0080. Team aware, crrt on hold as of this time. Catheter heparinized.\n\n Endo: Fs 122/135/156. This pm fs covered with 2 units regular insulin.\n\n ID: Awaiting ID approval for vancomycin dose.\n\n Plan: Start hd tomm. Monitor electrolytes and repleat as required. Medicate for discomfort. Encourage po intake with fluid restiction. Cipro dose tomm.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2150-07-08 00:00:00.000",
"description": "Report",
"row_id": 82658,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. /Pre liver transplant. Portal thrombus.\nHeight: (in) 66\nWeight (lb): 200\nBSA (m2): 2.00 m2\nBP (mm Hg): 102/60\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 16:17\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality.\n\nConclusions:\nSuboptimal study.\n\n1. The left atrium is mildly dilated. The left atrium is elongated.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. The LV is not well seen but limited views demonstrate normal\nregional left ventricular wall motion.. Overall left ventricular systolic\nfunction appears normal (LVEF>55%).\n3. Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation\n5.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen.\n6.There is no pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-08 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 923388,
"text": " 12:48 PM\n RENAL U.S. Clip # \n Reason: please eval for hydronephrosis\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis, renal failure worsening after Foley removal\n\n REASON FOR THIS EXAMINATION:\n please eval for hydronephrosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Worsening renal failure, cirrhosis.\n\n RENAL ULTRASOUND: The right kidney measures 10.3 cm, and the left kidney\n measures 10.8 cm. There is limited evaluation of the lower pole of the right\n kidney. There are no renal masses, stones, or hydronephrosis. The echogenicity\n of the kidneys is normal. Ascites is noted in the right upper and lower\n quadrants. The bladder is partially collapsed.\n There is a small nodular liver consistent with known cirrhosis.\n\n IMPRESSION: No hydronephrosis. Ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-06-29 00:00:00.000",
"description": "MRI ABDOMEN W/O & W/CONTRAST",
"row_id": 922238,
"text": " 6:44 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \n MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\n Reason: please evaluate mass\n Admitting Diagnosis: CIRRHOSIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis and new finding of liver mass\n REASON FOR THIS EXAMINATION:\n please evaluate mass\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: MRI of the abdomen with and without contrast \n\n COMPARISON: Abdominal ultrasound, .\n\n TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 Tesla\n magnet including dynamic 3d imaging obtained prior to, during, and after the\n uneventful intravenous administration of 0.1 millimole per kilogram of\n gadolinium-DTPA.\n Multiplanar reformats were essential in providing multiple perspectives for\n the dynamic series.\n\n There is a small right pleural effusion and right lower lobe atelectasis.\n There is a region of susceptibility artifact on the in-and-out-of-phase images\n within the right lower lobe which may represent artifact from a granuloma.\n Diffuse ascites is demonstrated within the abdomen. The liver contour is\n nodular, the liver is shrunken consistent with cirrhosis. There is\n splenomegaly and multiple portosplenic collaterals including paraesophageal\n varices and spontaneous splenorenal shunt, consistent with portal\n hypertension. Increased T1 signal is demonstrated within the portal vein on\n the in-and-out-of-phase images with lack of enhancement on post-contrast\n images suspicious for portal venous thrombosis. The liver lesion in question\n on the ultrasound is seen within segment VIII and measures 1.8 cm and\n demonstrates no evidence of early arterial enhancement, but does demonstrate\n delayed enhancement, which may represent a pseudocapsule. There is an 8 mm\n nodular focus of enhancement at the periphery of this lesion which is bright\n on the in-phase image and drops out on the out-of-phase image consistent with\n microscopic fat within the nodule. Although this is an atypical appearing\n nodule, an early hepatocellular carcinoma cannot be excluded. No other\n intrahepatic lesions are demonstrated. The pancreas, adrenal glands, and\n kidneys are unremarkable. Small periportal lymph nodes are demonstrated, the\n largest measuring 8 mm in short axis diameter.\n\n IMPRESSION:\n\n 1. Cirrhosis and evidence of portal hypertension given portosystemic\n collaterals, splenomegaly, and large volume ascites.\n\n 2. 1.7 cm lesion within segment VIII with unusual enhancement\n characteristics; however, which does contain an 8 mm peripheral nodule which\n contains some microscopic fat, early hepatocellular carcinoma cannot be\n (Over)\n\n 6:44 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \n MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\n Reason: please evaluate mass\n Admitting Diagnosis: CIRRHOSIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n excluded. A hemangioma would be much less likely.\n\n 3. No portal venous enhancement on the post-contrast images, these findings\n are suspicious for portal vein thrombosis.\n\n These findings were discussed with Dr. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-16 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 924370,
"text": " 12:42 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC. Failed attempt on floor\n Admitting Diagnosis: CIRRHOSIS\n ********************************* CPT Codes ********************************\n * PICC W/O PORT -59 DISTINCT PROCEDURAL SERVICE *\n * FLUOR GUID PLCT/REPLCT/REMOVE -59 DISTINCT PROCEDURAL SERVICE *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with ETOH cirrhosis, Hepatorenal syndrome, currently on CVVH as\n a bridge to transplant. Needs PICC access\n REASON FOR THIS EXAMINATION:\n Please place PICC. Failed attempt on floor\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT-SIDED 5 FRENCH DUAL LUMEN PICC LINE PLACEMENT VIA RIGHT BASILIC VEIN\n APPROACH; ULTRASOUND-GUIDED VENIPUNCTURE\n\n RADIOLOGISTS: and . Dr. , the Attending Radiologist,\n was present throughout the entire procedure.\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, and appropriate\n requisition. Once the above were verified, the patient was positioned in\n supine fashion with the right arm abducted and externally rotated. The right\n arm was then prepped and draped from the axilla to the antecubital fossa. A\n tourniquet was applied to the upper arm. Ultrasound was employed to visualize\n the right basilic vein which was noted to be widely patent and compressible.\n The skin was infiltrated with approximately 2 cc of 1% Xylocaine for local\n anesthesia at the anticipated needle puncture site. Uneventful retrograde\n one-wall venipuncture was achieved with a 22-gauge micropuncture needle.\n Subsequently, a guide wire was advanced by way of the basilic vein under\n fluoroscopic visualization to the level of superior vena cava. The\n intravascular length of the catheter to be placed was so determined at 34 cm.\n The catheter was tailored at the 34-cm mark and delivered using modified\n Seldinger technique to the level of superior vena cava. Both lumens of the\n catheter were flushed and heparinlocked per protocol. The catheter was\n secured in place with a StatLock device and then overlaid with a Tegaderm\n occlusive dressing. The patient tolerated procedure well without\n complication. Estimated blood loss was minimal.\n\n IMPRESSION: Status post successful placement of 5 French dual lumen PICC line\n placement via right basilic vein approach. Catheter is ready to employ. Post-\n procedural orders written.\n\n\n (Over)\n\n 12:42 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC. Failed attempt on floor\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-16 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 924436,
"text": " 9:11 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: pre-xpl eval, looking at extension of clot in smv\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with liver cirrhosis, portal vein thrombus, ascites, s/p 7.5L\n paracentesis 2 days ago, reacumulated ascites, increasing abdominal pain, low\n hct\n REASON FOR THIS EXAMINATION:\n pre-xpl eval, looking at extension of clot in smv\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n 54-year-old male with cirrhosis and known portal vein thrombosis status post\n paracentesis now with rapid reaccumulation of ascites.\n\n TECHNIQUE: MDCT continuously acquired axial images of the abdomen and pelvis\n were obtained after oral and 130 mL Optiray IV contrast. A delayed portal\n venous phase as well as coronal and sagittal reformatted images were obtained.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a large right pleural effusion\n with associated atelectasis of the right lower lobe. The liver is shrunken\n and nodular consistent with cirrhosis. There is associated cavernous\n transformation of the portal vein and numerous portosystemic collaterals\n noted. There is a large amount of ascites. The spleen is enlarged. The\n gallbladder, pancreas, adrenal glands and kidneys are unremarkable. Small\n bowel is noted to be diffusely dilated up to 4.3 cm. Gas is distributed\n throughout normal caliber colon and there is no focal change in caliber of the\n small bowel suggesting that these findings are more likely due to ileus. There\n is no bowel wall thickening or pneumatosis intestinalis. The portal vein does\n not opacify and there is soft tissue density within the lumen consistent with\n thrombus. The thrombus extends 1-cm into the SMV and 1.5-cm into the splenic\n vein. The remainder of the mesenteric veins opacify well. There is no\n mesenteric venous gas or free intraperitoneal gas. A small chronic\n nonocclusive thrombus within the infrarenal IVC is similar to MR .\n\n CT OF THE PELVIS WITH IV CONTRAST: Ascites tracks into the pelvis. There is\n stool mixed with gas in the rectum and sigmoid colon. The urinary bladder is\n unremarkable.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are\n identified. Old rib fracture deformities are noted.\n\n IMPRESSION:\n 1. Cirrhosis.\n 2. Large amount of ascites.\n 3. Portal vein thrombosis extends 1-cm into the superior mesenteric vein and\n 1.5-cm into the splenic vein.\n 4. Large right pleural effusion with atelectasis of the right lower lobe.\n 5. Ileus.\n (Over)\n\n 9:11 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: pre-xpl eval, looking at extension of clot in smv\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-09 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 923566,
"text": " 3:14 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: please place 3-port temporary dialysis catheter on the left,\n Admitting Diagnosis: CIRRHOSIS\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1752 CATH,HEM/PERTI DIALYSIS SHORT *\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis and worsening ARF, will need HD\n REASON FOR THIS EXAMINATION:\n please place 3-port temporary dialysis catheter on the left, R IJ line to be\n pulled by team later today, INR 2.5- to get 4U FFP\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis and worsening renal failure, requires hemodialysis.\n\n TECHNIQUE/FINDINGS: After informed consent was obtained, the patient's left\n supraclavicular area was prepped and draped in a sterile fashion. Under\n ultrasound guidance, a micropuncture set was used to enter into the left\n internal jugular vein just above the clavicle. Hard copy ultrasound images\n were obtained before and after venous access documenting vessel patency. A\n 0.035 wire was advanced into the IVC under flouroscopic guidance. After\n which, the tract was dilated and a 16 cm triple lumen catheter advanced with\n its tip in the proximal atrium. Catheter has three ports, one for\n aspiration/infusion and arterial and venous ports for dialysis. The catheter\n was sewn in place with two times 0- silk sutures. There were no\n complications.\n\n IMPRESSION: Placement of a non-tunneled hemodialysis line via the left IJ\n without complication. Catheter tip is in the proximal right atrium and ready\n for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-16 00:00:00.000",
"description": "TUNNELED W/O PORT",
"row_id": 924323,
"text": " 7:23 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: please place a tunnelled HD line\n Admitting Diagnosis: CIRRHOSIS\n ********************************* CPT Codes ********************************\n * TUNNELED W/O PORT *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL ADDENDUM\n MEDICATIONS: Moderate intravenous sedoanalgesia was employed in the course of\n the tunneled catheter placement. The patient received one dose of Versed 0.5\n mg IV as anxiolytic and 25 mcg of fentanyl IV as analgesic.\n\n\n 7:23 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: please place a tunnelled HD line\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with ETOH cirrhosis, Hepatorenal syndrome, currently on CVVH as\n a bridge to transplant.\n REASON FOR THIS EXAMINATION:\n please place a tunnelled HD line with an extra port to be used for blood draws\n and meds if needed\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: 14.5 French by 28 cm length Angiodynamics, EvenMore tunneled\n hemodialysis catheter placement in exchange for pre-positioned left internal\n jugular approach triple lumen temporary hemodialysis catheter; moderate\n intravenous pseudoanalgesia.\n\n CLINICAL INDICATION: Durable hemodialysis access requirement.\n\n INFORMED CONSENT: Procedural informed consent was obtained from the patient.\n Specifically discussed were the indications for the procedure as well as the\n attendant risk, potential complications and expected outcomes. The patient\n agreed to have the procedure performed and provided witnessed informed consent\n signature which in turn was placed in the medical record.\n\n OPERATORS: , M.D. (fellow).\n , M.D. (fellow).\n , M.D. (supervising staff).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, appropriate requisition,\n and appropriate informed consent. Once the above were verified, the patient\n was positioned in supine fashion on a special procedures table. This\n procedure was performed subsequent to an earlier performed right-sided PICC\n line placement. The latter procedure was dictated and reported under separate\n cover.\n\n The left upper anterior chest was prepped and draped in usual sterile fashion\n as was the external course of a pre-positioned temporary hemodialysis\n catheter. The hemodialysis catheter was accessed and aspirated free of the\n heparin content within the respected lumens. Subsequently, a 1.5 mm J, 0.035-\n inch wire was advanced through the catheter and steered using\n fluoroscopic visualization to the inferior vena cava. Subsequently,\n approximately 3 cc was infiltrated into the skin and subcutaneous tissues\n surrounding the entrance wound for this catheter. An additional 3 cc was\n infiltrated into the planned catheter exit site in the left upper anterior\n chest wall. An additional 10 cc was infiltrated subcutaneously along the\n planned tunnel to the entrance site of the temporary dialysis catheter.\n\n The angiodynamics 14.5 French by 28 cm catheter was then tunneled from an exit\n incision of the left upper anterior chest wall to the venipuncture/dermatotomy\n site in the left upper chest at the supraclavicular region. Subsequently, the\n (Over)\n\n 7:23 AM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: please place a tunnelled HD line\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n retention sutures on the temporary dialysis catheter were removed and the\n catheter itself delivered over the guidewire leaving the guidewire in situ.\n Subsequently, the peel-away sheath/dilator the tunneled dialysis catheter was\n advanced over the wire under fluoroscopic visualization carefully to the level\n of the superior vena cava. Subsequently, the inner dilator was removed as was\n the guidewire. The tunneled dialysis catheter was then delivered using\n modified Seldinger technique through the peel-away sheath to the right atrium\n level. The peel-away sheath was split and then removed.\n\n Hemostasis was achieved at both the venipuncture/dermatotomy site and the exit\n wound site using digital compression for approximately 5 minutes. The\n supraclavicular wound was then closed with dermatotomy and then overlaid with\n a 2 x 2 dressing, folded in quarters. Both wounds were then overlaid with a\n Tegaderm occlusive patch. Both lumens of the tunneled dialysis catheter were\n flushed and heparin locked per protocol. The patient tolerated the procedure\n well without incident.\n\n IMPRESSION:\n\n 1. Status post successful placement of tunneled hemodialysis catheter in\n exchange for a previous positioned left internal jugular post-temporary\n hemodialysis catheter. See above description. The catheter is ready to\n employ. Post-procedural orders written.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 922832,
"text": " 4:54 PM\n CHEST (PA & LAT) Clip # \n Reason: Pls evaluate for infiltrate\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man liver cirrhosis, portal vein thrombus awaiting liver transplant\n with rigors, leukopenia WBC 1\n REASON FOR THIS EXAMINATION:\n Pls evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old man with liver cirrhosis, portal vein thrombosis\n awaiting liver transplant, now with rigors, leukopenia. Evaluate for\n infiltrate.\n\n COMPARISON: AP upright portable chest x-ray dated .\n CT chest dated .\n\n PA AND LATERAL CHEST X-RAY: A right internal jugular central venous catheter\n terminates in unchanged position in the distal SVC. The cardiac silhouette,\n mediastinal and hilar contours are normal. The pulmonary vasculature is\n normal. Allowing for differences in technique, there is no significant\n interval change compared with prior study from . There is stable mild\n pulmonary edema and a small right- sided pleural effusion. Multiple old,\n healed right sided rib fractures are again noted.\n\n IMPRESSION: Stable mild pulmonary edema and small right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-02 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 922698,
"text": " 4:56 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assessment for liver metastasis\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man, cirrhotic, portal vein thrombus with 2cm mass adjacent to\n portal vein. Chest CT as work up for OLT to assess for possible metastatic\n disease.\n REASON FOR THIS EXAMINATION:\n assessment for liver metastasis\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis with hepatic lesions suspicious for hepatocellular\n carcinoma. Assess for metastatic disease.\n\n COMPARISON: Chest radiograph .\n\n TECHNIQUE: MDCT acquired contiguous axial images from the thoracic inlet to\n the upper abdomen were obtained without intravenous contrast.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: Poorly-defined, scattered, ground glass\n opacities in both upper lobes are either inflammatory or due to resolving\n pulmonary edema. 4 mm non-calcified solid nodule in the superior segment of\n the right lower lobe (series 4, image 27) is present. Small bilateral pleural\n effusions, right greater than left, are associated with dependent parenchymal\n opacities, likely atelectasis. A small dystrophic calcification involving the\n posterior inferior left pleura likely reflects prior pleural insult. Airways\n are patent to the subsegmental bronchi bilaterally.\n\n No pathologically enlarged mediastinal, hilar, or axillary lymph nodes are\n present. Coronary artery calcifications and focal calcified atherosclerotic\n plaque in the aortic arch are present. Heart, pericardium, and great vessels\n are otherwise unremarkable. Right internal jugular central venous catheter\n tip terminates in the distal SVC. Small mediastinal venous collaterals feed\n into a distended azygos vein.\n\n The liver is shrunken and nodular consistent with cirrhosis. Ill-defined\n hypodensity within segment VIII of the liver corresponds to the abnormality\n noted on recent MRI from . Splenomegaly with splenic and\n esophageal varices and ascites indicate portal hypertension.\n\n No osseous lesions are worrisome for malignancy.\n\n IMPRESSION:\n 1) 4 mm right lower lobe pulmonary nodule. 3 month follow up chest CT is\n recommended in this patient with possible hepatocellular carcinoma.\n\n 2) Small bilateral pleural effusions with associated mild compressive\n atelectasis.\n\n (Over)\n\n 4:56 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assessment for liver metastasis\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3) Bilateral upper lobe peripheral ground glass opacities are likely\n inflammatory in etiology or due to resolving pulmonary edema.\n\n 4) Cirrhosis with portal hypertension.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 923858,
"text": " 7:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis currently on CVVH\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION PERFORMED: AP chest.\n\n INDICATION: A single AP view of the chest is obtained at 0813 hours\n and compared with a prior radiograph performed on . Significant\n improvement in the appearance of pulmonary edema has occurred. There is no\n evidence of acute infiltrate, pleural effusion, or pneumothorax on the current\n examination. Left-sided vascular catheter has been inserted with its tip\n overlying the expected location of the SVC. Multiple prior rib fractures are\n noted on the right side. No pneumothorax is visible.\n\n IMPRESSION:\n\n Improvement in the mild pulmonary edema since prior examination. Insertion of\n left- sided vascular catheter with no evidence of hemothorax or pneumothorax\n on the current examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-02 00:00:00.000",
"description": "BONE SCAN",
"row_id": 922588,
"text": "BONE SCAN Clip # \n Reason: LIVER MASS, BEING EVALUATED FOR LIVER TRANSPLANT\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 26.3 mCi Tc-m MDP;\n HISTORY: 54 year old man with cirrhosis and liver mass, presenting for liver\n transplant work-up.\n\n INTERPRETATION:\n\n Whole body images of the skeleton were obtained in anterior and posterior\n projections. Mildly increased diffuse tracer activity over the soft tissue of\n the abdomen is consistent with ascites. There is asymmetric increased tracer\n activity in the region of the right sternoclavicular joint. There are no other\n worrisome foci of abnormal tracer activity.\n\n The kidneys and urinary bladder are visualized, the normal route of tracer\n excretion.\n\n There are no prior studies available for comparison.\n\n IMPRESSION: 1) Increased tracer activity in region of right sternoclavicular\n joint may be degenerative. If isolated osseous metastasis is considered, then\n correlation with CT may be of value. 2) Ascites. 3) If additional\n characterization of liver lesion is desired, then a blood pool study may be\n useful in evaluation of a possible hemangioma.\n\n\n , M.D.\n , M.D. Approved: FRI 8:19 AM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-01 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 922463,
"text": " 10:27 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: pls evaluate flow with doppler to evaluate ?portal vein \n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis, ascites, ?portal vein thrombus\n REASON FOR THIS EXAMINATION:\n pls evaluate flow with doppler to evaluate ?portal vein thrombus\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Ultrasound abdomen.\n\n INDICATION: Examine portal vein.\n\n FINDINGS: In relation to the right lobe of liver, again note is made of the\n low echogenic area measuring 2.36 cm. This was previously identified on\n ultrasound and on MR and the appearances may be consistent with a\n hepatocellular CA. Note is made of significant ascites. No other focal\n lesion in relation to the liver. The extrahepatic portal vein is visualized,\n however, there is no flow within the intrahepatic portal vein. The hepatic\n artery is visualized and there is normal flow. The hepatic veins are patent\n and demonstrate flow. There is splenomegaly with the spleen measuring 16 cm.\n Note is made of splenic varices.\n\n IMPRESSION:\n\n No flow seen within the portal vein. It may represent thrombosis.\n\n Lesion in right lobe of liver, which may represent hepatocellular carcinoma\n and previously identified on ultrasound and MR.\n\n Ascites.\n\n Splenomegaly.\n\n Splenic varices.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-06-26 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 921804,
"text": " 8:06 AM\n ABDOMEN U.S. (COMPLETE STUDY); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: evaluate for ascites, please mark spot for paracentesis\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis, distended abdomen.\n REASON FOR THIS EXAMINATION:\n evaluate for ascites, please mark spot for paracentesis\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Abdominal ultrasound.\n\n CLINICAL HISTORY: 54-year-old man with cirrhosis, distended abdomen.\n Evaluate for ascites. Please mark spot for paracentesis.\n\n FINDINGS: There is extensive ascites. The liver is small, echogenic with an\n irregular contour, consistent with cirrhosis. In the left lobe of the liver,\n anterior to the portal vein, there is a 2.2 cm demarcated hypoechoic mass.\n Given the patient's history, this is concerning for the presence of\n hepatocellular carcinoma. Additional imaging, such as MR may be\n considered for further characterization of this finding. A mark was made over\n the right lower quadrant for paracentesis.\n\n There is sludge in the gallbladder, without evidence of stones. No intra - or\n extrahepatic biliary ductal dilatation. The spleen is enlarged, measuring up\n to 15.9 cm.\n\n The kidneys are normal in size and echotexture, with the right kidney\n measuring 11.9 cm and the left kidney measuring 11.3 cm.\n\n IMPRESSION:\n 1. 2.2 cm hypoechoic mass in left hepatic lobe that is concerning for\n hepatocellular carcinoma.\n 2. Ascites marked for paracentesis at right lower quadrant.\n 3. Splenomegaly.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-06-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 921771,
"text": " 9:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate central line placement.\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis, has R sided central line.\n REASON FOR THIS EXAMINATION:\n evaluate central line placement.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Evaluate central line placement. 54-year-old man with\n cirrhosis.\n\n COMPARISON: None.\n\n FINDINGS: Right internal jugular vein with tip in the inferior third of the\n SVC. There is no pneumothorax. The size of the heart is normal. The\n mediastinal contour is unremarkable. Small right pleural effusion. Discoid\n atelectasis is seen in the left lower lobe.\n\n IMPRESSION: No pneumothorax. Small right pleural effusion. Vascular line in\n adequate position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-06-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 921973,
"text": " 11:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with hepatic encephalopathy, cirrhosis, and known gastric\n varices who presents with encephalopathy and altered MS.\n FOR THIS EXAMINATION:\n r/o bleed\n CONTRAINDICATIONS for IV CONTRAST:\n likely hepatorenal syndrome\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old man with hepatic encephalopathy, cirrhosis, and known\n gastric varices, who presents with encephalopathy and altered mental status.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, mass effect,\n hydrocephalus, shift of normally midline structures, or major vascular\n territorial infarction. Small foci of hypodensity in the frontal\n periventricular white matter are consistent with chronic microvascular\n ischemia. Osseous and soft tissue structures are unremarkable.\n\n IMPRESSION: No acute intracranial pathology identified, including no evidence\n of intracranial hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-06-26 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 921864,
"text": " 2:01 PM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: Please assess patency of portal vasculature.\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with etoh cirrhosis, hepatic encephalopathy, varices, and acute\n renal failure.\n REASON FOR THIS EXAMINATION:\n Please assess patency of portal vasculature.\n ______________________________________________________________________________\n FINAL REPORT\n DUPLEX DOPPLER ULTRASOUND OF THE LIVER\n\n CLINICAL HISTORY: 54-year-old man with alcoholic cirrhosis, hepatic\n encephalopathy, varices, and acute renal failure. Please assess patency of\n portal vasculature.\n\n FINDINGS: Duplex Doppler ultrasound of the liver was performed on .\n Comparison made to prior study performed earlier in the day.\n\n The portal vein is patent and demonstrates normal hepatopetal flow. The left\n portal vein demonstrates slow velocity and occasional to and fro-type wave\n pattern suggesting stagnant flow. No echogenic material is seen within the\n portal system to suggest the presence of thrombus. The hepatic veins are\n patent. The main, right, and left hepatic arteries are patent and demonstrate\n normal arterial flow.\n\n IMPRESSION:\n 1. Patent portal vein, with waveforms suggestive of stagnant flow, without\n specific evidence of intraluminal thrombus.\n 2. Please see report from previous ultrasound regarding description of left\n hepatic mass.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-17 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 924571,
"text": " 8:37 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please evaluate for distention or evidence of bleeding.\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with history of cirrhosis and ascites, s/p paracentesis today.\n REASON FOR THIS EXAMINATION:\n Please evaluate for distention or evidence of bleeding.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis, ascites, status post paracentesis today. Evaluate for\n distention or evidence of bleeding.\n\n ABDOMEN, SINGLE AP SUPINE PORTABLE VIEW.\n\n The lateral aspects of the abdomen are not included on this film, nor are the\n obturator foramina. Residual oral contrast is present in portions of the\n colon. There are multiple air-filled dilated loops of small bowel in a\n stepladder configuration. Nonethe less, air is seen throughout much of the\n colon. No supine film evidence of free air is identified. No bowel wall\n thickening is detected and no intramural emphysema is seen. Note that many\n forms of hemorrhage would not be evident radiographically.\n\n There appear to be rib fractures in the left posterior ninth and tenth ribs\n and question eleventh rib near the costovertebral junction. The possibility\n of metastatic lesions in these areas cannot be excluded.\n\n Residual contrast is noted in the bladder.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-03 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 922822,
"text": " 3:30 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: pls evaluate flow, acute intraabdominal process\n Admitting Diagnosis: CIRRHOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with cirrhosis, ascites, portal vein thrombus s/p 7.5L para 2\n days ago, reacumulated fluid now w/increasing abdominal pain\n REASON FOR THIS EXAMINATION:\n pls evaluate flow, acute intraabdominal process\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Ultrasound abdomen.\n\n INDICATION: Cirrhosis, ascites, portal vein thrombosis.\n\n FINDINGS:\n\n Again note is made of the area of low echogenicity in the right lobe of the\n liver which measures 2.5 x 2 x 1.5 cm. Again, no evidence of any flow in\n relation to the portal vein. The hepatic veins demonstrate normal flow. The\n hepatic artery has a normal waveform.\n\n There is ascites noted.\n\n The right kidney is visualized and is normal.\n\n Splenomegaly is noted with the spleen measuring almost 16 cm.\n\n The left kidney is normal.\n\n CONCLUSION:\n\n Thrombosis of intrahepatic portal vein.\n\n Ascites.\n\n Approximately 2.5 cm area of low echogenicity in relation to the right lobe of\n liver which may represent a hepatocellular CA.\n\n Splenomegaly.\n\n Splenic varices.\n\n\n"
}
] |
19,270 | 146,196 | A/P: 82 yo W w/ h/o CVA, ESRD, DMII, CHF, rectal ca admitted w/ increased pedal edema, G+ stool, sent to the MICU after admission w/ respiratory arrest and is now s/p intubation. She is now extubated, doing well, and be sent back to the floor. * 1) Respiratory failure - On admission, Mrs. was breathing comfortably with no complaints of SOB. On morning of admission (as per HPI) she experienced acute SOB-->respiratory distress. This was thought to be to flash pulmonary edema vs. mucus plug vs. PNA. Given h/o noncompliant diet(s/p sardines) and incomplete dialysis 2 days prior to admit, flash pulm edema seems most likely diagnosis. 2 L fluid taken off at emergent HD upon transfer to MICU with symptomatic improvement. Also started patient on levo/flagyl for ? PNA - however, f/u CXR showed improvement and was thought to be more consistent with atelectasis. After extubation, patient was stable from respiratory standpoint, with no further SOB or need for supplemental oxygen. * 2) ESRD - DMII; aneuric; admitted with volume overload secondary to dietary noncompliance(ate can of sardines ). s/p emergent dialysis on (with 2 units of RBCs). She was then continued on her outpatient M/W/F dialysis schedule and followed by renal team without further complications. * 3) CAD - demand ischemia w/ trop elevated during this admission (to 0.4); likely high in the setting of renal failure. BB or ace-I were held while she was in the ICU and initially on tranfser to floor because low BP; however, BP normalized and medications were restarted at outpatient doses. Aspirin and plavix were continued throughout hospitalization and on discharge. She is to follow up with Dr. on discharge for further evaluation/treatment of cardiac disease. * 4) NEURO - On admission, Mrs did not demonstrate any residual defects from her previous strokes. However, at onset of respiratory distress there was concern for ? stroke as patient did not appear to be moving L side of body. Head CT negative and after intubation, she was alert and able to move all 4 extremities. Neuro evaluated patient and felt that the episode was likely due to her tenuous cardiorespiratory/fluid status and not CVA. * 5) GIB - G+ stool on admission. Patient was anticoagulated on admission (coumadin started 8 weeks ago after pt had stroke on asa/plavix). INR 2.5 on admission). Hct had dropped 10 points since earlier in the month. Case discussed with GI team who planned to get EGD/colnoscopy when Mrs. was stabalized on floor. Of note, she has a hx of rectal cancer, noted on excisional biopsy. She received to units of blood during emergency dialysis after episode of respiratory distress, which increased hct from 28.5 ->33.2. Hct was stable throughout the rest of admission with no further transfusions required. Coumadin was held during admission for GI procedures and there was discussion with PCP as to whether to continue coumadin on d/c given acute drop in HCT. However, given risk of repeat CVA, her coumadin was restarted on d/c at 2.5mg each evening. PPI was continued during admission and on d/c. Colonoscopy was performed on with polypectomy (adenoma per path report) diverticulae, but no other gross abnormalities. Bx of antrum of stomach on EGD on revealed chronic inactive gastritis. No evidence of active bleeding per GI studies. Hematocrit was stabalized and patient was discharged with close f/u with Dr. to trend cbc. * 6) L arm swelling: Per patient, there was some difficulty with palcement of dialysis needle on Fri with ? nerve damage. She c/o continued swelling, numbness, tingling, and inability to use L hand. She had discussed with outpt nephrologist last friday - who told her it was likely nerve damage. Seen by OT who recommended wrist splint which pt refused to wear. U/S on without evidence of DVT . Her fistula remained patent with no needle placement issues during admission. Likely to nerve damage, but considered sympathetic nerve dystrophy syndrome. Symptomatic improvement during admission and she is to f/u with nephrologist and report and new/worsening symptoms. * 7) OPHTHALMOLOGIC ISSUES: The patient with a history of glaucoma and cataracts. The patient was continued on her glaucoma eyedrops (per her home regimen). * 8) Full code * 10) Communication - daughters(very involved in patient care), granddaughter | HD RN ON UNIT NOW PREPARING TO START.ACCESS- 2 PIV, LEFT UPPER ARM FISTULA. PT ARRIVED INTUBATED ON VENT AC MODE AND HYPOTENSION TO SBP 70'S. Resp Care: Pt intubated and ventilated with a/c, abg drawn from RRA, resp alkalosis/ good oxygenation, settings titrated; bs occ crackles, sxn thick blood tinged secretions, rsbi 70, will attempt sbt, wean to extubate. PT PLACED ON DOPAMINE BRIEFLY.NEURO- AROUSES TO VOICE. TEAM TO OBTAIN ABG FOR FIO2 AND VENT WEANING. TAKEN FOR STAT HEAD CT. PT STARTED ON PROPOFOL FOR SHORT TERM SEDATION WHILE INTUBATED.RESP- LS COARSE WITH RALES. MD GU: PT ANURIC AND HAVE HD TODAY TO PULL MORE FLUID OFFSKIN ; ABRASION NOTED ON LEFT ELBOW, AND ECCYMOTIC AREA NOTED AROUND LEFT FISTULA SITE, STAGE 2 DUCUBITUS NOTED ON RIGHT BUTTOCK DUODERM PLACED 1CM/ 1CMSOCIAL: 2 DAUGHTERS VERY INVOLVED W/ CAREENDO: PT ON FINGERSTICKS Q6HRS AND SSCCODE FULLPLAN:1. NURSING NOTE: ADMIT TO MICUPT ARRIVED FROM CC7 S/P RESP FAILURE AND EMERGENT INTUBATION LIKELY CHF AND FLASH PULMONARY EDEMA. OGT PLACED BY NURSING, CONFIRMED BY CXR BY DR . CONT FINGERSTICKS Q6HRS AND USE SSC SUCTIONING MINIMAL THIN TAN SECRETIONSCV: TELE SR 80S BP STABLE HRT SOUNDS S1S2 W/ MURMUR. FSBS 112.GU- ANURIC PER REPORT. AND TO REMAIN INTUBATED OVERNIGHT AND HAVE SBT IN AM FOR EARLY EXTUBATION. Pt intubated with 7.5 ETT, 23 cm at the left corner of her lip. CONT TO INFORM DAUGHTERS OF PT STATUS7. UPDATED BY NURSING AND DR .DISPO- FULL CODE PLAN IS TO HAVE HD WITH BLOOD TRANSFUSION TONIGHT. RADIAL PULSES +2 FINGERTIPS DUSKY HANDS COOL R> MD AWARE. EXTUBATE THIS AM AFTER 2. ? PUPILS SURGICAL. HCT REPORTED TO BE 28, ORDERED FOR 2UNITS PRBC'S TO BE GIVEN DURING HD.GI- ABD SOFT + BS NO STOOL. SUCTIONED FOR PINK FROTHY SPUTUM.CV- HR 80-100 SR WITH OCCAS PAC'S BP INITIALLY NEEDED DOPAMINE, SINCE WEANED OFF AND STILL TOLERATING PROPOFOL WELL. Respiratory CarePending respiratory failure, secondary to CHF. BP NOW 118/48. RSBI THIS AM 71 PT ON @0530 CPAP0 PS 5 FIO2 40% TV >300 RR18NEURO: PUPILS SURGICAL, MAE FOLLOWS COMMANDS, ALERT.RESP: AS ABOVE. +THRILL AND BRUIT.SOCIAL- DAUGHTERS AT BEDSIDE. Sinus rhythmAnterolateral ST-T changes suggest myocardial injury/ischemiaSince previous tracing of , ST-T wave abnormalities are more marked LS CLEAR UPPER LOBES W/ CRACKLES IN BASES. PEDAL PULSES +2LEFT ARM AV FISTULA + BRUIT AND THRILL.GI: OGT TO INTERMITTENT SUCTIONING DRAINING GREEN GASTRIC CONTENTS BS+ABD DISTENDED AND SOFT. VASCULAR US TO DO ARM US ? NURSING PROGRESS NOTESPT ENDED HER HD EARLY D/T LOW BP LAST EVENING 1.7 LITERS REMOVED 2 UNITS OF PRBC GIVEN FOR HCT 27 RECHECKED LAST NOC 31.5 THIS AM 32.CRT 7.3, BUN 97 BEFORE DIALYSIS CRT 6.0/ 68 BUN THIS AM. US OF LEFT ARM WAS CANCELLED WILL NEED VASCULAR US TO DO THE EXAM ? FOLLOW LYTES AND LABS6. ESRD. HD TODAY3. Sinus rhythmLateral ST-T changes are nonspecific, more pronounced than previousConsider ischemia Placed on mechanical ventilation, Assist Control mode, Tidal Volume 600cc, Set Rate 14 breaths per minute, FiO2 100%, Peep 5cm. CLOT4. SATS 100% ON VENT 600X14 100% +5. Breath sounds equal, diffuse rales. LEFT ARM TO HAVE ULTRASOUND THIS EVENING TO R/O CLOT.FISTULA SITE SWOLLEN WITH LARGE BRUISE. CLOT IN ARM. SATS 100% ALL SHIFT. PT RESTED COMFORTABLY LAST EVENING AND RECEIVED FENTANYL 50MCQS IV X3 DOSES. Pt to be closely monitored. MAE AND FOLLOWED SIMPLE COMMANDS. | 6 | [
{
"category": "Nursing/other",
"chartdate": "2171-11-04 00:00:00.000",
"description": "Report",
"row_id": 1516455,
"text": "NURSING PROGRESS NOTES\nPT ENDED HER HD EARLY D/T LOW BP LAST EVENING 1.7 LITERS REMOVED 2 UNITS OF PRBC GIVEN FOR HCT 27 RECHECKED LAST NOC 31.5 THIS AM 32.\nCRT 7.3, BUN 97 BEFORE DIALYSIS CRT 6.0/ 68 BUN THIS AM. PT RESTED COMFORTABLY LAST EVENING AND RECEIVED FENTANYL 50MCQS IV X3 DOSES. RSBI THIS AM 71 PT ON @0530 CPAP0 PS 5 FIO2 40% TV >300 RR18\n\nNEURO: PUPILS SURGICAL, MAE FOLLOWS COMMANDS, ALERT.\n\nRESP: AS ABOVE. LS CLEAR UPPER LOBES W/ CRACKLES IN BASES. SATS 100% ALL SHIFT. SUCTIONING MINIMAL THIN TAN SECRETIONS\n\nCV: TELE SR 80S BP STABLE HRT SOUNDS S1S2 W/ MURMUR. RADIAL PULSES +2 FINGERTIPS DUSKY HANDS COOL R> MD AWARE. PEDAL PULSES +2\nLEFT ARM AV FISTULA + BRUIT AND THRILL.\nGI: OGT TO INTERMITTENT SUCTIONING DRAINING GREEN GASTRIC CONTENTS BS+ABD DISTENDED AND SOFT. US OF LEFT ARM WAS CANCELLED WILL NEED VASCULAR US TO DO THE EXAM ? CLOT IN ARM. MD \n\nGU: PT ANURIC AND HAVE HD TODAY TO PULL MORE FLUID OFF\n\nSKIN ; ABRASION NOTED ON LEFT ELBOW, AND ECCYMOTIC AREA NOTED AROUND LEFT FISTULA SITE, STAGE 2 DUCUBITUS NOTED ON RIGHT BUTTOCK DUODERM PLACED 1CM/ 1CM\n\nSOCIAL: 2 DAUGHTERS VERY INVOLVED W/ CARE\n\nENDO: PT ON FINGERSTICKS Q6HRS AND SSC\n\nCODE FULL\n\nPLAN:\n1. EXTUBATE THIS AM AFTER \n2. ? HD TODAY\n3. VASCULAR US TO DO ARM US ? CLOT\n4. UNABLE TO RECHECK ABG ON D/T THERAPIST UNABLE TO DRAW\n5. FOLLOW LYTES AND LABS\n6. CONT TO INFORM DAUGHTERS OF PT STATUS\n7. CONT FINGERSTICKS Q6HRS AND USE SSC\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-03 00:00:00.000",
"description": "Report",
"row_id": 1516452,
"text": "Respiratory Care\nPending respiratory failure, secondary to CHF. Pt intubated with 7.5 ETT, 23 cm at the left corner of her lip. Breath sounds equal, diffuse rales. Placed on mechanical ventilation, Assist Control mode, Tidal Volume 600cc, Set Rate 14 breaths per minute, FiO2 100%, Peep 5cm. Pt to be closely monitored.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-03 00:00:00.000",
"description": "Report",
"row_id": 1516453,
"text": "NURSING NOTE: ADMIT TO MICU\nPT ARRIVED FROM CC7 S/P RESP FAILURE AND EMERGENT INTUBATION LIKELY CHF AND FLASH PULMONARY EDEMA. PT ARRIVED INTUBATED ON VENT AC MODE AND HYPOTENSION TO SBP 70'S. PT PLACED ON DOPAMINE BRIEFLY.\n\nNEURO- AROUSES TO VOICE. MAE AND FOLLOWED SIMPLE COMMANDS. PUPILS SURGICAL. TAKEN FOR STAT HEAD CT. PT STARTED ON PROPOFOL FOR SHORT TERM SEDATION WHILE INTUBATED.\n\nRESP- LS COARSE WITH RALES. SATS 100% ON VENT 600X14 100% +5. TEAM TO OBTAIN ABG FOR FIO2 AND VENT WEANING. SUCTIONED FOR PINK FROTHY SPUTUM.\n\nCV- HR 80-100 SR WITH OCCAS PAC'S BP INITIALLY NEEDED DOPAMINE, SINCE WEANED OFF AND STILL TOLERATING PROPOFOL WELL. BP NOW 118/48. HCT REPORTED TO BE 28, ORDERED FOR 2UNITS PRBC'S TO BE GIVEN DURING HD.\n\nGI- ABD SOFT + BS NO STOOL. OGT PLACED BY NURSING, CONFIRMED BY CXR BY DR . FSBS 112.\n\nGU- ANURIC PER REPORT. ESRD. HD RN ON UNIT NOW PREPARING TO START.\n\nACCESS- 2 PIV, LEFT UPPER ARM FISTULA. LEFT ARM TO HAVE ULTRASOUND THIS EVENING TO R/O CLOT.FISTULA SITE SWOLLEN WITH LARGE BRUISE. +THRILL AND BRUIT.\n\nSOCIAL- DAUGHTERS AT BEDSIDE. UPDATED BY NURSING AND DR .\n\nDISPO- FULL CODE PLAN IS TO HAVE HD WITH BLOOD TRANSFUSION TONIGHT. AND TO REMAIN INTUBATED OVERNIGHT AND HAVE SBT IN AM FOR EARLY EXTUBATION.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-04 00:00:00.000",
"description": "Report",
"row_id": 1516454,
"text": "Resp Care: Pt intubated and ventilated with a/c, abg drawn from RRA, resp alkalosis/ good oxygenation, settings titrated; bs occ crackles, sxn thick blood tinged secretions, rsbi 70, will attempt sbt, wean to extubate.\n"
},
{
"category": "ECG",
"chartdate": "2171-11-03 00:00:00.000",
"description": "Report",
"row_id": 274640,
"text": "Sinus rhythm\nAnterolateral ST-T changes suggest myocardial injury/ischemia\nSince previous tracing of , ST-T wave abnormalities are more marked\n\n"
},
{
"category": "ECG",
"chartdate": "2171-11-02 00:00:00.000",
"description": "Report",
"row_id": 274641,
"text": "Sinus rhythm\nLateral ST-T changes are nonspecific, more pronounced than previous\nConsider ischemia\n\n"
}
] |
47,949 | 130,852 | FINDINGS: There is a left frontal superior frontal gyrus subarachnoid hemorrhage (series 2, image 14 and series 601B, image 26). The lung apices are clear.A partially calcified left thyroid nodule is seen. Chest clear on exam. Possible left atrial abnormality. TECHNIQUE: Contiguous MDCT images of the C-spine were obtained. FINDINGS: The height of the vertebral bodies of the C-spine is preserved. Clinically correlate. TECHNIQUE: Axial CT images of the head were obtained. chest pathology. Axial, coronal, and sagittal reformats were acquired. There is no acute fracture. IMPRESSION: Focus of left frontal subarachnoid hemorrhage without evidence of fractures, unchanged from the outside hospital CT earlier from today. Heart size and vascularity are normal. COMPARISON: Outside hospital CT of the C-spine from . Please assess for fracture. Coronal and sagittal reformats were acquired. No fracture. COMPARISON: Outside hospital CT of the head from . The ventricles and sulci are normal in size and configuration. There is no large neck hematoma. There are moderate-to-severe degenerative changes at C6-C7 with posterior osteophytes, uncal and facet hypertrophy and posterior disc bulging with moderate narrowing of the spinal canal and moderate-to-severe narrowing of the neural foramina bilaterally. No additional foci of intracranial hemorrhage are identified. Sinus rhythm. The paranasal sinuses and mastoids are clear. Soft tissue laceration is seen at the vertex with skin staples in place. Severe degenerative changes at C6-C7. The -white matter differentiation is well preserved. If concern for spinal cord injury, MRI might be considered. No fracture is identified. IMPRESSION: 1. The lungs are clear as are the pleural spaces. Moderate to severe degenerative changes at C6/7 with posterior disc protrusion narrowing the spinal canal. If there is concern for spinal cord injury, MRI might be considered. FINDINGS: There are multiple healed right rib fractures. IMPRESSION: No evidence for active cardiopulmonary disease. REASON FOR THIS EXAMINATION: ? COMPARISONS: None. 7:40 AM CHEST (PORTABLE AP) Clip # Reason: ? Left anterior fascicular block.Increased voltage in the precordial leads suggestive of left ventricularhypertrophy. No fx. WET READ VERSION #1 FINAL REPORT INDICATION: 66-year-old man with head injury. WET READ VERSION #1 FINAL REPORT INDICATION: 66-year-old man with head injury. No previous tracing available for comparison. 4:01 AM CT C-SPINE W/O CONTRAST Clip # Reason: fx MEDICAL CONDITION: 66 year old man s/p head injury REASON FOR THIS EXAMINATION: fx No contraindications for IV contrast WET READ: JBRe SAT 6:07 AM 1. chest pathology Admitting Diagnosis: INTRACRANIAL HEMORRHAGE MEDICAL CONDITION: 66 year old man with traumatic SAH ? 4:00 AM CT HEAD W/O CONTRAST Clip # Reason: bleed MEDICAL CONDITION: 66 year old man s/p head injury REASON FOR THIS EXAMINATION: bleed No contraindications for IV contrast WET READ: JBRe SAT 6:01 AM Small focus of left frontal SAH is unchanged from the OSH CT a few hours earlier. 2. | 4 | [
{
"category": "Radiology",
"chartdate": "2199-09-21 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1210669,
"text": " 4:01 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p head injury\n REASON FOR THIS EXAMINATION:\n fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SAT 6:07 AM\n 1. No fx.\n 2. Moderate to severe degenerative changes at C6/7 with posterior disc\n protrusion narrowing the spinal canal. If concern for spinal cord injury, MRI\n might be considered.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with head injury. Please assess for fracture.\n\n TECHNIQUE: Contiguous MDCT images of the C-spine were obtained. Axial,\n coronal, and sagittal reformats were acquired.\n\n COMPARISON: Outside hospital CT of the C-spine from .\n\n FINDINGS: The height of the vertebral bodies of the C-spine is preserved.\n There is no acute fracture. There are moderate-to-severe degenerative changes\n at C6-C7 with posterior osteophytes, uncal and facet hypertrophy and posterior\n disc bulging with moderate narrowing of the spinal canal and\n moderate-to-severe narrowing of the neural foramina bilaterally.\n\n There is no large neck hematoma. The lung apices are clear.A partially\n calcified left thyroid nodule is seen. Clinically correlate.\n\n IMPRESSION:\n 1. No fracture. Severe degenerative changes at C6-C7. If there is concern\n for spinal cord injury, MRI might be considered.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-09-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1210668,
"text": " 4:00 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man s/p head injury\n REASON FOR THIS EXAMINATION:\n bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe SAT 6:01 AM\n Small focus of left frontal SAH is unchanged from the OSH CT a few hours\n earlier.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with head injury.\n\n TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal\n reformats were acquired.\n\n COMPARISON: Outside hospital CT of the head from .\n\n FINDINGS: There is a left frontal superior frontal gyrus subarachnoid\n hemorrhage (series 2, image 14 and series 601B, image 26). No additional foci\n of intracranial hemorrhage are identified. Soft tissue laceration is seen at\n the vertex with skin staples in place.\n\n The -white matter differentiation is well preserved. The ventricles and\n sulci are normal in size and configuration. The paranasal sinuses and\n mastoids are clear. No fracture is identified.\n\n IMPRESSION: Focus of left frontal subarachnoid hemorrhage without evidence of\n fractures, unchanged from the outside hospital CT earlier from today.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-09-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210673,
"text": " 7:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? chest pathology\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with traumatic SAH ? chest pathology. Chest clear on exam.\n REASON FOR THIS EXAMINATION:\n ? chest pathology\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: 66-year-old man with traumatic SAH.\n\n COMPARISONS: None.\n\n FINDINGS: There are multiple healed right rib fractures. Heart size and\n vascularity are normal. The lungs are clear as are the pleural spaces.\n\n IMPRESSION: No evidence for active cardiopulmonary disease.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2199-09-21 00:00:00.000",
"description": "Report",
"row_id": 251007,
"text": "Sinus rhythm. Possible left atrial abnormality. Left anterior fascicular block.\nIncreased voltage in the precordial leads suggestive of left ventricular\nhypertrophy. No previous tracing available for comparison.\n\n"
}
] |
|
50,596 | 118,069 | 32 yo F w/ depression hx and prior SA, admitted to the MICU for trazodone OD with EtOH intoxication; now transferred to the floor for further monitoring and recovery. | (#) DISPO: likely d/c to floor or the psych service in the am ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 06:34 PM Prophylaxis: DVT: SQ UF Heparin Stress ulcer: Not indicated VAP: Comments: Communication: ICU consent signed Comments: Code status: Full code Disposition: ICU In the ED, had some mild hypotension. In the ED, had some mild hypotension. Action: Maintained suicide precautions with 1:1 sitter. Action: Maintained suicide precautions with 1:1 sitter. Action: Maintained suicide precautions with 1:1 sitter. ICU Care Nutrition: Clear liqs Glycemic Control: Lines / Intubation: 18 Gauge - 06:34 PM Comments: Prophylaxis: DVT: SQ UF Heparin Stress ulcer: VAP: Comments: Not applicable. She denied nausea, HA, F/C, CP, SOB, abd pain; she was somnolent but easily arousable and conversant Hypotension (not Shock) Assessment: Recd one IVFB overnight for low BP, since BPs-98-104/60, HR-70s SR with no ectopy noted. She denied nausea, HA, F/C, CP, SOB, abd pain; she was somnolent but easily arousable and conversant Hypotension (not Shock) Assessment: Recd one IVFB overnight for low BP, since BPs-98-104/60, HR-70s SR with no ectopy noted. Imaging: no imagin Microbiology: UCx: pending ECG: EKG: (done at 3:15 pm on ) sinus at 94 BPM; QTC 450 Assessment and Plan 32 yoF w/ depression hx and prior SA, admitted from ED for trazodone OD with EtOH intoxication. Purse with pills was reported to be in ED safe per ED nurse. Purse with pills was reported to be in ED safe per ED nurse. Purse with pills was reported to be in ED safe per ED nurse. Sinus rhythmEarly precordial QRS transition may be normal variantSince previous tracing of , T wave changes decreased Elongated Qtc, hypotension, solmolence. Elongated Qtc, hypotension, solmolence. Elongated Qtc, hypotension, solmolence. -- will watch for hypotension; fluid boluses PRN for SBP < 90 -- monitor for somnolence, altered MS -- will check repeat lytes and EKG tonight; also in am -- will place on CIWA for possible EtOH withdrawal; denies in history but elevated EtOH on admission and unclear how reliable of a historian she is . (#) SUICIDE ATTTEMPT, DEPRESSION: -- will hold Celexa for now given trazodone OD -- will place SW consult -- 24 hour suicide watch -- will have psych see patient in the morning . History obtained from Patient Allergies: Last dose of Antibiotics: Infusions: Other ICU medications: Lorazepam (Ativan) - 03:22 AM Other medications: HSQ Changes to medical and family history: PMH, SH, FH and ROS are unchanged from Admission except where noted above and below Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 10:12 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 37.5C (99.5 Tcurrent: 37.5C (99.5 HR: 69 (69 - 88) bpm BP: 106/65(74) {86/44(55) - 113/68(78)} mmHg RR: 13 (13 - 20) insp/min SpO2: 97% Total In: 5,136 mL 2,079 mL PO: 500 mL 750 mL TF: IVF: 1,636 mL 1,329 mL Blood products: Total out: 1,360 mL 885 mL Urine: 760 mL 885 mL NG: Stool: Drains: Balance: 3,776 mL 1,194 mL Respiratory support O2 Delivery Device: None SpO2: 97% ABG: ///21/ Physical Examination General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended Extremities: Right: Absent, Left: Absent Skin: Not assessed, No(t) Rash: Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed Labs / Radiology 9.4 g/dL 236 K/uL 88 mg/dL 0.7 mg/dL 21 mEq/L 4.0 mEq/L 8 mg/dL 109 mEq/L 138 mEq/L 27.4 % 5.8 K/uL [image002.jpg] 04:32 AM WBC 5.8 Hct 27.4 Plt 236 Cr 0.7 Glucose 88 Other labs: PT / PTT / INR:14.0/30.2/1.2, ALT / AST:, Alk Phos / T Bili:35/0.4, Albumin:3.5 g/dL, Ca++:6.9 mg/dL, Mg++:1.5 mg/dL, PO4:3.2 mg/dL Fluid analysis / Other labs: Tox screen: etoh otherwise neg. | 17 | [
{
"category": "ECG",
"chartdate": "2200-01-25 00:00:00.000",
"description": "Report",
"row_id": 240140,
"text": "Sinus rhythm\nEarly precordial QRS transition may be normal variant\nSince previous tracing of , T wave changes decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2200-01-24 00:00:00.000",
"description": "Report",
"row_id": 240141,
"text": "Sinus rhythm. Minor non-diagnostic T wave flattening. Compared to the\nprevious tracing no major change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2200-01-23 00:00:00.000",
"description": "Report",
"row_id": 240142,
"text": "Sinus rhythm with baseline artifact. Probably normal tracing. No previous\ntracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Nursing",
"chartdate": "2200-01-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 655197,
"text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Suicidality / Suicide Attempt\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2200-01-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 655200,
"text": "Ms. is a 32 yoF with h/o prior suicide attempts, who presents\n after taking trazodone in an attempt to kill herself. Around noon\n yesterday , she drank \"five drinks\" of vodka, and then around 2\n pm, she ingested 30 pills of 50 mg trazodone. Within the next hour,\n she called the ambulance herself. This was done at her apartment, and\n she reports that she did this because she was upset about her\n boyfriend.\n .\n Of note, she has had three prior SA since , two of which\n resulted in hospitalization at , at which point she was\n put on Celexa. She has a PCP (Dr. ?) but no psychiatrist\n or psychologist currently.\n .\n In the ED, VS were T 98.0, HR 94, BP 133/97, RR 22, 99 % RA. The\n toxicology team saw her; she was considered out fo the time window for\n activated charcoal; no stomach pumping was performed. while she was\n wiating for a bed, she became hypotensive with BP 70-80, which improved\n with 2 L NS. On arrival to the MICU, VS were T 97.6, HR 86, BP 90/51,\n 100% RA, RR 19. She denied nausea, HA, F/C, CP, SOB, abd pain; she was\n somnolent but easily arousable and conversant\n Hypotension (not Shock)\n Assessment:\n Rec\nd one IVFB overnight for low BP, since BP\ns-98-104/60, HR-70\ns SR\n with no ectopy noted.\n Action:\n Rec\ning IVF D51/2 @ 125hr\n Response:\n BP stable\n Plan:\n Monitor BP\ns administer IVFB if needed.\n Suicidality / Suicide Attempt\n Assessment:\n No Suicidal ideation noted very sleepy but easily arousable. Has \n in room. Awaiting Psych Evaluation. A&Ox3. Will also obtain SW consult\n in attempt to help her find other housing, due to that she lives with\n boyfriend.\n Action:\n in room. Has a Privacy laert in place.\n Response:\n Is calm, and cooperative but sleepy\n Plan:\n Await Psych eval, continue with sitters.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n OVERDOSE\n Code status:\n Full code\n Height:\n Admission weight:\n 63 kg\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Past suicide attempts.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:101\n D:52\n Temperature:\n 99.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 80 bpm\n Heart rhythm:\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 2,733 mL\n 24h total out:\n 1,165 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:32 AM\n Potassium:\n 4.0 mEq/L\n 04:32 AM\n Chloride:\n 109 mEq/L\n 04:32 AM\n CO2:\n 21 mEq/L\n 04:32 AM\n BUN:\n 8 mg/dL\n 04:32 AM\n Creatinine:\n 0.7 mg/dL\n 04:32 AM\n Glucose:\n 88 mg/dL\n 04:32 AM\n Hematocrit:\n 27.4 %\n 04:32 AM\n Valuables / Signature\n Patient valuables: Has red duffle bag and laundry bag with personal\n care items and clothes inside.\n Other valuables: In EU safe.\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: In EU safe.\n Jewelry:\n Transferred from: MICU-7\n Transferred to: CC7\n Date & time of Transfer: 1300\n"
},
{
"category": "Physician ",
"chartdate": "2200-01-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655183,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Admitted overnight from the ED after presenting with a suicide\n attmept/trazadone overdose as well as etoh intoxication. In the ED,\n had some mild hypotension. Was not given activated charcoal for NGT\n lavage as she was felt to be too far out from ingestion.\n In ICU, SBP's ranged in 90-110's, received total of 1 L of NS.\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:22 AM\n Other medications:\n HSQ\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 69 (69 - 88) bpm\n BP: 106/65(74) {86/44(55) - 113/68(78)} mmHg\n RR: 13 (13 - 20) insp/min\n SpO2: 97%\n Total In:\n 5,136 mL\n 2,079 mL\n PO:\n 500 mL\n 750 mL\n TF:\n IVF:\n 1,636 mL\n 1,329 mL\n Blood products:\n Total out:\n 1,360 mL\n 885 mL\n Urine:\n 760 mL\n 885 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,776 mL\n 1,194 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.4 g/dL\n 236 K/uL\n 88 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 8 mg/dL\n 109 mEq/L\n 138 mEq/L\n 27.4 %\n 5.8 K/uL\n [image002.jpg]\n 04:32 AM\n WBC\n 5.8\n Hct\n 27.4\n Plt\n 236\n Cr\n 0.7\n Glucose\n 88\n Other labs: PT / PTT / INR:14.0/30.2/1.2, ALT / AST:, Alk Phos / T\n Bili:35/0.4, Albumin:3.5 g/dL, Ca++:6.9 mg/dL, Mg++:1.5 mg/dL, PO4:3.2\n mg/dL\n Fluid analysis / Other labs: Tox screen: etoh otherwise neg.\n U/A: WBC\n Microbiology: UCx: Pending\n ECG: QT interval about 450ms\n Assessment and Plan\n 32 yo F with h/o depression admitted with suicide attempt (trazadone\n and etoh) complicated by mild hypotension.\n Hypotension: Likely related to trazadone ingestion. Now normalized.\n Suicide attempt:\n -Psychiatry consult\n -Social work eval to assist with home situation (reported abusive\n boyfriend)\n - for now.\n FEN: Regular diet.\n D/c foley\n Rest of plan per resident note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:34 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2200-01-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 655169,
"text": "Ms. is a 32 yoF with h/o prior suicide attempts, who presents\n after taking trazodone in an attempt to kill herself. Around noon\n yesterday , she drank \"five drinks\" of vodka, and then around 2\n pm, she ingested 30 pills of 50 mg trazodone. Within the next hour,\n she called the ambulance herself. This was done at her apartment, and\n she reports that she did this because she was upset about her\n boyfriend.\n .\n Of note, she has had three prior SA since , two of which\n resulted in hospitalization at , at which point she was\n put on Celexa. She has a PCP (Dr. ?) but no psychiatrist\n or psychologist currently.\n .\n In the ED, VS were T 98.0, HR 94, BP 133/97, RR 22, 99 % RA. The\n toxicology team saw her; she was considered out fo the time window for\n activated charcoal; no stomach pumping was performed. while she was\n wiating for a bed, she became hypotensive with BP 70-80, which improved\n with 2 L NS. On arrival to the MICU, VS were T 97.6, HR 86, BP 90/51,\n 100% RA, RR 19. She denied nausea, HA, F/C, CP, SOB, abd pain; she was\n somnolent but easily arousable and conversant\n Hypotension (not Shock)\n Assessment:\n Rec\nd one IVFB overnight for low BP, since BP\ns-98-104/60, HR-70\ns SR\n with no ectopy noted.\n Action:\n Rec\ning IVF D51/2 @ 125hr\n Response:\n BP stable\n Plan:\n Monitor BP\ns administer IVFB if needed.\n Suicidality / Suicide Attempt\n Assessment:\n No Suicidal ideation noted very sleepy but easily arousable. Has \n in room. Awaiting Psych Evaluation. A&Ox3. Will also obtain SW consult\n in attempt to help her find other housing, due to that she lives with\n boyfriend.\n Action:\n in room. Has a Privacy laert in place.\n Response:\n Is calm, and cooperative but sleepy\n Plan:\n Await Psych eval, continue with sitters.\n"
},
{
"category": "Physician ",
"chartdate": "2200-01-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 655174,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Admitted overnight from the ED after presenting with a suicide\n attmept/trazadone overdose as well as etoh intoxication. In the ED,\n had some mild hypotension. Was not given activated charcoal for NGT\n lavage as she was felt to be too far out from ingestion.\n In ICU, SBP's ranged in 90-110's, received total of 1 L of NS.\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:22 AM\n Other medications:\n HSQ\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 69 (69 - 88) bpm\n BP: 106/65(74) {86/44(55) - 113/68(78)} mmHg\n RR: 13 (13 - 20) insp/min\n SpO2: 97%\n Total In:\n 5,136 mL\n 2,079 mL\n PO:\n 500 mL\n 750 mL\n TF:\n IVF:\n 1,636 mL\n 1,329 mL\n Blood products:\n Total out:\n 1,360 mL\n 885 mL\n Urine:\n 760 mL\n 885 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,776 mL\n 1,194 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.4 g/dL\n 236 K/uL\n 88 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 8 mg/dL\n 109 mEq/L\n 138 mEq/L\n 27.4 %\n 5.8 K/uL\n [image002.jpg]\n 04:32 AM\n WBC\n 5.8\n Hct\n 27.4\n Plt\n 236\n Cr\n 0.7\n Glucose\n 88\n Other labs: PT / PTT / INR:14.0/30.2/1.2, ALT / AST:, Alk Phos / T\n Bili:35/0.4, Albumin:3.5 g/dL, Ca++:6.9 mg/dL, Mg++:1.5 mg/dL, PO4:3.2\n mg/dL\n Fluid analysis / Other labs: Tox screen: etoh otherwise neg.\n U/A: WBC\n Microbiology: UCx: Pending\n ECG: QT interval about 450ms\n Assessment and Plan\n 32 yo F with h/o depression admitted with suicide attempt (trazadone\n and etoh) complicated by mild hypotension.\n Hypotension: Likely related to trazadone ingestion. Now normalized.\n Suicide attempt:\n -Psychiatry consult\n -Social work eval to assist with home situation (reported abusive\n boyfriend)\n - for now.\n FEN: Regular diet.\n D/c foley\n Rest of plan per resident note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:34 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2200-01-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655084,
"text": "32 yo female admitted from home with suicide attempt, took 30 pills of\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\n she had a fight with her boyfriend. had 2 other attempts since\n .-08. In EU BP was 90-100\ns/50 but became hypotensive to the\n 70\ns/40, required 3L\ns NS, and was sent to the MICU for monitoring.\n Suicidality / Suicide Attempt\n Assessment:\n BP-90-92/50 with HR-70\ns, is lethargic but is easily arousable and able\n to answer questions. Stated that she had a fight with her boyfriend,\n and that her has fear in her relationship so is on a Privacy alert.\n Is oriented times 2. PERL 2mm, moves all extremities. Is pleasant and\n cooperative, but stated that she still was to harm herself, but no\n attempts to, has sitters. Has not been seen by Pysch as yet.\n Action:\n Has sitters in room, rec\ning NS @ 125cc/hr.\n Response:\n Appears calm with stable BP\n Plan:\n Assess MS\ns and monitor BP\n"
},
{
"category": "Physician ",
"chartdate": "2200-01-23 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 655090,
"text": "Chief Complaint: Trazadone overdose\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 32 year old woman. Hx of depression. This afternoon had problems with\n her boyfriend. She drank Vodka (?5 drinks) and then at 2 PM took 30\n pills (trazadone 50 mg). She called an ambulance and was brought to the\n ED. Vital signs: afebrile, HR 94, BP 133/97, RR 22. Sats 95% on RA.\n Over the course of several hours, BP dropped to 70-80; was given fluids\n and admitted to the ICU. Urine output has been brisk. In MICU, still\n afebrile. BP 90/60. Patient denied fever, headache, chest pain,\n abdominal pain. She was somnolent but arousable.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Depression\n Prior suicide attempts X 3 since . Had been started on\n Celexa and Trazadone.\n Home meds: celexa, trazadone\n Mother breast ca, father DM type II, sister with MS.\n Occupation: Teaches English as 2nd language\n Drugs: None\n Tobacco: social, not daily.\n Alcohol: Occasional\n Other: Lives with boyfriend; hx of abuse - physical and emotional\n Review of systems:\n Flowsheet Data as of 09:53 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 76 (76 - 86) bpm\n BP: 92/50(59) {90/50(59) - 92/51(61)} mmHg\n RR: 18 (18 - 19) insp/min\n SpO2: 98%\n Total In:\n 3,300 mL\n PO:\n TF:\n IVF:\n 300 mL\n Blood products:\n Total out:\n 0 mL\n 700 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,600 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, Pupils dilated, No(t) Conjunctiva pale,\n No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: ),\n Good breath sounds throughout. I/E=\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent edema, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone:\n Not assessed\n Labs / Radiology\n 290\n 36.7\n 92\n 0.7\n 11\n 21\n 110\n 3.8\n 145\n 4.7\n [image002.jpg]\n Fluid analysis / Other labs: alcohol 281\n Tox negative for ASA, tylenol, benzo, barbiturates, TCA, opiates,\n cocaine, methadone\n UA: small leuk esterase, neg nitrites, WBC\n Assessment and Plan\n SUICIDALITY / SUICIDE ATTEMPT\n HYPOTENSION\n HYPERNATREMIA\n Patient with trazadone overdose and EtOH ingestion combining to depress\n her sensorium. She is more alert now. Would allow clear liquids,\n monitor ECG, and Oxygen saturations. Psychiatry consult in the AM.\n Patient states she was not trying to kill herself; was upset that her\n boyfriend slashed her tires. Patient to be observed with CIWA scale,\n although by hx is not a chronic drinker.\n Hypotension likely related to drug effect and some volume depletion.\n She has responded to fluid resuscitation. Remains free water depleted,\n which may have been exacerbated since admission by the volume\n resuscitation with NS. Would give free water; recheck Na.\n ICU Care\n Nutrition: Clear liqs\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 06:34 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2200-01-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 655091,
"text": "Chief Complaint: trazodone overdose, EtOH intoxication\n HPI:\n Ms. is a 32 yoF with h/o prior suicide attempts, who presents\n after taking trazodone in an attempt to kill herself. Around noon this\n afternoon, she drank \"five drinks\" (not \"shots\") of vodka, and then\n around 2 pm, she ingested 30 pills of 50 mg trazodone. Within the next\n hour, she called the ambulance herself. This was done at her\n apartment, and she reports that she did this because she was upset\n about her boyfriend.\n .\n Of note, she has had three prior SA since , two of which\n resulted in hospitalization at , at which point she was\n put on Celexa. She has a PCP (Dr. ?) but no psychiatrist\n or psychologist currently.\n .\n In the ED, VS were T 98.0, HR 94, BP 133/97, RR 22, 99 % RA. The\n toxicology team saw her; she was considered out fo the time window for\n activated charcoal; no stomach pumping was performed. while she was\n wiating for a bed, she became hypotensive with BP 70-80, which improved\n with 2 L NS. On arrival to the MICU, VS were T 97.6, HR 86, BP 90/51,\n 100% RA, RR 19. She denied nausea, HA, F/C, CP, SOB, abd pain; she was\n somnolent but easily arousable and conversant.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME MEDICATIONS:\n Celexa 40 mg QD\n Trazodone 50 mg QHS PRN (takes about two per month)\n Past medical history:\n Family history:\n Social History:\n Depression\n -- mother: breast CA\n -- father: , diet controlled\n -- older sister: MS\n -- older brother: healthy\n Occupation: works as an ESL instructor\n Drugs: denied IVDU, snorting drugs\n Tobacco: smokes cigarettes socially when she drinks; does not smoke\n daily\n Alcohol: drinks occ on weekends; denies having a \"drinking problems\" in\n teh past; denies drinking daily\n Other: -- has lived with her boyfriend 4 years; readily admits to\n emotional and physical abuse by boyfriend (he has put out cigarettes on\n her in the past; has been hit in the face before)\n -- originally from Western Mass\n Review of systems: see above\n Flowsheet Data as of 10:35 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 78 (73 - 88) bpm\n BP: 103/58(68) {90/50(59) - 103/58(68)} mmHg\n RR: 15 (15 - 20) insp/min\n SpO2: 99%\n Total In:\n 4,946 mL\n PO:\n 500 mL\n TF:\n IVF:\n 1,446 mL\n Blood products:\n Total out:\n 0 mL\n 1,320 mL\n Urine:\n 720 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,628 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n Physical Examination\n VS on arrival to the MICU: T 97.6, HR 86, BP 90/51, 100% RA, RR 19\n General: sleepy, but easily arousable; somewhat slurred speech but\n coherent and logical\n HEENT: MMM, 1 mm pupils R=L (PEERL)\n Lungs: CTA b/l, no wheezes or crackles\n Cardio: RRR, no m.r.g.\n Extremities: no LE edema\n Skin: no rashes, no track marks\n Neuro: sleeping when seen but easily arousable; Ox3, somewhat slurred\n speech; CN II - XII intact; normal muscle tone, normal strength\n throughout; gait deferred\n Labs / Radiology\n 290\n 92\n 0.7\n 11\n 21\n 110\n 3.8\n 145\n 36.7\n 4.7\n [image002.jpg]\n Fluid analysis / Other labs: EtOH 281; rest of urine/serum tox\n negative;\n UA WBC, Sm LE, neg nit.\n Imaging: no imagin\n Microbiology: UCx: pending\n ECG: EKG: (done at 3:15 pm on ) sinus at 94 BPM; QTC 450\n Assessment and Plan\n 32 yoF w/ depression hx and prior SA, admitted from ED for trazodone OD\n with EtOH intoxication.\n .\n (#) TRAZODONE OVERDOSE: risk of hypotension with anti-alpha1 effects;\n no evidence of serotonin syndrome currently. Curbsided tox fellow who\n said to look out for hypotension, CNS depression and Qtc prolongation.\n Recommended levophed if she needs pressors.\n -- will watch for hypotension; fluid boluses PRN for SBP < 90\n -- monitor for somnolence, altered MS\n -- will check repeat lytes and EKG tonight; also in am\n -- will place on CIWA for possible EtOH withdrawal; denies in history\n but elevated EtOH on admission and unclear how reliable of a historian\n she is\n .\n (#) SUICIDE ATTTEMPT, DEPRESSION:\n -- will hold Celexa for now given trazodone OD\n -- will place SW consult\n -- 24 hour suicide watch\n -- will have psych see patient in the morning\n .\n (#) NUTRITION: clear liquids o/n for possible GI upset with OD; will\n likely advance diet in the am; IVF for maintenance overnight\n .\n (#) PPX:\n -- SQH\n -- no need for protonix tonight; will consider starting in the am\n -- no need for bowel regimen tonight as patient just admitted\n .\n (#) CODE: full\n .\n (#) CONSENT: signed in chart\n .\n (#) COMMUNICATION: with patient\n .\n (#) DISPO: likely d/c to floor or the psych service in the am\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:34 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2200-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655148,
"text": "32 yo female admitted from home with suicide attempt, took 30 pills of\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\n she had a fight with her boyfriend. had 2 other attempts since\n .-08. In EU BP was 90-100\ns/50 but became hypotensive to the\n 70\ns/40, required 3L\ns NS, and was sent to the MICU for monitoring.\n Suicidality / Suicide Attempt\n Assessment:\n Pt slightly lethargic overnight with C/O wanting to sleep but easily\n arousable and able to answer questions, assist with care and turn\n self. Stated that she had a fight with her boyfriend, and that her has\n fear in her relationship so is on a Privacy alert. A & O x3, PEARL\n 2mm, moves all extremities. Is pleasant and cooperative, has 1:1\n sitter at bedside. Has not been seen by Pysch as yet.\n Action:\n Maintained suicide precautions with 1:1 sitter. Went through personal\n belongings\nclothes, no pills. Purse with pills was reported to be in\n ED safe per ED nurse.\n Response:\n Appears calm. No attempts to harm self. No verbalization of SI.\n Plan:\n Assess MS\ns, monitor for side effects of trazadone, ei. Elongated Qtc,\n hypotension, solmolence.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2200-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655149,
"text": "32 yo female admitted from home with suicide attempt, took 30 pills of\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\n she had a fight with her boyfriend. had 2 other attempts since\n .-08. In EU BP was 90-100\ns/50 but became hypotensive to the\n 70\ns/40, required 3L\ns NS, and was sent to the MICU for monitoring.\n Suicidality / Suicide Attempt\n Assessment:\n Pt slightly lethargic overnight with C/O wanting to sleep but easily\n arousable and able to answer questions, assist with care and turn\n self. Stated that she had a fight with her boyfriend, and that her has\n fear in her relationship so is on a Privacy alert. A & O x3, PEARL\n 2mm, moves all extremities. Is pleasant and cooperative, has 1:1\n sitter at bedside. Has not been seen by Pysch as yet.\n Action:\n Maintained suicide precautions with 1:1 sitter. Went through personal\n belongings\nclothes, no pills. Purse with pills was reported to be in\n ED safe per ED nurse.\n Response:\n Appears calm. No attempts to harm self. No verbalization of SI.\n Plan:\n Assess MS\ns, monitor for side effects of trazadone, ei. Elongated Qtc,\n hypotension, solmolence.\n Hypotension (not Shock)\n Assessment:\n BP 92-112 with maps predominantly over 60. Did have short period of\n time where MAP was 55. HR\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2200-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655150,
"text": "32 yo female admitted from home with suicide attempt, took 30 pills of\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\n she had a fight with her boyfriend. had 2 other attempts since\n .-08. In EU BP was 90-100\ns/50 but became hypotensive to the\n 70\ns/40, required 3L\ns NS, and was sent to the MICU for monitoring.\n Suicidality / Suicide Attempt\n Assessment:\n Pt slightly lethargic overnight with C/O wanting to sleep but easily\n arousable and able to answer questions, assist with care and turn\n self. Stated that she had a fight with her boyfriend, and that her has\n fear in her relationship so is on a Privacy alert. A & O x3, PEARL\n 2mm, moves all extremities. Is pleasant and cooperative, has 1:1\n sitter at bedside. Has not been seen by Pysch as yet.\n Action:\n Maintained suicide precautions with 1:1 sitter. Went through personal\n belongings\nclothes, no pills. Purse with pills was reported to be in\n ED safe per ED nurse.\n Response:\n Appears calm. No attempts to harm self. No verbalization of SI.\n Plan:\n Assess MS\ns, monitor for side effects of trazadone, ei. Elongated Qtc,\n hypotension, solmolence. Social work and Psych to see pt. Cont 1:1\n sitter for safety.\n Hypotension (not Shock)\n Assessment:\n BP 92-112 with maps predominantly over 60. Did have short period of\n time where MAP was 55. HR 70\ns-80\ns. QTc = 0.45\n Action:\n Bolused with 500cc NS x 2 with good effect. NS at 125cc/hr changed to\n D51/2 NS at 125cc/hr. Pt also taking in adequate PO liquids.\n Response:\n BP\ns maintained with MAP >60. Pt A & O x3, asymptomatic. Denies any\n N/V or other GI symptoms.\n Plan:\n Cont to assess BP, maintenance fluid. EKG changes with Qtc.\n"
},
{
"category": "Nursing",
"chartdate": "2200-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 655146,
"text": "32 yo female admitted from home with suicide attempt, took 30 pills of\n 50mg tablets of Trazadone and then took shots of Vodka. Stated that\n she had a fight with her boyfriend. had 2 other attempts since\n .-08. In EU BP was 90-100\ns/50 but became hypotensive to the\n 70\ns/40, required 3L\ns NS, and was sent to the MICU for monitoring.\n Suicidality / Suicide Attempt\n Assessment:\n BP-90-92/50 with HR-70\ns, is lethargic but is easily arousable and able\n to answer questions. Stated that she had a fight with her boyfriend,\n and that her has fear in her relationship so is on a Privacy alert.\n Is oriented times 2. PERL 2mm, moves all extremities. Is pleasant and\n cooperative, but stated that she still was to harm herself, but no\n attempts to, has sitters. Has not been seen by Pysch as yet.\n Action:\n Has sitters in room, rec\ning NS @ 125cc/hr.\n Response:\n Appears calm with stable BP\n Plan:\n Assess MS\ns and monitor BP\n"
},
{
"category": "Physician ",
"chartdate": "2200-01-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 655131,
"text": "Chief Complaint: admitted with trazodone overdose\n 24 Hour Events:\n None-- admitted\n Slept overnight, but easily arousable\n HD stable throughout the night\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:22 AM\n Other medications:\n SQH\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 85 (73 - 88) bpm\n BP: 113/68(78) {90/44(55) - 113/68(78)} mmHg\n RR: 17 (15 - 20) insp/min\n SpO2: 97%\n Total In:\n 5,136 mL\n 1,055 mL\n PO:\n 500 mL\n 500 mL\n TF:\n IVF:\n 1,636 mL\n 555 mL\n Blood products:\n Total out:\n 1,360 mL\n 270 mL\n Urine:\n 760 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,776 mL\n 785 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General: sleepy, but easily arousable; somewhat slurred speech but\n coherent and logical\n HEENT: MMM, 1 mm pupils R=L (PEERL)\n Lungs: CTA b/l, no wheezes or crackles\n Cardio: RRR, no m.r.g.\n Extremities: no LE edema\n Skin: no rashes, no track marks\n Neuro: sleeping when seen but easily arousable; Ox3, somewhat slurred\n speech; CN II - XII intact; normal muscle tone, normal strength\n throughout; gait deferred\n Labs / Radiology\n 236 K/uL\n 9.4 g/dL\n 88 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 8 mg/dL\n 109 mEq/L\n 138 mEq/L\n 27.4 %\n 5.8 K/uL\n [image002.jpg]\n 04:32 AM\n WBC\n 5.8\n Hct\n 27.4\n Plt\n 236\n Cr\n 0.7\n Glucose\n 88\n Other labs: PT / PTT / INR:14.0/30.2/1.2, ALT / AST:, Alk Phos / T\n Bili:35/0.4, Albumin:3.5 g/dL, Ca++:6.9 mg/dL, Mg++:1.5 mg/dL, PO4:3.2\n mg/dL\n Imaging: no new imaging\n Microbiology: UCx: pending\n Assessment and Plan\n 32 yoF w/ depression hx and prior SA, admitted from ED for trazodone OD\n with EtOH intoxication.\n (#) TRAZODONE OVERDOSE: risk of hypotension with anti-alpha1 effects;\n no evidence of serotonin syndrome currently. Curbsided tox fellow who\n said to look out for hypotension, CNS depression and Qtc prolongation.\n Recommended levophed if she needs pressors. Qtc unchanged on am EKG.\n -- will watch for hypotension; fluid boluses PRN for SBP < 90 (has not\n needed)\n -- monitor for somnolence, altered MS\n (#) SUICIDE ATTTEMPT, DEPRESSION:\n -- will hold Celexa for now given trazodone OD\n -- SW consult placed\n -- 24 hour suicide watch; will need sitter on the floor\n -- will have psych see patient in the morning\n (#) NUTRITION: clear liquids o/n for possible GI upset with OD; will\n likely advance diet in the am; IVF for maintenance overnight\n (#) PPX:\n -- SQH\n -- no need for protonix tonight; will consider starting in the am if\n not eating or admits to sx\n -- no need for bowel regimen tonight as patient just admitted\n (#) CODE: full\n (#) CONSENT: signed in chart\n (#) COMMUNICATION: with patient\n (#) DISPO: likely d/c to floor or the psych service later today; pn\n privacy alert b/c of boyfriend\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:34 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2200-01-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 655134,
"text": "Chief Complaint: admitted with trazodone overdose\n 24 Hour Events:\n None-- admitted\n Slept overnight, but easily arousable\n HD stable throughout the night\n History obtained from Patient\n Allergies:\n History obtained from Patient\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:22 AM\n Other medications:\n SQH\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 85 (73 - 88) bpm\n BP: 113/68(78) {90/44(55) - 113/68(78)} mmHg\n RR: 17 (15 - 20) insp/min\n SpO2: 97%\n Total In:\n 5,136 mL\n 1,055 mL\n PO:\n 500 mL\n 500 mL\n TF:\n IVF:\n 1,636 mL\n 555 mL\n Blood products:\n Total out:\n 1,360 mL\n 270 mL\n Urine:\n 760 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,776 mL\n 785 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General: sleepy, but easily arousable; somewhat slurred speech but\n coherent and logical\n HEENT: MMM, 1 mm pupils R=L (PEERL)\n Lungs: CTA b/l, no wheezes or crackles\n Cardio: RRR, no m.r.g.\n Extremities: no LE edema\n Skin: no rashes, no track marks\n Neuro: sleeping when seen but easily arousable; Ox3, somewhat slurred\n speech; CN II - XII intact; normal muscle tone, normal strength\n throughout; gait deferred\n Labs / Radiology\n 236 K/uL\n 9.4 g/dL\n 88 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 8 mg/dL\n 109 mEq/L\n 138 mEq/L\n 27.4 %\n 5.8 K/uL\n [image002.jpg]\n 04:32 AM\n WBC\n 5.8\n Hct\n 27.4\n Plt\n 236\n Cr\n 0.7\n Glucose\n 88\n Other labs: PT / PTT / INR:14.0/30.2/1.2, ALT / AST:, Alk Phos / T\n Bili:35/0.4, Albumin:3.5 g/dL, Ca++:6.9 mg/dL, Mg++:1.5 mg/dL, PO4:3.2\n mg/dL\n Imaging: no new imaging\n Microbiology: UCx: pending\n Assessment and Plan\n 32 yoF w/ depression hx and prior SA, admitted from ED for trazodone OD\n with EtOH intoxication.\n (#) TRAZODONE OVERDOSE: risk of hypotension with anti-alpha1 effects;\n no evidence of serotonin syndrome currently. Curbsided tox fellow who\n said to look out for hypotension, CNS depression and Qtc prolongation.\n Recommended levophed if she needs pressors. Qtc unchanged on am EKG.\n -- will watch for hypotension; fluid boluses PRN for SBP < 90 (has not\n needed)\n -- monitor for somnolence, altered MS\n (#) SUICIDE ATTTEMPT, DEPRESSION:\n -- will hold Celexa for now given trazodone OD\n -- SW consult placed\n -- 24 hour suicide watch; will need sitter on the floor\n -- will have psych see patient in the morning\n (#) NUTRITION: clear liquids o/n for possible GI upset with OD; will\n likely advance diet in the am; IVF for maintenance overnight\n (#) PPX:\n -- SQH\n -- no need for protonix tonight; will consider starting in the am if\n not eating or admits to sx\n -- no need for bowel regimen tonight as patient just admitted\n (#) CODE: full\n (#) CONSENT: signed in chart\n (#) COMMUNICATION: with patient\n (#) DISPO: likely d/c to floor or the psych service later today; pn\n privacy alert b/c of boyfriend\n ICU \n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:34 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n ------ Protected Section ------\n ADDENDUM:\n Drop in Hct overnight from 36\n 27 likely dilutional from aggressive\n IVF; no evidence of gross blood loss.\n Will recheck in the pm to ensure stable; will send with T&S to be\n cautious.\n ------ Protected Section Addendum Entered By: , MD\n on: 06:25 ------\n"
}
] |
25,415 | 139,671 | A/P: yo f with HTN, DM II, OA, h/o UTI's, who now presents with hematemesis, UTI, and pan-colitis. . #) Hematemesis: Upon admission, the patient was reported to have approximately 50cc of hematemsis. She was admitted to in hemodynamically stable condition. Her Hct upon admission was 50.0, thought to represent hemoconcentration severe dehydration in the setting of pan-colitis. This returned to her baseline around 28-30 after IVF hydration and then remained stable. GI was made aware of pt, however plan for EGD was deferred as pt/family wish to avoid aggressive invasive measures. The patient had no further episodes of hematemesis and her Hct remained stable. ASA, NSAIDS were avoided and she was put on Protonix. . #) Pan-colitis: An abdominal CT scan with contrast upon admission showed a pan-colitis. The differential included infectious (? C dif), inflammatory, or ischemic causes. An infectious etiology was thought to be most likely given fever, elevated WBC count, and was guaiac negative. Ischemia was thought to be less likely given pan colitis distribution. Stool cultures were sent and were negative (C dif x 3 was negative as well as Campylobacter, O&P and stool culture. She was treated with flagyl, and meropenem for 6 days. Pain control acheived with fentanyl patch + prn morphine. After three negative C difs and clinical improvement in her abdominal exam, her antibiotics were discontinued. . #) Respiratory distress/Hypoxia: While in the ICU, the patient was noted to have one episode of mild respiratory distress with pulmonary edema after getting IVF hydration. She was approximately +7 Liters at the time after aggressive IVF hydration for pan-colitis. Her respiratory distress was volume overload and mild CHF from diastolic dysfunction. She was gently diuresed with excellent response to Lasix 10mg IV and got daily Lasix. She will be discharged on daily PO Lasix which will need to be titrated based on daily weights, monitoring Cr and UOP (this was discussed with patient's PCP before discharge). . #) Acute Renal Failure: Upon admission, the patient's Cr was 1.0 (near her baseline 0.9-1.3). Her Cr climbed to as high as 1.4 after gentle diuresis for volume overload with Lasix. Her creatinine trended down and was 1.2 upon discharge. Her volume status and creatinine will need to be monitored as an outpatient as she will be going home on daily Lasix 10mg daily (this may need to be titrated, possibly qday or QOD). . #) UTI: The patient has a long history of multiple Klebsiella UTIs that are multi-drug resistant (ESBL, extended spectrum beta-lactamase producing). Her urine culture upon admission showed Klebsiella (again ESBL but sensitive to Meropenem, pt cannot take cephaloporins or PCN, Klebsiella was resistant to Cipro, Bactrim, Nitrofurantoin and Levofloxacin). She completed a 6 day course of Meropenem. . #) Tachycardia: The patient was admitted with tachycardia to the 120s thought to be intravascular volume depletion/dehydration as well as from diffuse abdominal pain. After volume resuscitation upon admission and resolution of pain, the patient's HR improved. She appears to run between 90s-105 at baseline. . #) Hypertension: Pt has a h/o of HTN, which was treated with metoprolol and initially with prn hydral and nitropaste. Her blood pressure improved during her hospital stay and she required only Metoprolol to control her BP during the remainder of her hospital stay. . #) Fever: Thought to be secondary to UTI and colitis. She completed 6 days of Meropenem for resistent Klebsiella UTI and Flagyl for colitis of unclear etiology (C dif x 3 negative). Her fevers trended down during this admission and she was afebrile before discharge. . #) Mental status change: Thought to be likely secondary to infection and hypovolemia superimposed on mild dementia. On HD #2, her MS improved significantly after IVFs. She was restarted on Remeron and Neurontin after her mental status returned to baseline. . #) Arthritis: Stable. She was continued on her outpatient low-dose prednisone, and fentanyl patch. . #) DM II: Her diabetes was reportedly diet controlled (thought possibly to be steroids). Finger sticks were elevated on admission likely due to infection. She was maintained on an insulin sliding scale and required minimal coverage. . #) FEN: Patient was maintained on a regular diet with thickened liquids. . #) Comm: son , HCP (cell: , office: , home: , admin assistant Ms. ), grandson () . #) Code: DNR/DNI (discussed with son, ); Son requesting no aggressive procedures preferring instead for medical management . | pt became wheezy-was given atrovent neb and 10mg iv lasix with brisk response of diuresis. K and Mg have been replaced.Resp: LS with rales in the bases, 02 SAT in the mid to upper 90s on 2 L NC. U/O HAD SLOWED DOWN AND PT WAS GIVEN LASIX 10MG IV AT MN WHICH HAD A GOOD EFFECT. NARRATIVE NOTE:PLEASE SEE ADM H&P FOR BACKGROUND INFORMATION.CV: B/P HAS RANGED FORM A LOW OF 116/62 WHEN PT ASLEEP, TO 185/122. Breathing improved to rr 12-14, LS c crackles at bases, occ wheezes on R. Sats 96-99 on 2L nc.CV: HR up to 114 c incr wob above, later 80s-90s, nsr. Fine expiratory wheezing on rt (pt turned to rt)Atrovent neb given some improvement in aeration no change in sats or WOB. PT IS PRESENTLY STILL HAVING A GOOD U/O.GI: ABD SOFT WITH + BS. nsg note addendum: 19:00-7:00t max 100.3po. sbp 100-130, altho had one dip to 90.GI: +BS, nt, nd. sob cleared entirely after 10mg iv lasix was given with brisk diuresis. WOB eventually resolve and spo2 remained in the mid 90's 2L nc. pt has been on 2lnc overnoc (not 4lnc as stated in above note). follows simple commands.cv: hr ranging 90s sr with no ectopy noted. urine was sent for cx.skin: r hip with pink area ota and ll leg with duoderm intact.lines: l w #22g piv and l brac. 2+ PERIPH EDEMA IN THE ARMS.RESP: LUNGS WITH CRACKLES IN THE BASES, UPPER LOBES CLEAR. hr 130s-140s with htn up to 220/130, diaphoretic. fld balance neg 240mls last 24 hrs, but 7.9L up los.Plan: F/u on am . PT HAS 1L OF LR BOLUS WITH LITTLE EFFECT. NPN 1900-0700Neuro: A&Ox2, c/o pain in lower legs, morphine 1mg x2 c good effect.Pt slept most of noc.Resp: Increased wob on eves c tachycard and RR up to 22. PRESENTLY HR HAS DECREASED TO THE 97-103 RANGE WHILE PT ASLEEP. medicated with 650mg po tylenol with temp down to 99.3po. Respiratory TherapyPt presents on 2L n/c Increased WOB after position change. 02 SATs have been in the mid to upper 90s on 5 L NC.GI: Tolerating food with almost no diarrhea today. sp02 ranging 96-100% on 4lnc.gi/gu: abd soft, nt, +bs, medium loose brown bm last eve. PT BRIGHT EYED THIS AM AND TALKING.GU: VERY POOR U/O. PPP BILAT.RESP: ON 2L N/C. 10mg lasix given c mod diuresis followed by usual dose of metoprolol and morphine 1mg. BS+ X4 SLOW. PT DX WITH PAN COLITIS AND HAS ONLY HAD PO MEDS OTHERWISE NPO FOR POSSIBLE SCOPE IF FURTHER GIB. SAO2 95-98% ON 2L N/C. CURRENTLY IVF AT 75CC/HR X 500CC.GI: PT ARRIVED WITH MOD AMT OF LIGHT BROWN SOFT STOOL. BUN 18/CREAT 1, WILL RECHECK IN AM. She has been given nebs for the wheezing with good effect. NARRATIVE NOTE:CV: B/P HAS RANGED FROM 90/39-161/74. medicated with total of 2mg iv morphine and repositioned back to r side with good effect. Cardiomegaly with a tortuous aorta is again seen and unchanged. Low attenuation splenic foci, which are incompletely characterized on this exam. CT ABDOMEN: There is mild dependent atelectasis. Sinus tachycardiaModest nonspecific ST-T wave changesSince previous tracing of , sinus tachycardia present and P-R intervalshorter Severe atherosclerotic disease; however, the mesenteric vessels appear patent. FINDINGS: Compared with 11/14 at 2:43 p.m., even allowing for a lighter radiographic technique, it appears that there has been interval engorgement and some upper zone redistribution of the pulmonary vessels consistent with mild CHF. Admitting Diagnosis: COLITIS ********************************* CPT Codes ******************************** * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. PROCEDURE AND FINDINGS: Since no suitable veins were visible, ultrasound was used to identify the left brachial vein, which was patent and compressible. Multiple small low attenuation splenic foci are noted. DOES NOT MOVE EXTREMITIES.RESP: LUNGS WITH BASE RALES AND EXP WHEEZES WHICH WERE INTERMITTENT. IMPRESSION: AP chest compared to through 19: Lung volumes remain quite low. There is low attenuation material within the bladder, which could represent blood clot. Heavy atherosclerotic disease but the mesenteric vessels are patent. REASON FOR THIS EXAMINATION: evaluate for edema, infiltrate. There is colonic diverticulosis. There is a fundal adenomyosis. A 0.018 guidewire was then advanced through the needle into the distal part of the SVC under fluoroscopic guidance. (Over) 4:38 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: HEMATEMASIS X1 TACHCARDIA,R/O PERF Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) Evaluate for edema, infiltrate. There is tortuosity of the aortic contour with wall calcifications. Tip of the left PIC catheter projects over the mid SVC. 2L N/C WAS STARTED AT HS AS SAO2 WOULD DECREASE WITH REST. Left renal cysts and additional low attenuation foci, which may represent cysts but are too small to be fully characterized are identified. REASON FOR THIS EXAMINATION: please eval for interval change FINAL REPORT INDICATION: Abdominal pain, fever, pancolitis. SAO2 WAS LOW 90'S ON R/A. She was given IV lasix and nitroglycerine paste and her BP has decreased to the 100s-120s., her HR was in the 100s and has dropped to the 80s after tylenol for a temp of 101.3. Gas-distended fundus of the stomach is noted. 8:10 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for edema, infiltrate. | 22 | [
{
"category": "Nursing/other",
"chartdate": "2127-11-21 00:00:00.000",
"description": "Report",
"row_id": 1593937,
"text": "Resp Care\n\nPt had episode of increased WOB; audible wheezing and desaturation this am. Pt received atrovent neb as well as lasix and nitro paste. WOB eventually resolve and spo2 remained in the mid 90's 2L nc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-11-22 00:00:00.000",
"description": "Report",
"row_id": 1593938,
"text": " nsg note: 19:00- 7:00\nthis is a y.o. woman adm from nsg home with coffee ground emesis, sob, abd pain. hr 130s-140s with htn up to 220/130, diaphoretic. tx'd with morphine but remained htn and tachy. ct revealed colitis and uti. dev. pulm edema -tx'd with lasix 10mg iv, nitropaste, and morphine with brisk u.o. overnight pt developed another episode of sob at 12am precipitated by repositioning. pt became wheezy-was given atrovent neb and 10mg iv lasix with brisk response of diuresis. sob resolved.\n\nneuro: a&ox3, legs remained contracted and painful with repositioning. doesn't move upper ext. but able to straighten them easily except hands contracted. follows simple commands.\n\ncv: hr ranging 90s sr with no ectopy noted. bp ranging 100s-150s/50s-60s. +pp. troponin ck yesterday was 300 with troponin back at .11. am pending.\n\nresp: acutely sob at 12am as described above with movement with diffuse wheezing settling after at rest and given atrovent neb. sob cleared entirely after 10mg iv lasix was given with brisk diuresis. sp02 ranging 96-100% on 4lnc.\n\ngi/gu: abd soft, nt, +bs, medium loose brown bm last eve. ate fried chicken without difficulty that her niece brought in to her last eve. taking pills crushed with raspberry ice without difficulty. foley patent with poor u.o. approx 20cc/hr at beginning of shift with inc. brisk u.o. s/o 10mg iv lasix. urine was sent for cx.\n\nskin: r hip with pink area ota and ll leg with duoderm intact.\n\nlines: l w #22g piv and l brac. picc line patent.\n\nsocial: neice was in to visit last eve. pt remains dnr/dni.\n\nplan: continue to monitor u.o., lung exam and need for more lasix, continue iv abx, follow ck, mb, troponin/am , need k, phos. repletion- did receive neutraphos last eve. send stool for o&p and cdiff w/a.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-11-22 00:00:00.000",
"description": "Report",
"row_id": 1593939,
"text": " nsg note addendum: 19:00-7:00\nt max 100.3po. medicated with 650mg po tylenol with temp down to 99.3po. c/o bilat leg pain at 6:40am with hr as high as 120 and sbp 130s-160. medicated with total of 2mg iv morphine and repositioned back to r side with good effect. u.o. dropping down to 23cc/hr by 7am. may need more lasix. 02 sat currently 98% on 2lnc. pt has been on 2lnc overnoc (not 4lnc as stated in above note). pt denies sob at this time and resting comfortably.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-11-22 00:00:00.000",
"description": "Report",
"row_id": 1593940,
"text": "NPN\n\nNeuro: Pt is alert and oriented x2, she has been dozing on and off through the day, in much part do to the morphine that she needed for pain.\n\nCV: BP has been stable, her HR has been 90s to the low 100s, she conts on lopressor 12.5 mg which she has been tolerating, it has not lowered her BP significantly (~ 10 points).\n\nResp: She has rales up from the bases, she becomes SOB and wheezy with any activity including eating. She has been given nebs for the wheezing with good effect. 02 SATs have been in the mid to upper 90s on 5 L NC.\n\nGI: Tolerating food with almost no diarrhea today. The flagyl was changed back to PO.\n\nGU: Her u/o has been 20-70cc/hr, she is presently ~ 200cc pos since MN and 8 liters pos since admit, she has not been given further lasix today.\n\nPain: She has been c/o L leg pain, she calls it a cramping pain, she has been given 1 mg of MS04 at a time with good effect though it makes her lethargic causing her to sleep most of the day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-11-23 00:00:00.000",
"description": "Report",
"row_id": 1593941,
"text": "Respiratory Therapy\nPt presents on 2L n/c Increased WOB after position change. Fine expiratory wheezing on rt (pt turned to rt)Atrovent neb given some improvement in aeration no change in sats or WOB. Pt remains 8L positive.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-11-23 00:00:00.000",
"description": "Report",
"row_id": 1593942,
"text": "NPN 1900-0700\nNeuro: A&Ox2, c/o pain in lower legs, morphine 1mg x2 c good effect.\nPt slept most of noc.\n\nResp: Increased wob on eves c tachycard and RR up to 22. 10mg lasix given c mod diuresis followed by usual dose of metoprolol and morphine 1mg. Breathing improved to rr 12-14, LS c crackles at bases, occ wheezes on R. Sats 96-99 on 2L nc.\n\nCV: HR up to 114 c incr wob above, later 80s-90s, nsr. sbp 100-130, altho had one dip to 90.\n\nGI: +BS, nt, nd. Tol thickened flds well for meds. Had mod sized soft,formed, golden brown stool, ob neg. spec sent to lab.\n\nGu: duiuresed ~ 500mls from 10mg lasix, not as much as previous noc. Breathing improved. fld balance neg 240mls last 24 hrs, but 7.9L up los.\n\nPlan: F/u on am . cont to monitor u/o, resp status, ls, sats, rr, VS. Cont to medicate for pain.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-11-23 00:00:00.000",
"description": "Report",
"row_id": 1593943,
"text": "NPN\n\nNeuro: Pt slept until 10:30, she was groggy until 11:30 but has been awake and alert, talking with her niece.\n\nCV: BP 100-120s/60s, HR 80s-100s, conts on lopressor but it is not lowering her HR very much\n\nResp: Still has periods of audible rales, given 10 mg of IV lasix with 150cc out in 2 hours. 02 SAT has been 94-95% on 2 L.\n\nGI: She had a very large amount of diarrhea - brown in color, poor appitite today, no abdominal pain.\n\nGU: Low u/o ~ 10cc/hr and amber, her urine has been 80-70cc/hr with the lasix.\n\nSoc: Her niece came in to visit, she wants to be called if she gets a bed tonight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-11-19 00:00:00.000",
"description": "Report",
"row_id": 1593931,
"text": "NARRATIVE NOTE:\n\nPLEASE SEE ADM H&P FOR BACKGROUND INFORMATION.\n\nCV: B/P HAS RANGED FORM A LOW OF 116/62 WHEN PT ASLEEP, TO 185/122. PT A LOPRESSOR 5MG IVP DOSE WHICH WAS NOT EFFECTIVE AND HYDRALAZINE 5MG IVP X2 WHICH WAS MUCH MORE EFFECTIVE IN DECREASING THE B/P. PT ALSO ARRIVED TACHYCARDIC AT 125-139 RANGE. PRESENTLY HR HAS DECREASED TO THE 97-103 RANGE WHILE PT ASLEEP. NO ECTOPY NOTED. PPP BILAT. PT HAS SLIGHT PERIPH EDEMA IN THE ARMS. HCT HAS INCREASED TO 50 AFTER APPROX 3L OF IVF, WILL RECHECK LABS IN AM. WBC 16.5.\n\nNEURO: PT IS USUALLY A&O X3, \"SHARP AS A TACK\" PER SON. UNABLE TO STATE WHERE SHE IS CONSISTANTLY BUT DOES RECALL THAT IT IS , HER 95TH BIRTHDAY. DOES FOLLOW SIMPLE COMMANDS TO SQUEEZE HANDS AND OPEN MOUTH ETC. PT HAS CHRONIC PAIN FROM ARTHRITIS. LEGS ARE CONTRACTED. PT WAS MED WITH MORPHINE 2MG IV X2 SO FAR FOR ABD PAIN. PT WILL CRY OUT AND MOAN WITH PAIN.\n\nRESP: PT HAS HAD BIL DIM BASES WITH RALES. SAO2 95-98% ON 2L N/C. NO RESP DISTRESS NOTED.\n\nGU: FOLEY CATH PATENT DRAINING SM AMTS OF DARK YELLOW TO AMBER URINE. PT HAS 2 NS BOLUSES OF 250CC OVER 1 HOUR EACH TO HELP INCREASE U/O WITH MARGINAL RESULTS. BUN 18/CREAT 1, WILL RECHECK IN AM. CURRENTLY IVF AT 75CC/HR X 500CC.\n\nGI: PT ARRIVED WITH MOD AMT OF LIGHT BROWN SOFT STOOL. BS+ X4 SLOW. PT DX WITH PAN COLITIS AND HAS ONLY HAD PO MEDS OTHERWISE NPO FOR POSSIBLE SCOPE IF FURTHER GIB. CT SCAN DID SHOW PAN COLITIS PRIOR TO MICU ADM.\n\nID: PT ON VANCO, FLAGYL, MEROPENEM, TEMP IN EW WAS 101.6 WBC'S AT MIDNIGHT 16.5.\n\nENDO: PT IS NIDDM. HAS SSIC.\n\nPLAN: CONT WITH ATB AND FOLLOW TEMPS. BLOOD CX IF TEMPS SPIKE. MONITOR VS AND LABS, REPLENISH LYTES AS NEEDED. SON IS HCP AND UPDATE WITH ANY CHANGES. PT IS DNR/DNI BUT OTHERWISE TREAT WITH IVF OR PRESSORS AS NEEDED. FAMILY FRIEND COME TO VISIT AND BE UPDATED PER HCP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-11-19 00:00:00.000",
"description": "Report",
"row_id": 1593932,
"text": "NPN\n\nNeuro: Pt has been lethargic for most of the day, more awake this afternoon, able to tell me her first name, when asked, \"Who is ?\". She said \"Me\". She has been deniing pain today though she is on 150mcg fent patch.\n\nCV: SBP 90s-low 100s, HR 80s-90s, she was not given her lopressor today due to her lowish BP. K and Mg have been replaced.\n\nResp: LS with rales in the bases, 02 SAT in the mid to upper 90s on 2 L NC. She has been given 2 liters IVF this shift and she is 5800cc pos for LOS.\n\nGI: ABD soft, she has been deniing ABD pain, she has had a small amount of loose mustard colored stool, a HCT will be sent after her KCl finishes.\n\nGU: She has had a poor u/o all day, 0-20cc/hr, her foley was flushed and then replaced due to the sedament in her urine but this did not improve her u/o nor did fluid boluses. We will check lytes and BUN/creat with the HTC - she did receive dye for the CT yesterday.\n\nSkin: She has a stage 2 decub on her shin as well as her R hip, her chest is also red - this was true this morning? if this is from vanco.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-11-24 00:00:00.000",
"description": "Report",
"row_id": 1593944,
"text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 111/55-165/73. NSR/ST WITH HR RANGING FROM 73-112, NO ECTOPY NOTED. PPP BILAT.\n\nRESP: ON 2L N/C. SAO2 HAS RANGED FROM 96-100%. RR 10-21. LUNGS HAVE VARIED DEPENDING ON ACTIVITY. DURING PERIODS OF REST LUNGS ARE CLEAR WITH RALES NOTED IN THE LOWER LOBES. WHEN PT IS EATING OR TALKING LUNGS TEND TO GET WHEEZY WITH OFTEN WHEEZES AUDIBLE WITHOUT STETHESCOPE. PT DENIES SOB OR ANY DIFFICULTY BREATHING EVEN WHEN WHEEZES ARE AUDIBLE.\n\nNEURO: A&O, MOSTLY X3 BUT DOES OCC FORGET THE DAY. PT HAS CONT TO TALK APPROPRIATELY AND AND FOLLOWS SIMPLE COMMANDS. DOES NOT MOVE EXT MUCH. LOWER EXT ARE CONTRACTED AND PT DOES NOT MOVE UPPER EXT MUCH OTHER THAN HER HANDS.\n\nGU: FOLEY CATH PATENT DRAINING CLEAR YELLOW URINE. U/O HAD SLOWED DOWN AND PT WAS GIVEN LASIX 10MG IV AT MN WHICH HAD A GOOD EFFECT. PT IS PRESENTLY STILL HAVING A GOOD U/O.\n\nGI: ABD SOFT WITH + BS. APPETITE IS FAIR TO GOOD. PT REQUIRES HELP WITH MEALS. NO STOOL THIS SHIFT.\n\nPLAN: PT IS CALLED OUT AND COUSILN WOULD LIKE TO BE NOTIFIED WHEN PT IS . PLAN IS TO MOVE PT WITH ROOM CLOSE TO NSG STATION SO PT IS ABLE TO CALL FOR NURSE EASILY IF SHE NEEDS. UPDATE FAMILY WITH ANY CHANGES IN PT CONDITION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-11-20 00:00:00.000",
"description": "Report",
"row_id": 1593933,
"text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 90/39-161/74. SR/ST WITH HR RANGING FROM 71-105, NO ECTOPY NOTED. PPP BILAT. 2+ PERIPH EDEMA IN THE ARMS.\n\nRESP: LUNGS WITH CRACKLES IN THE BASES, UPPER LOBES CLEAR. SAO2 HAS RANGED FSROM 92-100%. RR 5-23. NO SOB NOTED.\n\nNEURO: ALERT AND SOMEWHAT ORIENTED. DOES NOT HAVE DATE AND LOCATION BUT DOES KNOW HER FAMILY AND ABOUT HER LIFE. PT BRIGHT EYED THIS AM AND TALKING.\n\nGU: VERY POOR U/O. PT HAS 1L OF LR BOLUS WITH LITTLE EFFECT. URINE IS YELLOW WITH SEDIMENT.\n\nGI: NPO. HAS HAD NO C/O ABD PAIN.\n\nPLAN: CONT TO MONITOR LYTES AND REPLEAT AS NEEDED. LYTES PENDINA PRESIENTLY IF THERE IS ENOUGH BLOOD AS PT IS A HARD STICK. UPDATE FAMILY WITH ANY CHANGES IN PT CONDITION\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-11-20 00:00:00.000",
"description": "Report",
"row_id": 1593934,
"text": "NPN\n\nNeuro: Pt is alert, oriented to name and a hospital, asking to eat since she is thirsty, she did well eating jello and nectar thickened fluid.\n\nCV: Her BP has been 100s-120s/50s-60s, HR 80s, her lopressor dose was deceases to 12.5 mg .\n\nResp: LS with rales 2/3 up from the bases, her 02 SAT on RA has been in the mid to upper 90s. She is over 8 liters pos for LOS and is putting out ~ 10-20cc/hr of urine.\n\nGI: She denies abd pain, she has been tolerating a clear liquid diet. No stool to send for clx.\n\nGU: U/O 10-20cc/hr, her urine is still cloudy, remains on miropenim.\n\nSoc: She has been numerous visitors.\n\nAccess: Both of her periferal IVs infiltrated, a bedside PIC was unsuccessful, to have PIC placed in IR tomorrow, she has a periferal line in until then.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-11-21 00:00:00.000",
"description": "Report",
"row_id": 1593935,
"text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 119/67-154/74. NSR/ST WITH HR RNGING FROM 88-108, NO ECTOPY NOTED. PPP BILAT.\n\nNEURO: A&OX3. PT WAS QUITE TALKATIVE THROUGHOUT THE SHIFT. FOLLOWS SIMPLE COMMANDS. DOES NOT MOVE EXTREMITIES.\n\nRESP: LUNGS WITH BASE RALES AND EXP WHEEZES WHICH WERE INTERMITTENT. SAO2 WAS LOW 90'S ON R/A. 2L N/C WAS STARTED AT HS AS SAO2 WOULD DECREASE WITH REST. RR 14-29.\n\nGU: FOLEY CATH PATENT DRAINING LESS THAN ADEQUATE AMTS OF CLOUDY YELLOW URINE WITH SEDIMENT.\n\nGI: PT HAD A SM STOOL GREENISH IN COLOR, SPEC SENT TO THE LAB FOR O&P AND C-DIFF.\n\nPLAN: PT WILL GO TO IR FOR A PICC PLACEMENT TODAY. CONT TO MONITOR LYTES AND REPLENISH AS NEEDED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-11-21 00:00:00.000",
"description": "Report",
"row_id": 1593936,
"text": "NPN\n\nNeuro: Pt is alert and oriented to name and a hospital, she has been tired today and has been sleeping on and off.\n\nCV: She had a period of hypertention to the 180s when she was having respiratory distress. She was given IV lasix and nitroglycerine paste and her BP has decreased to the 100s-120s., her HR was in the 100s and has dropped to the 80s after tylenol for a temp of 101.3. Her CPK is 300, the top and MB are pending.\n\nResp: She became acutely SOB this morning, she had audible wheezes, she was 9000cc pos, hypertensive, RR was in the mid 20s and labored, 02 SAT mid 90s on 4 L NC. She was given IV lasix, nitroglycerine paste. Her respirations became less labored, her BP decreased and she has put out ~ 700cc of urine so far today.\n\nGI: She has started to have diarrea today - 3 times since this morning, a stool spec was sent ealier today.\n\nGU: Good u/o from the lasix, her creat was 1.2 today.\n\nID: She spiked today to 101.3, blood clx were sent, urine to be sent, she does not have cough.\n\nAccess: A single lumen PIC was placed today.\n"
},
{
"category": "ECG",
"chartdate": "2127-11-18 00:00:00.000",
"description": "Report",
"row_id": 311310,
"text": "Sinus tachycardia\nModest nonspecific ST-T wave changes\nSince previous tracing of , sinus tachycardia present and P-R interval\nshorter\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-11-21 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 936336,
"text": " 11:59 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC.\n Admitting Diagnosis: COLITIS\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with UTI, pan-colitis, hemetemesis, needs PICC for meropenem\n for ESBL klebsiella\n REASON FOR THIS EXAMINATION:\n please place PICC.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: This is a 75-year-old woman with UTI, pancolitis that\n needs PICC line to be placed for antibiotic therapy.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. , the\n attending radiologist, who was present and supervising throughout the\n procedure.\n\n PROCEDURE AND FINDINGS: Since no suitable veins were visible, ultrasound was\n used to identify the left brachial vein, which was patent and compressible.\n The left arm of the patient was then prepped and draped in standard sterile\n fashion. After injection of 5 cc of 1% lidocaine, a 21 gauge needle was\n advanced into the left brachial vein under ultrasonographic guidance. Hard\n copies of the images before and after the venipuncture were obtained. A 0.018\n guidewire was then advanced through the needle into the distal part of the SVC\n under fluoroscopic guidance. The needle was then exchanged for a 5 French\n micropuncture sheath. Based on the markers in the guidewire, it was decided\n that a length of 41 cm would be suitable. The line was then trimmed to this\n length and advanced over the wire into the distal part of the SVC under\n fluoroscopic guidance. The wire and the peel-away sheath was then removed and\n the line was flushed, heplocked and statlocked. Final fluoroscopic image of\n the chest demonstrates the tip of the catheter to be located in the distal\n part of the SVC. The patient tolerated the procedure well.\n\n IMPRESSION: Successful placement of 41 cm long single lumen line placed via\n the left brachial vein with the tip in the distal part of the SVC. The line\n is ready for use.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 935956,
"text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for edema, infiltrate.\n Admitting Diagnosis: COLITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abd pain, pan-colitis, low-grade fever, and crackles on\n exam.\n REASON FOR THIS EXAMINATION:\n evaluate for edema, infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 8:37 A.M. ON \n\n INDICATION: Pancolitis. Fever. Crackles. Evaluate for edema, infiltrate.\n\n FINDINGS: Compared with 11/14 at 2:43 p.m., even allowing for a lighter\n radiographic technique, it appears that there has been interval engorgement\n and some upper zone redistribution of the pulmonary vessels consistent with\n mild CHF.\n\n No confluent infiltrates or sizable pleural effusions are appreciated. The\n decreased lung volumes are about the same.\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-11-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 936664,
"text": " 6:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: COLITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abd pain, pan-colitis, low-grade fever, and increased\n crackles on exam.\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:40 A.M., .\n\n HISTORY: Abdominal pain, pancolitis, low-grade fever and increased crackles.\n\n IMPRESSION: AP chest compared to through 19:\n\n Lung volumes remain quite low. There is no focal pulmonary abnormality. I\n doubt that pulmonary edema is present. Heart size is normal. Thoracic aorta\n is generally large and unchanged. No pneumothorax or pleural effusion is\n seen. Tip of the left PIC catheter projects over the mid SVC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-11-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 936539,
"text": " 5:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: COLITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abd pain, pan-colitis, low-grade fever, and increased\n crackles on exam.\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Abdominal pain, low-grade fever.\n\n CHEST:\n\n There has been no significant change since the prior chest x-ray of . Some upper zone redistribution is present, but no infiltrates or other\n evidence of failure is seen.\n\n IMPRESSION: No change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-11-18 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 935875,
"text": " 4:38 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: HEMATEMASIS X1 TACHCARDIA,R/O PERF\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hematemasis x1, tachcardia\n\n REASON FOR THIS EXAMINATION:\n eval for perforation, ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JCT TUE 5:27 PM\n Pancolitis which could be infectious, inflammatory or ischemic.\n Heavy atherosclerotic disease but the mesenteric vessels are patent.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old woman with hematemesis and tachycardia.\n\n COMPARISON: .\n\n TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained\n with 100 cc Optiray IV contrast. A small amount of oral contrast was also\n given. Coronal and sagittal reformatted images were obtained.\n\n CT ABDOMEN: There is mild dependent atelectasis. The liver is unremarkable.\n The gallbladder is not distended. There is a fundal adenomyosis. The\n pancreas is unremarkable. Multiple small low attenuation splenic foci are\n noted. The adrenal glands are unremarkable. Left renal cysts and additional\n low attenuation foci, which may represent cysts but are too small to be fully\n characterized are identified. Stomach and small bowel loops are unremarkable.\n The colon is decompressed, but the wall is diffusely thickened. This is most\n prominent in the right colon and sigmoid colon. There is colonic\n diverticulosis. There is no free air. No mesenteric or retroperitoneal\n lymphadenopathy is identified. There is severe atherosclerotic disease\n including a large plaque in the proximal SMA. The mesenteric vessels do\n appear patent.\n\n CT PELVIS: Foley catheter is noted in the bladder. There is low attenuation\n material within the bladder, which could represent blood clot. The sigmoid\n colon and rectum are diffusely thickened. There is mild surrounding\n inflammatory stranding.\n\n BONE WINDOWS: There is severe osteopenia and degenerative changes of the\n lumbar spine and pelvis. Right hip prosthesis is noted.\n\n IMPRESSION:\n 1. Pancolitis. The appearance is nonspecific and could be secondary to\n infection, an inflammatory process, or ischemia. Severe atherosclerotic\n disease; however, the mesenteric vessels appear patent.\n 2. Gallbladder fundal adenomyosis.\n 3. Low attenuation splenic foci, which are incompletely characterized on this\n exam.\n (Over)\n\n 4:38 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: HEMATEMASIS X1 TACHCARDIA,R/O PERF\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-11-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 935858,
"text": " 2:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o free air\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abd pain\n REASON FOR THIS EXAMINATION:\n r/o free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain. Rule out free air.\n\n COMPARISON: CXR .\n\n FINDINGS: Upright plain radiograph of the chest. Cardiomegaly with a\n tortuous aorta is again seen and unchanged. Pulmonary vascularity is\n unremarkable. No infiltrate or consolidation is identified within the lung.\n No pleural effusion is seen. No intraperitoneal free air is identified.\n Gas-distended fundus of the stomach is noted.\n\n IMPRESSION: No intraperitoneal free air.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-11-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 936273,
"text": " 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: COLITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with abd pain, pan-colitis, low-grade fever, and increased\n crackles on exam.\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain, fever, pancolitis.\n\n COMPARISONS: .\n\n SINGLE VIEW CHEST, AP SEMI-ERECT: Allowing for technique, there is no\n significant change compared to the previous exam. There is no change in mild\n pulmonary edema. There is tortuosity of the aortic contour with wall\n calcifications. Degenerative changes are seen within both shoulder joints.\n\n"
}
] |
40,287 | 103,847 | In summary, this is a 58 year-old man presenting s/p ventricular fibrillation arrest, now intubated, sedated and paralyzed on cooling protocol, back in normal sinus rhythm. The period between onset of cardiac arrest and restoration of sinus pulse was approximately 6 minutes, per EMS report. .. # RHYTHM / VF ARREST: Shortly after presentation to the emergency room he went to the cath lab where there was evidence of coronary vasospasm of the LAD; there were no fixed lesions requiring stenting, only a 30% fixed stenosis of the LAD (see full catheterization report above). Urine toxicology was negative. Echo showed severe aortic regurgitation and mild symmetric LVH with preserved global systolic function. He was started on a nitro drip for vasospasm and afterload reduction in the setting of known AI. He was cooled per neuroprotective protocol post cardiac arrest and maintained in a hypothermic state for 24 hours. He was sedated throughout with Fentanyl and midazolam and paralyzed with vecuronium to minimize shivering. . Twenty-four hours after beginning cooling, his core body temperature was slowly warmed. He became increasingly agitated overnight and on the morning of HD 2, his sedation was weaned and he was extubated. Telemetry showed no further episodes of ventricular dysrhythmia. The presumed cause for his VF arrest is coronary artery vasospasm. It is unclear at this time whether the (exertional) anginal-type symptoms he describes in the weeks leading up to this event are also due to vasospasm. . During the hospital course, his nitro drip was switched over to long acting nitro and calcium channel blocker. An ICD was placed several days prior to discharge. He will have follow-up with his cardiologist at as well as follow-up in the clinic at . .. # PUMP / VALVES: An echocardiogram performed in the ED showed normal EF with severe AI and moderate LV dilation. Although he was initially hypotensive in the ED requiring neosynephrine he became hypertensive in cath lab and his pressor was discontinued. As above, there was no significant coronary artery disease and no regional wall motion abnormalities. A repeat TTE performed two days after admission showed normal LV function with EF of >55% and an aortic valve with three leaflets but functionally bileaflet; AR was 3+. It is unclear at this time whether his aortic insufficiency is at all related to his VF arrest. . As above, he was continued on afterload reducing agents. He will follow-up at with Dr. . Aortic valve replacement is being considered. .. # ISCHEMIA / CAD: As above, coronary angiography showed a 30% fixed stenosis of his proximal LAD. LCx and RCA were unremarkable. The LAD coronary vasospasm that likely caused his cardiac arrest was treated with Imdur and amlodipine. We continued his home dose of aspirin 81 mg qday. . # RESPIRATORY STATUS / PNEUMONIA: He was intubated in the field secondary to his cardiac arrest and continued on ventilation throughout the cooling and rewarming period. On HD 2, sedation was weaned and he was extubated on the morning of HD 3. . The night before extubation, he spiked a fever. Differential at that time included VAP, aspiration pna, pulmonary embolus, and endocarditis (given his known valvular disease). blood cultures grew gram positive cocci (later speciated as coag neg staph), and he was started empirically on IV vanco. A tranesophageal echo was done while he was still intubated that was negative for valvular vegetations. CXR came back showing bibasilar consolidations c/w aspiration pna. We started him empirically on Zosyn and continued the vanco. When blood culture speciation returned and he began tolerating PO, IV vanco and Zosyn were stopped and he was started on levo and flagyl to complete a seven day course of antibiotics. . Unfortunately, on day 7 of his antibiotic course he spiked a low-grade fever to 100.6, then on day 8 to 101.1. Repeat CXR, PA and lateral, showed worsening RLL pneumonia. Blood and urine cultures were negative. Infectious disease consultation recommended increasing dose of levo to 750 QDAY. We made this change and decided to treat for an additional 7 days for presumptive hospital acquired pneiumonia. He had no more fever over the next 24 hours. O2 sats were excellent on RA and there was no cough or sputum production. He is discharged with five days of PO levo remaining to complete a seven day course. .. # PLEURITIC CHEST PAIN / STATUS POST CHEST COMPRESSIONS: Chest pain was treated with IV morphine, switched over to oxycodone post-extubation. This was suppplemented by a lidocaine patch. At time of discharge, he is taking vicodin, lidocaine patch, and NSAIDs with adequate pain control. Narcotic-related constipation is treated with senna and docusate. .. # MENTAL STATUS: There was concern after extubation that he may have memory deficits s/p arrest. CT-head was ordered at admission and negative for acute intracranial process. Over the course of the hospitalization, he became increasingly alert and oriented. His MS at time of discharge is fully recovered and back to baseline pre-arrest. .. # ANEMIA: During hospital course, he had hematocrit in mid twenties that rose to 30 at time of discharge. Kidney function was normal; iron studies WNL and hemolysis labs negative. Unclear why this otherwise healthy man who runs 20 mi/wk should have anemia, other than possibly d/t marrow suppression in the setting of acute illness. This will need follow-up as outpatient. .. # After extubation, he was started on a regular diet. DVT prophylaxis with subcutaneous heparin. GI ulcer prophylaxis with an H2 blocker while intubated which was stopped after extubation. Code status was full throughout. | Pulmonary edema and cardiomegaly cleared. Pulmonary edema and cardiomegaly cleared. FINDINGS: There are bilateral opacifications in the lung base, with air bronchograms seen, and obscure hemidiaphragm. FINDINGS: There is a single chamber pacer/AICD in place with lead terminating in the region of the right ventricle. There has been interval removal of the endotracheal tube and nasogastric tube. Interval removal of endotracheal and nasogastric tubes. PROVISIONAL FINDINGS IMPRESSION (PFI): IPf 12:26 PM Bilateral opacifications in the lung base with evident air bronchograms and obscured diaphragm. FINAL REPORT STUDY: PA and lateral chest radiographs. PFI REPORT Bilateral opacifications in the lung base with evident air bronchograms and obscured diaphragm. FINDINGS: There are unchanged bibasilar opacities with air bronchograms. Removal of endotracheal and nasogastric tubes. Removal of endotracheal and nasogastric tubes. TECHNIQUE: Non-contrast head CT was obtained. Interval progression of right lung base opacity, likely pneumonia. Bilateral minimal pleural effusions. 9:07 AM ABDOMEN (SUPINE & ERECT) PORT Clip # Reason: evaluate for acute intraabdominal pathology. FINAL REPORT SUPINE AND DUCUBITUS ABDOMINAL RADIOGRAPHS: INDICATION: Abdominal discomfort, status post cardiac arrest. pulmonary edema? pulmonary edema? pulmonary edema? pulmonary edema? IMPRESSION: AP chest compared to :23 a.m.: Gastric distension has resolved following placement of an orogastric tube in the upper stomach. , E. 9:07 AM ABDOMEN (SUPINE & ERECT) PORT Clip # Reason: evaluate for acute intraabdominal pathology. 8:03 AM CHEST (PORTABLE AP) Clip # Reason: Intubated. These findings likely represent a right pleural effusion and given the chronicity of findings adjacent right lung base pneumonia. Visualized paranasal sinuses and mastoid air cells are otherwise well aerated. The endotracheal tube and nasogastric tube placements are unchanged compared to . There is mild thoracic scoliosis. , E. 8:03 AM CHEST (PORTABLE AP) Clip # Reason: Intubated. Mildly thickened aortic valve leaflets.Cannot exclude AS. Noatheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion.IMPRESSION: Mildly thickened bicuspid aortic valve with severe eccentricaortic regurgitation directed toward the anterior mitral leaflet. Right ventricular chamber size and free wall motion arenormal. Mildly dilated ascending aorta. Mildly dilated ascending aorta. Mildsymmetric left ventricular hypertrophy with dilated left ventricular andpreserved regional/global systolic function. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Functionally bicuspid aortic valve withthickened leaflets and eccentric, moderate to severe aortic regurgitation.Mildly dilated thoracic aorta.Dr. Sinus bradycardiaProlonged QT intervalInferior/lateral ST-T changes are nonspecificPoor R wave progressionrsr' in lead V1Since previous tracing of , sinus bradycardia present and leftventricular hypertrophy by voltage absent No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:There is mild symmetric left ventricular hypertrophy. Normalaortic arch diameter.AORTIC VALVE: Bicuspid aortic valve. Mild to moderate [+] TR.Borderline PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. The aortic root is mildly dilated at the sinus level. The left ventricularcavity is moderately dilated. Sinus rhythmPremature ventricular contractionsrsr' in lead V1Possible left ventricular hypertrophySince previous tracing of , ventricular premature complexes new; ST-Twave abnormalities are less An eccentric jet of moderate tosevere (3+) aortic regurgitation is seen. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Compared to the previous tracing of atrial ectopyis absent. The aortic root is moderately dilated at the sinus level.The ascending aorta is mildly dilated. There is normal regional and globalbiventricular systolic function. Mild mitralannular calcification. Normalregional LV systolic function.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Moderately dilated aortic sinus. Moderate to severe (3+) AR.MITRAL VALVE: Normal mitral valve leaflets. The aortic valve is bicuspid. Moderately dilated aortic root.Borderline pulmonary hypertension. PATIENT/TEST INFORMATION:Indication: Aortic valve disease.BP (mm Hg): 160/71HR (bpm): 72Status: InpatientDate/Time: at 16:02Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH. There is borderlinepulmonary artery systolic hypertension. The ascendingaorta is mildly dilated. Good (>20 cm/s) LAA ejectionvelocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: No mass or thrombus in the RA or RAA. Mild thickening of mitral valve chordae. Sinus rhythmPossible left atrial abnormalityLeft ventricular hypertrophyExtensive ST-T changes may be due to ventricular hypertrophy or ischemiarsr' in leads V1 and V2Since previous tracing of the same date, left atrial abnormality seen, T wavesmore prominent, sinus bradycardia absent Moderately dilated LV cavity. Overall left ventricular systolicfunction is normal. Sinus rhythm with atrial premature beats. The left lung is incompletely evaluated. FINDINGS: A single portable supine AP view of the chest was obtained. There has been interval advancement of the endotracheal tube, which now lies at the level of the inferior aspect of the clavicles, 4.8 cm above the carina. FINDINGS: A single portable AP supine view of the chest was obtained. MiniorST-T wave abnormalities. No ASDby 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness and cavity size. | 22 | [
{
"category": "Radiology",
"chartdate": "2170-08-10 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 1033649,
"text": " 9:07 AM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: evaluate for acute intraabdominal pathology.\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with persistent abdominal discomfort s/p out of hospital\n cardiac arrest and resuscitation.\n REASON FOR THIS EXAMINATION:\n evaluate for acute intraabdominal pathology.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CHgc FRI 10:16 AM\n No ileus or obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n SUPINE AND DUCUBITUS ABDOMINAL RADIOGRAPHS:\n\n INDICATION: Abdominal discomfort, status post cardiac arrest.\n\n COMPARISON: None available.\n\n FINDINGS: There is no evidence of ileus or obstruction. There is no evidence\n of free air. A radiopaque metallic wire projects over the expected location\n of the rectum, of unclear clinical significance.\n\n IMPRESSION: No evidence of ileus, obstruction or free air.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-08-10 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 1033650,
"text": ", E. 9:07 AM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: evaluate for acute intraabdominal pathology.\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with persistent abdominal discomfort s/p out of hospital\n cardiac arrest and resuscitation.\n REASON FOR THIS EXAMINATION:\n evaluate for acute intraabdominal pathology.\n ______________________________________________________________________________\n PFI REPORT\n No ileus or obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-08-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033647,
"text": " 9:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: INfection\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with s/p extubation, fever, last Xray concerning for PNA.\n REASON FOR THIS EXAMINATION:\n INfection\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc FRI 8:56 PM\n Bibasilar opacities suggesting pneumonia. Removal of endotracheal and\n nasogastric tubes.\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: Comparison is made to chest radiograph from .\n\n FINDINGS: There are unchanged bibasilar opacities with air bronchograms.\n Given the persistence of these findings since the previous study, these likely\n represent foci of infection. The lungs are otherwise clear. There is a small\n right pleural effusion.\n\n There has been interval removal of the endotracheal tube and nasogastric tube.\n There is mild thoracic scoliosis. The cardiac contours suggest left\n ventricular enlargement.\n\n IMPRESSION:\n 1. Persistent bibasilar opacities suggesting pneumonia.\n 2. Interval removal of endotracheal and nasogastric tubes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-08-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1032948,
"text": " 10:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 1102\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p cardiac arrest\n REASON FOR THIS EXAMINATION:\n r/o bleed or mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl TUE 11:14 AM\n no intracranial bleed or mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITHOUT CONTRAST.\n\n HISTORY: 50-year-old male status post cardiac arrest. Rule out bleed or\n mass.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS: There is no intra-axial or extra-axial hemorrhage, mass effect,\n shift of normally midline structures, or hydrocephalus. -white matter\n differentiation is preserved. Ventricles, sulci and basal cisterns are\n unremarkable. Structures within the posterior fossa are unremarkable.\n\n No suspicious lytic or blastic osseous lesion is identified. There is\n scattered opacification of ethmoid air cells, and thickening of the posterior\n aspect of the left maxillary sinus. Visualized paranasal sinuses and mastoid\n air cells are otherwise well aerated.\n\n IMPRESSION: No acute intracranial abnormality identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-08-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033648,
"text": ", E. 9:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: INfection\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with s/p extubation, fever, last Xray concerning for PNA.\n REASON FOR THIS EXAMINATION:\n INfection\n ______________________________________________________________________________\n PFI REPORT\n Bibasilar opacities suggesting pneumonia. Removal of endotracheal and\n nasogastric tubes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-08-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1034290,
"text": ", E. 9:22 AM\n CHEST (PA & LAT) Clip # \n Reason: lead placement\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p single chamber ICD\n REASON FOR THIS EXAMINATION:\n lead placement\n ______________________________________________________________________________\n PFI REPORT\n Significant progression of right lung base opacity, likely pneumonia.\n Interval placement of single chamber pacer/AICD with lead in good position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-08-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033412,
"text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated.\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p VF arrest, now intubated.\n REASON FOR THIS EXAMINATION:\n Intubated.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf 12:26 PM\n Bilateral opacifications in the lung base with evident air bronchograms and\n obscured diaphragm. This finding might suggest bilateral pneumonia in the\n lung bases. Please correlate clinically. Minimal bilateral pleural\n effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50-year-old man, status post cardiac arrest, now intubated.\n\n TECHNIQUE: AP semiupright portable chest radiograph.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: There are bilateral opacifications in the lung base, with air\n bronchograms seen, and obscure hemidiaphragm. This might be consistent with\n consolidation within the lung base bilaterally. There is minimal bilateral\n pleural effusion. The endotracheal tube and nasogastric tube placements are\n unchanged compared to . The mediastinal and cardiac silhouettes\n are unchanged compared to .\n\n IMPRESSION: Bilateral opacifications in the lung base, likely consistent with\n pneumonia. Please correlate clinically. Bilateral minimal pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-08-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1034289,
"text": " 9:22 AM\n CHEST (PA & LAT) Clip # \n Reason: lead placement\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p single chamber ICD\n REASON FOR THIS EXAMINATION:\n lead placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SPfc TUE 11:55 AM\n Significant progression of right lung base opacity, likely pneumonia.\n Interval placement of single chamber pacer/AICD with lead in good position.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest radiographs.\n\n HISTORY: 58-year-old man status post single chamber ICD placement.\n\n COMPARISON: Comparison is made to chest radiograph from .\n\n FINDINGS: There is a single chamber pacer/AICD in place with lead terminating\n in the region of the right ventricle. There is no pneumothorax.\n\n There is significant interval increase in right lung base opacity. This\n appears to be progressive since . There is blunting of the\n right costophrenic angle. These findings likely represent a right pleural\n effusion and given the chronicity of findings adjacent right lung base\n pneumonia. The left lung is unchanged from past studies. There is a large\n cardiac silhouette, and mediastinal contours are unremarkable.\n\n IMPRESSION:\n 1. Interval progression of right lung base opacity, likely pneumonia.\n 2. Interval placement of single chamber pacer/AICD with lead in good\n position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-08-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033413,
"text": ", E. 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated.\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p VF arrest, now intubated.\n REASON FOR THIS EXAMINATION:\n Intubated.\n ______________________________________________________________________________\n PFI REPORT\n Bilateral opacifications in the lung base with evident air bronchograms and\n obscured diaphragm. This finding might suggest bilateral pneumonia in the\n lung bases. Please correlate clinically. Minimal bilateral pleural\n effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033131,
"text": " 6:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: OG tube placement? pulmonary edema?\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with vfib arrest intubated in the field\n REASON FOR THIS EXAMINATION:\n OG tube placement? pulmonary edema?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 1:35 PM\n OG tube okay in stomach, no gastric distention. Pulmonary edema and\n cardiomegaly cleared. ET tube okay.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:51 A.M. ON \n\n HISTORY: A-fib arrest. Check ET and orogastric tube.\n\n IMPRESSION: AP chest compared to :23 a.m.:\n\n Gastric distension has resolved following placement of an orogastric tube in\n the upper stomach. Previous mild pulmonary edema has improved and cardiac\n size returned to . No pneumothorax. ET tube in standard placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033132,
"text": ", E. 6:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: OG tube placement? pulmonary edema?\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with vfib arrest intubated in the field\n REASON FOR THIS EXAMINATION:\n OG tube placement? pulmonary edema?\n ______________________________________________________________________________\n PFI REPORT\n OG tube okay in stomach, no gastric distention. Pulmonary edema and\n cardiomegaly cleared. ET tube okay.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-08-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032943,
"text": " 10:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ETT placement, cardiomeg\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with vfib arrest, intubated\n REASON FOR THIS EXAMINATION:\n assess ETT placement, cardiomeg\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE PORTABLE VIEW OF THE CHEST\n\n HISTORY: 50-year-old male with v fib arrest, intubated. Assess for ET tube\n placement, cardiomegaly.\n\n COMPARISON: None.\n\n FINDINGS: A single portable supine AP view of the chest was obtained. Trauma\n stabilization hardware overlies the lateral aspect of the chest bilaterally,\n limiting evaluation. The lateral left lung is not included on this study.\n\n The endotracheal tube tip terminates above the clavicles, 10.2 cm above the\n carina. Cardiac size is difficult to assess on this frontal view due to\n magnification. The right lung is clear. The left lung is incompletely\n evaluated. Note is made of an air distended loop of bowel or stomach in the\n left upper quadrant.\n\n IMPRESSION: ET tube terminates 10.2 cm above the carina and should be\n advanced. Limited study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-08-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032957,
"text": " 11:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ETT advancment\n REASON FOR THIS EXAMINATION:\n assess for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST\n\n HISTORY: 50-year-old male with ET tube advancement. Assess for ET tube\n placement.\n\n COMPARISON: Portable chest x-ray from today () at 10:31 a.m.\n\n FINDINGS: A single portable AP supine view of the chest was obtained. There\n has been interval advancement of the endotracheal tube, which now lies at the\n level of the inferior aspect of the clavicles, 4.8 cm above the carina. There\n is no focal airspace consolidation.\n\n Bilateral upper lobe ill defined opacities likely relate to cephalization of\n vessels and pulmonary edema. The cardiac silhousette is enlarged, with a left\n ventricular configuration. The stomach is air distended.\n\n IMPRESSION:\n 1. Endotracheal tube tip now lies 4.8 cm above the carina.\n 2. Findings consistent with pulmonary edema, although developing infiltrates\n cannot be excluded. Repeat radiographs following diruesis recommended.\n 3. Air distention of the stomach. The patient may benefit from nasogatric\n tube placement.\n\n"
},
{
"category": "Echo",
"chartdate": "2170-08-09 00:00:00.000",
"description": "Report",
"row_id": 87765,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Endocarditis. Ventricular ectopy.\nHeight: (in) 71\nWeight (lb): 152\nBSA (m2): 1.88 m2\nBP (mm Hg): 115/47\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 10:22\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: No mass/thrombus in the LAA. Good (>20 cm/s) LAA ejection\nvelocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No mass or thrombus in the RA or RAA. No ASD\nby 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. No\natheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No masses or vegetations\non aortic valve. Moderate to severe (3+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nNo mass/thrombus is seen in the left atrium or left atrial appendage. No mass\nor thrombus is seen in the right atrium or right atrial appendage. No atrial\nseptal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses and cavity size are normal. Overall left ventricular systolic\nfunction is normal. Right ventricular chamber size and free wall motion are\nnormal. The aortic root is mildly dilated at the sinus level. The ascending\naorta is mildly dilated. The aortic valve has three leaflets but is\nfunctionally bileaflet. Leaflets are thickened and deformed. No masses or\nvegetations are seen on the aortic valve. An eccentric jet of moderate to\nsevere (3+) aortic regurgitation is seen. The mitral valve leaflets are\nstructurally normal. No mass or vegetation is seen on the mitral valve.\nTrivial mitral regurgitation is seen.\n\nIMPRESSION: No vegetations seen. Functionally bicuspid aortic valve with\nthickened leaflets and eccentric, moderate to severe aortic regurgitation.\nMildly dilated thoracic aorta.\n\nDr. was notified in person of the results on at 11:00 AM.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2170-08-07 00:00:00.000",
"description": "Report",
"row_id": 87766,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease.\nBP (mm Hg): 160/71\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 16:02\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Normal\nregional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic sinus. Mildly dilated ascending aorta. Normal\naortic arch diameter.\n\nAORTIC VALVE: Bicuspid aortic valve. Mildly thickened aortic valve leaflets.\nCannot exclude AS. Severe (4+) AR. Eccentric AR jet directed toward the\nanterior mitral leaflet.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nBorderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity is moderately dilated. There is normal regional and global\nbiventricular systolic function. Right ventricular chamber size and free wall\nmotion are normal. The aortic root is moderately dilated at the sinus level.\nThe ascending aorta is mildly dilated. The aortic valve is bicuspid. The\naortic valve leaflets are mildly thickened. The study is inadequate to exclude\nsignificant aortic valve stenosis. Severe (4+) aortic regurgitation is seen.\nThe aortic regurgitation jet is eccentric, directed toward the anterior mitral\nleaflet. The mitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Mildly thickened bicuspid aortic valve with severe eccentric\naortic regurgitation directed toward the anterior mitral leaflet. Mild\nsymmetric left ventricular hypertrophy with dilated left ventricular and\npreserved regional/global systolic function. Moderately dilated aortic root.\nBorderline pulmonary hypertension.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2170-08-07 00:00:00.000",
"description": "Report",
"row_id": 220972,
"text": "Sinus bradycardia\nBorderline prolonged QT interval\nrsr' in leads V1 and V2 - consider incomplete right bundle branch block\nLeft ventricular hypertrophy\nExtensive ST-T changes may be due to hypertrophy and/or ischemia\nNo previous tracing available for comparison\n\n"
},
{
"category": "ECG",
"chartdate": "2170-08-14 00:00:00.000",
"description": "Report",
"row_id": 220966,
"text": "Sinus rhythm\nPremature ventricular contractions\nrsr' in lead V1\nPossible left ventricular hypertrophy\nSince previous tracing of , ventricular premature complexes new; ST-T\nwave abnormalities are less\n\n"
},
{
"category": "ECG",
"chartdate": "2170-08-13 00:00:00.000",
"description": "Report",
"row_id": 220967,
"text": "Sinus bradycardia.\nrSr'(V1) - probable normal variant\nLeft ventricular hypertrophy\nInferior/lateral ST-T changes are probably due to ventricular hypertrophy\nQT interval prolonged for rate\nSince previous tracing of , increased QRS voltage\n\n"
},
{
"category": "ECG",
"chartdate": "2170-08-10 00:00:00.000",
"description": "Report",
"row_id": 220968,
"text": "Sinus bradycardia with slowing of the rate as compared with prior tracing\nof . Delayed precordial R wave transition and diffuse non-specific\nST-T wave changes. Compared to the previous tracing of atrial ectopy\nis absent. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2170-08-09 00:00:00.000",
"description": "Report",
"row_id": 220969,
"text": "Sinus rhythm with atrial premature beats. RSR' pattern in lead V1. Minior\nST-T wave abnormalities. Since the previous tracing of the rate is\nfaster. ST-T wave abnormalities may be less prominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2170-08-09 00:00:00.000",
"description": "Report",
"row_id": 220970,
"text": "Sinus bradycardia\nProlonged QT interval\nInferior/lateral ST-T changes are nonspecific\nPoor R wave progression\nrsr' in lead V1\nSince previous tracing of , sinus bradycardia present and left\nventricular hypertrophy by voltage absent\n\n"
},
{
"category": "ECG",
"chartdate": "2170-08-07 00:00:00.000",
"description": "Report",
"row_id": 220971,
"text": "Sinus rhythm\nPossible left atrial abnormality\nLeft ventricular hypertrophy\nExtensive ST-T changes may be due to ventricular hypertrophy or ischemia\nrsr' in leads V1 and V2\nSince previous tracing of the same date, left atrial abnormality seen, T waves\nmore prominent, sinus bradycardia absent\n\n"
}
] |
17,554 | 192,233 | The pt was admitted after his procedure which he tolerated well. Please see the dictated operative note for further details. While in the PACU, he was noted to have brief apneic periods, and so was transfered to the ICU for extended PACU recovery when the APCU closed for the evening. His stay in the ICU was unremarkable, and by the morning of POD#1, all of his apneic issues had resolved, and he was transfered out to the regular floor. The Physical Therapy service began working with the pt on POD#1 and continued to work with him throughout his hospitalization. The pt was started on Lovenox on POD#1 as well. On POD#2, the pt was transitioned to oral pain medications and his Foley catheter was removed. Xrays obtained demonstrated the hip to be located with all components in good position. The pt was transfused 1 unit of PRBC on POD#3 for a Hct=26.2 with an appropriate elevation of his hematocrit to 28.1. By the day of discharge he was tolerating a regular diet with his pain well controlled on oral pain medication. He was discharged to home with home PT with instructions to follow up with Dr. in the office in ~2 weeks. | INDICATION: Revision right hip. ABDUCTOR PILLOW IN PLACE.RESP: LUNGS CLEAR THROUGHOUT. RIGHT HIP PORTABLE AP IN THE OR : Since , there is a new drain over the right total hip replacement, incompletely imaged. The heart size, mediastinal and hilar contours are within normal limits and stable compared to the previous study. RR 11-14, VERY SHORT PERIODS OF APNEA NOTED. FINDINGS: Three views of the right hip show a well-positioned right total hip prosthesis with a noncemented femoral component and subcutaneous gas adjacent to the recent surgical site. RIGHT Clip # Reason: RIGHT TOTAL HIP REVISION Admitting Diagnosis: FAILED TOTAL HIP REPLACEMENT/SDA FINAL REPORT Right hip in the operating room. MONITOR V/S AND LYTES, REPLENISH PRN. Small bilateral pleural effusions. NO RESP DISTRESS NOTED.NEURO: A&O X3. Underlying subcutaneous edema and emphysema are postoperative. BS SLOW X4 QUADS. C/O MILD PAIN ON ARRIVAL, USING PCA MORPHINE WITH RELIEF NOTED.GU/GI: ABD SOFT, NON-TENDER. B/P HAS RANGED FROM 119/49-135/62. NARRATIVE NOTE:CV: PP EASILY PALPABLE X4. 2 views were obtained from the C-arm videoscope demonstrating normal positioning of the hip prosthesis in image 1 and posterior dislocation of the prosthetic head in image 2. Additionally, there are apparent small bilateral pleural effusions on the lateral view. OPENS EYES SPONTANEOULY. ; -59 DISTINCT PROCEDURAL SERVICE Clip # Reason: TOTAL HIP REPLACEMENT Admitting Diagnosis: FAILED TOTAL HIP REPLACEMENT/SDA FINAL REPORT CLINICAL HISTORY: Total hip replacement. The lungs reveal a subtle area of increased opacity in the left lower lobe posteriorly, new in the interval. INDICATION: Asthma and productive cough. PT TO USE PCA TO PREVENT PAIN. KEEP ABDUCTOR PILLOW IN PLACE. PT ABLE TO MOVE ALL TOES ON COMMAND. SAO2 98-100% ON 2L N/C. Degenerative changes are observed in the spine. IN O.R. D51/2NS WITH 20KCL INFUSING AT 100CC/HR.PLAN: CONT TO MONITOR R LEG FOR GOOD PEDAL PULSES AND MOVEMENT. Surgical clips are present within the pelvis. SB WITH H/R RANGING FROM 53-59, NO ECTOPY NOTED. FOLEY CATH PATENT, DRAINING CLEAR YELLOW URINE IN ADEQUATE AMTS. Several clips are present in the pelvis. IMPRESSION: Subtle left lower lobe opacity, concerning for an early focus of pneumonia. 9:59 AM HIP UNILAT MIN 2 VIEWS RIGHT Clip # Reason: evaluate hardware position MEDICAL CONDITION: 61 year old man s/p R THA REASON FOR THIS EXAMINATION: evaluate hardware position FINAL REPORT INDICATION: Right hip prosthesis placement. Follow up radiographs may be helpful to document resolution following appropriate therapy. BOTH FEET COOL TO TOUCH. 4:56 PM HIP UNILAT MIN 2 VIEWS IN O.R. PT WILL MOVE OUT TO THE FLOOR TODAY. FOLLOWS ALL COMMANDS CONSISTANTLY. TOOK SIPS OF WATER WITH NO N/V. NO NUMBNESS OR TINGLING IN LOWER EXTREMITIES. 6:55 PM HIP 1 VIEW IN O.R. 9:59 AM CHEST (PA & LAT) Clip # Reason: r/o infiltrate MEDICAL CONDITION: 61 year old man with asthma, now w/ productive cough and decreased spirometry REASON FOR THIS EXAMINATION: r/o infiltrate FINAL REPORT 2 VIEWS CHEST: COMPARISON: . AT HOME PT STRAIGHT CATH SELF . EASILY AROUSED WITH VERBAL STIMULI. | 5 | [
{
"category": "Radiology",
"chartdate": "2154-06-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 868605,
"text": " 9:59 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with asthma, now w/ productive cough and decreased spirometry\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n 2 VIEWS CHEST:\n\n COMPARISON: .\n\n INDICATION: Asthma and productive cough.\n\n The heart size, mediastinal and hilar contours are within normal limits and\n stable compared to the previous study. The lungs reveal a subtle area of\n increased opacity in the left lower lobe posteriorly, new in the interval.\n Additionally, there are apparent small bilateral pleural effusions on the\n lateral view. Degenerative changes are observed in the spine.\n\n IMPRESSION: Subtle left lower lobe opacity, concerning for an early focus of\n pneumonia. Follow up radiographs may be helpful to document resolution\n following appropriate therapy.\n\n Small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-06-19 00:00:00.000",
"description": "OO HIP 1 VIEW IN O.R. IN O.R.",
"row_id": 868415,
"text": " 6:55 PM\n HIP 1 VIEW IN O.R. IN O.R.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: TOTAL HIP REPLACEMENT\n Admitting Diagnosis: FAILED TOTAL HIP REPLACEMENT/SDA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Total hip replacement.\n\n RIGHT HIP PORTABLE AP IN THE OR :\n\n Since , there is a new drain over the right total hip replacement,\n incompletely imaged. Several clips are present in the pelvis. Underlying\n subcutaneous edema and emphysema are postoperative.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-06-19 00:00:00.000",
"description": "OR HIP UNILAT MIN 2 VIEWS IN O.R. RIGHT",
"row_id": 868401,
"text": " 4:56 PM\n HIP UNILAT MIN 2 VIEWS IN O.R. RIGHT Clip # \n Reason: RIGHT TOTAL HIP REVISION\n Admitting Diagnosis: FAILED TOTAL HIP REPLACEMENT/SDA\n ______________________________________________________________________________\n FINAL REPORT\n Right hip in the operating room.\n\n INDICATION: Revision right hip.\n\n 2 views were obtained from the C-arm videoscope demonstrating normal\n positioning of the hip prosthesis in image 1 and posterior dislocation of the\n prosthetic head in image 2.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-06-21 00:00:00.000",
"description": "R HIP UNILAT MIN 2 VIEWS RIGHT",
"row_id": 868604,
"text": " 9:59 AM\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n Reason: evaluate hardware position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p R THA\n\n REASON FOR THIS EXAMINATION:\n evaluate hardware position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right hip prosthesis placement.\n\n FINDINGS: Three views of the right hip show a well-positioned right total hip\n prosthesis with a noncemented femoral component and subcutaneous gas adjacent\n to the recent surgical site. No bone destruction, bone erosion, acute\n fracture, dislocation, or radiopaque foreign bodies seen. Surgical clips are\n present within the pelvis.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-06-20 00:00:00.000",
"description": "Report",
"row_id": 1492256,
"text": "NARRATIVE NOTE:\n\nCV: PP EASILY PALPABLE X4. PT ABLE TO MOVE ALL TOES ON COMMAND. BOTH FEET COOL TO TOUCH. NO NUMBNESS OR TINGLING IN LOWER EXTREMITIES. B/P HAS RANGED FROM 119/49-135/62. SB WITH H/R RANGING FROM 53-59, NO ECTOPY NOTED. ABDUCTOR PILLOW IN PLACE.\n\nRESP: LUNGS CLEAR THROUGHOUT. RR 11-14, VERY SHORT PERIODS OF APNEA NOTED. SAO2 98-100% ON 2L N/C. NO RESP DISTRESS NOTED.\n\nNEURO: A&O X3. FOLLOWS ALL COMMANDS CONSISTANTLY. EASILY AROUSED WITH VERBAL STIMULI. OPENS EYES SPONTANEOULY. C/O MILD PAIN ON ARRIVAL, USING PCA MORPHINE WITH RELIEF NOTED.\n\nGU/GI: ABD SOFT, NON-TENDER. BS SLOW X4 QUADS. TOOK SIPS OF WATER WITH NO N/V. FOLEY CATH PATENT, DRAINING CLEAR YELLOW URINE IN ADEQUATE AMTS. AT HOME PT STRAIGHT CATH SELF . D51/2NS WITH 20KCL INFUSING AT 100CC/HR.\n\nPLAN: CONT TO MONITOR R LEG FOR GOOD PEDAL PULSES AND MOVEMENT. KEEP ABDUCTOR PILLOW IN PLACE. MONITOR V/S AND LYTES, REPLENISH PRN. PT WILL MOVE OUT TO THE FLOOR TODAY. PT TO USE PCA TO PREVENT PAIN.\n"
}
] |
16,650 | 176,541 | Patient seen in ED where U/S and CT studies confirmed all wounds were superficial to deep structures. Initially 0-silk sutures were placed in chest wounds to control hematoma. On Day 2 these were removed and deep monocryl and superficial nylon sutures were placed. Patient was seen by psychiatry who deemed him section 12 and requiring of psychiatric hospitaliztion. Patient was kept on a 1:1 sitter as a precaution for his own safety until a psychiatric bed could obtained. Please monitor for wound infection. Patient was kept on surgical floor with 1:1 sitter through weekend because of psychiatric team's concern of hematocrit, however HCT was deemed to be stable and on HD4 he was cleared for discharge to psychiatric bed. | free air under diaphragm or pneumothorax. On RA with clear and equal but diminished BS. Low attenuation renal lesions, likely cysts, but incompletely characterized. There is a small calcified granuloma in the right lung base. Mild-moderate coronary artery calcifications are present. HISTORY: Trauma, otherwise unspecified. Limited views of the upper abdomen demonstrate bilateral low attenuation renal lesions, likely cysts, but incompletely characterized on current study. CT OF THE CHEST WITH CONTRAST: The heart, pericardium, and great vessels are unremarkable. Few small foci of subcutaneous air, and tiny amount of air in anterior abdominal fat. Abd soft, obese with +BS. Few small foci of subcutaneous air and air in the anterior abdominal fat. Skin w/d/i except for stab wound. COMPARISON: No prior radiographs are obtained. 4:38 PM CT CHEST W/CONTRAST Clip # Reason: free air under diaphragm? There are a few small foci of subcutaneous air, and air within the anterior abdominal fat, but there is no free intraperitoneal air seen. A few small mediastinal lymph nodes are seen, but do not meet CT criteria for pathologic enlargement. SR, normotensive. After arrival to EW pt scanned and no injury to major organs. (Over) 4:38 PM CT CHEST W/CONTRAST Clip # Reason: free air under diaphragm? No definite pleural effusion or pneumothorax is seen. Foley patent with good UO. The central bronchi are patent to the subsegmental level. Contrast: OPTIRAY Amt: 75 FINAL REPORT (Cont) Hemodynamically stable. cont to have sitter at bedside as pt has active SI but no HI. IMPRESSION: No definite radiographic evidence of traumatic injury to the chest. Pt denies any pain in area. Meds- Prozac and glucophage (Has not been taking them recently because of care coverage). BG in 300s now slowly decreasing. Lung volumes are diminished but otherwise the lungs remain clear. Lopressor held at 2am for SBP<110. The cardiac silhouette remains normal in size. ptx? ptx? ptx? IMPRESSION: 1. No evidence of pneumothorax or free intraperitoneal air. No BM.Plan- Seen by psychiatry and will be section 12 after medically cleared. Afebrile. In the setting of trauma, however mediastinal vascular injury cannot be entirely excluded. HCT on arrival 29.3. COMPARISON: None. There are old right posterior rib fractures. No significant axillary, hilar, or mediastinal lymphadenopathy is seen. MAEs well. No displaced fractures are noted. Left chest wall hematoma, approximately 9 x 5 cm. Left chest wall hematoma, approximately 9 x 5 cm. No pneumothorax, diaphramatic injury or free air in abd. No contraindications for IV contrast WET READ: DSsd FRI 5:25 PM No pneumothorax or free intraperitoneal air. Wounds covered with DSD and at 4am noted small amt bleeding. No focal areas of consolidation are seen. Large L chest hematoma. FINDINGS: Trauma backboard artifact is evident. There is hematoma in the left lower chest wall and upper abdominal wall, overlying the left rectus abdominis muscle, measuring approximately 9.5 x 5.6 cm. HCT at 2300 25.6 and am labs pending. Ativan 2 mg given with good effect. There is no pulmonary embolism, pleural effusion, or pneumothorax. IVF at 125cc/h with good UO. TECHNIQUE: MDCT-acquired axial imaging from the thoracic inlet to the upper abdomen after 75 cc Optiray intravenous contrast. Area marked and timed. PMHx- Depression with h/o of suicide attempt in and , DM. PIV x 1, TLC in L groin. 3. ? ROS Pt is alert and orientated x 3. 2. This study, however, was made available for my review after a chest CT had been acquired and has already been dictated separately. The mediastinum is widened likely secondary to positioning, habitus, and AP portable technique. Renal ultrasound is recommended for further characterization. Was feeling "little edgy" being in the hospital and unable to sleep. 3:52 PM CHEST (PORTABLE AP) Clip # Reason: TRAUMA FINAL REPORT AP PORTABLE CHEST AT 1603 HOURS. Admitted to ICU for close monitoring. Married 2 years, seperated in and divorced . Multiplanar reformatted images obtained and reviewed. Sats > 95%. Contrast: OPTIRAY Amt: 75 MEDICAL CONDITION: 60 year old man with multiple stab wounds to left chest, hemodynamically stable REASON FOR THIS EXAMINATION: free air under diaphragm? Calm, cooperative and very pleasant. Strained relationship with father and not very close to his 2 sisters. Slept most of the night. Pt from upstate NY. He was found by passerbys who called 911. FINAL REPORT HISTORY: 60-year-old male with multiple stab wounds to the left chest. Figured he had enough money to live off of for 6 weeks, quit his job, tried to do the things he enjoyed and then when the money ran out kill himself. Pt has impressive educational backround and has had several careers including a teaching position at and in biology. | 3 | [
{
"category": "Radiology",
"chartdate": "2122-02-20 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 953845,
"text": " 4:38 PM\n CT CHEST W/CONTRAST Clip # \n Reason: free air under diaphragm? ptx?\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with multiple stab wounds to left chest, hemodynamically stable\n REASON FOR THIS EXAMINATION:\n free air under diaphragm? ptx?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd FRI 5:25 PM\n No pneumothorax or free intraperitoneal air. Left chest wall hematoma,\n approximately 9 x 5 cm. Few small foci of subcutaneous air, and tiny amount\n of air in anterior abdominal fat.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old male with multiple stab wounds to the left chest.\n Hemodynamically stable. ? free air under diaphragm or pneumothorax.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired axial imaging from the thoracic inlet to the upper\n abdomen after 75 cc Optiray intravenous contrast. Multiplanar reformatted\n images obtained and reviewed.\n\n CT OF THE CHEST WITH CONTRAST: The heart, pericardium, and great vessels are\n unremarkable. There is no pulmonary embolism, pleural effusion, or\n pneumothorax. No focal areas of consolidation are seen. The central bronchi\n are patent to the subsegmental level. No significant axillary, hilar, or\n mediastinal lymphadenopathy is seen. There is a small calcified granuloma in\n the right lung base. Mild-moderate coronary artery calcifications are\n present. A few small mediastinal lymph nodes are seen, but do not meet CT\n criteria for pathologic enlargement.\n\n There is hematoma in the left lower chest wall and upper abdominal wall,\n overlying the left rectus abdominis muscle, measuring approximately 9.5 x 5.6\n cm. There are a few small foci of subcutaneous air, and air within the\n anterior abdominal fat, but there is no free intraperitoneal air seen.\n\n Limited views of the upper abdomen demonstrate bilateral low attenuation renal\n lesions, likely cysts, but incompletely characterized on current study. There\n are old right posterior rib fractures.\n\n IMPRESSION:\n 1. No evidence of pneumothorax or free intraperitoneal air.\n\n 2. Left chest wall hematoma, approximately 9 x 5 cm. Few small foci of\n subcutaneous air and air in the anterior abdominal fat.\n\n 3. Low attenuation renal lesions, likely cysts, but incompletely\n characterized. Renal ultrasound is recommended for further characterization.\n\n (Over)\n\n 4:38 PM\n CT CHEST W/CONTRAST Clip # \n Reason: free air under diaphragm? ptx?\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-02-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 953842,
"text": " 3:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 1603 HOURS.\n\n HISTORY: Trauma, otherwise unspecified.\n\n COMPARISON: No prior radiographs are obtained. This study, however, was made\n available for my review after a chest CT had been acquired and has already\n been dictated separately.\n\n FINDINGS: Trauma backboard artifact is evident. Lung volumes are diminished\n but otherwise the lungs remain clear. The mediastinum is widened likely\n secondary to positioning, habitus, and AP portable technique. In the setting\n of trauma, however mediastinal vascular injury cannot be entirely excluded.\n The cardiac silhouette remains normal in size. No definite pleural effusion\n or pneumothorax is seen. No displaced fractures are noted.\n\n IMPRESSION: No definite radiographic evidence of traumatic injury to the\n chest.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-02-21 00:00:00.000",
"description": "Report",
"row_id": 1480072,
"text": "NPN 2300-0700\n Pt is a 60 male BIBA after suicide attempt in Yard. Pt used a 5 inch paring knife and stabbed himself 4 times in chest area. Figured he had enough money to live off of for 6 weeks, quit his job, tried to do the things he enjoyed and then when the money ran out kill himself. He was found by passerbys who called 911. After arrival to EW pt scanned and no injury to major organs. No pneumothorax, diaphramatic injury or free air in abd. Large L chest hematoma. HCT on arrival 29.3. Admitted to ICU for close monitoring.\n\n PMHx- Depression with h/o of suicide attempt in and , DM.\n\n Meds- Prozac and glucophage (Has not been taking them recently because of care coverage).\n\n Pt from upstate NY. Strained relationship with father and not very close to his 2 sisters. Married 2 years, seperated in and divorced . Pt has impressive educational backround and has had several careers including a teaching position at and in biology.\n\n ROS\n Pt is alert and orientated x 3. MAEs well. Calm, cooperative and very pleasant. Was feeling \"little edgy\" being in the hospital and unable to sleep. Ativan 2 mg given with good effect. Slept most of the night.\n On RA with clear and equal but diminished BS. Sats > 95%.\n SR, normotensive. Lopressor held at 2am for SBP<110. Afebrile. BG in 300s now slowly decreasing. HCT at 2300 25.6 and am labs pending. PIV x 1, TLC in L groin. IVF at 125cc/h with good UO. Skin w/d/i except for stab wound. Wounds covered with DSD and at 4am noted small amt bleeding. Area marked and timed. Pt denies any pain in area.\n Abd soft, obese with +BS. Foley patent with good UO. No BM.\n\nPlan- Seen by psychiatry and will be section 12 after medically cleared. cont to have sitter at bedside as pt has active SI but no HI.\n"
}
] |
14,197 | 170,569 | 61-year-old man with a history of cirrhosis secondary to NASH with complication of esophageal varices, diabetes, atrial fibrillation, AVR, hypertension, diastolic CHF who presents with GI bleed and episode of hemetemesis in the ED, found to have volume overload on cath and difficult to control anticoagulation. #. Upper GI bleed, secondary to esophageal varices: Patient has previous admission in for esophageal bleeding. Liver performed endoscopy and found three actively bleeding varices in the fundus of the stomach, which where glued and appeared to have stopped bleeding. Endoscopy demonstrated varices at the lower third of the esophagus with old blood in the stomach. patient was kept on a PPI drip as well as an octreotide drip and transitioned to PO PPI and off octreotide. We actively followed the patient's hematocrit after the pRBC transfusions. Patient's hct was stable. total of 3uPRBC were transfused. Received 5 days zosyn antibiotics. He was discharged on sucralfate and PPI . . On transfer to the - service, the patient received 4U PRBC, as well as 2U FFP and his crits and INR remained stable. Cardiology was consulted, as patient had UGIB in the context of supratherapeutic INR for AVR and atrial fibrillation. After discussing the risks and benefits of anticoagulation in his situation, the patient's INR goal was decreased to . While on the floor, the patient was initially on octreotide and protonix drips. He was also started on Zosyn for SBP ppx and completed 5 days of treatment. Zosyn was started because the patient is allergic to cephalosporins. He was restarted on coumadin at 5 mg daily once all active bleeding had stopped. His home nadolol was held during the acute setting of bleeding, but was then restarted. . # Protection of airway: The patient had been intubated to protect his airway because of significant hemetemesis. After stabilization the patient was extubated without difficulty. . # Supratherapeutic INR: INR on admission was 5.4. Patient received 2 units of fresh frozen plasma. there was transient improvement in his INR. . On the floor, the patient was given another two units of FFP. After consulting cardiology it was decided (after discussion of risk/benefit with patient) that INR goal should be , given the high risk this patient has for bleeding. He was also restarted on coumadin, once it was sure that his hematocrits were stable and he was no longer bleeding. He was started on a heparin drip and warfarin was uptitrated over a longer than usual period of time to 10mg daily. This had been his home dose that he had come in on supratherapeutic and he denied med noncompliance or change in diet/meds. He likely has a narrow therapeutic window for INR and needs to be closely monitored. Home INR monitoring was set up and will be delivered to patient after discharge. He will follow up for INR check 1 and 3 days after discharge and results to be faxed to PCP, plan was discussed with by phone. . # Atrial fibrillation: Patient appeared to be in sinus rhythm on monitor on admission. CHADS score would be at least 3. Remained stable in the MICU. . On the floor, the patient was given another 2U FFP. Once his crits were stable, the patient was restarted on coumadin, with new INR goal of . While on the floor, the patient was still in sinus and continued on his home dronedarone . #. Aortic valve replacement: Holding anticoagulation in setting of upper GI bleed. Once his crits were stable, the patient was restarted on coumadin. Cardiolgy was also consulted, and it was decided that his INR goal should be . . # Diastolic congestive heart failure: Patient with history of diastolic CHF, last EF >55% in 5/. The patient appears to have interstitial pulonary edema on chest X-ray. Holding furosemide and spironolactone due to GI bleed. Stopping hemorrhage will take precedence over diuresis, especially as patient is intubated. . While on the floor, the patient appeared somewhat overloaded, especially in the setting of received blood product. He was restarted on diuresis with IV Lasix 40 mg , as well as spironlactone 50 mg daily. He was transitioned to PO dosing but creatinine did not tolerate higher than 40mg PO dose. Additional fluid should be diuresed as outpatient. . # Diabetes: Patient had good glycemic control on 20mg Lantus daily with minimal SSI coverage. BS should be closely monitored by PCP as . and dose increased as needed. . # cirrhosis: likely Etoh; the patient has not had alcohol since 5/. The patient was evaluated for TIPS on his last admission and on hepatic venogram, did not have elevated portosystemic pressure. Given the patient's abstinence from etoh and tenuous situation given need for anticoagulation superimposed with elevated bleeding risk with varices, liver transplantation is an option. He had a R heart cath this admission to assess for pulmonary hypertension. On R heart cath, the patient had elevated wedge and pulmonary pressures could not be assessed. He was then started on aggressive diueresis, IV Lasix 40 mg , as well as spironlactone 50 mg daily and transitioned to 40mg PO daily, limited by creatinine. The patient will have to pursue this as an outpatient, as he will need repeat R heart cath once his volume status is optimized. . # depression/anxiety: The patient was also continued on his duloxetine 30 mg daily. He affect seemed somewhat depressed during admission. . . Transitional issues: -repeat right heart cath as outpatient once volume status optimized -trend creatiniine while diuresing -close INR monitoring, including home monitor as outpatient -INR check by VNA and | Unchanged moderate cardiomegaly with mild fluid overload, bilateral areas of basal atelectasis, and a small left pleural effusion. Unchanged moderate cardiomegaly with signs of mild fluid overload. No larger pleural effusions. Probable sinus rhythm. Otherwise, normaltracing. Q-T interval prolongation. Otherwise, normal tracing. The monitoring and support devices are in constant position, except for the nasogastric tube that has been removed in the interval. Compared to theprevious tracing of sinus bradycardia is new. Low amplitude P wave. Otherwise, unchanged. Left atrial abnormality.Leftward axis. Sinus bradycardia. No interval appearance of other parenchymal opacities. FINDINGS: As compared to the previous radiograph, there is no relevant change. No pneumonia, mild retrocardiac atelectasis. COMPARISON: . COMPARISON: . Known sternotomy wires after valvular repair. Leftward axis. Evaluation for interval change. FINDINGS: As compared to the previous radiograph, the patient has been intubated. QTc interval is longer. The patient has also received a nasogastric tube, the course of the tube is unremarkable, the tip of the tube projects over the distal parts of the stomach. Since the previous tracingof the rate is faster. The tip of the endotracheal tube projects 4 cm above the carina. 9:46 PM CHEST (PORTABLE AP) Clip # Reason: Eval ETT and NGT placement Admitting Diagnosis: UPPER GI BLEED MEDICAL CONDITION: 61 year old man with UGIB s/p intubation REASON FOR THIS EXAMINATION: Eval ETT and NGT placement FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post intubation, evaluation for nasogastric tube placement. | 4 | [
{
"category": "Radiology",
"chartdate": "2173-01-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1221122,
"text": " 9:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval ETT and NGT placement\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with UGIB s/p intubation\n REASON FOR THIS EXAMINATION:\n Eval ETT and NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post intubation, evaluation for nasogastric tube\n placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n intubated. The tip of the endotracheal tube projects 4 cm above the carina.\n The patient has also received a nasogastric tube, the course of the tube is\n unremarkable, the tip of the tube projects over the distal parts of the\n stomach.\n\n Known sternotomy wires after valvular repair.\n\n Unchanged moderate cardiomegaly with signs of mild fluid overload. No larger\n pleural effusions. No pneumonia, mild retrocardiac atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-01-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1221133,
"text": " 3:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with upper GI bleed, history of diastolic\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Upper gastrointestinal bleed, history of diastolic disease.\n Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The monitoring and support devices are in constant position, except\n for the nasogastric tube that has been removed in the interval. Unchanged\n moderate cardiomegaly with mild fluid overload, bilateral areas of basal\n atelectasis, and a small left pleural effusion. No interval appearance of\n other parenchymal opacities.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2173-01-27 00:00:00.000",
"description": "Report",
"row_id": 197630,
"text": "Sinus bradycardia. Leftward axis. Otherwise, normal tracing. Compared to the\nprevious tracing of sinus bradycardia is new. Otherwise, normal\ntracing.\n\n"
},
{
"category": "ECG",
"chartdate": "2173-01-23 00:00:00.000",
"description": "Report",
"row_id": 197631,
"text": "Low amplitude P wave. Probable sinus rhythm. Left atrial abnormality.\nLeftward axis. Q-T interval prolongation. Since the previous tracing\nof the rate is faster. QTc interval is longer. Otherwise, unchanged.\n\n"
}
] |
27,331 | 104,786 | A/P 67-year-old gentleman with metastatic colon CA presenting with AMS . # Respiratory distress: CTA negative for large PE, though could not r/o small PE. CXR showed RLL atelectasis. PNA could not be completely ruled out. Exam and CXR dont support pulm edema. No echo in the system. LENIs were negative. He was given vanc and levo as well as albuterol and atrovent nebs. All cultures were negative. He was stabilized in the and transfered to the floor. . # AMS - His mental status waxed and waned during his stay. He was minimally interactive by the time he was called out of the to OMED. He had no intracranial disease by CT. His AMS was likely from hepatic encephalopathy vs infection, though there was little evidence of infection. He was given antibiotics as above as well as lactulose for possible hepatic encephalopathy. Mr. also showed evidence of seizure activity in the final days of his stay. Given his poor prognosis and acute decline, his family decided to transition to CMO status. All non-comfort meds were decreased. Palliative care was consulted. He passed on . . # ONCOLOGIC - Patient with widely metastatic colon CA s/p failed first and second-line chemotherapy, most recently started on Erbitux. Imaging as above. He was transitioned to CMO as above. . # LE edema: stable and chronic. d/c'd lasix with CMO status. . # ELEVATED LFTs - Likely related to progression of widely metastic colon CA with known involvement of liver. No acute intra-abdominal pathology seen on Abdominal CT; cholecystitis is on differential and HIDA or U/S more sensitive for cholecystitis, but given comorbidities, patient was not a candidate for surgical intervention. . # osteoarthritis - comfort care as above . # CODE - CMO | There is sigmoid diverticulosis, without evidence of diverticulitis. Unchanged appearance of widespread intrahepatic metastatic disease. COMPARISON: Non-contrast head CT, . FINDINGS: Evaluation is limited secondary to severe edema bilaterally. TECHNIQUE: Non-contrast head CT. BS+, pt unable to hold lactulose enema, pt w/poor rectal tone. Widespread ill-defined intrahepatic nodules and masses are grossly unchanged when compared to , and remain consistent with metastatic disease. Mild atelectasis at the right base and elevation of the right hemidiaphragm are unchanged. C/o discomfort during ultrasound, prelim report no DVT.RESP: tachypnic, RR 30s. A previously identified subcentimeter right lower lobe pulmonary nodule is not well evaluated as it is present in the region of consolidated lung. There is some linear opacity at the right base representing mild atelectasis. Non-diagnostic small Q waves in the inferior leads.Anterolateral ST-T wave changes which are non-specific. There are a few small mediastinal lymph nodes not pathologic by CT size criteria. Pt w/gross sacral and bilateral lower extremity. Visualized lung apices are unremarkable. HR tachy 110-120s ST, no VEA noted. Right paracentral disc bulge at C5/6 without significant canal narrowing. TECHNIQUE: MDCT axial images of the head pre and post a bolus of Optiray IV contrast with multiplanar reformats. Small bilateral pleural effusions and consolidation of a portion of the dependent lower lobes, right worse than left. There is minimal periventricular white matter hypodensity, most consistent with chronic small vessel ischemic disease. The visualized brain parenchyma is unremarkable. Low QRS voltagein the precordial leads. IMPRESSION: No acute intracranial process. IMPRESSION: No acute intracranial process. Visualized paranasal sinuses are normally aerated. Allowing for these limitations, the common femoral, superficial femoral, and popliteal veins on both right and left lower extremities demonstrated normal flow, augmentation, compressibility, and waveforms. Broad-based posterior disc bulges at C3/4 and C4/5 result in mild-to-moderate central canal stenosis. Mild atelectasis at the right lung base. IMPRESSION: No relevant change as compared to . CT OF THE HEAD WITHOUT AND WITH IV CONTRAST: There is no evidence of hemorrhage, shift of normally midline structures, mass effect, hydrocephalus or infarction. Multilevel degenerative changes, as described above, with mild-moderate ventral canal narrowing at C3/4 and C4/5 levels. FINDINGS: In comparison with the previous examination, there are no major relevant changes. CT OF THE CHEST WITH IV CONTRAST: There is no evidence of pulmonary embolism, although assessment of the small segmental and subsegmental pulmonary arterial branches is somewhat limited by patient respiratory motion and contrast timing. TECHNIQUE: MDCT axial images of the chest after rapid bolus of Optiray IV contrast with multiplanar reformats. Limited evaluation of the upper abdomen demonstrates a large amount of ascites. There is mild periventricular white matter hypodensity consistent with mild chronic microvascular infarction. Numerous small mesenteric lymph nodes are not significantly changed. IMPRESSION: Limited exam, but no evidence to suggest DVT. OSSEOUS STRUCTURES: Multilevel thoracolumbar degenerative changes are similar, and there is no sign of suspicious osteolytic or sclerotic lesion. Clinical correlation issuggested. Additionally, the exam was limited given patient discomfort and the right tibials and peroneals on the right were not visualized. There are small bilateral pleural effusions and associated dependent consolidation of the lower lobes, right greater than left. In ICU, immediately started on heparin drip, then sent to CT scan of chest that showed no PE, heparin D/Ced, and CT of head was negative. No evidence of substantial pleural effusions. TECHNIQUE: MDCT acquired axial imaging was performed of the abdomen and pelvis after administration of intravenous contrast only. Prevertebral and paraspinal soft tissues are normal. The visualized osseous structures are unremarkable. LS: coarse upper, deminished bases. TECHNIQUE: MDCT-acquired axial imaging was performed through the cervical spine without intravenous contrast. No acute intrathoracic process. No opacity suggestive of pneumonia. IMPRESSION: No acute cervical spine fracture or malalignment. Facet osteophytes result in mild neural foraminal narrowing on the left at C4/5, on the right at C5/6, and also on the left at C5/6. COMPARISON: CT from . CT ABDOMEN: Visualized lung bases demonstrate small bilateral pleural effusions, and minor bibasilar atelectasis. MICU NPNNEURO: VERY LETHARGIC AND DISORIENTATED, RESPONDS TO PAIN.RESP: SATS ARE FINE ON ROOM AIR, TACHYPNEIC AT TIMES AND STOKE BREATHIGN AT TIMES. No signs of hyperhydration. No intraluminal luminal thrombus was identified. There is some interval worsening in the right mid and lower lobe atelectasis and pulmonary edema. There is no acute aortic abnormality. NGT placed as patient appeared to fail bedside swallow eval, clearing of throat after POs. NPN 1900-0700:Neuro: lethargic and dozing most og the time, oriented only to his name, pulling at tubes, restrained for safety, denied pain.Resp: On RA sating in 90s, LS CTA to coarse in upper lobes, diminished at bases, nonproductive cough.CV: SEE carevieu for details, tachycardiac, given 3 boluses of a total of 1.5 L NS, with a PIV line, difficult to palpate peripheral pulses.GI?GU: ascites, with NGT for meds, lactulose for encephalopathy, passed loose BM, diaper applied, with foley, icteric U/O, was low imporoved after NS boluses (see carevieu).Integ: T 98.6, restrained for safety.Social: DNI/DNR, wife and daughter visited and updated on .Plan: called out to a floor, monitor mental status, U/O, HR, bolus as needed, administer lactulose for encephalopathy, update family on any chamnges in pt's condition, still DNI/DNR. CTA unable to rule out small subsegmental PE due to motion artifact. IMPRESSION: Standard position of NG tube. No pulmonary embolism. No oral contrast was administered. No evidence of intracranial metastatic disease. There is no free intraperitoneal air. No new nodules are identified. Mild degenerative change is seen at the atlantodental interface anteriorly and superiorly, likely calcification of the apical dental ligament. CHEST PORTABLE: Comparison is made to a prior examination of . The gallbladder, pancreas, spleen, and adrenal glands are unremarkable. COMPARISON: CT torso . Interval worsening in atelectasis and pulmonary edema. | 15 | [
{
"category": "Radiology",
"chartdate": "2121-12-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 994967,
"text": " 4:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for mass, bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with altered mental status s/p fall, metastatic colon ca\n REASON FOR THIS EXAMINATION:\n eval for mass, bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with altered mental status, status post fall.\n History of metastatic colon cancer. Please evaluate for mass or bleed.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intracranial hemorrhage, mass, mass effect, or evidence\n of acute vascular territorial infarction. There is minimal periventricular\n white matter hypodensity, most consistent with chronic small vessel ischemic\n disease. The ventricles and sulci are normal in size and configuration.\n There is no fracture. Visualized paranasal sinuses are normally aerated.\n\n IMPRESSION: No acute intracranial process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-12-13 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 994968,
"text": " 4:34 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with altered mental status s/p fall, metastatic colon ca\n REASON FOR THIS EXAMINATION:\n eval for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd SAT 6:47 PM\n no fx or malalignment\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with altered mental status, metastatic colon\n cancer, status post multiple falls.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired axial imaging was performed through the cervical\n spine without intravenous contrast. Multiplanar reformatted images were\n obtained and reviewed.\n\n CT CERVICAL SPINE: There is no fracture, or acute cervical spine\n malalignment. Prevertebral and paraspinal soft tissues are normal. There is\n no lytic or sclerotic bony lesion.\n\n Mild degenerative change is seen at the atlantodental interface anteriorly and\n superiorly, likely calcification of the apical dental ligament. Facet\n osteophytes result in mild neural foraminal narrowing on the left at C4/5, on\n the right at C5/6, and also on the left at C5/6. Broad-based posterior disc\n bulges at C3/4 and C4/5 result in mild-to-moderate central canal stenosis.\n Right paracentral disc bulge at C5/6 without significant canal narrowing.\n\n Visualized lung apices are unremarkable. The visualized brain parenchyma is\n unremarkable.\n\n IMPRESSION: No acute cervical spine fracture or malalignment. Multilevel\n degenerative changes, as described above, with mild-moderate ventral canal\n narrowing at C3/4 and C4/5 levels.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-12-13 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 994969,
"text": " 4:35 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: abscess? bloody mass? free fluid?\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with colon CA now with abd distention and altered mental status\n REASON FOR THIS EXAMINATION:\n abscess? bloody mass? free fluid?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with colon cancer, now with abdominal distension\n and altered mental status.\n\n COMPARISON: CT from .\n\n TECHNIQUE: MDCT acquired axial imaging was performed of the abdomen and\n pelvis after administration of intravenous contrast only. No oral contrast\n was administered.\n\n CT ABDOMEN: Visualized lung bases demonstrate small bilateral pleural\n effusions, and minor bibasilar atelectasis.\n\n Widespread ill-defined intrahepatic nodules and masses are grossly unchanged\n when compared to , and remain consistent with metastatic disease. As\n before, some of these masses are situated near the liver capsule, and deform\n the liver surface. The overall amount of ascites within the abdomen has\n increased.\n\n The gallbladder, pancreas, spleen, and adrenal glands are unremarkable.\n Kidneys enhance and excrete contrast symmetrically. There is no\n hydronephrosis. There is no free intraperitoneal air. Numerous small\n mesenteric lymph nodes are not significantly changed.\n\n CT PELVIS: Free fluid extends into the pelvis, and within the\n processus vaginalis, through an inguinal hernia into the left hemiscrotum. The\n urinary bladder is decompressed with a Foley catheter balloon in place. There\n is sigmoid diverticulosis, without evidence of diverticulitis.\n\n OSSEOUS STRUCTURES: Multilevel thoracolumbar degenerative changes are\n similar, and there is no sign of suspicious osteolytic or sclerotic lesion.\n Note is again made of prior left hip surgery.\n\n IMPRESSION:\n\n 1. Unchanged appearance of widespread intrahepatic metastatic disease.\n\n 2. Increased ascites.\n (Over)\n\n 4:35 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: abscess? bloody mass? free fluid?\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-12-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 994963,
"text": " 4:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with metastatic ca, change in mental status, sob\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE.\n\n INDICATION: 67-year-old man with metastatic carcinoma, change in mental\n status, shortness of breath. Evaluate for infiltrate.\n\n CHEST PORTABLE: Comparison is made to a prior examination of . The\n heart is normal in size. There is an elevated hemidiaphragm. There is some\n linear opacity at the right base representing mild atelectasis. The pulmonary\n vasculature is normal. The lungs are otherwise clear. Port-A-Cath is\n identified with its tip in the right atrium. There are no pleural effusions.\n\n IMPRESSION:\n\n 1. No acute intrathoracic process. No evidence for pneumonia.\n\n 2. Mild atelectasis at the right base and elevation of the right\n hemidiaphragm are unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-12-15 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 995195,
"text": " 4:36 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: evaluate for DVT's\n Admitting Diagnosis: DEHYDRATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with bilateral lower extremity edema, metastatic colon ca, CTA\n unable to rule out small subsegmental PE due to motion artifact\n REASON FOR THIS EXAMINATION:\n evaluate for DVT's\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral lower extremity edema with metastatic colon cancer. CTA\n unable to rule out small subsegmental PE due to motion artifact. Please\n evaluate for DVTs.\n\n FINDINGS: Evaluation is limited secondary to severe edema bilaterally. The\n SVC in the mid and distal portions on the left were difficult to visualize,\n though the color flow in these sections appeared normal. Additionally, the\n exam was limited given patient discomfort and the right tibials and peroneals\n on the right were not visualized. Allowing for these limitations, the common\n femoral, superficial femoral, and popliteal veins on both right and left lower\n extremities demonstrated normal flow, augmentation, compressibility, and\n waveforms. No intraluminal luminal thrombus was identified.\n\n IMPRESSION: Limited exam, but no evidence to suggest DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 995075,
"text": " 6:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for intrathrocic pathology.\n Admitting Diagnosis: DEHYDRATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with respiratory alkylosis, bronchial breath sounds, and desats\n to 80s on 4L.\n REASON FOR THIS EXAMINATION:\n please eval for intrathrocic pathology.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n COMPARISON: .\n\n INDICATION: Desaturation, followup.\n\n FINDINGS: In comparison with the previous examination, there are no major\n relevant changes. Due to projection, the pre-existing slight elevation of the\n hemidiaphragms is a little more visible. No evidence of substantial pleural\n effusions. The size of the cardiac silhouette is within the upper range of\n normal. No signs of hyperhydration. Mild atelectasis at the right lung base.\n No opacity suggestive of pneumonia. The Port-A-Cath is in standard position.\n\n IMPRESSION: No relevant change as compared to . No cardiac\n decompensation, no overhydration, no pneumonia.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2121-12-15 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 995086,
"text": " 12:34 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please doa CTA chest to eval for PE\n Admitting Diagnosis: DEHYDRATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with CA colon now w/ acute onset SOB, tachypnea, droppig satts,\n tachycardia\n REASON FOR THIS EXAMINATION:\n please doa CTA chest to eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with metastatic colon cancer, now with acute onset\n of difficulty breathing, tachypnea and tachycardia with concern for pulmonary\n embolism.\n\n COMPARISON: CT torso .\n\n TECHNIQUE: MDCT axial images of the chest after rapid bolus of Optiray IV\n contrast with multiplanar reformats.\n\n CT OF THE CHEST WITH IV CONTRAST: There is no evidence of pulmonary embolism,\n although assessment of the small segmental and subsegmental pulmonary arterial\n branches is somewhat limited by patient respiratory motion and contrast\n timing. There is no acute aortic abnormality. There are a few small\n mediastinal lymph nodes not pathologic by CT size criteria. There are small\n bilateral pleural effusions and associated dependent consolidation of the\n lower lobes, right greater than left. A previously identified subcentimeter\n right lower lobe pulmonary nodule is not well evaluated as it is present in\n the region of consolidated lung. No new nodules are identified.\n\n Limited evaluation of the upper abdomen demonstrates a large amount of\n ascites. Most of the visualized liver is occupied by confluent hypodense\n metastatic lesions.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are\n identified.\n\n IMPRESSION:\n\n 1. No pulmonary embolism. However, there is poor filling of the segmental\n branches for the left lower lobe. If clinically indicated, a repeated CTA\n coould be performed for better evaluation.\n\n 2. Small bilateral pleural effusions and consolidation of a portion of the\n dependent lower lobes, right worse than left.\n\n 3. Large amount of ascites and evidence of significant hepatic metastatic\n disease.\n\n These findings, including the need for further imaging if high clinical\n (Over)\n\n 12:34 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: please doa CTA chest to eval for PE\n Admitting Diagnosis: DEHYDRATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n suspicion for PE were discussed with Dr. at 12:30PM on \n by Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-12-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 995187,
"text": " 3:58 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval ngt position\n Admitting Diagnosis: DEHYDRATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with metastatic Colon Ca s/p ngt placement\n REASON FOR THIS EXAMINATION:\n please eval ngt position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n INDICATION: Metastatic colon cancer, NG tube placement. There is comparison\n with the prior from at 2:42 p.m. The NG tube is in the\n proximal stomach. There is some interval worsening in the right mid and lower\n lobe atelectasis and pulmonary edema. No other interval change.\n\n IMPRESSION: Standard position of NG tube. Interval worsening in atelectasis\n and pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-12-15 00:00:00.000",
"description": "CT HEAD W/ & W/O CONTRAST",
"row_id": 995085,
"text": " 12:33 AM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: ?METS, BLEED\n Admitting Diagnosis: DEHYDRATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with metastatic CA colon now w/ acute onset SOB, and change in\n mental status\n REASON FOR THIS EXAMINATION:\n please eval for brain mets\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with metastatic colon cancer, now with difficulty\n breathing and change of mental status with concern for intracranial metastatic\n disease.\n\n COMPARISON: Non-contrast head CT, .\n\n TECHNIQUE: MDCT axial images of the head pre and post a bolus of Optiray IV\n contrast with multiplanar reformats.\n\n CT OF THE HEAD WITHOUT AND WITH IV CONTRAST: There is no evidence\n of hemorrhage, shift of normally midline structures, mass effect,\n hydrocephalus or infarction. There is mild periventricular white matter\n hypodensity consistent with mild chronic microvascular infarction. There is\n no evidence of abnormal brain parenchymal enhancement or focal mass lesion.\n The paranasal sinuses and mastoid air cells are clear. The visualized osseous\n structures are unremarkable.\n\n IMPRESSION: No acute intracranial process. No evidence of intracranial\n metastatic disease.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-12-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 995177,
"text": " 2:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evalute NG tube\n Admitting Diagnosis: DEHYDRATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with metastatic Colon CA s/p NG tube placement\n REASON FOR THIS EXAMINATION:\n please evalute NG tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube placement.\n\n FINDINGS: In comparison with the study of , the patient has taken a\n slightly better inspiration. The Dobbhoff tube extends to the lower body of\n the stomach.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-12-15 00:00:00.000",
"description": "Report",
"row_id": 1619961,
"text": "NPN 0700-1900\nNeuro: difficult to arouse patient to painful stimulation this morning, however, after lactulose enema able to arouse patient to voice. Pt oriented to self only. AFebrile. Pt pulled out NGT necessitating hand mitts to prevent pulling of NGT. NGT placed as patient appeared to fail bedside swallow eval, clearing of throat after POs. Pt c/o discomfort on coccyx after lying of stretcher for ultrasound, repositioned on side and verbalized comfort.\nCV: b/p 95-120/50-60s, restarted PO lasix once NGT placement reconfirmed after pulling out 1st NGT. HR tachy 110-120s ST, no VEA noted. Pt given one 500cc IVF bolus and appeared to have increase in abdominal discomfort during bolus. Bolus given for lactate level of 5.2. Pt w/gross sacral and bilateral lower extremity. C/o discomfort during ultrasound, prelim report no DVT.\nRESP: tachypnic, RR 30s. LS: coarse upper, deminished bases. O2 sats RA 95%+ when pleth appears accurate.\nGI: ABD distended d/t ascites. BS+, pt unable to hold lactulose enema, pt w/poor rectal tone. Pt passing watery enema w/blood tinge x 2 today.\nGU: foley patent, restarted lasix PO @ 1800, monitor response.\nSocial: dtr and wife called, updated on care. Wife spoke w/MD @ length RE: status and consent for ICU.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-12-16 00:00:00.000",
"description": "Report",
"row_id": 1619962,
"text": "NPN 1900-0700:\nNeuro: lethargic and dozing most og the time, oriented only to his name, pulling at tubes, restrained for safety, denied pain.\n\nResp: On RA sating in 90s, LS CTA to coarse in upper lobes, diminished at bases, nonproductive cough.\n\nCV: SEE carevieu for details, tachycardiac, given 3 boluses of a total of 1.5 L NS, with a PIV line, difficult to palpate peripheral pulses.\n\nGI?GU: ascites, with NGT for meds, lactulose for encephalopathy, passed loose BM, diaper applied, with foley, icteric U/O, was low imporoved after NS boluses (see carevieu).\n\nInteg: T 98.6, restrained for safety.\n\nSocial: DNI/DNR, wife and daughter visited and updated on .\n\nPlan: called out to a floor, monitor mental status, U/O, HR, bolus as needed, administer lactulose for encephalopathy, update family on any chamnges in pt's condition, still DNI/DNR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-12-16 00:00:00.000",
"description": "Report",
"row_id": 1619963,
"text": "MICU NPN\nNEURO: VERY LETHARGIC AND DISORIENTATED, RESPONDS TO PAIN.\n\nRESP: SATS ARE FINE ON ROOM AIR, TACHYPNEIC AT TIMES AND STOKE BREATHIGN AT TIMES. APPEARS COMFORTABLE.\n\nCV: HR AND BP STABLE\n\nGI: CONTINUES TO HAVE LOOSE DIARRHEA MUSHROOM CATH INSERTED, DRAINING WELL. CONTINUES TO BE NPO USING NGT FOR MEDS.\n\nGU: SEE CAREVUE FORMOST UP TO DATE URINE OUTPUT.\n\nSOCIAL: WIFE IN TODAY STATED CONCERNS ABOUT PT'S NEEDS AND HOW SHE WOULD LIKE HOSPICE TO GET INVOLVED, PALLIATIVE CARE CONSULT REQUESTED.\n\nPLAN: PT. IS CALLED OUT TO 7 SOUTH IS GOING TO BED 740.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-12-15 00:00:00.000",
"description": "Report",
"row_id": 1619960,
"text": "Admission and NPN 2100-0700:\n67 yo male pt with hx of metastatic colonic CA, s/p 1st and 2nd line chemotherapy who was admitted to ED via EMS on with altered mental status and hallucinations when pt was noted by family to be incoherent, and more somnolent, talking to people who were not present and to deceased pets; no trauma or fall prior to this onset, he had been lethargic for several days and staying in bed, had anorexia and poor PO intake for several days. In ED CT was negative for bleeding, labs showed elevated LFTs, leukocytosis and dehydration, given fluids and antibiotics and admitted to 11 , where he developed deterioration in his mental status and occasional desaturatiopn, started on non0rebreather 100%, and transferred to for CT scans of chest and brain, ? PE. In ICU, immediately started on heparin drip, then sent to CT scan of chest that showed no PE, heparin D/Ced, and CT of head was negative. HO attributed the mental changes to encephalopathy, given lactulose enema, which didn't seem to work well.\n\nROS:\nNeuro: very lethargic, barely responsive to verbal stimuli, oriented only to his name, at times agitated in bed especially when he was on the CT table, got very restless, localizes pain, not follows commands, denied pain though he had bilateral knee replacement, which cause pain as per family, didn't recognize daughter or wife, very confused, .\n\nResp: received on NRB, then was on RA sating well, when in CT placed on NRB again, Sat 93-100%, LS coarse in upper lobes to diminished at bases, nonproductive cough.\n\nCV: ST HR 107-127, BP 107-129/72-101, with portocath on left chest area, heparin D/Ced, on levaquin and vancomycin, weak peripheral pulses, given bicarb pre and post CT scan wiuth contrast, cool extremities.\n\nGI/GU: with diffused ascites, paracentesis done and specimen sent for cx, NPO, passed loose stool, with foley icteric U/O.\n\nInteg: T max 98, icteric skin, with left heal blister, yellow base, cleaned and open to air, washed up.\n\nPlan: monitor mental status closely, monitor respiratory status and saturation, O2 as needed, pulmonary toileting, ? insert NG tube and administer Lactulose for encephalopathy.\n"
},
{
"category": "ECG",
"chartdate": "2121-12-13 00:00:00.000",
"description": "Report",
"row_id": 251687,
"text": "Sinus rhythm. Non-diagnostic small Q waves in the inferior leads.\nAnterolateral ST-T wave changes which are non-specific. Low QRS voltage\nin the precordial leads. Compared to the previous tracing of \nanterolateral ST-T wave abnormalities are new. Clinical correlation is\nsuggested.\n\n"
}
] |
98,227 | 165,553 | The patient was brought to the Operating Room on where the patient underwent CABG x 5. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. He received a unit of PRBC on POD 3 for hct 22%. Hct would rise to 28%. He was started on Flomax and Foley was re-placed for failure to void. The foley was discontinued again and he was able to void without difficulty. The patient was evaluated by the physical therapy service for assistance with strength and mobility. On POD 4 he developed tachycardia in the 110s and hypotension with SBP in the 90s and 80s. He remained stable and was monitored overnight. Heart rate remained in the low 100s and BP would dip to the 90s. He is asymptomatic and medications were titrated accordingly. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to Rehab in good condition with appropriate follow up instructions. Expected length of stay at rehab is less than 30 days. | Cardiomediastinal silhouette has a normal postoperative appearance. Right jugular line ends low in the SVC. The left ventricular cavity sizeis normal. Mild regionalLV systolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; midinferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo;inferior apex - hypo; remaining LV segments contract normally.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.Simple atheroma in ascending aorta. There are simpleatheroma in the ascending and descending thoracic aorta.The aortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic stenosis or aortic regurgitation.The mitral valve appears structurally normal with trivial mitralregurgitation.Post bypass:Intact thoracic aorta.Normal RV and LV systolic function. Right IJ catheter is in unchanged position. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.GENERAL COMMENTS: Written informed consent was obtained from the patient. Left pleural effusion and atelectasis are small. Minimal atelectasis is seen at the bases. Simple atheroma in descending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). There is mild regional left ventricular systolic dysfunction withhypokinesis in the inferior and inferoseptal region. Good (>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. Left pleural tube has been removed and there may be a very small left apical pneumothorax but no appreciable left pleural effusion is collected. Compared to the previoustracing of no diagnostic interval change. Moderate left basal atelectasis is stable, moderate right basal atelectasis is worsened. No spontaneous echo contrast or thrombus isseen in the body of the left atrium/left atrial appendage or the body of theright atrium/right atrial appendage.Left ventricular wall thicknesses are normal. Hypertension.Status: InpatientDate/Time: at 15:41Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. Normal sinus rhythm. Lower lobe atelectasis is minimal. Left pleural effusion is probably small. IMPRESSION: AP chest compared to and : Since , the patient has been extubated and lung volumes are accordingly lower. Normal LV cavity size. FINDINGS: In comparison with study of , the lateral projection shows small bilateral pleural effusions. Borderline low voltage in thelimb leads. Non-specific ST-T wave abnormalities. Estimated LVEF is 50-55%.The remaining left ventricular segments contract normally.Right ventricular chamber size and free wall motion are normal.The diameters of aorta at the sinus, ascending and arch levels are normal.There are complex (>4mm) atheroma in the aortic arch. Right-sided jugular line is in mid SVC. There is no pulmonary edema. Results were personally reviewed with the MD caring forthe patient.Conclusions:Pre-BypassThe left atrium is normal in size. No TEE related complications. Chest tube discontinued. No spontaneous echo contrast or thrombus in theLA/LAA or the RA/RAA. FINDINGS: ET tube ends at 5.9 cm above carina. Overall LVEF 55%.No new valvular findings.Previously hypokinetic inferior wall is moving better. The patient was under general anesthesiathroughout the procedure. The patient appears tobe in sinus rhythm. CONCLUSION: The patient had recent CABG surgery. There is no pneumothorax. I certify I was present incompliance with HCFA regulations. No evidence of acute vascular congestion, pneumothorax, or pneumonia. Right bundle-branch block. No AS. Tube and lines are in adequate position. Coronary artery disease. Complex (>4mm) atheroma in the aorticarch. The NG tube is in the stomach. 7:37 PM CHEST PORT. PATIENT/TEST INFORMATION:Indication: Chest pain. ATEE was performed in the location listed above. COMPARISON: . 1:37 PM CHEST (PA & LAT) Clip # Reason: eval for effusion Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 73 year old man s/p cabg REASON FOR THIS EXAMINATION: eval for effusion FINAL REPORT HISTORY: CABG. 10:36 AM CHEST (PORTABLE AP) Clip # Reason: evaluate for ptx Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 73 year old man with s/p CABG, CTs d/c'd REASON FOR THIS EXAMINATION: evaluate for ptx FINAL REPORT AP CHEST, 10:53 A.M. . LINE PLACEMENT Clip # Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 73 year old man s/p CABG REASON FOR THIS EXAMINATION: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY FINAL REPORT PORTABLE AP CHEST X-RAY INDICATION: CABG, fast track early extubation. | 5 | [
{
"category": "Echo",
"chartdate": "2196-09-21 00:00:00.000",
"description": "Report",
"row_id": 67096,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Coronary artery disease. Hypertension.\nStatus: Inpatient\nDate/Time: at 15:41\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mild regional\nLV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid\ninferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo;\ninferior apex - hypo; remaining LV segments contract normally.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\nSimple atheroma in ascending aorta. Complex (>4mm) atheroma in the aortic\narch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. A\nTEE was performed in the location listed above. I certify I was present in\ncompliance with HCFA regulations. The patient was under general anesthesia\nthroughout the procedure. No TEE related complications. The patient appears to\nbe in sinus rhythm. Results were personally reviewed with the MD caring for\nthe patient.\n\nConclusions:\nPre-Bypass\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. There is mild regional left ventricular systolic dysfunction with\nhypokinesis in the inferior and inferoseptal region. Estimated LVEF is 50-55%.\nThe remaining left ventricular segments contract normally.\nRight ventricular chamber size and free wall motion are normal.\nThe diameters of aorta at the sinus, ascending and arch levels are normal.\nThere are complex (>4mm) atheroma in the aortic arch. There are simple\natheroma in the ascending and descending thoracic aorta.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis or aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nPost bypass:\nIntact thoracic aorta.\nNormal RV and LV systolic function. Overall LVEF 55%.\nNo new valvular findings.\nPreviously hypokinetic inferior wall is moving better.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2196-09-21 00:00:00.000",
"description": "Report",
"row_id": 143717,
"text": "Normal sinus rhythm. Right bundle-branch block. Borderline low voltage in the\nlimb leads. Non-specific ST-T wave abnormalities. Compared to the previous\ntracing of no diagnostic interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-09-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1253257,
"text": " 7:37 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST X-RAY\n\n INDICATION: CABG, fast track early extubation.\n\n COMPARISON: .\n\n FINDINGS:\n\n ET tube ends at 5.9 cm above carina. Right-sided jugular line is in mid SVC.\n Lower lobe atelectasis is minimal. There is no pneumothorax. Left pleural\n effusion is probably small. The NG tube is in the stomach.\n\n CONCLUSION:\n\n The patient had recent CABG surgery. Tube and lines are in adequate position.\n Left pleural effusion and atelectasis are small.\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-09-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1253597,
"text": " 1:37 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n FINDINGS: In comparison with study of , the lateral projection shows small\n bilateral pleural effusions. Minimal atelectasis is seen at the bases. Right\n IJ catheter is in unchanged position.\n\n No evidence of acute vascular congestion, pneumothorax, or pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-09-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1253462,
"text": " 10:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p CABG, CTs d/c'd\n REASON FOR THIS EXAMINATION:\n evaluate for ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:53 A.M. .\n\n HISTORY: 73-year-old man after CABG. Chest tube discontinued.\n\n IMPRESSION: AP chest compared to and :\n\n Since , the patient has been extubated and lung volumes are\n accordingly lower. Left pleural tube has been removed and there may be a very\n small left apical pneumothorax but no appreciable left pleural effusion is\n collected. Moderate left basal atelectasis is stable, moderate right basal\n atelectasis is worsened. There is no pulmonary edema. Cardiomediastinal\n silhouette has a normal postoperative appearance. Right jugular line ends low\n in the SVC.\n\n\n"
}
] |
43,323 | 156,689 | 69 year old male with history of emphysema, SCC diagnosed in s/p left upper lobectomy and s/p neoadjuvant chemoradiation, PE/DVT in , pericardial effusion w/ tamponade requiring pericardial window in , s/p IVC filter placement who presented from clinic with SOB and CTA showing multiple PEs and multifocal right sided pneumonia. . Pt was initially admitted to OMED service and started on heparin drip for the PEs, and given ceftriaxone, vanco and levoflox for the pneumonia. He then became hypoxic and was transferred to the ICU for further monitoring. He required intubation for worsening respiratory status, which was initially felt to be mostly related to pneumonia. There was also a concern for diffuse alveolar hemorrhage so he underwent a bronchoscopy showing minimial bleeding. Heparin drip was stopped as it was felt his bleeding risk was higher than PE risk given his filter. His respiratory status and chest xray began to improve initially on broad spectrum antibiotics. On the evening of , he became acutely tachycardic up to 140s, felt to be in atrial flutter. An echo was obtained showing a severe amount of tricuspid regurg. Overnight his clinical status worsened significantly, with rising lactate and worsening electrolytes. A ferritin level was checked and found to be , then > on recheck. Unclear etiology but likely due to some systemic inflammatory process that was contributing to underlying shock. Her family was updated on the poor prognosis and the decision was made to withdraw treatment and make the patient CMO. He passed away with family at bedside. | Mildly dilated aortic root. Left upper lung opacities which are due to combination of loculated fluid and collapsed adjacent lung and elevation of the left hemidiaphragm and left hilus are unchanged in appearance. Rule out pulmonary embolus.Diffuse T wave abnormalities. Moderatepulmonary systolic hypertension.Compared with the findings of the prior study (images reviewed) of ,the rhythm is now sinus (without ectopy) and the left ventricular ejectionfraction appears normal. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is normal in size. There is moderate pulmonary artery systolichypertension. There is a trivial/physiologic pericardial effusion.IMPRESSION: Suboptimal image quality. No MS.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. There is moderate pulmonaryartery systolic hypertension. The gallbladder is within normal limits. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. EndocarditisHeight: (in) 71Weight (lb): 187BSA (m2): 2.05 m2BP (mm Hg): 102/64HR (bpm): 119Status: InpatientDate/Time: at 16:05Test: Portable TTE (Complete)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: Mild symmetric LVH. Left upper lung opacities from loculated pleural fluid and collapse of the adjacent lung as suggested from the chest CT dated is unchanged. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Moderate tosevere [3+] tricuspid regurgitation is seen. The mitral valve appears structurally normal withtrivial mitral regurgitation. Mild mitralannular calcification. Unchanged small pericardial effusion. Left atrial abnormality. Left atrial abnormality. 6. low density of the intravascular space consistent with anemia. Evidence of left upper lobe resection, elevation of the left hilum and cardiomediastinal silhouette are unchanged. Unchanged small amount of pericardial effusion that is mainly concentrated on the left side. The aorticvalve leaflets (3) are mildly thickened but aortic stenosis is not present.The mitral valve leaflets are mildly thickened. Extensive pneumonic consolidations in the right lung are unchanged. Suboptimal image quality - ventilator. PATIENT/TEST INFORMATION:Indication: Worsening hupoxia.Height: (in) 71Weight (lb): 187BSA (m2): 2.05 m2BP (mm Hg): 108/59HR (bpm): 77Status: OutpatientDate/Time: at 11:18Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildy dilated aortic root. T Admitting Diagnosis: PULMONARY EMBOLISM FINAL REPORT (Cont) Few prominent mediastinal lymph nodes are identified, for example, a right paratracheal lymph node that measures 11 mm and a subcarinal lymph node with punctate calcifications that measures 12.4 mm on its short axis (2:30). Small pleural effusions bilaterally are unchanged. Diverticulosis is seen along the course of the colon without signs of diverticulitis. The right ventricular free wall is hypertrophied. Probable prior inferior myocardialinfarction of indeterminate age. FINDINGS: CHEST: A central line is seen with its tip in the inferior margin of the superior vena cava. Mild thickening of mitral valve chordae. The aortic root ismildly dilated at the sinus level. The left ventricularcavity is unusually small. Typical atrial flutter is present again. Colon diverticulosis without signs of diverticulitis. Overall left ventricular systolic function isnormal (LVEF 60%). Status post left upper lobectomy. Note is made to a calcified right hilar node and a calcified nodule in the right lower lobe, most consistent with old granulomatous disease. Inferior ST segment elevationraises concern for myocardial ischemia. Otherwise, the large and small bowel is within normal limits. Sinus rhythm with ventricular premature beats. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality as the patient was difficult toposition. If clinically indicated, a transesophagealechocardiographic examination is recommended.Conclusions:There is mild symmetric left ventricular hypertrophy. Normal ascending aorta diameter.AORTIC VALVE: Normal aortic valve leaflets (3). Small left pleural effusion that was not seen on prior examination. Prolonged (>250ms)transmitral E-wave decel time.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. e/o occult infection. e/o occult infection. e/o occult infection. e/o occult infection. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Abnormal diastolic septalmotion/position consistent with RV volume overload.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Possible prior myocardial infarction ofindeterminate age with residual ST segment elevations suggesting possibleaneurysm. The rightventricular cavity is dilated There is abnormal diastolic septalmotion/position consistent with right ventricular volume overload. given rapidity, infection and possible additional edema are likely 2. stable appearance of left hemithorax with post-surgical and radiation changes. Reidentified are ground-glass opacities in the right upper, middle and lower lobes as well as in the superior segment of the left lower lobe. Small amount of ascites is seen. ST segment depressions in leads I and aVL andT wave flattening in leads V2-V6 persist when compared to the previous tracingof . Normal biventricular systolic function.No significant valvular disease. Compared to theprevious tracing of ST segment elevation in the inferior leads was seenon the prior tracing suggesting that these findings may be chronic and may beassociated with an aneurysm. Sinus rhythm. Sinus rhythm. Normal mainPA. FINDINGS: Endotracheal tube ends approximately 5.2 cm above the carina and is appropriate. An orogastric tube is seen to course below the diaphragm and ends into the stomach; however, the distal end is beyond the radiograph view. Normal tricuspidvalve supporting structures. COMPARISON: Prior CT of the chest from . FINDINGS: In comparison with the earlier study of this date, the tip of the endotracheal tube lies just above the clavicles, approximately 6.8 cm above the carina. Free fluid is seen within the pelvis. S1-Q3-T3 is present as well as theanterolateral T wave changes noted previously, all compatible with acutepulmonary embolism.TRACING #2 The heart is within normal limits regarding size and configuration. TOTAL EXAM DLP: 1308.95 mGy-cm. FINDINGS: In comparison with the earlier study of this date, there has been placement of a right IJ catheter that extends to the cavoatrial junction or possibly into the upper portion of the right atrium. | 12 | [
{
"category": "Radiology",
"chartdate": "2130-02-04 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1225737,
"text": " 3:28 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Please evaluate for worsening infiltrate, effusion, fluid ov\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with PE/DVT, s/p LUL lobectomy with hypoxia\n REASON FOR THIS EXAMINATION:\n Please evaluate for worsening infiltrate, effusion, fluid overload,\n pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Worsening hypoxia.\n\n Comparison is made with prior study performed 5 hours earlier.\n\n There appears to be increase in left pleural effusion that is loculated in the\n left apex. Otherwise, there are no interval changes. No pneumothorax or\n overt pulmonary edema. Extensive pneumonic consolidations in the right lung\n are unchanged. Evidence of left upper lobe resection, elevation of the left\n hilum and cardiomediastinal silhouette are unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-02-08 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1226250,
"text": " 12:28 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: desaturations with movement, ? ETT tube positioning?\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with ETT\n REASON FOR THIS EXAMINATION:\n desaturations with movement, ? ETT tube positioning?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ET tube positioning.\n\n FINDINGS: In comparison with the earlier study of this date, the tip of the\n endotracheal tube lies just above the clavicles, approximately 6.8 cm above\n the carina. Otherwise, there is little change in the appearance of the heart\n and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-02-06 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1225994,
"text": " 6:11 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: s/p IJ line placement\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with s/p line\n REASON FOR THIS EXAMINATION:\n s/p IJ line placement\n ______________________________________________________________________________\n WET READ: OXZa MON 7:02 PM\n Right IJ tip at superior cavoatrial junction. otherwise, not significantly\n changed\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: IJ placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a right IJ catheter that extends to the cavoatrial junction or\n possibly into the upper portion of the right atrium. The remainder of the\n study is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-02-08 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1226288,
"text": " 5:55 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? e/o occult infection. Please include down to mid-thigh. T\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with fevers for past 24 hrs.\n REASON FOR THIS EXAMINATION:\n ? e/o occult infection. Please include down to mid-thigh. Thanks.\n CONTRAINDICATIONS for IV CONTRAST:\n Worsening renal failure\n ______________________________________________________________________________\n WET READ: OXZa WED 7:42 PM\n 1. increased, predominantly ground glass opacities throughout the right lung.\n given rapidity, infection and possible additional edema are likely\n 2. stable appearance of left hemithorax with post-surgical and radiation\n changes.\n 3. no pleural or pericardial effusion\n 4. intubated with material in distal trachea distal to balloon\n 5. small amount of perihepatic and pelvic ascites.\n 6. low density of the intravascular space consistent with anemia. known\n pulmonary emboli are not evaluated on this non-contrast study\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR THE EXAMINATION: This is a 69-year-old man with fever for the past\n 24 hours. The request is to rule out an occult infection.\n\n The patient is status post left upper lung lobectomy and neoadjuvant\n chemoradiation due due to squamous cell carcinoma.\n\n COMPARISON: Prior CT of the chest from .\n\n TECHNIQUE: CT of the chest, body and pelvis without IV contrast\n administration. Oral contrast was given.\n\n Coronal and sagittal reformations were made.\n\n TOTAL EXAM DLP: 1308.95 mGy-cm.\n\n FINDINGS:\n\n CHEST: A central line is seen with its tip in the inferior margin of the\n superior vena cava.\n\n Highly positioned endotracheal tube is seen\n Nasogastric tube is seen with its tip in the stomach.\n\n The heart is within normal limits regarding size and configuration. Unchanged\n small amount of pericardial effusion that is mainly concentrated on the left\n side.\n\n Status post left upper lobectomy. The surgical bed is filled with fluid with\n no gas bubbles within it.\n (Over)\n\n 5:55 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? e/o occult infection. Please include down to mid-thigh. T\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Few prominent mediastinal lymph nodes are identified, for example, a right\n paratracheal lymph node that measures 11 mm and a subcarinal lymph node with\n punctate calcifications that measures 12.4 mm on its short axis (2:30).\n Note is made to a calcified right hilar node and a calcified nodule in the\n right lower lobe, most consistent with old granulomatous disease.\n\n Reidentified are ground-glass opacities in the right upper, middle and lower\n lobes as well as in the superior segment of the left lower lobe.\n Consolidations are seen in the right lower lobe and in the superior segment of\n the left lower lobe.\n Both findings have increased in size in comparison to prior examinations\n\n Small amount of left pleural effusion is detected that was not seen on prior\n examination.\n\n ABDOMEN: The liver is with no gross pathology. The gallbladder is within\n normal limits. The spleen, the pancreas and both adrenals are with no gross\n pathology. Both kidneys are unremarkable. No peritoneal or retroperitoneal\n lymphadenopathy is detected.\n Diverticulosis is seen along the course of the colon without signs of\n diverticulitis. Otherwise, the large and small bowel is within normal limits.\n Small amount of ascites is seen.\n An IVC filter is identified.\n\n PELVIS: The urinary bladder is catheterized with a Foley catheter. Prostate\n gland is with no gross pathology. Free fluid is seen within the pelvis.\n There is no concerning lymphadenopathy in the pelvis.\n Vasectomy clips are seen.\n\n OSSEOUS STRUCTURES: Degenerative changes are seen along the course of the\n spine. No concerning lytic or osteoblastic lesions are identified.\n\n IMPRESSION:\n 1. Interval increase in the size of pulmonary ground-glass opacities and\n consolidations. These findings are consistent with multifocal pneumonia.\n 2. Unchanged small pericardial effusion.\n 3. Small left pleural effusion that was not seen on prior examination.\n 4. New ascites is seen.\n 5. Colon diverticulosis without signs of diverticulitis.\n\n Findings were discussed by Dr and the patient's referring\n physician Dr by phone at 11:00, .\n\n (Over)\n\n 5:55 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? e/o occult infection. Please include down to mid-thigh. T\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-02-06 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1225923,
"text": " 12:04 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: intubation\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with intubation\n REASON FOR THIS EXAMINATION:\n intubation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n TECHNIQUE: A single semi-upright portable chest view was reviewed in\n comparison with prior chest radiographs through with the most\n recent from , .\n\n FINDINGS:\n\n Endotracheal tube ends approximately 5.2 cm above the carina and is\n appropriate. An orogastric tube is seen to course below the diaphragm and\n ends into the stomach; however, the distal end is beyond the radiograph view.\n Bilateral lung opacities, right side more than left, which increased between\n and , concerning for an aspiration or pulmonary\n edema have improved over past five to six hours. Small pleural effusions\n bilaterally are unchanged. Left upper lung opacities which are due to\n combination of loculated fluid and collapsed adjacent lung and elevation of\n the left hemidiaphragm and left hilus are unchanged in appearance. The\n mediastinal silhouette is stable.\n\n IMPRESSION:\n 1. Bilateral lung opacities, right side more than left, which increased\n between and , concerning for an aspiration or\n pulmonary edema have improved.\n\n 2. Left upper lung opacities from loculated pleural fluid and collapse of the\n adjacent lung as suggested from the chest CT dated is\n unchanged.\n\n"
},
{
"category": "Echo",
"chartdate": "2130-02-10 00:00:00.000",
"description": "Report",
"row_id": 102166,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial flutter. Endocarditis\nHeight: (in) 71\nWeight (lb): 187\nBSA (m2): 2.05 m2\nBP (mm Hg): 102/64\nHR (bpm): 119\nStatus: Inpatient\nDate/Time: at 16:05\nTest: Portable TTE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Overall normal LVEF\n(>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. Abnormal diastolic septal\nmotion/position consistent with RV volume overload.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Moderate to severe [3+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Normal main\nPA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - ventilator. Suboptimal image quality -\npatient unable to cooperate. If clinically indicated, a transesophageal\nechocardiographic examination is recommended.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity is unusually small. Overall left ventricular systolic function is\nnormal (LVEF 60%). The right ventricular free wall is hypertrophied. The right\nventricular cavity is dilated There is abnormal diastolic septal\nmotion/position consistent with right ventricular volume overload. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. The tricuspid valve leaflets are mildly thickened. Moderate to\nsevere [3+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion. If clinically\nindicated, a transesophageal echocardiographic examination is recommended to\nrule out vegetations.\n\nIMPRESSION: No definite vegetations seen. Intercurrent development of moderate\npulmonary hypertension, moderate-to-severe tricuspid regurgitation and right\nheart chamber enlargement concerning for acute right heart strain. Consider\nacute pulmonary embolism.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2130-02-06 00:00:00.000",
"description": "Report",
"row_id": 102167,
"text": "PATIENT/TEST INFORMATION:\nIndication: Worsening hupoxia.\nHeight: (in) 71\nWeight (lb): 187\nBSA (m2): 2.05 m2\nBP (mm Hg): 108/59\nHR (bpm): 77\nStatus: Outpatient\nDate/Time: at 11:18\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildy dilated aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Prolonged (>250ms)\ntransmitral E-wave decel time.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmildly dilated at the sinus level. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic stenosis or\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is moderate pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Normal biventricular systolic function.\nNo significant valvular disease. Mildly dilated aortic root. Moderate\npulmonary systolic hypertension.\n\nCompared with the findings of the prior study (images reviewed) of ,\nthe rhythm is now sinus (without ectopy) and the left ventricular ejection\nfraction appears normal.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2130-02-03 00:00:00.000",
"description": "Report",
"row_id": 292783,
"text": "Sinus rhythm with ventricular premature beats. Inferior ST segment elevation\nraises concern for myocardial ischemia. Lateral ST-T wave changes may be due to\nmyocardial ischemia. Clinical correlation is suggested. Compared to the\nprevious tracing of ST segment elevation in the inferior leads was seen\non the prior tracing suggesting that these findings may be chronic and may be\nassociated with an aneurysm. Lateral ST-T wave changes are also chronic.\nClinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2130-02-10 00:00:00.000",
"description": "Report",
"row_id": 296372,
"text": "Typical atrial flutter is present again. S1-Q3-T3 is present as well as the\nanterolateral T wave changes noted previously, all compatible with acute\npulmonary embolism.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2130-02-09 00:00:00.000",
"description": "Report",
"row_id": 296373,
"text": "Atrial flutter with 2:1 response. S1-Q3-T3 pattern. Rule out pulmonary embolus.\nDiffuse T wave abnormalities. Compared to the previous tracing of \natrial flutter is new. Intra-atrial conduction defect cannot be interpreted\nsince rhythm is no longer sinus.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2130-02-07 00:00:00.000",
"description": "Report",
"row_id": 296374,
"text": "Sinus rhythm. Left atrial abnormality. Probable prior inferior myocardial\ninfarction of indeterminate age. ST segment depressions in leads I and aVL and\nT wave flattening in leads V2-V6 persist when compared to the previous tracing\nof .\n\n"
},
{
"category": "ECG",
"chartdate": "2130-02-04 00:00:00.000",
"description": "Report",
"row_id": 296375,
"text": "Sinus rhythm. Left atrial abnormality. Possible prior myocardial infarction of\nindeterminate age with residual ST segment elevations suggesting possible\naneurysm. Compared to tracing #1 no diagnostic interim change.\nTRACING #2\n\n"
}
] |
45,847 | 184,460 | The patient was brought to the operating room on where the patient underwent AVR, CABG x 2. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis, given the patient's preoperative stay of greater than 24 hours. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was hemodynamically stable, weaned from inotropic and vasopressor support. She did exhibit some immediate post-op confusion which resolved on discontinuation of narcotics. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. She did develop rapid atrial fibrillation and converted to sinus rhythm with IV amiodarone bolus and drip. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged in good condition with appropriate follow up instructions and all appointments advised. | Stable bibasilar atelectasis obscuring hemidiaphragms. Mild (1+) aortic regurgitation isseen.The mitral valve leaflets are mildly thickened. Mild (1+) MR.TRICUSPID VALVE: Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. FINDINGS: Right internal jugular venous catheter position is stable with tip in the lower SVC. Unchanged mildly enlarged cardiac silhouette. Mild pulmonary edema, moderate retrocardiac atelectasis. Normal position of the pleural and mediastinal drains. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderately thickened aortic valveleaflets. Improved mild vascular congestion. Improved mild vascular congestion. Improved mild vascular congestion. Mediastinal and hilar contours are normal. Porcine aortic valve replacement seen. Improved mild vascular congestion without pulmonary edema. Sternotomy sutures midline and intact. Aorta intact. Normal course of the right internal jugular vein central venous access line, the tip of the line projects over the inferior SVC. Mean residualgradient is 15 - 18 mmHg.No MR. .Very good biventricular systolic fxn. No TEE relatedcomplications.Conclusions:Pre-CPB:No spontaneous echo contrast is seen in the left atrial appendage.Overall left ventricular systolic function is normal (LVEF>55%).Right ventricular chamber size and free wall motion are normal.There are simple atheroma in the descending thoracic aorta.There are three aortic valve leaflets. ASStatus: InpatientDate/Time: at 12:28Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal descending aorta diameter. Normal sinus rhythm. No larger pleural effusions. TECHNIQUE: Chest PA and lateral radiograph obtained. Simple atheroma in descending aorta.AORTIC VALVE: Three aortic valve leaflets. IMPRESSION: Overall improved aeration of the lungs with stable bibasilar atelectasis. FINDINGS: Status post CABG, the sternal wires are in correct alignment. Mild (1+) mitral regurgitationis seen.There is no pericardial effusion.Post-CPB:The patient is on no inotropes.There is a prosthetic aortic valve with no AI and no leak. Right IJ catheter remains in place. Possible small bilateral pleural effusions. Possible small bilateral pleural effusions. Possible small bilateral pleural effusions. Possible small bilateral pleural effusions. New interstitial pulmonary edema and bibasilar left greater than right opacification, likely atelectasis though pneumonia is not excluded. Consider left ventricular hypertrophy. Left anteriorfascicular block. COMPARISON: Preoperative chest x-ray from . The patient was undergeneral anesthesia throughout the procedure. The endotracheal tube, nasogastric tube, and mediastinal drains have been removed. No pulmonary edema. No pulmonary edema. No pulmonary edema. FINDINGS: In comparison with the study of , the left chest tube has been removed and there is no evidence of pneumothorax. Compared to theprevious tracing of the ST-T wave changes in leads I and aVL are moreprominent. FINAL REPORT INDICATION: Status post CABG. , CSURG FA6A 10:01 AM CHEST (PA & LAT) Clip # Reason: eval effusion pod 5 from avr and cabg Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 71 year old woman with s/p avr and cabg REASON FOR THIS EXAMINATION: eval effusion pod 5 from avr and cabg PFI REPORT PFI: Overall improved aeration of the lungs with stable bibasilar atelectasis. COMPARISON: Comparison is made to portable chest film performed , and preop PA and lateral performed . I certifyI was present in compliance with HCFA regulations. 10:01 AM CHEST (PA & LAT) Clip # Reason: eval effusion pod 5 from avr and cabg Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 71 year old woman with s/p avr and cabg REASON FOR THIS EXAMINATION: eval effusion pod 5 from avr and cabg PROVISIONAL FINDINGS IMPRESSION (PFI): PBec MON 3:40 PM PFI: Overall improved aeration of the lungs with stable bibasilar atelectasis. ST-T wave changes in leads I and aVL. The aortic valve leaflets aremoderately thickened. The aortic valve has also been replaced. Continued enlargement of the cardiac silhouette with elevation of pulmonary venous pressure and bibasilar atelectatic change. Severe AS (area 0.8-1.0cm2). The TEE probe was passed withassistance from the anesthesioology staff using a laryngoscope. The tip of the endotracheal tube projects 3 cm above the carina. There is severe aortic valve stenosis (valve area 0.9 by2 observers; peak gradient 34, mean 22). No other diagnostic intervalchange. 4:43 PM CHEST PORT. PATIENT/TEST INFORMATION:Indication: CABG/AI/ ? Other parameters aspre-bypass. FINAL REPORT INDICATION: 71-year-old woman status post AVR and CABG, evaluate for effusion. No evidence of pneumothorax. No evidence of pneumothorax. Frontal plane axis at minus 55 degrees. LINE PLACEMENT Clip # Reason: PTX, EFFUSION - CARDIAC SURGERY, FAST TRACK EXTUBATION - ICU Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT /SDA MEDICAL CONDITION: 71 year old woman with s/p AVR/CABG - - CARDIAC SURGERY, FAST TRACK EXTUBATION - ICU PROVIDER REASON FOR THIS EXAMINATION: PTX, EFFUSION - CARDIAC SURGERY, FAST TRACK EXTUBATION - ICU PROVIDER WET READ: DLrc WED 5:47 PM New support hardware in standard positions. | 6 | [
{
"category": "Radiology",
"chartdate": "2105-10-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1155076,
"text": " 12:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PTX s/p chest tube removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with AVR/CABG\n REASON FOR THIS EXAMINATION:\n eval for PTX s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube removal, to assess for pneumothorax.\n\n FINDINGS: In comparison with the study of , the left chest tube has been\n removed and there is no evidence of pneumothorax. Continued enlargement of\n the cardiac silhouette with elevation of pulmonary venous pressure and\n bibasilar atelectatic change. The endotracheal tube, nasogastric tube, and\n mediastinal drains have been removed. Right IJ catheter remains in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-10-26 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1155469,
"text": " 10:01 AM\n CHEST (PA & LAT) Clip # \n Reason: eval effusion pod 5 from avr and cabg\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p avr and cabg\n REASON FOR THIS EXAMINATION:\n eval effusion pod 5 from avr and cabg\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PBec MON 3:40 PM\n PFI: Overall improved aeration of the lungs with stable bibasilar\n atelectasis. Improved mild vascular congestion. No pulmonary edema.\n Possible small bilateral pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman status post AVR and CABG, evaluate for\n effusion.\n\n TECHNIQUE: Chest PA and lateral radiograph obtained.\n\n COMPARISON: Comparison is made to portable chest film performed , and preop PA and lateral performed .\n\n FINDINGS: Right internal jugular venous catheter position is stable with tip\n in the lower SVC. Sternotomy sutures midline and intact. Porcine aortic\n valve replacement seen. Stable bibasilar atelectasis obscuring\n hemidiaphragms. Possible small bilateral pleural effusions. Improved mild\n vascular congestion without pulmonary edema. Unchanged mildly enlarged\n cardiac silhouette. Mediastinal and hilar contours are normal.\n\n IMPRESSION: Overall improved aeration of the lungs with stable bibasilar\n atelectasis. Improved mild vascular congestion. No pulmonary edema.\n Possible small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-10-26 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1155470,
"text": ", CSURG FA6A 10:01 AM\n CHEST (PA & LAT) Clip # \n Reason: eval effusion pod 5 from avr and cabg\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p avr and cabg\n REASON FOR THIS EXAMINATION:\n eval effusion pod 5 from avr and cabg\n ______________________________________________________________________________\n PFI REPORT\n PFI: Overall improved aeration of the lungs with stable bibasilar\n atelectasis. Improved mild vascular congestion. No pulmonary edema.\n Possible small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-10-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1154764,
"text": " 4:43 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: PTX, EFFUSION - CARDIAC SURGERY, FAST TRACK EXTUBATION - ICU\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with s/p AVR/CABG - - CARDIAC SURGERY, FAST TRACK EXTUBATION\n - ICU PROVIDER \n REASON FOR THIS EXAMINATION:\n PTX, EFFUSION - CARDIAC SURGERY, FAST TRACK EXTUBATION - ICU PROVIDER \n \n ______________________________________________________________________________\n WET READ: DLrc WED 5:47 PM\n New support hardware in standard positions. No evidence of pneumothorax. New\n interstitial pulmonary edema and bibasilar left greater than right\n opacification, likely atelectasis though pneumonia is not excluded.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG.\n\n COMPARISON: Preoperative chest x-ray from .\n\n FINDINGS: Status post CABG, the sternal wires are in correct alignment. The\n tip of the endotracheal tube projects 3 cm above the carina. Normal position\n of the pleural and mediastinal drains. Normal course of the right internal\n jugular vein central venous access line, the tip of the line projects over the\n inferior SVC.\n\n No evidence of pneumothorax. No larger pleural effusions. Mild pulmonary\n edema, moderate retrocardiac atelectasis.\n\n The aortic valve has also been replaced.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2105-10-21 00:00:00.000",
"description": "Report",
"row_id": 64876,
"text": "PATIENT/TEST INFORMATION:\nIndication: CABG/AI/ ? AS\nStatus: Inpatient\nDate/Time: at 12:28\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Severe AS (area 0.8-1.0cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications.\n\nConclusions:\nPre-CPB:\nNo spontaneous echo contrast is seen in the left atrial appendage.\nOverall left ventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal.\nThere are simple atheroma in the descending thoracic aorta.\nThere are three aortic valve leaflets. The aortic valve leaflets are\nmoderately thickened. There is severe aortic valve stenosis (valve area 0.9 by\n2 observers; peak gradient 34, mean 22). Mild (1+) aortic regurgitation is\nseen.\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\nis seen.\nThere is no pericardial effusion.\n\nPost-CPB:\nThe patient is on no inotropes.\nThere is a prosthetic aortic valve with no AI and no leak. Mean residual\ngradient is 15 - 18 mmHg.\nNo MR. .\nVery good biventricular systolic fxn. Aorta intact. Other parameters as\npre-bypass.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2105-10-21 00:00:00.000",
"description": "Report",
"row_id": 129563,
"text": "Normal sinus rhythm. Frontal plane axis at minus 55 degrees. Left anterior\nfascicular block. ST-T wave changes in leads I and aVL. Compared to the\nprevious tracing of the ST-T wave changes in leads I and aVL are more\nprominent. Consider left ventricular hypertrophy. No other diagnostic interval\nchange.\n\n"
}
] |
10,774 | 179,525 | Upper GI bleed: Pt. initially with borderline hypotension and tachycardia. Responded well to fluid resuscitation. Admitted initially to ICU, where an EGD was performed on AM of hospital day 2. EGD revealed duodenitis, no active bleed, no ulcer, Barrett's esophagus. In the ICU, was transfused 2 units pRBC, 1 unit FFP. Given initial low BP and GIB, all antihypertensives were initially held, as was coumadin.Throughout the rest of hospital stay, pt. had stable vital signs, no further GIB. Hct responded appropriately to transfusion, remained stable. Antihypertensives and coumadin were restarted on HD 3 and were tolerated well. Overall, continued ASA and warfarin, but stopped plavix after consultation with Cardiology. . Respiratory distress/asthma flare: On Hospital day 3, began to have increasing respiratory distress. Exam notable for marked wheezing. CXR with no definite infiltrates. While initially volume overloaded after MICU stay, no longer had evidence of CHF. Overall, he was treated with prednisone and nebs for asthma flare. Also empirically treated for PNA - although limited evidence for this on cxr - with rocephin/azithro. Will be d/c with levaquin to complete 7 day course. . Chest pressure: On the night of HD 3, patient had an episode of L-sided chest pain that was ssociated with diaphoresis and an increased 02 requirement (responded to 2L NC). Pain resolved quickly with 3 SL nitroglycerin, albuterol neb, and IV lasix. Cardiac enzymes were trended and over the following day climbed from 0.05 to a peak of 0.08. He had no further events, and had stress MIBI in hospital prior to discharge, which again demonstrated his severe ischemic dilated cardiomyopathy and also multiple predominantly fixed perfusion defects - previous stress in with progressively worse reversible perfusion defects. Will continue medicla management. . ARF on CKD: Pt. had briefly elevated Cr, which returned quickly to baseline with fluid resuscitation. In setting of GIB, seemed c/w prerenal picture. ACEI was initially held, but restarted without adverse effect once Cr returned to baseline. Remained at baseline thereafter with re-introduction of meds. . Abdominal pain/constipation: On HD 3, pt. developed bilateral lower quadrant abdominal pain, which he attributed to not having had a bowel movement since admission to hospital. Abdominal exam was benign, KUB unremarkable. Had relief after BM. . | INR 2.6.Resp: 2L NC, o2sat 94-97, rr 17-22, LS clear upper diminished lower. Diet advanced to regular and tol well by pt with no N/V/D. Probable slow atrialtachycardia or possibly with 2;1 block. Next Hct due at 19:00.Resp) LS CTA with no resp distress noted. CE WERE DONE IN ER. HE BECAME LIGHTHEADED AND CALLED EMS. no c/o pain.Cardiac: Pacemaker and AICD, V-paced w/ occassional pvc's, HR 75-98, SBP 75-111, MAPs >55, given 1L NS bolus over 2H for decreased BP w/ some effect. PT DENIES CHEST PAIN. PT IS V PACED WITH PVC'S NOTED. Pt inc to DB&C W/A.GI) Abd dist/soft and non-tender to touch. voiding urine in adequate amts, approximately >75cc/hr, yellow/clear.ID: Temp 96.3-98.8, WBC 9.0. PT HAS AICD AND PACEMAKER. VSS as noted and found NOT to be orthostatic. Regular wide complex tachycardia, mechanism, uncertain. Pt is stable and VSS and WNL's. Since the previous tracing of Ventricular ectopyb and intermittent ventricular paced beats are not seen. Intraventricular conduction delay.Probable atypical right bundle-branch block with left anterior fascicularblock. Diffuse ST-T wave abnormalities. Abd soft distended/non-tender. NO FURTHER TREATMENT AT THIS TIME BUT PT HAS BEEN T/C FOR 6 UNITS OF PRBC'S TOTAL.RESP) PT LUNGS ARE CLEAR WITH OCCASIONAL EXP WHEEZING. PT DENIES PAIN. Pt denies any cardiac symptoms. Hct and VSS. MONITOR FOR HYPOTENSION PT HAS HISTORY OF ASTHMA.GI/GU) PT HAD EGD THIS AFTERNOON. PT HAD NG LAVAGE THAT WAS NEGATIVE. MAE.CV) PT IS STABLE. ON ARRIVAL TO ED HIS BP WAS IN THE 80'S, HR 105, HCT WAS 42, BUN AND CR ELEVATED. No bm this shift so far. Pt in for cardiology c/s re ? PT 3MG VERSED ADN 75 MCG OF FENT AND TOLERATED PROCEEDURE WELL. ACCORDING TO NOTES PT HCT IS BASELINE 31. PT WAS SUSPECT FOR VOLUME DEPLETION AND 3 L NS, 2 UNITS PRBC'S, AND 2 UNIT FFP (ONE IN ER AND ONE ON FLOOR) TRANSFERED TO MICU FOR FUTHER ASSESSMENT.NEURO) PT ALERT AND ORIETNED TIMES THREE. CLEAR YELLOW URINE.SKIN) NO BREAKDOWN NOTED.ID) AFEB NO ANTIBIOTICSSOCIAL) WIFE .PLAN) MONITOR HCT Q 6 HRS. pacer interigation. MD may be causing the pt to vagal, given 12.5mg Anzimet IV PRN. HR 80-100. PT CAN TX Q 3-4HRS. No signs of any bleeding at this time, and hct stable as noted (35.2->35.4). BP IS 90-110/60-70'S. hct stable @ 34.0 from 35.2, no blood products overnight, cont to monitor hct Q6H, next lab @ 0800. LAST HCT WAS AT 1415 WHICH RESULTED IN HCT 34. Had EGD yesterday and found nothing at the time. No edema noted. Pt is awaiting bed on floor.Neuro) Pt is awake and oriented x 3.CV) Pt is Ventricular paced with PVC's and is in and out of RBBB. HCT ARE Q 6 HRS. 7am to 7pm:Pt has had an uneventful day. PT BASELINE SBP IS IN THE 90'S. Cont med regimen and icu treatment. HL'd.GU) Good U/O via urinal.pain) Pt denies any discomfort.Soc) wife and son updated this am. PT CAN HAVE CLEAR LIQUIDS. Technically difficult studyProbable atrial fibrillation with rapid ventricular responseProbable ventricular coupletsMarked left axis deviationIntraventricular conduction defectLVH with secondary ST-T changesPossible RVH with secondary ST-T changesSince previous tracing, rhythm more irregular ventricular couplets new PT SATS ARE IN THE HIGH 90'S ON 2 LNC. Stool black and gritty, but guiac neg x2. PT IS ALSO ON ADVAIR. No signs of infection at this time. NPN: 0700-1900CODE STATUS: FULLALL: NKDAPMH: CAD, CABG, AICD, V PACED, EF 15-20%, A FIB, HYPOTYROID, HYPERLIPIDEMIA, DEPRESSION, ? PT HAS STRONG COUGH. PT IS VOIDING IN URINAL. Nursing Progress Note 1900-0700*Full Code*Access: Rant 18g PIV, Lhand 20g PIV*NKDA**Please see admit note/FHP for admit info and hxNeuro: pt A&O x3, follows commands, able to make needs known, assists w/ turns. 4pm:Pt to be transfered to 724. MAP > 60. Skin intact, iv sites wnl.Psychosocial: wife called yesterday but not heard from this shift.Dispo: cont to monitor BP and treat MD orders if needed (baseline systolic in 90's), monitor hct (next lab 0800). Pt to be transfered on telemetry. PT VERY PLEASANT AND COOPERATIVE. PT CONTINUES TO HAVE TARRY BLACK STOOLS IN SCANT AMOUNTS. c/o some increased dizziness when BP lower, but mentating well and easy to arouse from sleep. +BS, pt had 3 sm/med stools w/in 30 min (on and off bed pan). Pt OOB to chair. All belongings with pt on transfer. DEMENTIA, ANEMIA, VALVE REPLACEMENTREASON FOR ADMISSION: 70 Y/O M WHO HAD BLACK TARRY STOOLS TIMES TWO DAYS. Hx asthma, w/ some wheezing yesterday, albuterol neb prn, advair .GI/GU: clear liquid diet, had jello/apple juice/ice cream and tolerated well. | 6 | [
{
"category": "ECG",
"chartdate": "2139-01-11 00:00:00.000",
"description": "Report",
"row_id": 149562,
"text": "Technically difficult study\nProbable atrial fibrillation with rapid ventricular response\nProbable ventricular couplets\nMarked left axis deviation\nIntraventricular conduction defect\nLVH with secondary ST-T changes\nPossible RVH with secondary ST-T changes\nSince previous tracing, rhythm more irregular ventricular couplets new\n\n"
},
{
"category": "ECG",
"chartdate": "2139-01-06 00:00:00.000",
"description": "Report",
"row_id": 149563,
"text": "Regular wide complex tachycardia, mechanism, uncertain. Probable slow atrial\ntachycardia or possibly with 2;1 block. Intraventricular conduction delay.\nProbable atypical right bundle-branch block with left anterior fascicular\nblock. Diffuse ST-T wave abnormalities. Since the previous tracing of \nVentricular ectopyb and intermittent ventricular paced beats are not seen.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-01-06 00:00:00.000",
"description": "Report",
"row_id": 1404455,
"text": "NPN: 0700-1900\nCODE STATUS: FULL\n\nALL: NKDA\n\nPMH: CAD, CABG, AICD, V PACED, EF 15-20%, A FIB, HYPOTYROID, HYPERLIPIDEMIA, DEPRESSION, ? DEMENTIA, ANEMIA, VALVE REPLACEMENT\n\nREASON FOR ADMISSION: 70 Y/O M WHO HAD BLACK TARRY STOOLS TIMES TWO DAYS. HE BECAME LIGHTHEADED AND CALLED EMS. ON ARRIVAL TO ED HIS BP WAS IN THE 80'S, HR 105, HCT WAS 42, BUN AND CR ELEVATED. PT HAD NG LAVAGE THAT WAS NEGATIVE. PT WAS SUSPECT FOR VOLUME DEPLETION AND 3 L NS, 2 UNITS PRBC'S, AND 2 UNIT FFP (ONE IN ER AND ONE ON FLOOR) TRANSFERED TO MICU FOR FUTHER ASSESSMENT.\n\nNEURO) PT ALERT AND ORIETNED TIMES THREE. PT ABLE TO MAKE NEEDS KNOWN, PT FOLLOWS ALL COMMANDS. PT VERY PLEASANT AND COOPERATIVE. PT DENIES PAIN. MAE.\n\nCV) PT IS STABLE. BP IS 90-110/60-70'S. PT BASELINE SBP IS IN THE 90'S. HR 80-100. PT HAS AICD AND PACEMAKER. PT IS V PACED WITH PVC'S NOTED. PT DENIES CHEST PAIN. CE WERE DONE IN ER. HCT ARE Q 6 HRS. LAST HCT WAS AT 1415 WHICH RESULTED IN HCT 34. ACCORDING TO NOTES PT HCT IS BASELINE 31. NO FURTHER TREATMENT AT THIS TIME BUT PT HAS BEEN T/C FOR 6 UNITS OF PRBC'S TOTAL.\n\nRESP) PT LUNGS ARE CLEAR WITH OCCASIONAL EXP WHEEZING. PT CAN TX Q 3-4HRS. PT IS ALSO ON ADVAIR. PT SATS ARE IN THE HIGH 90'S ON 2 LNC. PT HAS STRONG COUGH. PT HAS HISTORY OF ASTHMA.\n\nGI/GU) PT HAD EGD THIS AFTERNOON. PT 3MG VERSED ADN 75 MCG OF FENT AND TOLERATED PROCEEDURE WELL. PT CONTINUES TO HAVE TARRY BLACK STOOLS IN SCANT AMOUNTS. PT CAN HAVE CLEAR LIQUIDS. PT IS VOIDING IN URINAL. CLEAR YELLOW URINE.\n\nSKIN) NO BREAKDOWN NOTED.\n\nID) AFEB NO ANTIBIOTICS\n\nSOCIAL) WIFE .\n\nPLAN) MONITOR HCT Q 6 HRS.\n MONITOR FOR HYPOTENSION\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-01-07 00:00:00.000",
"description": "Report",
"row_id": 1404456,
"text": "Nursing Progress Note 1900-0700\n*Full Code\n\n*Access: Rant 18g PIV, Lhand 20g PIV\n\n*NKDA\n\n**Please see admit note/FHP for admit info and hx\n\nNeuro: pt A&O x3, follows commands, able to make needs known, assists w/ turns. c/o some increased dizziness when BP lower, but mentating well and easy to arouse from sleep. no c/o pain.\n\nCardiac: Pacemaker and AICD, V-paced w/ occassional pvc's, HR 75-98, SBP 75-111, MAPs >55, given 1L NS bolus over 2H for decreased BP w/ some effect. MD may be causing the pt to vagal, given 12.5mg Anzimet IV PRN. hct stable @ 34.0 from 35.2, no blood products overnight, cont to monitor hct Q6H, next lab @ 0800. INR 2.6.\n\nResp: 2L NC, o2sat 94-97, rr 17-22, LS clear upper diminished lower. Hx asthma, w/ some wheezing yesterday, albuterol neb prn, advair .\n\nGI/GU: clear liquid diet, had jello/apple juice/ice cream and tolerated well. +BS, pt had 3 sm/med stools w/in 30 min (on and off bed pan). Stool black and gritty, but guiac neg x2. Had EGD yesterday and found nothing at the time. Abd soft distended/non-tender. voiding urine in adequate amts, approximately >75cc/hr, yellow/clear.\n\nID: Temp 96.3-98.8, WBC 9.0. No signs of infection at this time. Skin intact, iv sites wnl.\n\nPsychosocial: wife called yesterday but not heard from this shift.\n\nDispo: cont to monitor BP and treat MD orders if needed (baseline systolic in 90's), monitor hct (next lab 0800). Cont med regimen and icu treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-01-07 00:00:00.000",
"description": "Report",
"row_id": 1404457,
"text": "7am to 7pm:\n\nPt has had an uneventful day. Hct and VSS. Pt is awaiting bed on floor.\n\nNeuro) Pt is awake and oriented x 3.\n\nCV) Pt is Ventricular paced with PVC's and is in and out of RBBB. Pt in for cardiology c/s re ? pacer interigation. Pt denies any cardiac symptoms. VSS as noted and found NOT to be orthostatic. MAP > 60. No edema noted. No signs of any bleeding at this time, and hct stable as noted (35.2->35.4). Next Hct due at 19:00.\n\nResp) LS CTA with no resp distress noted. Pt inc to DB&C W/A.\n\nGI) Abd dist/soft and non-tender to touch. Diet advanced to regular and tol well by pt with no N/V/D. No bm this shift so far. HL'd.\n\nGU) Good U/O via urinal.\n\npain) Pt denies any discomfort.\n\nSoc) wife and son updated this am. Pt OOB to chair.\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-01-07 00:00:00.000",
"description": "Report",
"row_id": 1404458,
"text": "4pm:\n\nPt to be transfered to 724. Pt is stable and VSS and WNL's. All belongings with pt on transfer. Pt to be transfered on telemetry.\n"
}
] |
13,492 | 130,812 | 65y/o male transferred to from OSH s/p being kicked in the face by a horse. Pt. evaluated in the Emergency department by emergency medicine and trauma surgery staff. Pt. was imaged and found to have multiple facial fractures and mandibular fractures. The plastic surgery service was consulted and determined that the facial fractures were non-operative in nature. Pt. was admitted to the trauma service in anticipation of mandibular repair by OMFS. Pt. was taken to surgery by Dr. of OMFS and an ORIF of the mandible with wiring was performed. Pt. was followed postoperatively on the trauma service, pain was controlled, pured diet was started, nutrition was consulted and pt. was instructed regarding proper nutrition with a wired jaw. Pt. experienced a gouty attack of bilateral feet while recovering, R>L, rheumatology was consulted, and indomethacin and colchicine were begun. Pt. improved quickly and was able to walk with minimal pain prior to discharge. Pt. to be followed by OMFS for outpatient care. | Right mandibular body and left condyle fractures and maxillary sinus fractures. IMPRESSION: Segmental right mandible fracture. FINDINGS: With regard to the mandible, there is a complex fracture at the angle of the right ramus that extends to below the right condyle of the mandible resulting in complete displacement and mild angulation. Fracture of the mandible and maxillary sinuses are noted. On the left, there is a complete fracture through the ramus at the base of the mandibular condyle with minimal displacement and angulation. An additional fracture is noted in the region of the left mandibular condyle. There has been interval open reduction and internal fixation of a right mandibular fracture, which is maintained in satisfactory alignment with a plate and interlocking screws. Bilateral lateral wall fractures of the maxillary sinus with associated opacification, see details above. There is an associated lateral wall of fracture in the left maxillary sinus. Multiple mandibular fractures, see details above. There are bilateral fractures of the medial and lateral pterygoid plates. FINDINGS: Five views of the mandible redemonstrate a segmental fracture of the right portion of the mandible involving the body and ramus, which is displaced several millimeters superiorly. FINAL REPORT This is a skull study dated , with clinical indication of mandibular fracture status post open reduction and internal fixation. Right inferior orbital rim fracture, minimally displaced. Right and left lateral maxillary sinus wall fractures with associated opacification in both sinuses. Bilateral medial and lateral pterygoid plate fractures. Right inferior orbital rim fracture. Evaluate for fractures. Complete fracture through the right mandibular body. 2:42 PM SKULL (, LFT LAT, & BASE) Clip # Reason: evaluation of fracture. 2:09 PM MANDIBLE (PA, & BOTH OBLS) Clip # Reason: FX, MANDIBLE WIRING Admitting Diagnosis: MANDIBULAR FRACTURE FINAL REPORT TWO PORTABLE FILMS ON THE OR FOR FRACTURED MANDIBLE WITH WIRING Portable films of the mandible with somewhat limited diagnostic demonstrates of the mandible with wiring present. PA AND LATERAL CHEST RADIOGRAPHS: The aorta is tortuous and there is a left ventricular prominence to the cardiac silhouette. There is a minimally displaced right inferior orbital rim fracture. Pterygoid plate fractures. There is also a completely displaced fracture in the right body of the mandible. Again noted is right maxillary sinus opacification. Known fractures involving the right inferior orbital rim and maxillary sinuses are better demonstrated on the recent CT of the facial bones performed . TECHNIQUE: CT C-spine with sagittal and coronal reformatting. There is also a lateral wall fracture of the maxillary sinus on the right. There is complete opacification of the right maxillary sinus. (Over) 4:44 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: eval fir fx FINAL REPORT (Cont) AP and lateral radiograph centered at the level of the mandible were submitted for interpretation and compared to a previous study of . FINDINGS: The vertebral body heights and disc spaces are preserved. The multiple orbital and sinus fractures noted on the prior CT scan are not well demonstrated on these radiographs. Pt awake and cuff leak checked. COMPARISON: Facial bone CT, . A questionable infiltrate in the left upper lobe is present. On the left, there is an air fluid level seen in the left maxillary sinus. There has also been interval placement of hardware in the region of the oropharynx. Three cerclage wires overlie the mid portion of the mandible. 7:27 PM CHEST (PORTABLE AP) Clip # Reason: confirm nasotracheal tube placement Admitting Diagnosis: MANDIBULAR FRACTURE MEDICAL CONDITION: 64 year old man with NTT REASON FOR THIS EXAMINATION: confirm nasotracheal tube placement FINAL REPORT PORTABLE CHEST INDICATION: Intubation. 19/07 PT TO SICU S/P JAW FROM TRAMA ETT IN PLACE SEDATED VSS PROPOFOL IN PROGRESS NEURO SEDATED NO MOTION SL GAG ONLY TO BE DEEPLY SEDATED MD ETT VENT FULL CMV CONTROL SAT 100 SCANT SPUTUM BILAT B/S THRUOUT HEART S1S2 SPLIT S1 RBBB PULSES POS 3 2/6 M MITRIL AREA NSR GI POS B/S NOTED NPO PLAN SEDATED PLIERS AT BEDSIDE T/P ROM The patient has been intubated and the tube terminates at the level of the thoracic inlet, 5 cm above the carina. Admitting Diagnosis: MANDIBULAR FRACTURE MEDICAL CONDITION: 65 year old man s/p R ramus mandibular fracture, s/p ORIF R mandibular body fracture, evaluation of repair REASON FOR THIS EXAMINATION: evaluation of fracture. | 12 | [
{
"category": "Radiology",
"chartdate": "2122-09-12 00:00:00.000",
"description": "MANDIBLE (PA, TOWNES & BOTH OBLS)",
"row_id": 883408,
"text": " 2:09 PM\n MANDIBLE (PA, & BOTH OBLS) Clip # \n Reason: FX, MANDIBLE WIRING\n Admitting Diagnosis: MANDIBULAR FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n TWO PORTABLE FILMS ON THE OR FOR FRACTURED MANDIBLE WITH WIRING\n\n Portable films of the mandible with somewhat limited diagnostic demonstrates\n _____ of the mandible with wiring present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-09-13 00:00:00.000",
"description": "SKULL (CALDWELL, LFT LAT, TOWNES & BASE)",
"row_id": 883492,
"text": " 2:42 PM\n SKULL (, LFT LAT, & BASE) Clip # \n Reason: evaluation of fracture.\n Admitting Diagnosis: MANDIBULAR FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man s/p R ramus mandibular fracture, s/p ORIF R mandibular body\n fracture, evaluation of repair\n REASON FOR THIS EXAMINATION:\n evaluation of fracture.\n ______________________________________________________________________________\n FINAL REPORT\n This is a skull study dated , with clinical indication of\n mandibular fracture status post open reduction and internal fixation.\n\n AP and lateral radiograph centered at the level of the mandible were submitted\n for interpretation and compared to a previous study of .\n There has been interval open reduction and internal fixation of a right\n mandibular fracture, which is maintained in satisfactory alignment with a\n plate and interlocking screws. Three cerclage wires overlie the mid portion\n of the mandible. An additional fracture is noted in the region of the left\n mandibular condyle. There has also been interval placement of hardware in the\n region of the oropharynx. Known fractures involving the right inferior\n orbital rim and maxillary sinuses are better demonstrated on the recent CT of\n the facial bones performed .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-09-11 00:00:00.000",
"description": "MANDIBLE (PA, TOWNES & BOTH OBLS)",
"row_id": 883301,
"text": " 11:55 AM\n MANDIBLE (PA, & BOTH OBLS) Clip # \n Reason: To delineate fracture lines and assess mandibular height\n Admitting Diagnosis: MANDIBULAR FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with multiple mandible fractures\n REASON FOR THIS EXAMINATION:\n To delineate fracture lines and assess mandibular height\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiple mandible fractures.\n\n COMPARISON: Facial bone CT, .\n\n FINDINGS: Five views of the mandible redemonstrate a segmental fracture of\n the right portion of the mandible involving the body and ramus, which is\n displaced several millimeters superiorly. Again noted is right maxillary\n sinus opacification. The multiple orbital and sinus fractures noted on the\n prior CT scan are not well demonstrated on these radiographs.\n\n IMPRESSION: Segmental right mandible fracture. Multiple other facial bone\n fractures are better demonstrated on recent CT examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-09-11 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 883300,
"text": " 11:55 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: PRE-OP FOR MANDIBLE \n Admitting Diagnosis: MANDIBULAR FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with pre-op for mandible fx surgery\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop for mandible surgery.\n\n COMPARISON: None.\n\n PA AND LATERAL CHEST RADIOGRAPHS: The aorta is tortuous and there is a left\n ventricular prominence to the cardiac silhouette. The lungs are clear. The\n osseous structures appear unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-09-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 883423,
"text": " 7:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm nasotracheal tube placement\n Admitting Diagnosis: MANDIBULAR FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with NTT\n REASON FOR THIS EXAMINATION:\n confirm nasotracheal tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n INDICATION: Intubation.\n\n The patient has been intubated and the tube terminates at the level of the\n thoracic inlet, 5 cm above the carina. The heart is enlarged. There are low\n lung volumes. A questionable infiltrate in the left upper lobe is present.\n\n"
},
{
"category": "ECG",
"chartdate": "2122-09-11 00:00:00.000",
"description": "Report",
"row_id": 210148,
"text": "Sinus rhythm\nConduction defect of RBBB type\nInferior ST-T changes\nLow QRS voltages in precordial leads\nProbable left ventricular hypertrophy by voltage in lead aVL\nSince previous tracing, no significant change\nClinical correlation is suggested\n\n"
},
{
"category": "ECG",
"chartdate": "2122-09-09 00:00:00.000",
"description": "Report",
"row_id": 210149,
"text": "Sinus rhythm\nRight bundle branch block\nLow precordial lead QRS voltage - is nonspecific\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-09-09 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 883074,
"text": " 5:58 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: eval for fracture/subluxation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man kicked in head by horse\n REASON FOR THIS EXAMINATION:\n eval for fracture/subluxation\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AZm WED 6:58 PM\n no injury to C- spine. right mandibular fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old man horse dentist kicked in the head by a horse.\n\n TECHNIQUE: CT C-spine with sagittal and coronal reformatting.\n\n FINDINGS: The vertebral body heights and disc spaces are preserved. No\n fractures or dislocations are visualized. The visualized thecal sac is\n normal.\n\n Fracture of the mandible and maxillary sinuses are noted.\n\n IMPRESSION: No evidence of traumatic injury to the cervical spine. Right\n mandibular body and left condyle fractures and maxillary sinus fractures.\n DFDgf\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-09-09 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 883068,
"text": " 4:44 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: eval fir fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man kicked in head by horse c mult mandibular fxs, maxilla fx and\n orbital fx on OSH study\n REASON FOR THIS EXAMINATION:\n eval fir fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JVg WED 6:09 PM\n Complete fractures of the right and left mandibular rami. Complete fracture\n through the right mandibular body. Right and left lateral maxillary sinus wall\n fractures with associated opacification in both sinuses. Right inferior\n orbital rim fracture. No orbital floor fracture. Pterygoid plate fractures.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old man kicked in head by horse with multiple fractures\n including mandibular, maxilla, and orbital fractures seen on outside hospital\n study. Evaluate for fractures.\n\n TECHNIQUE: Axial and coronal non-contrast images of the paranasal sinuses and\n facial bones without contrast.\n\n FINDINGS: With regard to the mandible, there is a complex fracture at the\n angle of the right ramus that extends to below the right condyle of the\n mandible resulting in complete displacement and mild angulation. On the left,\n there is a complete fracture through the ramus at the base of the mandibular\n condyle with minimal displacement and angulation. There is also a completely\n displaced fracture in the right body of the mandible.\n\n There is complete opacification of the right maxillary sinus. There is a\n minimally displaced right inferior orbital rim fracture. There is also a\n lateral wall fracture of the maxillary sinus on the right. On the left, there\n is an air fluid level seen in the left maxillary sinus. There is an\n associated lateral wall of fracture in the left maxillary sinus.\n\n There are bilateral fractures of the medial and lateral pterygoid plates. A\n small amount of opacification in the right mastoid air cells is seen, however,\n no fractures are seen throughout the temporal bones.\n\n IMPRESSION:\n 1. Multiple mandibular fractures, see details above.\n 2. Right inferior orbital rim fracture, minimally displaced.\n 3. Bilateral lateral wall fractures of the maxillary sinus with associated\n opacification, see details above.\n 4. Bilateral medial and lateral pterygoid plate fractures.\n\n A wet read of these findings was sent to the emergency department at 6:00 p.m.\n on .\n (Over)\n\n 4:44 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: eval fir fx\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-09-12 00:00:00.000",
"description": "Report",
"row_id": 1437701,
"text": " 19/07\n PT TO SICU S/P JAW FROM TRAMA ETT IN PLACE SEDATED VSS PROPOFOL IN PROGRESS\n NEURO SEDATED NO MOTION SL GAG ONLY TO BE DEEPLY SEDATED MD \n ETT VENT FULL CMV CONTROL SAT 100 SCANT SPUTUM BILAT B/S THRUOUT\n HEART S1S2 SPLIT S1 RBBB PULSES POS 3 2/6 M MITRIL AREA NSR\n GI POS B/S NOTED NPO\n PLAN SEDATED PLIERS AT BEDSIDE T/P ROM\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-09-13 00:00:00.000",
"description": "Report",
"row_id": 1437702,
"text": "Resp Care\nPt remains on vent, Nasaly intubated with #7 @ 27, patent and secure. Bs cta. Suctioned small amt of thick white to clear secretions. Rsbi 28. Placed on cpap/ps 5/5 40%. plan to extubate with team present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-09-13 00:00:00.000",
"description": "Report",
"row_id": 1437703,
"text": "Resp Care\nPt received on mech vent. Pt awake and cuff leak checked. Pt extubated over cook catheter with success. Currently on 4 L NC. Breath sounds are diminished bilat.\n"
}
] |
19,071 | 187,636 | 1) CVS-- Given h/o cardiac problems and new onset CP, pt was admitted for R/O MI. A CXR on admit noted no acute pulmonary process. Stable cardiac enlargement and aortic contour. EKG showed Atrial fibrillation with a moderate ventricular response and a suggestion of group beating. Borderline intraventricular conduction delay. Non-specific ST-T wave changes with relatively short interval consistent with digitalis effect, although ischemia, etc. is not excluded. Non-diagnostic Q waves in lead III. Prominent R wave in lead V3 without diagnostic criteria for left ventricular hypertrophy. Compared to the previous tracing of ST-T wave changes are more apparent. Mr. ruled out with 2 sets of negative enzymes. Tele bed was not d/c'ed, as he continued to have runs of NSVT up to 15 beats, during his hospitalization. He remained asymptomatic during these runs, only complaining of some dizziness. Mr.G was tried on a beta blocker, but he became bradycardic to the low 30s, so it was d/c'ed. His blood pressure was controlled with lisinopril 10mg qd and lasix 20mg qd, until his renal function worsened and these were discontinued and hydarlazine started. After epicardial pacemaker, pt was started on beta-blocker and hydralazine was deacresed. Pt was also started on Isordil. During Mr.G's hospitalization, an echo, stress test, and persantine mibi were obtained to evaluate further the etiology of the pt's cardiomyopathy. Echo showed an EF of 33%, as well as left ventricular cavity dilation with severe global hypokinesis c/w diffuse process (toxin, metabolic, multivessel CAD, etc.) Severe mitral regurgitation. Pulmonary artery systolic hypertension. Moderate tricuspid regurgitation. On stress test, Mr.G was found to have no anginal symptoms with an uninterpretable ECG. Finally, persantine mibi showed a predominantly fixed, moderate to severe perfusion defect in the distal inferior wall, extending into the inferior portion of the lateral wall. EP was consulted and determined that Mr.G was not a candidate for PM with EPS+ICD because his suprapubic catheter put him at risk for infection. Rather, it was decided that Mr.G should have an epicardial pacer, then rate controlled with beta-blockade +/- amiodarone. Mr.G was weaned off coumadin to an INR below 2.0 and he was started on heparin. On Mr. G had epicardial pacemaker placed. Pt was restart on warfarin once stable from pacemaker surgery. 2)Acute on chronic renal failure--On presentation, Mr.G's Cr was 4.1. His suprapubic catheter was flushed and found to be patent, ruling out a post-obstructive etiology. With gentle hydration, it down to 3.1, suggesting he was pre-renal. An echo to evaluate renal function found small kidneys + echogenicity. A renal consult found the echo to be highly suggestive of a chronic process (CKD (KDOQI)- stage IV) with HTN likely the cause. Biopsy not helpful with such small kidneys. No acute need for hemodialysis at this time and estimated GFR to be 17-20 cc/min. As well, Mr.G's PTH was elevated to 132, likely secondary to unresponsive failing kidneys, as he was not hypercalcemic. After a bout of diarrhea, Mr.G's renal function again deteriorated with Cr to 4.0. Lasix and ace inhibitor were held. It was decided not to give IV fluids in the face of Mr.G's poor cardiac function (EF 33%)...His electrolytes were monitored and repleted as necessary, and bicarb was given, as Mr. down to 16. Pt BUN/Cre stabalized with a Cre around 3.3-3.8. Pt will follow up with renal outpatient. 3) GU--It is unclear exactly why Mr.G has the supra-pubic catheter, presumably because of urinary incontinence. Of note, his PSA was elevated to 7.8. It was decided that Mr.G's urological problems and renal function could be further evaluated on an outpatient basis. A U/A gre out proteus mirabilis, but it was thought that this was due to contamination/catheterization. Abx were held in the abscence of fever or elevated WBC. Repeat Urine Cx showed mixed flora consistent with contamination with feces. Pt will follow up with outpatient. 3) ?Hypothyroidism-- TSH and T4 wnl -- unclear if needs chronic thyroxine given normal levels. f/u with outpatient PCP if staying in . 4) Diarrhea--On presentation, Mr.G had an episode of diarrhea, which resolved on its own. Stool was negative for C. diff. O+P showed several parasites, of debatable pathogenic significnace. However, in light of Mr.G's symptomatology, Flagyl was initiated and later decreased to renal dosing, as Mr.G's Cr bumped after the initiation of therapy. The diarrhea resolved. Pt finished course of flagyl while in hospital 5) Dizziness and weakness- During hospital course it was noticed that pt was dizzy and appeared to be weak. After speaking to family it was determined that this was the pt's baseline before hospitalization. A CT of head was done which showed encephalomalacia consistent with old infarcts. A MRA could not be performed since pt had a pacemaker. | Underlying rhythm again appearsto be atrial fibrillation with a slow to moderate ventricular response.Compared to the previous tracing of multiple abnormalities are aspreviously reported without diagnostic change, in the presence of the baselineartifact. Leftventricular hypertrophy with intraventricular conduction delay. There is mildglobal right ventricular free wall hypokinesis.AORTIC VALVE: The aortic valve leaflets are mildly thickened. Probable atrial fibrillationVentricular premature complexesNonspecific intraventricular conduction delayProbable left ventricular hypertrophy with ST-T wave abnormalitiesCannot exclude in part ischemia - clinical correlation is suggestedSince previous tracing of , ventricular ectopy seen Probable atrial fibrillationNonspecific intraventricular conduction delayProbable left ventricular hypertrophy with ST-T wave abnormalitiesCannot exclude in part ischemia - clinical correlation is suggestedSince previous tracing of , ventricular ectopy not seen There is mildpulmonary artery systolic hypertension. Intraventricular conduction delay related to leftventricular hypertrophy. ST-T wave abnormalities persist as recorded on thetracing of . Left ventricular wall thicknesses arenormal. Atrial fibrillation with a slow ventricular response. There is noaortic valve stenosis. The left ventricular cavity is mildly dilated with severe globalhypokinesis. Atrial fibrillation with a moderate ventricular response and a suggestion ofgroup beating. Moderate[2+] tricuspid regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Borderline intraventricular conduction delay. Moderate tricuspidregurgitation.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). There is blunting of the right and left lateral costophrenic recess consistent with small pleural effusions. 2) Global hypokinesis with decreased ejection fraction. Prominent R wave in lead V3 without diagnostic criteria for leftventricular hypertrophy. TECHNIQUE: Noncontrast head CT. Stress and resting perfusion images demonstrate a markedly enlarged left ventricle with moderate to severe perfusion defect in the distal inferior wall, extending into the inferolateral wall. IMPRESSION: 1) Predominantly fixed, moderate to severe perfusion defect in the distal inferior wall, extending into the inferior portion of the lateral wall. Non-specificST-T wave changes with relatively short interval consistent with digitaliseffect, although ischemia, etc. Left ventricular function.BP (mm Hg): 120/80Status: InpatientDate/Time: at 12:25Test: TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is markedly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. Atrial fibrillation with a controlled ventricular response. Leftventricular hypertrophy. Pulmonary artery systolic hypertension. The leftventricular cavity is mildly dilated. Severe (4+) mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Hypodensities in the periventricular white matter areas bilaterally are likely residua of chronic microvascular infarction. There is mild pulmonary artery systolichypertension.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,the echo findings indicate a moderate risk (prophylaxis recommended). Exclude digitalis excess if clinically indicated.Clinical correlation is suggested.TRACING #1 The ventricles and sulci are prominent, consistent with atrophy. There is severe global left ventricularhypokinesis. Mitral valve disease. Compared to the previoustracing of -4 the anterolateral ST-T wave abnormalities are somewhat moreprominent. Compared to the previoustracing of ventricular paced rhythm is no longer recorded. There is no pericardial effusion.IMPRESSION: Left ventricular cavity dilation with severe global hypokinesisc/w diffuse process (toxin, metabolic, multivessel CAD, etc.) Theaortic valve leaflets are mildly thickened but not stenotic. Rule out pulmonary congestion. TheST-T wave abnormalities persist without diagnostic interim change.TRACING #1 Stable cardiac enlargement and aortic contour. Non-diagnostic Q waves inlead III. IMPRESSION: Findings consistent with old infarctions. However, the accuracy of this percentage is in question due to the arrhythmia. No aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are moderately thickened. FINDINGS: There is marked cardiomegaly. FINAL REPORT INDICATION: Acute renal failure. Severe mitralregurgitation. The kidneys are atrophic and echogenic bilaterally. The tips of the papillary musclesare calcified. A ventricular pacemaker is now present. REASON FOR THIS EXAMINATION: Please evaluate for renal obstruction Additionally,pt w/questionable shifting dullness on exam and bulging flank. Atrial fibrillation with a rapid ventricular response. Atrial fibrillation with a rapid ventricular response. The mitral valve leaflets are moderately thickened.Severe (4+) mitral regurgitation is seen. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation/flutter. Clinicaldecisions regarding the need for prophylaxis should be based on clinical andechocardiographic data.Conclusions:The left atrium is markedly dilated. Atrial fibrillation and ventricular paced rhythm. Diffise ST-T waveabnormalities persist without diagnostic interim change compared to theprevious tracing of .TRACING #2 IMPRESSION: Small echogenic kidneys. Congestive heart failure. Non-specific ST-T wave abnormalities persist withoutdiagnostic interim change.TRACING #1 Baseline artifact precludes precise assessment. TECHNIQUE: Single AP view of the chest is provided. Resting perfusion images were obtained with thallium-201. Rightventricular chamber size is normal with mild global free wall hypokinesis. There is variation in theprecordial lead placement as compared to the previous tracing of . IMPRESSION: Marked cardiomegaly with CHF as described above. CHEST X-RAY: Single portable AP view was obtained and compared to prior study of . This is predominantly fixed on the rest perfusion images. Coronary artery disease. There is prominence of the descending aorta which is stable in the interval. There are several large areas of encephalomalacia, the largest within the right parietotemporal region, with smaller areas affecting the left frontal and left posterior parietal regions, likely residua of previous infarctions. Also with shifting dullness on exam. /nkg , M.D. IMPRESSION: No acute pulmonary process. There is bilateral prominent pulmonary arteries with increased haziness in the perihilar regions and possibly vascular redistribution. PLease mark for ascites if any. Compared to the previous tracing of ST-T wavechanges are more apparent. There is a small cyst at the midpole of the right kidney. The cardiac silhouette is enlarged. Approved: 11:42 AM West RADLINE ; A radiology consult service. | 15 | [
{
"category": "Radiology",
"chartdate": "2172-06-19 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 830712,
"text": " 9:05 AM\n RENAL U.S. Clip # \n Reason: Please evaluate for obstruction.\n Admitting Diagnosis: R/O MYOCARDIAL INFARCTION-ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ARF--suprapubic catheter for ?prostate CA.\n REASON FOR THIS EXAMINATION:\n Please evaluate for renal obstruction Additionally,pt w/questionable shifting\n dullness on exam and bulging flank. PLease mark for ascites if any.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute renal failure. Suprapubic catheter for question of\n prostate cancer. Also with shifting dullness on exam.\n\n FINDINGS: There is no ascites. The kidneys are atrophic and echogenic\n bilaterally. The right and left kidney measure 7.6 cm and 8.7 cm respectively\n and demonstrate increased cortical echogenicity. There is a small cyst at the\n midpole of the right kidney. There is no hydronephrosis. Inflated balloon of\n the suprapubic catheter is identified below the anterior abdominal wall.\n\n IMPRESSION: Small echogenic kidneys. No ascites.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2172-06-24 00:00:00.000",
"description": "Report",
"row_id": 62389,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Congestive heart failure. Coronary artery disease. Mitral valve disease. Left ventricular function.\nBP (mm Hg): 120/80\nStatus: Inpatient\nDate/Time: at 12:25\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is markedly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is mildly dilated. There is severe global left ventricular\nhypokinesis. No masses or thrombi are seen in the left ventricle.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. There is mild\nglobal right ventricular free wall hypokinesis.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. There is no\naortic valve stenosis. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are moderately thickened. There is\nmild thickening of the mitral valve chordae. The tips of the papillary muscles\nare calcified. Severe (4+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Moderate\n[2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic\nhypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a moderate risk (prophylaxis recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is markedly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is mildly dilated with severe global\nhypokinesis. No masses or thrombi are seen in the left ventricle. Right\nventricular chamber size is normal with mild global free wall hypokinesis. The\naortic valve leaflets are mildly thickened but not stenotic. No aortic\nregurgitation is seen. The mitral valve leaflets are moderately thickened.\nSevere (4+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Left ventricular cavity dilation with severe global hypokinesis\nc/w diffuse process (toxin, metabolic, multivessel CAD, etc.) Severe mitral\nregurgitation. Pulmonary artery systolic hypertension. Moderate tricuspid\nregurgitation.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-06-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 830669,
"text": " 4:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: any cardiac abnormaility\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with cp\n REASON FOR THIS EXAMINATION:\n any cardiac abnormaility\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest pain.\n\n CHEST X-RAY: Single portable AP view was obtained and compared to prior study\n of . The cardiac silhouette is enlarged. There is prominence\n of the descending aorta which is stable in the interval. Elevation of the left\n hemidiaphragm is present, which is also stable. There are no infiltrates or\n consolidations.\n\n IMPRESSION: No acute pulmonary process. Stable cardiac enlargement and aortic\n contour.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-07-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 832416,
"text": " 4:33 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: DIZZINESS ATAXIA R/O INFARCT\n Admitting Diagnosis: R/O MYOCARDIAL INFARCTION-ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p epicardial pacemaker, renal insuff, and a-fib,\n presenting with dizziness and ataxia\n REASON FOR THIS EXAMINATION:\n r/o infarct\n CONTRAINDICATIONS for IV CONTRAST:\n Renal insufficiency\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ataxia and dizziness after epicardial pacemaker placement.\n\n COMPARISON: None.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no sign of intracranial hemorrhage, mass effect, shift of\n the normally midline structures, or hydrocephalus. There are several large\n areas of encephalomalacia, the largest within the right parietotemporal\n region, with smaller areas affecting the left frontal and left posterior\n parietal regions, likely residua of previous infarctions. Hypodensities in\n the periventricular white matter areas bilaterally are likely residua of\n chronic microvascular infarction. There are focal calcifications in both\n frontal lobes. The ventricles and sulci are prominent, consistent with\n atrophy. There is no sign of fracture or bone destruction. The paranasal\n sinuses and orbits are unremarkable.\n\n IMPRESSION: Findings consistent with old infarctions. CT is not a sensitive\n examination for acute infarction, and to exclude this, MR \n weighting would be the test of choice.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-06-23 00:00:00.000",
"description": "PERSANTINE MIBI",
"row_id": 831016,
"text": "PERSANTINE MIBI Clip # \n Reason: SOB, CHF.; observation for suspected coronary artery disease\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Seventy-three year old male with CHF, no documented coronary artery\n disease and frequent ectopy and shortness of breath.\n\n SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB:\n Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142\n mg/kg/min. Two minutes after the cessation of infusion, Tc-m sestamibi was\n administered IV.\n\n INTERPRETATION:\n\n Image Protocol: Gated SPECT.\n\n Resting perfusion images were obtained with thallium-201.\n Tracer was injected 15 minutes prior to obtaining the resting images.\n\n Stress and resting perfusion images demonstrate a markedly enlarged left\n ventricle with moderate to severe perfusion defect in the distal inferior wall,\n extending into the inferolateral wall. This is predominantly fixed on the rest\n perfusion images.\n\n Ejection fraction calculated from gated wall motion images obtained after\n Dipyridamole administration is 33%, with global hypokinesis. However, the\n accuracy of this percentage is in question due to the arrhythmia.\n\n IMPRESSION: 1) Predominantly fixed, moderate to severe perfusion defect in the\n distal inferior wall, extending into the inferior portion of the lateral wall.\n 2) Global hypokinesis with decreased ejection fraction.\n\n /nkg\n\n\n , M.D.\n , M.D. Approved: 11:42 AM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2172-07-05 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 832296,
"text": " 3:23 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: r/o pulmonary congestion\n Admitting Diagnosis: R/O MYOCARDIAL INFARCTION-ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p epicardial pacer\n REASON FOR THIS EXAMINATION:\n r/o pulmonary congestion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 73 y/o man with epicardial pacer. Rule out pulmonary\n congestion.\n\n TECHNIQUE: Single AP view of the chest is provided.\n\n FINDINGS: There is marked cardiomegaly. There is bilateral prominent\n pulmonary arteries with increased haziness in the perihilar regions and\n possibly vascular redistribution. These findings have increased compared to\n prior film from . The findings are consistent with CHF. There is no\n evidence for pneumothorax. There is blunting of the right and left lateral\n costophrenic recess consistent with small pleural effusions. An epicardial\n pacer is noted in the left hemithorax.\n\n IMPRESSION:\n\n Marked cardiomegaly with CHF as described above.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2172-07-08 00:00:00.000",
"description": "Report",
"row_id": 123806,
"text": "Probable atrial fibrillation\nNonspecific intraventricular conduction delay\nProbable left ventricular hypertrophy with ST-T wave abnormalities\nCannot exclude in part ischemia - clinical correlation is suggested\nSince previous tracing of , ventricular ectopy not seen\n\n"
},
{
"category": "ECG",
"chartdate": "2172-07-07 00:00:00.000",
"description": "Report",
"row_id": 123807,
"text": "Probable atrial fibrillation\nVentricular premature complexes\nNonspecific intraventricular conduction delay\nProbable left ventricular hypertrophy with ST-T wave abnormalities\nCannot exclude in part ischemia - clinical correlation is suggested\nSince previous tracing of , ventricular ectopy seen\n\n\n"
},
{
"category": "ECG",
"chartdate": "2172-07-04 00:00:00.000",
"description": "Report",
"row_id": 123852,
"text": "Atrial fibrillation with a rapid ventricular response. Compared to the previous\ntracing of -4 the anterolateral ST-T wave abnormalities are somewhat more\nprominent. Otherwise, no diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2172-07-03 00:00:00.000",
"description": "Report",
"row_id": 123853,
"text": "Atrial fibrillation with a rapid ventricular response. Compared to the previous\ntracing of ventricular paced rhythm is no longer recorded. Left\nventricular hypertrophy with intraventricular conduction delay. The ventricular\nresponse has increased. Non-specific ST-T wave abnormalities persist without\ndiagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2172-07-01 00:00:00.000",
"description": "Report",
"row_id": 123854,
"text": "Atrial fibrillation and ventricular paced rhythm. Occasional fusion beats. Left\nventricular hypertrophy. Intraventricular conduction delay related to left\nventricular hypertrophy. ST-T wave abnormalities persist as recorded on the\ntracing of . A ventricular pacemaker is now present.\n\n"
},
{
"category": "ECG",
"chartdate": "2172-06-20 00:00:00.000",
"description": "Report",
"row_id": 123855,
"text": "Atrial fibrillation with a controlled ventricular response. Diffise ST-T wave\nabnormalities persist without diagnostic interim change compared to the\nprevious tracing of .\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2172-06-20 00:00:00.000",
"description": "Report",
"row_id": 123856,
"text": "Atrial fibrillation with a slow ventricular response. There is variation in the\nprecordial lead placement as compared to the previous tracing of . The\nST-T wave abnormalities persist without diagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2172-06-18 00:00:00.000",
"description": "Report",
"row_id": 123858,
"text": "Atrial fibrillation with a moderate ventricular response and a suggestion of\ngroup beating. Borderline intraventricular conduction delay. Non-specific\nST-T wave changes with relatively short interval consistent with digitalis\neffect, although ischemia, etc. is not excluded. Non-diagnostic Q waves in\nlead III. Prominent R wave in lead V3 without diagnostic criteria for left\nventricular hypertrophy. Compared to the previous tracing of ST-T wave\nchanges are more apparent. Exclude digitalis excess if clinically indicated.\nClinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2172-06-18 00:00:00.000",
"description": "Report",
"row_id": 123857,
"text": "Baseline artifact precludes precise assessment. Underlying rhythm again appears\nto be atrial fibrillation with a slow to moderate ventricular response.\nCompared to the previous tracing of multiple abnormalities are as\npreviously reported without diagnostic change, in the presence of the baseline\nartifact. Clinical correlation is suggested.\nTRACING #2\n\n"
}
] |
91,520 | 149,828 | The patient was admitted to the General Surgery Service for evaluation and treatment of the aforementioned complaint on . He was made NPO and started on IV fluid rescusitation. A foley was placed. He was given Dilaudid IV PRN for pain with good effect. In the ED, he was started on IV Vancomycin and Zosyn, which was changed to IV Flagyl and Cipro given the gallbladder findings once admitted. He was started on nebulizer treatments, chest PT, and aggressive respiratory toilet for tachypnea. Labwork and diagnostic studies were performed. He was hemodynamically stable. On , the patient was sent for an ERCP. At the time of the ERCP, he underwent an uncomplicated intubation. He was doing well during the procedures until pressures fell from baseline 170s/90s, to 80s/50s briefly while insufflating stomach. O2 sats fell at that time to unclear levels. He was noted to be gurgling. His pressures came back up and he never required pressors. ERCP with sphincterotomy and drainage of sludge was performed. At the end of case, his O2 saturation was 95% on 100% FiO2 with CO2 65. He remained intubated and was transferred to the for further care. | At the time of ERCP, he underwent anuncomplicated intubation. At the time of ERCP, he underwent anuncomplicated intubation. PPx - -pneumoboots -lansoprazole -bowel regimen . PPx - -pneumoboots -lansoprazole -bowel regimen . PPx - -pneumoboots -lansoprazole -bowel regimen . He was taken for ERCP. He was taken for ERCP. Wall motion, Pulm edema.Height: (in) 69Weight (lb): 218BSA (m2): 2.14 m2BP (mm Hg): 144/97HR (bpm): 93Status: InpatientDate/Time: at 15:30Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. - continue to hold lisinopril given recent hypotension . CXR with low lung volumes and plate like atelecatasis ( pre-intubation). There is a trivial/physiologic pericardial effusion. #) Hypertension: on lisinopril as an outpatient. #) Hypertension: on lisinopril as an outpatient. - stop heparin for now; pneumoboots for prophylaxis - continue to trend . - stop heparin for now; pneumoboots for prophylaxis - continue to trend . #) Hypertension: Holding lisinopril. Dispo - Pending extubation ICU Care Nutrition: NPO Glycemic Control: Lines: 18 Gauge - 09:27 PM 20 Gauge - 10:03 PM Prophylaxis: DVT: pneumoboots Stress ulcer: ppi VAP: Comments: Communication: Comments: Code status: Full code Disposition: icu Dispo - Pending extubation ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 09:27 PM 20 Gauge - 10:03 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: PPx - -pneumoboots -bowel regimen . PPx - -pneumoboots -lansoprazole -bowel regimen . PPx - -pneumoboots -lansoprazole -bowel regimen . PPx - -pneumoboots -lansoprazole -bowel regimen . PPx - -pneumoboots -lansoprazole -bowel regimen . PPx - -pneumoboots -lansoprazole -bowel regimen . - continue to hold lisinopril given recent hypotension . - continue to hold lisinopril given recent hypotension . Currently normotensive. Currently normotensive. Currently normotensive. - stop heparin for now; pneumoboots for prophylaxis - continue to trend . - stop heparin for now; pneumoboots for prophylaxis - continue to trend . - stop heparin for now; pneumoboots for prophylaxis - continue to trend . - repeat ABG . #) Hypertension: Holding lisinopril. #) Hypertension: Holding lisinopril. #) Hypertension: Holding lisinopril. Remians NPO. Remians NPO. - will need to restart lisinopril going forward given DM and chronic HTN . AST 241, ALT 344, Alk phos 198. Pt afebrile. #) Pancreatitis: Likely was secondary to a gallstone that has subsequently passed. #) Pancreatitis: Likely was secondary to a gallstone that has subsequently passed. #) Thrombocytopenia: Improving today Unclear etiology. #) Hypertension: on lisinopril as an outpatient. #) Hypertension: on lisinopril as an outpatient. #) Hypertension: on lisinopril as an outpatient. ABG 7.47/42/90. Afebrile. Afebrile. - increase PEEP to 10 - wean FiO2 as tolerated - transition to PSV if possible - stop IVF - consider further diuresis. - increase PEEP to 10 - wean FiO2 as tolerated - transition to PSV if possible - stop IVF - consider further diuresis. IMPRESSION: Right cephalic vein thrombus, without evidence of DVT. Small left greater than right fat-containing inguinal hernias are noted. IMPRESSION: Multifocal atelectasis without evidence for pneumonic consolidation or edema. no tenderness good pulses no cvl REASON FOR THIS EXAMINATION: R/O DVT WET READ: JXKc FRI 2:46 PM Thrombus in the right cephalic vein. IMPRESSION: AP chest reviewed in the absence of other chest radiographs or imaging of the torso. CT ABDOMEN: Small right and trace left pleural effusion are noted. The remainder of the vessels demonstrate normal compression, flow, and augmentation without evidence of DVT. Similarly, a bulge in the right lower paratracheal contour in the mediastinum could be a distended azygos vein, less likely adenopathy. Evaluation for focal lesion limited on this early arterial phase exam. SUPINE ABDOMEN: No prior comparisons. The gallbladder is within normal limits, without evidence of gallstones, gallbladder wall thickening, or pericholecystic fluid. Small amount of pericholecystic fluid, nonspecific, without additional findings to suggest cholecystitis. Periportal edema noted. Q waves in leads III, aVF.Consider inferior myocardial infarction. An endotracheal tube has been withdrawn. Small amount of pericholecystic and periportal fluid, of uncertain significance. The gallbladder appears otherwise unremarkable without evidence of stones or hydropic distention. There is expansion of the cephalic vein in the mid and distal portions, with internal echogenicity and non-compressibility, compatible with thrombus. Evaluation is limited by single arterial phase of contrast. The right costophrenic sulcus is now blunted. There is a small amount of fluid adjacent to the gallbladder. FINDINGS: Grayscale and color Doppler son of the right internal jugular, subclavian, axillary, brachials, basilic and cephalic veins were obtained. Mild-to- moderate enlargement of the heart is again noted. No definite mass is seen in the region of the ileocecal valve. IMPRESSION: Normal ERCP. Mild cardiomegaly is unchanged. Possible small right effusion. (Over) 4:24 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # CTA PELVIS W&W/O C & RECONS Reason: r/o dissection, please r/o PE Contrast: OPTIRAY Amt: 80 FINAL REPORT (Cont) CT PELVIS: The cecum is moderately distended with a large amount of fecal material. | 42 | [
{
"category": "Echo",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Report",
"row_id": 62450,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Wall motion, Pulm edema.\nHeight: (in) 69\nWeight (lb): 218\nBSA (m2): 2.14 m2\nBP (mm Hg): 144/97\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 15:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No MS.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and regional/global systolic function (LVEF>55%). There is\nno ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic regurgitation. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\nmitral valve prolapse. The pulmonary artery systolic pressure could not be\ndetermined. There is a trivial/physiologic pericardial effusion.\n\n\n"
},
{
"category": "Nursing",
"chartdate": "2103-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 461814,
"text": "Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n Pt s/p ERCP as stated above. Abd soft and non-tender. Denies nausea\n and vomiting. Afebrile. Remians NPO. Positive BOS x 4.\n Action:\n Maintains NPO. Monitoring abd assessment.\n Response:\n Abdomen soft and non-tender. Pt comfortable.\n Plan:\n Continue to monitor for further s/s of infection. Monitor labs.\n Remain NPO. ? transfer to tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 40% face tent. LS clear. Non-productive cough. Pt\n denies SOB or resp distress. O2 sats 96-99%.\n Action:\n O2 weaned to 2 LNC.\n Response:\n Pt stable on 2LNC. Sats 96%. RR 20\ns-30\n Plan:\n Continue to monitor resp status.\n ------ Protected Section ------\n Pt originally called out to floor. Report given to 12 and Dr.\n decided to keep pt in ICU for another night as the pt was\n tachypneic. RR high 20\ns-low 30\ns on 2 LNC throughout shift. Denies\n discomfort.\n Pt has bed on 9 for the morning.\n ------ Protected Section Addendum Entered By: , RN\n on: 04:59 ------\n"
},
{
"category": "Nursing",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 461564,
"text": "Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 461566,
"text": "Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n S/P ERCP as mentioned above ,Abdomen firm distended with hypoactive\n bowel sounds\n Action:\n Labs on admission AST/ALT 241/340\n Response:\n Continued\n Plan:\n Monitor labs\n Continue NPO\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted intubated from procedure room,wheezy on admission\n Action:\n ABG on admission 7.39/48/151\n Multiple vent changes\n Nebs given,Lasix 10 mg IV\n Response:\n Able to wean vent\n Plan:\n Possible extubation at AM,PRN nebs\n"
},
{
"category": "Respiratory ",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 461575,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt received from IR S/P ERCP intub with OETT and placed on\n mech vent as per Metavision. Lung sounds coarse suct sm th white sput.\n ABGs stable on current vent settings. Cont wean PSV and hopefully extub\n today.\n"
},
{
"category": "Physician ",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 461561,
"text": "TITLE:\n Chief Complaint:\n HPI:\n Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP.\n .\n At the time of ERCP, he underwent anuncomplicated intubation. He was\n doing well during the procedures until pressures fell from baseline\n 170s/90s, to 80s/50s briefly while insufflating stomach. O2 sats fell\n at that time to unclear levels. He was noted to be gurgling. His\n pressures came back up and he never required pressors. ERCP with\n sphincterotomy and drainage of sludge was performed. At the end of case\n he was satting 95% on 100% FiO2 with CO2 65. He remained intubated and\n was transferred to the for further care.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Metronidazole - 12:36 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Home medications\n lisinopril 5 mg daily\n omeprazole 20 mg \n simvastatin 40 mg daily\n ASA 81 mg daily:\n Past medical history:\n Family history:\n Social History:\n - traumatic brain injury ( in )\n - insomnia\n - hyperlipidemia\n - umbilical hernia\n - H. pylori\n - chronic polyps\n - diabetes mellitus type II\n not obtained\n per OMR: Has a son who is quite involved in his care. He does not\n smoke or drink EtOH.\n Review of systems:\n Flowsheet Data as of 01:57 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.5\nC (97.7\n HR: 94 (88 - 115) bpm\n BP: 127/91(98) {117/83(90) - 189/101(98)} mmHg\n RR: 24 (19 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 81 mL\n 330 mL\n PO:\n TF:\n IVF:\n 81 mL\n 330 mL\n Blood products:\n Total out:\n 760 mL\n 560 mL\n Urine:\n 160 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -679 mL\n -230 mL\n Respiratory\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 600) mL\n Vt (Spontaneous): 397 (397 - 397) mL\n PS : 15 cmH2O\n RR (Set): 19\n RR (Spontaneous): 26\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n SpO2: 97%\n ABG: 7.39/48/151/22/3\n Ve: 9.8 L/min\n PaO2 / FiO2: 377\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 63 K/uL\n 12.4 g/dL\n 118 mg/dL\n 0.9 mg/dL\n 18 mg/dL\n 22 mEq/L\n 107 mEq/L\n 4.6 mEq/L\n 138 mEq/L\n 36.8 %\n 12.4 K/uL\n [image002.jpg]\n \n 2:33 A5/26/ 09:58 PM\n \n 10:20 P5/26/ 10:57 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 12.4\n Hct\n 36.8\n Plt\n 63\n Cr\n 0.9\n TC02\n 30\n Glucose\n 118\n Other labs: ALT / AST:340/241, Alk Phos / T Bili:163/1.5,\n Differential-Neuts:83.1 %, Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %,\n Albumin:2.6 g/dL, LDH:546 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\n pancreatitis, aspiration peri-proceudre, restriction from large\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\n pain, immobility, and volume overload. He has received a significant\n amount of volume and been net in several liters daily for 2 days.\n Also, CXR notable for low lung volumes and atelectasis.\n - increase PEEP to 10\n - wean FiO2 as tolerated\n - transition to PSV if possible\n - stop IVF\n - consider diuresis in AM\n .\n #) Pancreatitis: Patient presented with exam and labs consistent with\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\n Furthermore, elevated TBili and pancreatic enzymes that quickly\n improved are consistent with the theory of a stone that was passed.\n - stop IV fluid hydration\n - trend LFTs\n - continue cipro/flagyl for now; re-address this with surgery\n - continue NPO for now; may consider advance in AM\n .\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\n currently. The time course would be too fast for HIT (no known\n exposure to heparin within the past 30 days), and no evidence of\n thrombosis, but the magnitude is approximately right for that. No\n obvious medications that would cause this.\n - stop heparin for now; pneumoboots for prophylaxis\n - continue to trend\n .\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\n admission (possibly due to mild acute renal failure) and BPs per\n nursing records mostly 150s-160s. Hypotensive briefly during\n procedure, possibly a vagal reaction to stomach insufflation and/or\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\n - continue to monitor\n - hydralazine PRN\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo - Pending extubation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 461562,
"text": "TITLE:\n Chief Complaint:\n HPI:\n Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP.\n .\n At the time of ERCP, he underwent anuncomplicated intubation. He was\n doing well during the procedures until pressures fell from baseline\n 170s/90s, to 80s/50s briefly while insufflating stomach. O2 sats fell\n at that time to unclear levels. He was noted to be gurgling. His\n pressures came back up and he never required pressors. ERCP with\n sphincterotomy and drainage of sludge was performed. At the end of case\n he was satting 95% on 100% FiO2 with CO2 65. He remained intubated and\n was transferred to the for further care.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Metronidazole - 12:36 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Home medications\n lisinopril 5 mg daily\n omeprazole 20 mg \n simvastatin 40 mg daily\n ASA 81 mg daily:\n Past medical history:\n Family history:\n Social History:\n - traumatic brain injury ( in )\n - insomnia\n - hyperlipidemia\n - umbilical hernia\n - H. pylori\n - chronic polyps\n - diabetes mellitus type II\n not obtained\n per OMR: Has a son who is quite involved in his care. He does not\n smoke or drink EtOH.\n Review of systems:\n Flowsheet Data as of 01:57 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.5\nC (97.7\n HR: 94 (88 - 115) bpm\n BP: 127/91(98) {117/83(90) - 189/101(98)} mmHg\n RR: 24 (19 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 81 mL\n 330 mL\n PO:\n TF:\n IVF:\n 81 mL\n 330 mL\n Blood products:\n Total out:\n 760 mL\n 560 mL\n Urine:\n 160 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -679 mL\n -230 mL\n Respiratory\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 600) mL\n Vt (Spontaneous): 397 (397 - 397) mL\n PS : 15 cmH2O\n RR (Set): 19\n RR (Spontaneous): 26\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n SpO2: 97%\n ABG: 7.39/48/151/22/3\n Ve: 9.8 L/min\n PaO2 / FiO2: 377\n Physical Examination\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\n Gen: intubated, sedated, appears comfortable\n Heart: regular, tachycardic, no murmurs\n Lungs: diffuse wheezes, otherwise clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: not responsive to verbal or physical stimuli\n Labs / Radiology\n 63 K/uL\n 12.4 g/dL\n 118 mg/dL\n 0.9 mg/dL\n 18 mg/dL\n 22 mEq/L\n 107 mEq/L\n 4.6 mEq/L\n 138 mEq/L\n 36.8 %\n 12.4 K/uL\n [image002.jpg]\n \n 2:33 A5/26/ 09:58 PM\n \n 10:20 P5/26/ 10:57 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 12.4\n Hct\n 36.8\n Plt\n 63\n Cr\n 0.9\n TC02\n 30\n Glucose\n 118\n Other labs: ALT / AST:340/241, Alk Phos / T Bili:163/1.5,\n Differential-Neuts:83.1 %, Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %,\n Albumin:2.6 g/dL, LDH:546 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\n pancreatitis, aspiration peri-proceudre, restriction from large\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\n pain, immobility, and volume overload. He has received a significant\n amount of volume and been net in several liters daily for 2 days.\n Also, CXR notable for low lung volumes and atelectasis.\n - increase PEEP to 10\n - wean FiO2 as tolerated\n - transition to PSV if possible\n - stop IVF\n - consider diuresis in AM\n .\n #) Pancreatitis: Patient presented with exam and labs consistent with\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\n Furthermore, elevated TBili and pancreatic enzymes that quickly\n improved are consistent with the theory of a stone that was passed.\n - stop IV fluid hydration\n - trend LFTs\n - continue cipro/flagyl for now; re-address this with surgery\n - continue NPO for now; may consider advance in AM\n .\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\n currently. The time course would be too fast for HIT (no known\n exposure to heparin within the past 30 days), and no evidence of\n thrombosis, but the magnitude is approximately right for that. No\n obvious medications that would cause this.\n - stop heparin for now; pneumoboots for prophylaxis\n - continue to trend\n .\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\n admission (possibly due to mild acute renal failure) and BPs per\n nursing records mostly 150s-160s. Hypotensive briefly during\n procedure, possibly a vagal reaction to stomach insufflation and/or\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\n - continue to monitor\n - hydralazine PRN\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo - Pending extubation\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n"
},
{
"category": "Nursing",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 461563,
"text": "Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP\n .H/O pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 461615,
"text": "Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n S/P ERCP as mentioned above ,Abdomen firm distended with hypoactive\n bowel sounds\n Small Bm X1 @0600\n Denies any pain or discomfort\n Action:\n Labs on admission AST/ALT 241/340\n AM labs repeated at 0600\n Response:\n Continued\n Plan:\n Follow up on AM labs\n Continue NPO\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted intubated from procedure room deeply sedated on\n admission,sedations weaned appropriately\npt more awake and able to\n communicate and follow commands,wheezy on admission,low grade temp. ST\n 115 and NBP systolic 180\ns on admission which did not require any\n intervention\n WBC 10.5\n Action:\n ABG on admission 7.39/48/151\n Multiple vent changes and ABG :please see metavision for\n details,currently on CPAP + PS 40/10/15.\n Propofol 10 mg/kg/min\n Nebs given,Lasix 10 mg IV\n Blood cultures x 1\n Response:\n Able to wean vent\n Haemodinamically stable\n Responded well to lasix 10 mg\n Plan:\n Possible extubation at AM,PRN nebs\n"
},
{
"category": "Nursing",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 461571,
"text": "Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n S/P ERCP as mentioned above ,Abdomen firm distended with hypoactive\n bowel sounds\n Action:\n Labs on admission AST/ALT 241/340\n Response:\n Continued\n Plan:\n Monitor labs\n Continue NPO\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted intubated from procedure room,wheezy on admission\n Action:\n ABG on admission 7.39/48/151\n Multiple vent changes and ABG :please see metavision for details.\n Nebs given,Lasix 10 mg IV\n Response:\n Able to wean vent\n Plan:\n Possible extubation at AM,PRN nebs\n"
},
{
"category": "General",
"chartdate": "2103-04-17 00:00:00.000",
"description": "Generic Note",
"row_id": 461556,
"text": "MICU ATTENDING ADMISSION NOTE\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with Dr\n \ns note above, including the assessment and plan. I would\n emphasize and add the following points:\n Mr presents after ERCP procedure this evening, done for\n management of acute gallstone pancreatitis. He was admitted to Dr\n \ns service 2 days ago with severe abdominal pain, lipase of\n 12,400 and creatinine of 2.0. His USG did shows features of\n peri-cholecystic fluid collection but no dilation of intra or\n extra-hepatic ducts. He has responded well to LR fluid resuscitation on\n the floor with improving LFT\ns and creatinine. His Calcium is down to\n 7.2 and his Hct is down to 34 with fluids. His ERCP/sphincterotomy was\n fairly unrevealing ( no stones, normal pancreatic ducts). He needed\n FiO2 of 100% during procedure with transient hypotension too. He has\n received Cipro/ Flagyl so far.\n Exam notable for edematous BM Tm 100.4 BP 144/70 HR of 88 RR of 16\n with sats of 99% on PEEP 10 . He has 2 IV\ns in RUE, good breath sounds\n in all lung fields and distended belly with scant bowel sounds.\n Labs notable for WBC 14.5 K, HCT of 34.9 , Cr 1.2 , Ca of 7.2.\n CXR with low lung volumes and plate like atelecatasis (\n pre-intubation).\n Agree with plan to support on ventilator with higher PEEP to offset\n abdominal distension and chest wall anasarca. We will use IVF\ns in\n bolus form only if hemodynamically unstable. He will benefit from\n gentle diuresis if BP allows in am and attempts at PSV/ CPAP\n support provided we can wean FiO2 tonight. He appears to have responded\n to vigorous fluid rescucitation but remains at high risk for other\n complications from pancreatitis.\n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n _________\n , MD\n Division of Pulmonary, Critical Care and Sleep Medicine\n \n , KS-B23\n , \n"
},
{
"category": "Nursing",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 461712,
"text": "Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n Pt s/p ERCP as above. Abd soft, non-tender. AST 241, ALT 344, Alk phos\n 198. Pt afebrile.\n Action:\n Monitoring abdominal assessment and labs as ordered. Pt NPO for now.\n Response:\n Abdomen remains soft, non-tender. BS present.\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on vent settings CPAP/PS 15/10 FiO2 40%. BBS CTA\n to diminished at bases. Atelectasis to LLL improved on CXR per team.\n ABG 7.47/42/90. Pt awake, though comfortable on propofol at\n 10mcg/kg/min. Pt denies SOB, free of s/s distress\n Action:\n Monitoring respiratory status closely. Vent settings weaned gradually\n to CPA/PS 5/5 FiO2 40%. Echo done at bedside given concern for previous\n pulmonary edema.\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 461689,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:00 PM\n BLOOD CULTURED - At 05:40 AM\n EKG - At 06:28 AM\n .\n - admitted to from ERCP, intubated\n - weaned FiO2 from 100% to 40%, increased PEEP from 5 to 10\n - changed to pressure support\n - ET tube was too deep and was pulled back\n - received 10 mg IV lasix x 1 with excellent UOP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Metronidazole - 12:36 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 104 (88 - 115) bpm\n BP: 134/93(99) {117/76(88) - 189/101(100)} mmHg\n RR: 27 (19 - 27) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 81 mL\n 377 mL\n PO:\n TF:\n IVF:\n 81 mL\n 377 mL\n Blood products:\n Total out:\n 760 mL\n 1,560 mL\n Urine:\n 160 mL\n 1,560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -679 mL\n -1,183 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 600) mL\n Vt (Spontaneous): 435 (397 - 435) mL\n PS : 15 cmH2O\n RR (Set): 19\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n SpO2: 94%\n ABG: 7.47/42/90./30/6\n Ve: 9.2 L/min\n PaO2 / FiO2: 225\n Physical Examination\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\n Gen: intubated but awake\n Heart: regular, tachycardic, no murmurs\n Lungs: clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: awake and following commands\n Labs / Radiology\n 69 K/uL\n 13.0 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 104 mEq/L\n 142 mEq/L\n 36.2 %\n 10.5 K/uL\n [image002.jpg]\n 09:58 PM\n 10:57 PM\n 02:49 AM\n 04:23 AM\n WBC\n 12.4\n 10.5\n Hct\n 36.8\n 36.2\n Plt\n 63\n 69\n Cr\n 0.9\n 1.0\n TCO2\n 30\n 31\n Glucose\n 118\n 111\n Other labs: PT / PTT / INR:15.2/25.1/1.3, ALT / AST:344/241, Alk Phos /\n T Bili:198/3.0, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:546 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:1.0 mg/dL\n LFTs:\n AST 241\n ALT 340\n AP 163\n Tbili: 1.8\n Assessment and Plan\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Hypoxia: Likely contributions from volume overload and atelectasis\n with V/Q mismatch. Also there would be concern for procedure-related\n complication, but there was no stone extraction, so an inflammatory\n response to that seems less likely. Also, he was apparently having\n some respiratory issues prior to ERCP given the choice for elective\n intubation. Regardless, he has diuresed well to a single 10 mg IV\n lasix dose, now on PSV, and A-a gradient has improved.\n - decrease PEEP to 5\n - repeat ABG\n - SBT\n - extubate\n - no further IV fluids or diuresis for now\n .\n #) Pancreatitis: Likely was secondary to a gallstone that has\n subsequently passed. Improving by most accounts (clinical exam per\n notes, fever curve, labs). Bump in tbili today may be procedure\n related. Co-managing with surgery.\n - advance diet as tolerated after extubation\n - continue cipro/flagyl as per the preference of surgery\n - trend LFTs\n - no need for further IV fluid hydration\n .\n #) Thrombocytopenia: Unclear etiology. Platelets stable today after\n having fallen from 173 on admit to 63 currently. The time course would\n be too fast for HIT, but there was a suggestion of portal vein\n thrombosis on admission CT (but this was prior to heparin). After\n discussion with surgery, they would like to send PF4 antibody. PPI\n could also cause thrombocytopenia\n - no heparin for now\n - f/u PF4 antibody\n - stop PPI\n - continue to trend platelets\n .\n #) Hypertension: Holding lisinopril. Currently normotensive.\n - continue to hold lisinopril given recent hypotension\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo\n likely to return to surgical service today pending\n extubation\n ICU Care\n Nutrition: advance diet today as tolerated\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: call out to floor\n"
},
{
"category": "Nursing",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 461783,
"text": "Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n Pt s/p ERCP as stated above. Abd soft and non-tender. Denies nausea\n and vomiting. Afebrile. Remians NPO. Positive BOS x 4.\n Action:\n Maintains NPO. Monitoring abd assessment.\n Response:\n Abdomen soft and non-tender. Pt comfortable.\n Plan:\n Continue to monitor for further s/s of infection. Monitor labs.\n Remain NPO. ? transfer to tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 40% face tent. LS clear. Non-productive cough. Pt\n denies SOB or resp distress. O2 sats 96-99%.\n Action:\n O2 weaned to 2 LNC.\n Response:\n Pt stable on 2LNC. Sats 96%. RR 20\ns-30\n Plan:\n Continue to monitor resp status.\n"
},
{
"category": "Nursing",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 461784,
"text": "Demographics\n Attending MD:\n M.\n Admit diagnosis:\n PANCREATITIS\n Code status:\n Full code\n Height:\n Admission weight:\n 99 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:152\n D:89\n Temperature:\n 99.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,068 mL\n 24h total out:\n 3,150 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:40 PM\n Potassium:\n 3.7 mEq/L\n 02:40 PM\n Chloride:\n 103 mEq/L\n 02:40 PM\n CO2:\n 27 mEq/L\n 02:40 PM\n BUN:\n 14 mg/dL\n 02:40 PM\n Creatinine:\n 0.8 mg/dL\n 02:40 PM\n Glucose:\n 113 mg/dL\n 02:40 PM\n Hematocrit:\n 37.7 %\n 02:40 PM\n Finger Stick Glucose:\n 130\n 06:00 PM\n Valuables / Signature\n Patient valuables: sent with pt\n valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4\n Transferred to: 12 \n Date & time of Transfer: 2330\n Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n Pt s/p ERCP as stated above. Abd soft and non-tender. Denies nausea\n and vomiting. Afebrile. Remians NPO. Positive BOS x 4.\n Action:\n Maintains NPO. Monitoring abd assessment.\n Response:\n Abdomen soft and non-tender. Pt comfortable.\n Plan:\n Continue to monitor for further s/s of infection. Monitor labs.\n Remain NPO. ? transfer to tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 40% face tent. LS clear. Non-productive cough. Pt\n denies SOB or resp distress. O2 sats 96-99%.\n Action:\n O2 weaned to 2 LNC.\n Response:\n Pt stable on 2LNC. Sats 96%. RR 20\ns-30\n Plan:\n Continue to monitor resp status.\n"
},
{
"category": "Physician ",
"chartdate": "2103-04-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 461849,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:33 PM\n - Extubated afternoon\n - Attempted to call out to 9, surgery would like him monitored\n overnight for high respiratory rate.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 11:40 PM\n Metronidazole - 12:56 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 82 (80 - 98) bpm\n BP: 129/81(93) {126/81(93) - 159/102(116)} mmHg\n RR: 23 (20 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,308 mL\n 168 mL\n PO:\n TF:\n IVF:\n 1,308 mL\n 168 mL\n Blood products:\n Total out:\n 3,150 mL\n 1,020 mL\n Urine:\n 3,150 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,842 mL\n -852 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 23 (23 - 406) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 91\n SpO2: 93%\n ABG: ///27/\n Ve: 9.2 L/min\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\n Gen: intubated but awake\n Heart: regular, tachycardic, no murmurs\n Lungs: clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: awake and following commands\n Labs / Radiology\n 84 K/uL\n 12.9 g/dL\n 92 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 106 mEq/L\n 142 mEq/L\n 38.5 %\n 8.0 K/uL\n [image002.jpg]\n 09:58 PM\n 10:57 PM\n 02:49 AM\n 04:23 AM\n 02:40 PM\n 04:10 AM\n WBC\n 12.4\n 10.5\n 10.6\n 8.0\n Hct\n 36.8\n 36.2\n 37.7\n 38.5\n Plt\n 63\n 69\n 76\n 84\n Cr\n 0.9\n 1.0\n 0.8\n 0.8\n TCO2\n 30\n 31\n Glucose\n 118\n 111\n 113\n 92\n Other labs: PT / PTT / INR:16.2/24.7/1.4, ALT / AST:249/129, Alk Phos /\n T Bili:204/1.2, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.8 g/dL, LDH:444 IU/L,\n Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n PANCREATITIS, ACUTE\n THROMBOCYTOPENIA, ACUTE\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Hypoxia: Likely contributions from volume overload and atelectasis\n with V/Q mismatch. Also there would be concern for procedure-related\n complication, but there was no stone extraction, so an inflammatory\n response to that seems less likely. Also, he was apparently having\n some respiratory issues prior to ERCP given the choice for elective\n intubation. Regardless, he has diuresed well to a single 10 mg IV\n lasix dose, now on PSV, and A-a gradient has improved.\n - decrease PEEP to 5\n - repeat ABG\n - SBT\n - extubate\n - no further IV fluids or diuresis for now\n .\n #) Pancreatitis: Likely was secondary to a gallstone that has\n subsequently passed. Improving by most accounts (clinical exam per\n notes, fever curve, labs). Bump in tbili today may be procedure\n related. Co-managing with surgery.\n - advance diet as tolerated after extubation\n - continue cipro/flagyl as per the preference of surgery\n - trend LFTs\n - no need for further IV fluid hydration\n .\n #) Thrombocytopenia: Unclear etiology. Platelets stable today after\n having fallen from 173 on admit to 63 currently. The time course would\n be too fast for HIT, but there was a suggestion of portal vein\n thrombosis on admission CT (but this was prior to heparin). After\n discussion with surgery, they would like to send PF4 antibody. PPI\n could also cause thrombocytopenia\n - no heparin for now\n - f/u PF4 antibody\n - stop PPI\n - continue to trend platelets\n .\n #) Hypertension: Holding lisinopril. Currently normotensive.\n - continue to hold lisinopril given recent hypotension\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo\n likely to return to surgical service today pending\n extubation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2103-04-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 461851,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:33 PM\n - Extubated afternoon\n - Attempted to call out to 9, surgery would like him monitored\n overnight for high respiratory rate.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 11:40 PM\n Metronidazole - 12:56 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 82 (80 - 98) bpm\n BP: 129/81(93) {126/81(93) - 159/102(116)} mmHg\n RR: 23 (20 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,308 mL\n 168 mL\n PO:\n TF:\n IVF:\n 1,308 mL\n 168 mL\n Blood products:\n Total out:\n 3,150 mL\n 1,020 mL\n Urine:\n 3,150 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,842 mL\n -852 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, 2L\n Gen: awake\n Heart: regular, tachycardic, no murmurs\n Lungs: clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: awake and following commands\n Labs / Radiology\n 84 K/uL\n 12.9 g/dL\n 92 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 106 mEq/L\n 142 mEq/L\n 38.5 %\n 8.0 K/uL\n [image002.jpg]\n 09:58 PM\n 10:57 PM\n 02:49 AM\n 04:23 AM\n 02:40 PM\n 04:10 AM\n WBC\n 12.4\n 10.5\n 10.6\n 8.0\n Hct\n 36.8\n 36.2\n 37.7\n 38.5\n Plt\n 63\n 69\n 76\n 84\n Cr\n 0.9\n 1.0\n 0.8\n 0.8\n TCO2\n 30\n 31\n Glucose\n 118\n 111\n 113\n 92\n Other labs: PT / PTT / INR:16.2/24.7/1.4, ALT / AST:249/129, Alk Phos /\n T Bili:204/1.2, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.8 g/dL, LDH:444 IU/L,\n Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.0 mg/dL\n HIT antibody negative\n Blood cx , NGTD\n Assessment and Plan\n PANCREATITIS, ACUTE\n THROMBOCYTOPENIA, ACUTE\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Increased respiratory rate: likely\n Likely contributions from volume overload and atelectasis with V/Q\n mismatch. Also there would be concern for procedure-related\n complication, but there was no stone extraction, so an inflammatory\n response to that seems less likely. Also, he was apparently having\n some respiratory issues prior to ERCP given the choice for elective\n intubation. Regardless, he has diuresed well to a single 10 mg IV\n lasix dose, now on PSV, and A-a gradient has improved.\n - decrease PEEP to 5\n - repeat ABG\n - SBT\n - extubate\n - no further IV fluids or diuresis for now\n .\n #) Pancreatitis: Likely was secondary to a gallstone that has\n subsequently passed. Improving by most accounts (clinical exam per\n notes, fever curve, labs). Bump in tbili today may be procedure\n related. Co-managing with surgery.\n - advance diet as tolerated after extubation\n - continue cipro/flagyl as per the preference of surgery\n - trend LFTs\n - no need for further IV fluid hydration\n .\n #) Thrombocytopenia: Improving today\n Unclear etiology. Platelets stable today after having fallen from 173\n on admit to 63 currently. The time course would be too fast for HIT,\n but there was a suggestion of portal vein thrombosis on admission CT\n (but this was prior to heparin). After discussion with surgery, they\n would like to send PF4 antibody. PPI could also cause\n thrombocytopenia\n - no heparin for now\n - f/u PF4 antibody\n - stop PPI\n - continue to trend platelets\n .\n #) Hypertension: Holding lisinopril. Currently normotensive.\n - continue to hold lisinopril given recent hypotension\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo\n likely to return to surgical service today pending\n extubation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2103-04-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 461979,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 03:33 PM\n - Extubated yesterday afternoon\n - Attempted to call out to 9, surgery would like him monitored\n overnight for high respiratory rate.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 11:40 PM\n Metronidazole - 12:56 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 82 (80 - 98) bpm\n BP: 129/81(93) {126/81(93) - 159/102(116)} mmHg\n RR: 23 (20 - 30) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,308 mL\n 168 mL\n PO:\n TF:\n IVF:\n 1,308 mL\n 168 mL\n Blood products:\n Total out:\n 3,150 mL\n 1,020 mL\n Urine:\n 3,150 mL\n 1,020 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,842 mL\n -852 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, 2L\n Gen: awake and interactive\n Heart: regular, tachycardic, no murmurs\n Lungs: clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: awake and following commands\n Labs / Radiology\n 84 K/uL\n 12.9 g/dL\n 92 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 106 mEq/L\n 142 mEq/L\n 38.5 %\n 8.0 K/uL\n [image002.jpg]\n 09:58 PM\n 10:57 PM\n 02:49 AM\n 04:23 AM\n 02:40 PM\n 04:10 AM\n WBC\n 12.4\n 10.5\n 10.6\n 8.0\n Hct\n 36.8\n 36.2\n 37.7\n 38.5\n Plt\n 63\n 69\n 76\n 84\n Cr\n 0.9\n 1.0\n 0.8\n 0.8\n TCO2\n 30\n 31\n Glucose\n 118\n 111\n 113\n 92\n Other labs: PT / PTT / INR:16.2/24.7/1.4, ALT / AST:249/129, Alk Phos /\n T Bili:204/1.2, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.8 g/dL, LDH:444 IU/L,\n Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.0 mg/dL\n HIT antibody negative\n Blood cx , NGTD\n Assessment and Plan\n PANCREATITIS, ACUTE\n THROMBOCYTOPENIA, ACUTE\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, transferred to ICU with\n difficulty extubating, now extubated but mildly tachypneic.\n .\n #) Increased respiratory rate: likely secondary to discomfort in\n abdomen, may still have some extra volume on board. Echo yesterday\n showed normal EF, so it is unclear exactly why he went into pulmonary\n edema. Regardless, he was successfully extubated and RR is improving.\n - repeat ABG\n .\n #) Pancreatitis: All labs, fever curve improving. Likely was secondary\n to a gallstone that has subsequently passed. Improving by most\n accounts (clinical exam per notes, fever curve, labs). Co-managing\n with surgery. He will go back to their service today.\n - advance diet as tolerated\n - continue cipro/flagyl as per the preference of surgery\n - trend LFTs\n - no need for further IV fluid hydration\n .\n #) Thrombocytopenia: Improving today. HIT antibody negative.\n Heparin and PPI stopped yesterday.\n - continue to trend platelets\n .\n #) Hypertension: Holding lisinopril. Currently normotensive.\n - will need to restart lisinopril going forward given DM and chronic\n HTN\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo\n likely to return to surgical service today pending\n extubation\n ICU Care\n Nutrition: advance diet\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: return to surgery today\n"
},
{
"category": "Nursing",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 461600,
"text": "Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n S/P ERCP as mentioned above ,Abdomen firm distended with hypoactive\n bowel sounds\n Denies any pain or discomfort\n Action:\n Labs on admission AST/ALT 241/340\n AM labs repeated at 0600\n Response:\n Continued\n Plan:\n Follow up on AM labs\n Continue NPO\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted intubated from procedure room deeply sedated on\n admission,sedations weaned appropriately\npt more awake and able to\n communicate and follow commands,wheezy on admission,low grade temp.\n Action:\n ABG on admission 7.39/48/151\n Multiple vent changes and ABG :please see metavision for\n details,currently on CPAP + PS 40/10/15.\n Propofol 10 mg/kg/min\n Nebs given,Lasix 10 mg IV\n Blood cultures x 1\n Response:\n Able to wean vent\n Responded well to lasix 10 mg\n Plan:\n Possible extubation at AM,PRN nebs\n"
},
{
"category": "General",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Generic Note",
"row_id": 461681,
"text": "TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined. He has diuresed 2L\n overnight. Abd exam relatively unremarkable\n no tenderness mild\n distention. We are switching to PSV, reducing PEEP to 5 and will do a\n long SBT prior to extubation.\n Time spent 40 min\n Critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 461764,
"text": "Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n Pt s/p ERCP as above. Abd soft, non-tender. AST 241, ALT 344, Alk phos\n 198. Pt afebrile.\n Action:\n Monitoring abdominal assessment and labs as ordered. Pt NPO for now.\n Response:\n Abdomen remains soft, non-tender. BS present.\n Plan:\n Continue monitor abdominal assessment. Monitor labs. Pt to remain NPO\n for now.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated on vent settings CPAP/PS 15/10 FiO2 40%. BBS CTA\n to diminished at bases. Atelectasis to LLL improved on CXR per team.\n ABG 7.47/42/90. Pt awake, though comfortable on propofol at\n 10mcg/kg/min. Pt denies SOB, free of s/s distress\n Action:\n Monitoring respiratory status closely. Vent settings weaned gradually\n to CPA/PS 5/5 FiO2 40%. Echo done at bedside given concern for previous\n pulmonary edema.\n Response:\n Pt tolerated vent weaning well and was extubated ~1600. Pt presently\n resting quietly in bed. BBS CTA to diminished at bilat bases. SpO2\n >97%. Pt denies SOB, reports comfortable remains free of distress.\n Plan:\n Continue to monitor respiratory status. Anticipate C/O to floor (\n 9) tomorrow if pt remains stable.\n"
},
{
"category": "Physician ",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 461632,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:00 PM\n BLOOD CULTURED - At 05:40 AM\n EKG - At 06:28 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Metronidazole - 12:36 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 104 (88 - 115) bpm\n BP: 134/93(99) {117/76(88) - 189/101(100)} mmHg\n RR: 27 (19 - 27) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 81 mL\n 377 mL\n PO:\n TF:\n IVF:\n 81 mL\n 377 mL\n Blood products:\n Total out:\n 760 mL\n 1,560 mL\n Urine:\n 160 mL\n 1,560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -679 mL\n -1,183 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 600) mL\n Vt (Spontaneous): 435 (397 - 435) mL\n PS : 15 cmH2O\n RR (Set): 19\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n SpO2: 94%\n ABG: 7.47/42/90./30/6\n Ve: 9.2 L/min\n PaO2 / FiO2: 225\n Physical Examination\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\n Gen: intubated, sedated, appears comfortable\n Heart: regular, tachycardic, no murmurs\n Lungs: diffuse wheezes, otherwise clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: not responsive to verbal or physical stimuli\n Labs / Radiology\n 69 K/uL\n 13.0 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 104 mEq/L\n 142 mEq/L\n 36.2 %\n 10.5 K/uL\n [image002.jpg]\n 09:58 PM\n 10:57 PM\n 02:49 AM\n 04:23 AM\n WBC\n 12.4\n 10.5\n Hct\n 36.8\n 36.2\n Plt\n 63\n 69\n Cr\n 0.9\n 1.0\n TCO2\n 30\n 31\n Glucose\n 118\n 111\n Other labs: PT / PTT / INR:15.2/25.1/1.3, ALT / AST:344/241, Alk Phos /\n T Bili:198/3.0, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:546 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:1.0 mg/dL\n LFTs:\n AST 241\n ALT 340\n AP 163\n Tbili: 1.8\n CXR:\n Assessment and Plan\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\n pancreatitis, aspiration peri-proceudre, restriction from large\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\n pain, immobility, and volume overload. He has received a significant\n amount of volume and been net in several liters daily for 2 days.\n Also, CXR notable for low lung volumes and atelectasis.\n - increase PEEP to 10\n - wean FiO2 as tolerated\n - transition to PSV if possible\n - stop IVF\n - consider further diuresis.\n .\n #) Pancreatitis: Patient presented with exam and labs consistent with\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\n Furthermore, elevated TBili and pancreatic enzymes that quickly\n improved are consistent with the theory of a stone that was passed.\n Now Tibili increasing again\n - stop IV fluid hydration\n - trend LFTs\n - continue cipro/flagyl for now; re-address this with surgery\n - continue NPO for now; may consider advance in AM\n .\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\n currently. The time course would be too fast for HIT (no known\n exposure to heparin within the past 30 days), and no evidence of\n thrombosis, but the magnitude is approximately right for that. No\n obvious medications that would cause this.\n - stop heparin for now; pneumoboots for prophylaxis\n - continue to trend\n .\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\n admission (possibly due to mild acute renal failure) and BPs per\n nursing records mostly 150s-160s. Hypotensive briefly during\n procedure, possibly a vagal reaction to stomach insufflation and/or\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\n - continue to monitor\n - hydralazine PRN\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo - Pending extubation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 461633,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:00 PM\n BLOOD CULTURED - At 05:40 AM\n EKG - At 06:28 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Metronidazole - 12:36 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 104 (88 - 115) bpm\n BP: 134/93(99) {117/76(88) - 189/101(100)} mmHg\n RR: 27 (19 - 27) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 81 mL\n 377 mL\n PO:\n TF:\n IVF:\n 81 mL\n 377 mL\n Blood products:\n Total out:\n 760 mL\n 1,560 mL\n Urine:\n 160 mL\n 1,560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -679 mL\n -1,183 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 600) mL\n Vt (Spontaneous): 435 (397 - 435) mL\n PS : 15 cmH2O\n RR (Set): 19\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n SpO2: 94%\n ABG: 7.47/42/90./30/6\n Ve: 9.2 L/min\n PaO2 / FiO2: 225\n Physical Examination\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\n Gen: intubated, sedated, appears comfortable\n Heart: regular, tachycardic, no murmurs\n Lungs: diffuse wheezes, otherwise clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: not responsive to verbal or physical stimuli\n Labs / Radiology\n 69 K/uL\n 13.0 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 104 mEq/L\n 142 mEq/L\n 36.2 %\n 10.5 K/uL\n [image002.jpg]\n 09:58 PM\n 10:57 PM\n 02:49 AM\n 04:23 AM\n WBC\n 12.4\n 10.5\n Hct\n 36.8\n 36.2\n Plt\n 63\n 69\n Cr\n 0.9\n 1.0\n TCO2\n 30\n 31\n Glucose\n 118\n 111\n Other labs: PT / PTT / INR:15.2/25.1/1.3, ALT / AST:344/241, Alk Phos /\n T Bili:198/3.0, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:546 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:1.0 mg/dL\n LFTs:\n AST 241\n ALT 340\n AP 163\n Tbili: 1.8\n CXR:\n Assessment and Plan\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\n pancreatitis, aspiration peri-proceudre, restriction from large\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\n pain, immobility, and volume overload. He has received a significant\n amount of volume and been net in several liters daily for 2 days.\n Also, CXR notable for low lung volumes and atelectasis.\n - increase PEEP to 10\n - wean FiO2 as tolerated\n - transition to PSV if possible\n - stop IVF\n - consider further diuresis.\n .\n #) Pancreatitis: Patient presented with exam and labs consistent with\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\n Furthermore, elevated TBili and pancreatic enzymes that quickly\n improved are consistent with the theory of a stone that was passed.\n Now Tibili increasing again\n - stop IV fluid hydration\n - trend LFTs\n - continue cipro/flagyl for now; re-address this with surgery\n - continue NPO for now; may consider advance in AM\n .\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\n currently. The time course would be too fast for HIT (no known\n exposure to heparin within the past 30 days), and no evidence of\n thrombosis, but the magnitude is approximately right for that. No\n obvious medications that would cause this.\n - stop heparin for now; pneumoboots for prophylaxis\n - continue to trend\n .\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\n admission (possibly due to mild acute renal failure) and BPs per\n nursing records mostly 150s-160s. Hypotensive briefly during\n procedure, possibly a vagal reaction to stomach insufflation and/or\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\n - continue to monitor\n - hydralazine PRN\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo - Pending extubation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 461636,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:00 PM\n BLOOD CULTURED - At 05:40 AM\n EKG - At 06:28 AM\n .\n - admitted to from ERCP, intubated\n - weaned FiO2 from 100% to 40%, increased PEEP from 5 to 10\n - changed to pressure support\n - pulled back ET tube\n - received 10 mg IV lasix x 1 with excellent UOP\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 12:00 AM\n Metronidazole - 12:36 AM\n Infusions:\n Propofol - 10 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.8\nC (100.1\n HR: 104 (88 - 115) bpm\n BP: 134/93(99) {117/76(88) - 189/101(100)} mmHg\n RR: 27 (19 - 27) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 81 mL\n 377 mL\n PO:\n TF:\n IVF:\n 81 mL\n 377 mL\n Blood products:\n Total out:\n 760 mL\n 1,560 mL\n Urine:\n 160 mL\n 1,560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -679 mL\n -1,183 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 600) mL\n Vt (Spontaneous): 435 (397 - 435) mL\n PS : 15 cmH2O\n RR (Set): 19\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n SpO2: 94%\n ABG: 7.47/42/90./30/6\n Ve: 9.2 L/min\n PaO2 / FiO2: 225\n Physical Examination\n VS T 99.8, HR 115, BP 189/101, RR 20, O2 97%\n Gen: intubated, sedated, appears comfortable\n Heart: regular, tachycardic, no murmurs\n Lungs: diffuse wheezes, otherwise clear anteriorly\n Abdomen: distended, somewhat tense, bowel sounds present, no\n tenderness elicited\n Ext: 1+ pitting edema\n Neuro: not responsive to verbal or physical stimuli\n Labs / Radiology\n 69 K/uL\n 13.0 g/dL\n 111 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 104 mEq/L\n 142 mEq/L\n 36.2 %\n 10.5 K/uL\n [image002.jpg]\n 09:58 PM\n 10:57 PM\n 02:49 AM\n 04:23 AM\n WBC\n 12.4\n 10.5\n Hct\n 36.8\n 36.2\n Plt\n 63\n 69\n Cr\n 0.9\n 1.0\n TCO2\n 30\n 31\n Glucose\n 118\n 111\n Other labs: PT / PTT / INR:15.2/25.1/1.3, ALT / AST:344/241, Alk Phos /\n T Bili:198/3.0, Amylase / Lipase:60/41, Differential-Neuts:83.1 %,\n Lymph:12.1 %, Mono:4.4 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:546 IU/L,\n Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:1.0 mg/dL\n LFTs:\n AST 241\n ALT 340\n AP 163\n Tbili: 1.8\n CXR:\n Assessment and Plan\n .H/O PANCREATITIS, ACUTE\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n .\n 57 year-old man presented with epigastric discomfort and laboratory\n data consistent with gallstone pancreatitis, now with difficulty\n extubating.\n .\n #) Hypoxia: Patient remains intubated with a substantial A-a gradient\n of ~500. P/F ratio 151. Differential includes ARDS secondary to\n pancreatitis, aspiration peri-proceudre, restriction from large\n abdomen, V/Q mismatching secondary to atelectasis in the setting of\n pain, immobility, and volume overload. He has received a significant\n amount of volume and been net in several liters daily for 2 days.\n Also, CXR notable for low lung volumes and atelectasis.\n - increase PEEP to 10\n - wean FiO2 as tolerated\n - transition to PSV if possible\n - stop IVF\n - consider further diuresis.\n .\n #) Pancreatitis: Patient presented with exam and labs consistent with\n gallstone pancreatitis. Triglycerides normal and no history of EtOH.\n Furthermore, elevated TBili and pancreatic enzymes that quickly\n improved are consistent with the theory of a stone that was passed.\n Now Tibili increasing again\n - stop IV fluid hydration\n - trend LFTs\n - continue cipro/flagyl for now; re-address this with surgery\n - continue NPO for now; may consider advance in AM\n .\n #) Thrombocytopenia: platelets have fallen from 173 on admit to 63\n currently. The time course would be too fast for HIT (no known\n exposure to heparin within the past 30 days), and no evidence of\n thrombosis, but the magnitude is approximately right for that. No\n obvious medications that would cause this.\n - stop heparin for now; pneumoboots for prophylaxis\n - continue to trend\n .\n #) Hypertension: on lisinopril as an outpatient. This was stopped on\n admission (possibly due to mild acute renal failure) and BPs per\n nursing records mostly 150s-160s. Hypotensive briefly during\n procedure, possibly a vagal reaction to stomach insufflation and/or\n sedation. SBP on arrival to ICU 190, but quickly fell to 150s.\n - continue to monitor\n - hydralazine PRN\n .\n #) DM2: diagnosed in , diet controlled, HgA1c 5.8% in .\n - insulin SS\n .\n #. FEN - NPO\n .\n #. Access - PIV\n .\n #. PPx -\n -pneumoboots\n -lansoprazole\n -bowel regimen\n .\n #. Code - full code, confirmed with son \n .\n #. Communication - son \n .\n #. Dispo - Pending extubation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 09:27 PM\n 20 Gauge - 10:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2103-04-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 461892,
"text": "Demographics\n Attending MD:\n M.\n Admit diagnosis:\n PANCREATITIS\n Code status:\n Full code\n Height:\n Admission weight:\n 99 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:152\n D:89\n Temperature:\n 99.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,068 mL\n 24h total out:\n 3,150 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 02:40 PM\n Potassium:\n 3.7 mEq/L\n 02:40 PM\n Chloride:\n 103 mEq/L\n 02:40 PM\n CO2:\n 27 mEq/L\n 02:40 PM\n BUN:\n 14 mg/dL\n 02:40 PM\n Creatinine:\n 0.8 mg/dL\n 02:40 PM\n Glucose:\n 113 mg/dL\n 02:40 PM\n Hematocrit:\n 37.7 %\n 02:40 PM\n Finger Stick Glucose:\n 130\n 06:00 PM\n Valuables / Signature\n Patient valuables: sent with pt\n valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4\n Transferred to: 12 \n Date & time of Transfer: 2330\n Mr. is a 57-year-old man who presented with epigastric and\n back pain and reportedly a witnessed syncopal episode. Labs on\n presentation showed lipase of , amylase 476, AST/ALT of 784/567,\n and a total bili of 1.8. CT showed a small amount of pericholecystic\n and periportal fluid, and US was without stones or evidence of\n cholecystitis. He was treated with a dose of vancomycin/zosyn in the\n ED followed by ciprofloxacin and flagyl. He was aggressively fluid\n resusucitated with LR at 150 cc/h. He was taken for ERCP on \n ERCP with sphincterotomy and drainage of sludge was performed. At the\n end of case he was satting 95% on 100% FiO2 with CO2 65. He remained\n intubated and was transferred to the for further care.\n .H/O pancreatitis, acute\n Assessment:\n Pt s/p ERCP as stated above. Abd soft and non-tender. Denies nausea\n and vomiting. Afebrile. Remians NPO. Positive BOS x 4.\n Action:\n Maintains NPO. Monitoring abd assessment.\n Response:\n Abdomen soft and non-tender. Pt comfortable.\n Plan:\n Continue to monitor for further s/s of infection. Monitor labs.\n Remain NPO. ? transfer to tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 40% face tent. LS clear. Non-productive cough. Pt\n denies SOB or resp distress. O2 sats 96-99%.\n Action:\n O2 weaned to 2 LNC.\n Response:\n Pt stable on 2LNC. Sats 96%. RR 20\ns-30\n Plan:\n Continue to monitor resp status.\n ------ Protected Section ------\n Agree with above note.\n ------ Protected Section Addendum Entered By: , RN\n on: 09:14 ------\n"
},
{
"category": "ECG",
"chartdate": "2103-04-18 00:00:00.000",
"description": "Report",
"row_id": 121673,
"text": "Sinus tachycardia with increase in rate as compared with previous tracing\nof . There is non-specific ST-T wave flattening and delayed precordial\nR wave transition as previously recorded without diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-15 00:00:00.000",
"description": "Report",
"row_id": 121674,
"text": "Sinus rhythm. Within normal limits.\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-24 00:00:00.000",
"description": "Report",
"row_id": 121631,
"text": "Sinus rhythm. Probable anterior myocardial infarction. Non-specific\ninferior ST-T wave changes. Compared to the previous tracing of \nthe inferior Q waves are less prominent. Otherwise, no diagnostic interim\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2103-04-23 00:00:00.000",
"description": "Report",
"row_id": 121632,
"text": "Sinus rhythm. Somewhat late R wave progression. Q waves in leads III, aVF.\nConsider inferior myocardial infarction. Since the previous tracing of \nthe limb lead QRS voltage is more prominent.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1080514,
"text": " 4:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement, interval change\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man intubated after ERCP.\n REASON FOR THIS EXAMINATION:\n ET tube placement, interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n\n REASON FOR EXAM: 57-year-old male intubated after ERCP.\n\n ET tube tip is 3 cm above the carina. Moderate cardiomegaly is stable.\n Multiple opacities, greater on the lower lobes that have minimally improved in\n the left base, are consistent with atelectasis. The lungs are better\n aerated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-23 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1081435,
"text": " 3:56 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ELEVATED LFTS\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with RUQ pain, recurrent elevation of amylase and lipase\n REASON FOR THIS EXAMINATION:\n eval for signs of cholecystitis\n ______________________________________________________________________________\n WET READ: JXKc MON 4:39 PM\n Fatty liver. No gallstones or evidence of cholecystitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old male with right upper quadrant pain, recurrent elevation\n of amylase and lipase. Evaluate for signs of cholecystitis.\n\n COMPARISON: .\n\n FINDINGS: The liver is diffusely echogenic, compatible with fatty\n infiltration. No focal hepatic lesion is identified. The portal vein is\n patent with hepatopetal flow. The gallbladder is within normal limits,\n without evidence of gallstones, gallbladder wall thickening, or\n pericholecystic fluid. No son sign was evident. There is no\n intra- or extra-hepatic biliary ductal dilatation with the CBD measuring 5 mm.\n Visualized pancreatic head is grossly unremarkable, with the remainder of the\n pancreas not well visualized due to overlying bowel gas.\n\n IMPRESSION:\n 1. Diffusely echogenic liver, compatible with fatty infiltration. Other\n forms of liver disease, and more advanced liver disease cannot be entirely\n excluded on this study.\n 2. No evidence of gallstones or cholecystitis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1080172,
"text": " 8:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess pulm status\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57M with rigid abdomen, with exam and laboratory data consistent with acute\n pancreatitis. now with increased work of breathing,SOB\n REASON FOR THIS EXAMINATION:\n assess pulm status\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Shortness of breath. Patient with pancreatitis.\n\n Comparison is made with prior study, .\n\n Mild cardiomegaly is unchanged. Bilateral multifocal subsegmental atelectases\n have increased. There is no pneumothorax or enlarging pleural effusions.\n There are low lung volumes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-18 00:00:00.000",
"description": "ERCP BILIARY&PANCREAS BY GI UNIT",
"row_id": 1080799,
"text": " 2:30 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: Please review ERCP images done \n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 yr old male. Admitted with acute pancreatitis - suspected gallstone\n pancreatitis. Elevated transaminases with normal bilirubin.\n REASON FOR THIS EXAMINATION:\n Please review ERCP images done \n ______________________________________________________________________________\n FINAL REPORT\n ERCP\n\n COMPARISON: None.\n\n HISTORY: 57-year-old male with acute pancreatitis, elevated transaminases and\n normal bilirubin.\n\n FINDINGS: Fifteen fluoroscopic images were obtained without a radiologist\n present and submitted for review. This demonstrates normal contrast\n opacification of the hepatobiliary tree. There is no evidence of compression,\n filling defects, or ductal abnormalities.\n\n IMPRESSION: Normal ERCP. Please refer to ERCP note for further details.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-23 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1081439,
"text": " 4:23 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: PANCREATITIS\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man pre-op for cholecystectomy\n REASON FOR THIS EXAMINATION:\n please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old male, for preoperative evaluation for cholecystitis.\n\n COMPARISON: CXR .\n\n PA AND LATERAL CHEST: Elevation of the right hemidiaphragm is associated with\n right basilar atelectasis. Band-like atelectasis along the medial aspect of\n the left lung is not significantly changed in the short interval. Mild-to-\n moderate enlargement of the heart is again noted. The pulmonary vascularity\n is stable. There is no pleural effusion or pneumothorax.\n\n IMPRESSION: Multifocal atelectasis without evidence for pneumonic\n consolidation or edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1081057,
"text": " 5:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with fever\n REASON FOR THIS EXAMINATION:\n please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Fever.\n\n One portable view. Comparison with . There is some motion artifact.\n There is streaky density bilaterally consistent with subsegmental atelectasis.\n The right costophrenic sulcus is now blunted. The heart and mediastinal\n structures are unchanged. An endotracheal tube has been withdrawn.\n\n IMPRESSION: Limited study demonstrating interval improvement in subsegmental\n atelectasis. Possible small right effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-15 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1080107,
"text": " 4:24 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: r/o dissection, please r/o PE\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with acute onset chest and abdominal pain, radiating to the\n back with distention and firmness on abdominal exam\n REASON FOR THIS EXAMINATION:\n r/o dissection, please r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CTA of the chest and abdomen, .\n\n INDICATION: Acute onset chest and abdominal pain, rigid abdomen. ?\n dissection.\n\n COMPARISON: Abdominal radiographs from same day.\n\n TECHNIQUE: Volumetric CT acquisition of the chest and abdomen was performed\n following administration of intravenous contrast per CTA dissection protocol.\n Multiplanar reformatted images were obtained and reviewed.\n\n CTA CHEST: Thoracic aorta is normal in caliber and contour throughout. There\n is no dissection. Heart is mildly enlarged, with evidence of left ventricular\n hypertrophy. There is no pleural or pericardial effusion. Central airways\n are patent to the subsegmental level. There is no pathologic intrathoracic\n lymphadenopathy.\n\n Evaluation of the lung parenchyma is markedly limited due to respiratory\n motion artifact, and expiratory phase of scan acquisition.\n\n CTA ABDOMEN: Abdominal aorta is normal in caliber and contour throughout.\n There is no dissection.\n\n Liver contour is normal. There is no biliary ductal dilatation or ascites.\n Evaluation is limited by single arterial phase of contrast. There is somewhat\n ill-defined heterogeneous appearance to the parenchyma in the right lobe of\n the liver. Periportal edema noted. Main portal vein is just beginning to\n opacify, limiting evaluation for portal vein thrombus. Small amount of fluid\n is also seen in the porta hepatis, tracking along the region of the third\n portion of the duodenum. The duodenum itself is somewhat difficult to evaluate\n as it is largely collapsed. The stomach is mildly distended, with fluid and\n ingested material. There is a small amount of pericholecystic fluid though\n the GB is not fully distended.\n\n Pancreas, spleen, adrenal glands, and kidneys are normal. There is no free\n air or free intraperitoneal fluid.\n\n There is appearance to the abdominal mesentery in the left upper\n quadrant, with multiple small lymph nodes.\n (Over)\n\n 4:24 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CTA PELVIS W&W/O C & RECONS\n Reason: r/o dissection, please r/o PE\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT PELVIS: The cecum is moderately distended with a large amount of fecal\n material. Fecal material is also seen in the terminal ileum, which is\n borderline distended, measuring just greater than 3 cm. Fecal material is\n seen within the small bowel as far proximal as the mid ileum in the right\n upper quadrant. Proximal loops of small bowel are collapsed, however, and\n there is no sign of obstruction. No definite mass is seen in the region of\n the ileocecal valve. The appendix is normal.\n\n There is no free fluid, or abnormal intra-abdominal lymphadenopathy.\n\n There is no osseous lesion suspicious for malignancy.\n\n IMPRESSION:\n 1. No aortic dissection.\n 2. Heterogeneous appearance of the liver. Evaluation for focal lesion limited\n on this early arterial phase exam. If there is concern for portal vein\n thrombosis, recommend correlation with ultrasound.\n 3. Small amount of pericholecystic and periportal fluid, of uncertain\n significance. No other definite evidence of pancreatitis or cholecystitis.\n 4. appearance of the abdominal mesentery, with multiple small nodes\n could be seen in the setting of mesenteric adenitis/panniculitis.\n 5. Marked fecal impaction in the cecum, with small bowel fecalization seen as\n well, but no definite evidence of obstruction.\n\n Findings discussed with Dr. at time of study interpretation on\n .\n SESHa\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1080104,
"text": " 4:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o acute intrapulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with acute onset abdomin pain, tachypnic\n REASON FOR THIS EXAMINATION:\n r/o acute intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:23 P.M. ON \n\n HISTORY: Acute onset of abdominal pain and tachypnea.\n\n IMPRESSION: AP chest reviewed in the absence of other chest radiographs or\n imaging of the torso.\n\n Heart is mildly-to-moderately enlarged. A 28-mm wide elliptical nodular\n opacity projecting over the left heart border could be fluid trapped in the\n major fissure though there is no evidence of pleural effusion collecting\n elsewhere. Similarly, a bulge in the right lower paratracheal contour in the\n mediastinum could be a distended azygos vein, less likely adenopathy. Lungs\n are low in volume but otherwise clear. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-20 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 1080959,
"text": " 1:24 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: SWELLING IN RT ARM; R/O DVT\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with pancreatitis. Developed swollen right arm over 24 hrs.\n no tenderness good pulses no cvl\n REASON FOR THIS EXAMINATION:\n R/O DVT\n ______________________________________________________________________________\n WET READ: JXKc FRI 2:46 PM\n Thrombus in the right cephalic vein.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old male with pancreatitis, with swollen right arm over the\n last 24 hours. Rule out DVT.\n\n No prior studies are available for comparison.\n\n FINDINGS: Grayscale and color Doppler son of the right internal jugular,\n subclavian, axillary, brachials, basilic and cephalic veins were obtained.\n There is expansion of the cephalic vein in the mid and distal portions, with\n internal echogenicity and non-compressibility, compatible with thrombus. The\n remainder of the vessels demonstrate normal compression, flow, and\n augmentation without evidence of DVT.\n\n IMPRESSION: Right cephalic vein thrombus, without evidence of DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1080482,
"text": " 9:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: aspiration or other acute process?\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hypoxia after ERCP.\n REASON FOR THIS EXAMINATION:\n aspiration or other acute process?\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Hypoxia after ERCP, intubated.\n\n Comparison is made to prior study performed a day earlier.\n\n ET tube tip is 2.2 cm above the carina. It can be withdrawn a couple of\n centimeters for standard positioning. There are lower lung volumes. Increased\n opacity in the left lower lobe is new and consistent with almost complete\n collapse of the left lower lobe. Right lower lobe atelectasis has worsened.\n Atelectases in the upper lobes medially are stable. There is no pneumothorax\n or pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-15 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1080103,
"text": " 4:11 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with acute onset abdomin pain and fullness, distended on exam\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute onset abdominal pain.\n\n SUPINE ABDOMEN: No prior comparisons. There is no sign of free\n intraperitoneal air on this single supine radiograph. Several stool-filled\n loops of colon are noted, but bowel gas pattern is otherwise unremarkable.\n Visualized skeletal structures are normal.\n\n Please refer to CT abdomen performed same day.\n SESHa\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-15 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1080114,
"text": " 6:15 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOP ABD/PEL LIMITEDClip # \n Reason: EVAL FOR PV THROMBOSIS AND LIVER MASS SEEN IN CT SCAN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with ? portal vein thrombosis and liver mass on CT abdomen\n REASON FOR THIS EXAMINATION:\n evaluate portal vein and liver texture\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND OF THE RIGHT UPPER QUADRANT.\n\n Comparison is made with a CT abdomen performed on the same day.\n\n CLINICAL HISTORY: 57-year-old man with heterogeneous appearance of the liver\n on CT and periduodenal stranding, question portal venous thrombosis.\n\n FINDINGS: The liver has a heterogeneous echotexture, which may be related to\n fatty replacement though more serious forms of liver disease cannot be\n excluded. No focal liver lesions are detected. There is a small amount of\n fluid adjacent to the gallbladder. The gallbladder appears otherwise\n unremarkable without evidence of stones or hydropic distention. No\n son sign is elicited. The main portal vein, left portal\n vein, right anterior and posterior portal veins are patent with correct\n direction of flow. The right, left, and middle hepatic veins demonstrate\n patency.\n\n IMPRESSION:\n 1. Heterogeneous hepatic echotexture may be related to fatty replacement\n though more advanced forms of liver disease cannot be excluded.\n 2. Small amount of pericholecystic fluid, nonspecific, without additional\n findings to suggest cholecystitis.\n 3. Patent portal vein with no evidence of central thrombosis.\n SESHa\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-25 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1081747,
"text": " 9:56 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: IV contrast, eval for hepatic abscess\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p lap chole who was found to have ?hepatic abscess intraop\n REASON FOR THIS EXAMINATION:\n IV contrast, eval for hepatic abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 57 year old man post laparoscopic cholecystectomy was found to\n have a possible hepatic abscess intraoperatively.\n\n COMPARISON: Multiple prior exams, the most recent ultrasound performed\n and the most recent CTA chest performed .\n\n CT ABDOMEN: Small right and trace left pleural effusion are noted. Mild\n cardiomegaly is stable.\n\n Segmental peripheral subcentimeter cystic lesions in the right liver periphery\n predominantly involve the subcapsular portion of segment VIII, with some\n extending to segment V peripherally. They are slightly more prominent since\n . Fluid tracking along the falciform ligament is within the spectrum\n of postsurgical change and there is no evidence of rim enhancement or\n drainable fluid collection. A right abdominal appraoch drainage catheter\n enters medial to the 9th costochondral junction and courses through the\n gallbladder fossa to terminate near the falciform ligament. A second right\n abdominal catheter enters below the right 10th rib anteriorly courses\n posterior to the liver and loops around the liver to terminate anterior to the\n left lobe adjacent to the falciform ligament. Stranding adjacent to the\n splenic flexure is within the spectrum of post- surgical change. Scattered\n subcentimeter renal hypodensities likely represent cysts but are too small to\n characterize. The abdominal loops of large and small bowel are unremarkable.\n There is no pneumatosis, free air, or evidence of obstruction.\n\n CT PELVIS: The rectum, sigmoid, prostate and seminal vesicles are\n unremarkable. Air within the bladder is likely related to Foley\n catheterization. Small left greater than right fat-containing inguinal hernias\n are noted.\n\n Bone windows demonstrate no lesion concerning for metastasis or infection.\n\n IMPRESSION:\n\n 1. Focal heterogeneous peripheral subcentimeter cystic lesions most\n prominent along segment VIII have increased in conspicuity since and\n likely represent focal cholangitis or microabscess. This should be followed\n to ensure it does not progress to frank abscess.\n\n 2. No evidence of drainable fluid collection. Fluid tracking along the\n (Over)\n\n 9:56 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: IV contrast, eval for hepatic abscess\n Admitting Diagnosis: PANCREATITIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n falciform ligament demonstrates no rim enhancement to suggest abscess and is\n likely within the spectrum of post-surgical change. There is no abdominal\n fluid collection.\n\n 3. Subcentimeter renal hypodensities likely represent cysts but are too small\n to be characterized.\n\n"
}
] |