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Admission Date : [ * * 2115 - 2 - 22 * * ] Discharge Date : [ * * 2115 - 3 - 19 * * ]
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100035.txt
1
Date of Birth : [ * * 2078 - 8 - 9 * * ] Sex : M
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100035.txt
2
Service : MEDICINE
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[ "Service", ":", "MEDICINE" ]
100035.txt
3
Allergies : Vicodin
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100035.txt
4
Attending : [ * * First Name3 ( LF ) 4891 * * ] Chief Complaint : Post - cardiac arrest , asthma exacerbation
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100035.txt
5
Major Surgical or Invasive Procedure : Intubation Removal of chest tubes placed at an outside hospital R CVL placement
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100035.txt
6
History of Present Illness : Mr .
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100035.txt
7
[ * * Known lastname 3234 * * ] is a 36 year old gentleman with a PMH signifciant with dilated cardiomyopathy s/p AICD , asthma , and HTN admitted to an OSH with dyspnea now admitted to the MICU after PEA arrest x2 .
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100035.txt
8
The patient initially presented to LGH ED with hypoxemic respiratory distress .
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100035.txt
9
While at the OSH , he received CTX , azithromycin , SC epinephrine , and solumedrol .
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100035.txt
10
While at the OSH , he became confused and subsequently had an episode of PEA arrest and was intubated .
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100035.txt
11
He received epinephrine , atropine , magnesium , and bicarb .
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100035.txt
12
In addition , he had bilateral needle thoracostomies with report of air return on the left , and he subsequently had bilateral chest tubes placed .
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100035.txt
13
After approximately 15 - 20 minutes of rescucitation , he had ROSC .
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100035.txt
14
He received vecuronium and was started on an epi gtt for asthma and a cooling protocol , and was then transferred to [ * * Hospital1 18 * * ] for further evaluation .
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100035.txt
15
Of note , the patient was admitted to LGH in [ * * 1 - 4 * * ] for dyspnea , and was subsequently diagnosed with a CAP and asthma treated with CTX and azithromycin .
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100035.txt
16
Per his family , he has also had multiple admissions this winter for asthma exacerbations .
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100035.txt
17
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100035.txt
18
In the [ * * Hospital1 18 * * ] ED , 35.3 102 133/58 100 % AC 500x20 , 5 , 1.0 with an ABG 7.16/66/162 .
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100035.txt
19
He had a CTH which was unremarkable .
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100035.txt
20
He then had a CTA chest , afterwhich he went into PEA arrest .
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100035.txt
21
Rescucitation last approximately 10 - 15 minutes with multiple rounds of epi and bicarb , with ROSC .
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100035.txt
22
He was then admitted to the MICU for further management .
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100035.txt
23
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100035.txt
24
Currently , the patient is intubated , sedated , and parlyzed .
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100035.txt
25
Past Medical History : Asthma Dilated cardiomyopathy Multiple admissions for dyspnea this winter ( [ * * 1 - 26 * * ] ) .
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100035.txt
26
Anxiety/depression CKD HLD Obesity HTN
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100035.txt
27
Social History : Unknown
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100035.txt
28
Family History : Unknown
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100035.txt
29
Physical Exam : ADMISSION : VS : 35.9 124 129/67 99 % AC 480x24 , 5 , 1.0 Gen : ETT in place , intubated , sedated .
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100035.txt
30
HEENT : ETT in place .
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100035.txt
31
CV : Tachy S1+S2 Pulm : Poor air movement bilaterally .
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100035.txt
32
Diffuse wheezes bilaterally .
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100035.txt
33
Abd : S/D hypoactive BS Ext : 1+ edema bilaterally Neuro : Unresponsive .
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100035.txt
34
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100035.txt
35
Discharge : 98.5 102/65 76 20 95 - 98 % RA In cage bed to prevent patient from falling out of bed .
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100035.txt
36
Occasionally calling out .
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100035.txt
37
Lungs clear without wheezes .
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100035.txt
38
Pertinent Results : Labs on Admission : [ * * 2115 - 2 - 22 * * ] 08 : 50AM BLOOD WBC - 19.5 * RBC - 4.76 Hgb - 14.9 Hct - 44.3 MCV - 93 MCH - 31.4 MCHC - 33.7 RDW - 12.9 Plt Ct - 201 [ * * 2115 - 2 - 22 * * ] 08 : 50AM BLOOD PT - 14.1 * PTT - 25.9 INR ( PT ) - 1.2 * [ * * 2115 - 2 - 22 * * ] 08 : 50AM BLOOD Glucose - 306 * UreaN - 21 * Creat - 1.2 Na - 144 K - 4.1 Cl - 111 * HCO3 - 28 AnGap - 9 [ * * 2115 - 2 -
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100035.txt
39
22 * * ] 08 : 50AM BLOOD Albumin - 3.4 * Calcium - 6.2 * Phos - 5.5 * Mg - 2.2 [ * * 2115 - 2 - 22 * * ] 09 : 32AM BLOOD calTIBC - 320 Ferritn - 1129 * TRF - 246 [ * * 2115 - 2 - 22 * * ] 07 : 17AM BLOOD Type - ART pO2 - 162 * pCO2 - 66 * pH - 7.16 * calTCO2 - 25 Base XS -- 6 Intubat - INTUBATED .
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100035.txt
40
Labs on Discharge [ * * 2115 - 3 - 18 * * ] 11 : 34AM BLOOD Type - ART pO2 - 95 pCO2 - 33 * pH - 7.54 * calTCO2 - 29 Base XS - 5 Intubat - NOT INTUBA [ * * 2115 - 3 - 5 * * ] 05 : 35AM BLOOD ALT - 49 * AST - 23 AlkPhos - 53 TotBili - 0.9 [ * * 2115 - 3 - 19 * * ] 04 : 45AM BLOOD Glucose - 73 UreaN - 25 * Creat - 1.4 * Na - 133 K - 4.1 Cl - 95 * HCO3 - 21 * AnGap - 21 * [ * * 2115 - 3 - 19 * * ] 04 : 45AM
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100035.txt
41
BLOOD WBC - 12.4 * RBC - 4.47 * Hgb - 14.3 Hct - 41.3 MCV - 93 MCH - 32.0 MCHC - 34.6 RDW - 13.3 Plt Ct - 352 [ * * 2115 - 3 - 19 * * ] 04 : 45AM BLOOD Neuts - 56 Bands - 0 Lymphs - 38 Monos - 3 Eos - 3 Baso - 0 Atyps - 0 Metas - 0 Myelos - 0 .
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100035.txt
42
CXR ( in MICU ) : Mr read - cardiomegaly , RIJ in SVC , ETT 4.5 cm above carina .
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100035.txt
43
Blunting of costophrenic angles bilaterally with low lung volumes .
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100035.txt
44
Loss of retrocardiac diagphragm and bilateral opacities ( L>R ) .
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100035.txt
45
CXR : 1 .
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100035.txt
46
NG tube at 7.2 cm above the carina .
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100035.txt
47
[ * * Month ( only ) 116 * * ] consider advancing for optimal placement .
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100035.txt
48
2 .
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100035.txt
49
Severe cardiomegaly with globular shape .
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100035.txt
50
In the absence of prior comparison , the differential is broad , including moderate pericardial effusion , mediastinal hemorrhage , or acute cardiac failure .
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100035.txt
51
Recommend clinical correlation .
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100035.txt
52
.
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100035.txt
53
CTH : My read , no acute bleed .
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100035.txt
54
CTA Chest : 1 .
[ 0, 0, 0, 0, 0 ]
[ "CTA", "Chest", ":", "1", "." ]
100035.txt
55
No evidence of pulmonary embolism , although evaluation of subsegmental branches is limited .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "No", "evidence", "of", "pulmonary", "embolism", ",", "although", "evaluation", "of", "subsegmental", "branches", "is", "limited", "." ]
100035.txt
56
2 .
[ 0, 0 ]
[ "2", "." ]
100035.txt
57
Moderate cardiomegaly without pericardial effusion .
[ 0, 0, 0, 0, 0, 0 ]
[ "Moderate", "cardiomegaly", "without", "pericardial", "effusion", "." ]
100035.txt
58
3 .
[ 0, 0 ]
[ "3", "." ]
100035.txt
59
Bilateral dependent atelectasis .
[ 0, 0, 0, 0 ]
[ "Bilateral", "dependent", "atelectasis", "." ]
100035.txt
60
4 .
[ 0, 0 ]
[ "4", "." ]
100035.txt
61
Multiple nondisplaced rib fractures on the right , some of which are subacute .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "Multiple", "nondisplaced", "rib", "fractures", "on", "the", "right", ",", "some", "of", "which", "are", "subacute", "." ]
100035.txt
62
Also possible subtle nondisplaced fractures of the left ribs .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "Also", "possible", "subtle", "nondisplaced", "fractures", "of", "the", "left", "ribs", "." ]
100035.txt
63
5 .
[ 0, 0 ]
[ "5", "." ]
100035.txt
64
Nondisplaced acute sternal fracture in addition to a subacute nondisplaced sternal fracture .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "Nondisplaced", "acute", "sternal", "fracture", "in", "addition", "to", "a", "subacute", "nondisplaced", "sternal", "fracture", "." ]
100035.txt
65
.
[ 0 ]
[ "." ]
100035.txt
66
TTE : The left atrium is moderately dilated .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "TTE", ":", "The", "left", "atrium", "is", "moderately", "dilated", "." ]
100035.txt
67
The estimated right atrial pressure is 10 - 20mmHg .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "The", "estimated", "right", "atrial", "pressure", "is", "10", "-", "20mmHg", "." ]
100035.txt
68
Left ventricular wall thicknesses are normal .
[ 0, 0, 0, 0, 0, 0, 0 ]
[ "Left", "ventricular", "wall", "thicknesses", "are", "normal", "." ]
100035.txt
69
The left ventricular cavity is severely dilated .
[ 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "The", "left", "ventricular", "cavity", "is", "severely", "dilated", "." ]
100035.txt
70
LV systolic function appears depressed ( ejection fraction ? 30 percent ) with regional variation .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "LV", "systolic", "function", "appears", "depressed", "(", "ejection", "fraction", "?", "30", "percent", ")", "with", "regional", "variation", "." ]
100035.txt
71
There is considerable beat - to - beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "There", "is", "considerable", "beat", "-", "to", "-", "beat", "variability", "of", "the", "left", "ventricular", "ejection", "fraction", "due", "to", "an", "irregular", "rhythm/premature", "beats", "." ]
100035.txt
72
The right ventricular free wall thickness is normal .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "The", "right", "ventricular", "free", "wall", "thickness", "is", "normal", "." ]
100035.txt
73
The right ventricular cavity is dilated with depressed free wall contractility .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "The", "right", "ventricular", "cavity", "is", "dilated", "with", "depressed", "free", "wall", "contractility", "." ]
100035.txt
74
The aortic root is mildly dilated at the sinus level .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "The", "aortic", "root", "is", "mildly", "dilated", "at", "the", "sinus", "level", "." ]
100035.txt
75
The ascending aorta is mildly dilated .
[ 0, 0, 0, 0, 0, 0, 0 ]
[ "The", "ascending", "aorta", "is", "mildly", "dilated", "." ]
100035.txt
76
The aortic valve leaflets ( 3 ) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "The", "aortic", "valve", "leaflets", "(", "3", ")", "appear", "structurally", "normal", "with", "good", "leaflet", "excursion", "and", "no", "aortic", "stenosis", "or", "aortic", "regurgitation", "." ]
100035.txt
77
The mitral valve leaflets are structurally normal .
[ 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "The", "mitral", "valve", "leaflets", "are", "structurally", "normal", "." ]
100035.txt
78
There is no mitral valve prolapse .
[ 0, 0, 0, 0, 0, 0, 0 ]
[ "There", "is", "no", "mitral", "valve", "prolapse", "." ]
100035.txt
79
Mild ( 1+ ) mitral regurgitation is seen .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "Mild", "(", "1+", ")", "mitral", "regurgitation", "is", "seen", "." ]
100035.txt
80
The pulmonary artery systolic pressure could not be determined .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "The", "pulmonary", "artery", "systolic", "pressure", "could", "not", "be", "determined", "." ]
100035.txt
81
There is no pericardial effusion .
[ 0, 0, 0, 0, 0, 0 ]
[ "There", "is", "no", "pericardial", "effusion", "." ]
100035.txt
82
.
[ 0 ]
[ "." ]
100035.txt
83
ECG ( post - arrest ) : Sinus with 1 : 1 conduction .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "ECG", "(", "post", "-", "arrest", ")", ":", "Sinus", "with", "1", ":", "1", "conduction", "." ]
100035.txt
84
LAA .
[ 0, 0 ]
[ "LAA", "." ]
100035.txt
85
LAD , RBBB , LAFB .
[ 0, 0, 0, 0, 0, 0 ]
[ "LAD", ",", "RBBB", ",", "LAFB", "." ]
100035.txt
86
STD in V4 - V6 .
[ 0, 0, 0, 0, 0, 0 ]
[ "STD", "in", "V4", "-", "V6", "." ]
100035.txt
87
.
[ 0 ]
[ "." ]
100035.txt
88
ECG ( pre - arrest ) : Sinus with 1 : 1 conduction .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "ECG", "(", "pre", "-", "arrest", ")", ":", "Sinus", "with", "1", ":", "1", "conduction", "." ]
100035.txt
89
LAD , bifascicular block .
[ 0, 0, 0, 0, 0 ]
[ "LAD", ",", "bifascicular", "block", "." ]
100035.txt
90
No lateral STD .
[ 0, 0, 0, 0 ]
[ "No", "lateral", "STD", "." ]
100035.txt
91
.
[ 0 ]
[ "." ]
100035.txt
92
ECG ( OSH , unclear pre/post arrest ) : Sinus with 1 : 1 conduction .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "ECG", "(", "OSH", ",", "unclear", "pre/post", "arrest", ")", ":", "Sinus", "with", "1", ":", "1", "conduction", "." ]
100035.txt
93
Bifascicular ( RBBB , LAFB ) block .
[ 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "Bifascicular", "(", "RBBB", ",", "LAFB", ")", "block", "." ]
100035.txt
94
STD in V5 - 6 .
[ 0, 0, 0, 0, 0, 0 ]
[ "STD", "in", "V5", "-", "6", "." ]
100035.txt
95
.
[ 0 ]
[ "." ]
100035.txt
96
EEG [ * * 2 - 27 * * ] IMPRESSION : This is an abnormal video EEG telemetry due to the slow and disorganized background of 6.5 Hz with bursts of generalized slowing that showed no clear reactivity .
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[ "EEG", "[", "*", "*", "2", "-", "27", "*", "*", "]", "IMPRESSION", ":", "This", "is", "an", "abnormal", "video", "EEG", "telemetry", "due", "to", "the", "slow", "and", "disorganized", "background", "of", "6.5", "Hz", "with", "bursts", "of", "generalized", "slowing", "that", "showed", "no", "clear", "reactivity", "." ]
100035.txt
97
These findings indicate a severe encephalopathy .
[ 0, 0, 0, 0, 0, 0, 0 ]
[ "These", "findings", "indicate", "a", "severe", "encephalopathy", "." ]
100035.txt
98
This may be consistent with the patient's history of anoxia ; however , toxic/metabolic disturbances , infection , and medication effects are also among the most frequent causes of encephalopathy .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "This", "may", "be", "consistent", "with", "the", "patient's", "history", "of", "anoxia", ";", "however", ",", "toxic/metabolic", "disturbances", ",", "infection", ",", "and", "medication", "effects", "are", "also", "among", "the", "most", "frequent", "causes", "of", "encephalopathy", "." ]
100035.txt
99
No clear epileptiform discharges or seizures were seen .
[ 0, 0, 0, 0, 0, 0, 0, 0, 0 ]
[ "No", "clear", "epileptiform", "discharges", "or", "seizures", "were", "seen", "." ]
100035.txt
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